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Fifty years of medical specialty certification role of the American Board of Medical Specialties
Soecial article II
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Fifty years of medical specialty certification role of the American Board of Medical Specialties Thomas B. Ferguson, M.D.,* and Donald G. Langsley, M.D. St. Louis, MO, and Evanston, IL Those who have had experience with the voluntary system of medical specialty certification will surely prefer it to an imposed bureaucratic type of control. Despite the deficiencies and problems associated with it, as Churchill noted about democracy: "It is the best that exists." Medical science and medical practice are constantly advancing and changing. With those changes it is reasonable to expect change in the specialty credentialing system. However, that change should be thoughtful, cautious, and should be made only in the best interest of the patients for whom we are responsible. (J AM ACAD DERMATOL 11:911-916, 1984.)
Specialism is the dominant identity of today's medical practitioner. Contrary to conventional wisdom that it is new, it goes back as far as the sixth century Bc. Hanlon ~ reminds us that Herodotus wrote in his Persian Wars, Each physician applies himself to one disease only, and not more. All places abound in physicians; some physicians are for the eyes, others for the head, others for the teeth, others for the parts about the belly, and others for internal disorders, t Two hundred years before Herodotus an Egyptian court physician was described as "the guardian of the belly of Pharo."2 Specialism emphasizes the science of medicine and has had a major influence on medical education and research. Most students enter medical school with the intent to specialize and with an Reprint requests to: Dr. Donald G. Langsley, Executive Vice President, American Board of Medical Specialties, One American Plaza, Suite 805, Evanston, IL 60201. *Barnes Hospital Plaza, St. Louis. +From Hanlon CR: Specialization in medicine. J Thorac Cardiovasc Surg 64:179-185, 1972.
interest in at least one particular specialty, though that interest often changes. Today 97% of entering medical students plan to become a specialist and more than 90% of graduates of Liaison Committee for Medical Education (LCME) accredited schools do complete a residency, though only about 70% of them are eventually certified. The basic purpose of certification is to protect the interest of the public through the establishment and maintenance of standards for the physician who renders specialized care. The result has been a vast improvement in medicaI care since the turn of the century. The basic goal of specialization is excellence (the motto of the American Board of Medical Specialties [ABMS] is "excellence," supported by skill, ethics, and honor). In contrast, the goal of licensure is to establish the minimal level o f competence to protect the public safety, health, and property. At least three agencies could serve as the specialist certifying group: teaching hospitals could certify, but they are subject to a conflict of interest; government agencies could certify, but they represent political and economic influences; the medical profession is the best-qualified group be911
912
Journal of the American Academyof Dermatology
Ferguson and Langsley
Abbreviations used AAMC Association of American Medical Colleges ABMS American Board of Medical Specialties ACGME Accreditation Council on Graduate Medical Education ACCME Accreditation Council on Continuing Medical Education AMA American Medical Association AHA American Hospital Association AHME Association for Hospital Medical Education CMSS Council of Medical Specialty Societies COCERT Committee on Certification, Subcertification and Recertification COSEP Committee on the Study of Evaluation Procedures FSMB Federation of State Medical Boards LCME Liaison Committee for Medical Education LCSB Liaison Committee on Specialty Boards NBME National Board of Medical Examiners
cause it places responsibility in the hands of those best qualified to evaluate competence.
History of the A B M S The medical specialty societies were the basic impetus to specialty education and certification. Groups o f physicians especially interested in certain diseases, age groups, or styles of practice banded together out o f their interest in mutual education and improvement in their practice. The concept o f a specialty board was proposed in 1908 by the president of a specialty society. Dr. Derrick T. Vail, in his presidential address to the American Academy o f Ophthalmology and Otolaryngology, proposed requiring an educational program of sufficient length to assure proper training and passing an examination given by a certifying board before being able to practice as a specialist in ophthalmology. In 1915, a joint committee from the American Ophthalmological Society, the Section of Ophthalmology of the American Medical Association ( A M A ) , and the Academy of Ophthalmology published a report recommending the establishment o f a board to "anange, control and supervise examinations to test the preparation of those who design to enter on the special or exclusive practice of ophthalmology". The report called for such a board to fix requirements that included completion o f medical school at least 2 years prior to the examination, adequate study of ophthalmology and allied subjects, and payment of an examination fee. The board was to prepare
lists of approved medical schools, hospitals, and private instructors deenred competent to give the required instruction in the specialty. The board was officially incorporated in 1917. It was almost a decade before the second board was formed. The American Board of Otolaryngology was incorporated in 1924; the third, in obstetrics and gynecology, was established in 1930. The fourth specialty board to be formed was in dermatology. For dermatology, a 1931 meeting of the American Dermatological Association saw the appointment of a committee to determine the advisability of forming a board in dermatology. A similar committee was appointed by the AMA Section on Dermatology and Syphilology. Both committees recommended the formation of a board and in 1932 it was started with both groups as sponsors. In 1939 a third sponsor, the American Academy of Dermatology, was added. The board corresponded with the other specialty boards, obtaining information that was useful in setting the arrangements for the examinations. The first written examination in 1933 was an essay type test. The first oral examination was held later that year. By 1949, the written examination was changed from essay type to multiple choice questions. In 1976, the oral examination was replaced by an examination based on answers to prepared questions following the viewing of projected photographic slides and microscopic examinations of histopathologic sections. ~ By 1933, after four boards were formed, it had
Volume 11 Number 5, Part 1 November, 1984
become apparent that new specialties were developing and that national standards should be established for the recognition o f the specialists with the use of a certification system that would set educational requirements and assure the public that a candidate had passed an examination given by experts. At a conference attended by the four original "founding" specialty boards, the American Hospital Association (AHA), the Association of American Medical Colleges (AAMC), the AMA Council on Medical Education and Hospitals, the Federation of State Medical Boards (FSMB) and the National Board of Medical Examiners (NBME), it was resolved that: the examination and certification of specialists is best carried out by the National Boards (specialty boards) . . .; second, that the efficacy of these boards will be brought to their best level by the formation of an advisory committee or council created by two delegated representatives from the official specialty boards now in existence or in the process of formation and the other organizations at the meeting.* Thus was the Advisory Board on Medical Specialties established on Sept. 2, 1933. At that time it was also recommended that individual specialty boards should be established in at least the twelve recognized specialties of that era. Within 5 years, twelve boards had been established and consideration had begun for the recognition of subspecialties. By 1948 there was a total of eighteen board members of ABMS. No new specialty boards were formed during the period 1949 to 1969. In the next decade, the remaining five boards were approved. Presently there are twenty-three. With the formal organization of the Advisory Board, 1933, Louis B. Wilson was elected president, J. S. Rodman, vice-president, and Paul Titus, secretary-treasurer. Although the AMA was not a founding member of the ABMS in 1933, there have been continuing cooperation and collaborative establishment of the Liaison Committee on Specialty Boards (LCSB). From 1933 to 1970, the Advisory Board oper* From American Board of Medical Specialties: Annual report and reference handbook. Evanston, 1983, American Board of Medical Specialties.
Fif0' years o2I"medical specialS" certification
913
ated as a federation and met annually to discuss items of concern. By 1969 efforts at reorganization to make the ABMS a more useful organization had begun, and in 1970 the members voted to reorganize as the American Board of Medical Specialties. With the reorganization of 1970, the member boards vested more authority in the ABMS, especially authority for the approval of new boards and new forms of certification. In July 1970, with the retirement of Dr. Louis Buie (who had served for 12 years as part-time secretarytreasurer), Dr. John C. Nunemaker was employed as full-time executive director. Dr. Glen R. Leymaster succeeded him in 1975 and Dr. Donald G. Langsley, in 1981. Activities of the ABMS Governance. The Assembly, a group of 113 voting representatives plus alternates, governs itself through a committee structure and meets in plenary session semiannually. The standing committees include an executive committee, a committee to review applications for certification and recertification (COCERT), a research-oriented committee to study evaluation procedures (COSEP), and the usual organizational committees for nominations, finance, and bylaws. Four representatives to the Accreditation Council on Graduate Medical Education (ACGME) and three representatives to the Accreditation Council on Continuing Medical Education (ACCME) are also elected. Certification. A major responsibility of the ABMS is to approve new forms of certification and new specialty boards. Through its assembly (which consists of voting representatives of twenty-three member boards in proportion to the number of certificates issued, five associate members, and three public members), the ABMS considers applications to issue new forms of certification such as Certificates of Special Qualifications (formerly called Certificates of Special Competence). During the 1940s, subspecialty certification was attempted through subsidiary boards formed under the aegis of existing specialty boards. By 1970, the numbers of subspecialty areas had doubled and by 1980 they had quadrupled. The ABMS (after various reviews) decided that subspecialty certification should be arranged by pri-
914
Ferguson and Langsley
mary boards (which could act jointly with other primary boards) to develop certification for subspecialties (special competence or qualifications). Recertifieation. The concept that certification did not suggest lifelong competence was mentioned as far back as the 1936 annual meeting when one item on the agenda was "reregistration at stipulated intervals." In 1940, a report was published by the Commission on Graduate Medical Education called "Time Limit on Certificat i o n . " The report included the statement: Many persons argue that certification of a specialist indicates that he is up-to-date and competent at the time of examination but this does not prove that he continues indefinitely thereafter to be competent and aware of all important new knowledge in his field. This is obviously true and, as the certifying boards become established and as they complete the examination of the large group of physicians already practicing the specialties, they may find it desirable to issue certificates that are valid for a stated period only. In 1969, the American Board of Internal Medicine and the American Board of Family Practice adopted policies of recertification, the former voluntary and the latter mandatory. By 1973, all the members of ABMS had adopted the principle o f recertification, and in 1975 guidelines on recertification were punished. In 1974, the American Board o f Internal Medicine was the first board to examine diplomates for recertification. By 1980, twelve boards had received ABMS approval o f their recertification plans, and by 1982, nine boards had administered recertification examinations. In 1981, the first recertification plan was approved for a subspecialty (pediatric surgery) and by 1983, seven boards had established time-limited certification (mandatory recertification) for those certified after the time limit. However, recertification has not been universally accepted. A m o n g some groups it has been an issue that rouses the ire o f many practitioners. They are threatened by another examination (along with the threat o f loss of the status of being a certified specialist) and by increasing external control. E d u c a t i o n a l activities. The specialty boards (acting through the ABMS) have been involved in
Journal of the American Academyof Dermatology
establishing national accreditation standards and procedures for graduate medical education (residency programs) and for continuing medical education. Joining with the AAMC, the AHA, the AMA, and the Council of Medical Specialty Societies (CMSS), the ABMS is one of the sponsors of the ACGME, the organization for accreditation of residency programs. Each of the individual specialty boards is a co-sponsor of the Residency Review Committee in that specialty. The ABMS is also one of the sponsors of the ACCME, along with the AAMC, AHA, AMA, CMSS, the Association for Hospital Medical Education (AHME), and the FSMB. Specialty boards exert influence on the quality of graduate medical education by establishing educational requirements for eligibility for certification. They influence the content and length of the residency programs by these requirements. Through the ACGME they also have an influence on the standards by which residency programs are accredited (called "special requirements"). Along with its indirect influence on medical education, the ABMS has sponsored direct education through a series of ABMS conferences. Those conferences have been for both ABMS members and other interested parties. The conferences have been on topics related to the evaluation of medical skills, such as validation of the certification process, oral examinations, noncognitive skills, recertification, and legal aspects of certification and accreditation. The papers from these conferences formerly were duplicated and distributed as proceedings to those who attended, but in 1982 ABMS initiated a book publishing program that uses papers from such conferences plus other invited contributions as the contents of a series of case-bound books sold to a wide audience. Four such books were published in 1982-1983, and at least one more (on computer applications in evaluating physicians) is scheduled for 1984. As part of its educational responsibilities, ABMS is charged by its bylaws to publish a list of diplomates certified by the specialty boards. Beginning in 1939, this was done by arrangement with Marquis' Who's Who, and the Directot~y of Medical Specialists was published approximately every 2 years. It is presently in its twenty-first
Volume 11 Number 5, Part 1 November, 1984
edition. However, ABMS also recognized the usefulness of individual specialty directories and in 1983 began the publication of a series of them. Seven were published during 1983 and included emergency medicine, nuclear medicine, neurological surgery, ophthalmology, plastic surgery, thoracic surgery, and urology. Dermatology and eight others are scheduled for 1984, and by the end of 1985 all specialties will be represented in this series. The directories are published using an on-line computerized data base in the ABMS offices developed during 1983. These directories serve as a source of information about certified specialists for the professional and the public. This data base will be of help to member boards and to research studies on medical specialist manpower. ABMS provides information to its members and to others in the general fields of medical education and medical practice through its periodical publications. An Annual Report and Reference Handbook updates information on the medical specialty certification movement each year. It is distributed to approximately 5,000 persons and institutions. A monthly publication called the ABMS Record is sent to approximately a thousand persons. It contains information on meetings and activities of groups involved in graduate medical education and also information on legislation, regulations, and judicial matters related to certification. Another monthly publication called the Evaluation Exchange goes to the same thousand persons. It abstracts recent publications on technologic developments within the field of evaluation and measurement likely to be of interest to specialty boards and others in graduate and continuing medical education. Research. In 1971, ABMS established a Committee on the Study of Evaluation Procedures (COSEP). This committee was charged with 1. the development of educational conferences and programs 2. the accumulation of information and statistics about evaluation technics and procedures 3. the coordination of activities leading to improvement in content, construct, criterion, and predictive validity of certification examinations 4. the organization and coordination of high priority research and the development of such activities
Fif~ years of medical specialty certification 915
5. assisting specialty boards in developing specific projects and grant proposals It has provided consultation on evaluation, particularly on concerns about the validation of examination procedures. Three specific research projects involving collaboration o f several boards are underway. COSEP has developed an Advisory Council with representation from each board. There is widespread recognition that the improvement and validation of specialty examination procedures are a major priority for ABMS and that the collaboration and resources of individual boards plus the coordination of COSEP can enhance progress in this area. Problems and issues A major concern for ABMS is the proliferation of certificates of special qualifications (subspecialties) and its potential for the fragmentation of m e d i c a l c a r e . a,4 Subspecialists tend to identify with their subspecialist colleagues and subspecialty organizations rather than with their primary specialty. The argument in favor of subspecialization is that it provides better care. However, the move toward increasing numbers of subspecialties is also a threat to the value of a primary board certificate. Can we logically expect one to be both a superspecialist and an all-purpose clinician.'? Another problem is that the proliferation of subspecialties promotes jurisdictional problems. It may increase the cost of medical education and the cost of medical care and may make it difficult for the general public to find the right practitioner for a specific problem. The pendulum swings from the depth and competence of the subspecialist to the breadth of the generalist. Does superspecialization represent "too much science and too little caring for the patient"? is the question asked by Paul Beeson. ~ The American College of Surgeons (in 1983) approved a position stating that programs of special interest education are expected to be developed to train surgeons to teach, advance research, and provide sophisticated care for certain groups. Training programs may be developed in institutions that have the capability. Review (accreditation) mechanisms may be established by appropriate bodies. The recognition of completion may be awarded by the institution, but special in-
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Journal of the American Academy of Dermatology
Ferguson and Langsley
terest should not be recognized b y formal certification or special competence certificates. Another issue has been the effort of hospital medical staff committees to seek a national standard for awarding practice privileges. However, A B M S does not view certification as the only valid claim of competence, especially with reference to privileges to practice in hospitals. Such decisions should be made by local committees by evaluating a variety of information about a specific individual practitioner. Certification is considered only one of these criteria. Still, the tendency to try to use certification for privileging and for compensation by third party payers is a problem. The issue of knowledge versus performance is one that has concerned the ABMS for many years. Knowledge and skill are prerequisites to competent performance, but no guarantor. The basic issue is really one o f predictive validity. The question o f whether board certification examinations truly predict performance is an issue that is presently under intensive study. A B M S is presently studying previous efforts to test predictive validity and is preparing a long-term program project that will attempt to investigate the many facets of this key question. Another issue is that of self-designated boards. It is a fact that any person or organization can claim the title of a board. There are several dozen such organizations--some of them organized by highly excellent and ethical individuals and some of them that seem to be willing to sell a certificate! Unless such boards claim to be recognized by A B M S , there is little that can be done about them except education of the public and the involved professions. Indeed, there is positive value
in public education because a diplomate of an A B M S - a p p m v e d board has met high standards. One of the challenges for ABMS is to make the public more aware of the certification process and the usefulness of it. An issue that will be more prominent in the future has to do with nonmedical health care professionals. The ABMS member boards now certify only physicians (with the single exception that the American Board of Radiology certifies Ph.D. radiological physicists). In this world of changing roles and rules when hospitals are increasingly giving independent admission and treatment privileges to nonphysicians (as required by the Joint Commission on the Accreditation of Hospitals), ABMS may one day rethink that position. This is not to suggest that nonphysicians should automatically be included in the certification process, but rather that ABMS will eventually have to consider whether there is usefulness in considering the certification of limited disciplines that have a special relationship to physicians as the radiological physicist has a special relationship to the radiologist. REFERENCES
1. Hanlon CR: Specialization in medicine. J Thorac Cardiovasc Surg 64:179-185, 1972. 2. Livingood CS: History of the American Board of Dermatology 1932-82. J AM ACADDERMATOL7:821-850, 1982.
3. Meyers R: A critical look at medical education in the United States with comments on the role of specialty boards. Perspect Biol Med 1:48-68, 1957. 4. Rosen G: Changing attitudes of the medical profession to specialization. Bull Hist Med 12:343-354, 1942. 5. Beeson PB: The natural history of medical subspecialties. Ann Intern Med 93:624-626, 1980.
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Fifty years of medical specialty certification role of the American Board of Medical Specialties Thomas B. Ferguson, M.D.,* and Donald G. Langsley, M.D. St. Louis, MO, and Evanston, IL Those who have had experience with the voluntary system of medical specialty certification will surely prefer it to an imposed bureaucratic type of control. Despite the deficiencies and problems associated with it, as Churchill noted about democracy: "It is the best that exists." Medical science and medical practice are constantly advancing and changing. With those changes it is reasonable to expect change in the specialty credentialing system. However, that change should be thoughtful, cautious, and should be made only in the best interest of the patients for whom we are responsible. (J AM ACAD DERMATOL 11:911-916, 1984.)
Specialism is the dominant identity of today's medical practitioner. Contrary to conventional wisdom that it is new, it goes back as far as the sixth century Bc. Hanlon ~ reminds us that Herodotus wrote in his Persian Wars, Each physician applies himself to one disease only, and not more. All places abound in physicians; some physicians are for the eyes, others for the head, others for the teeth, others for the parts about the belly, and others for internal disorders, t Two hundred years before Herodotus an Egyptian court physician was described as "the guardian of the belly of Pharo."2 Specialism emphasizes the science of medicine and has had a major influence on medical education and research. Most students enter medical school with the intent to specialize and with an Reprint requests to: Dr. Donald G. Langsley, Executive Vice President, American Board of Medical Specialties, One American Plaza, Suite 805, Evanston, IL 60201. *Barnes Hospital Plaza, St. Louis. +From Hanlon CR: Specialization in medicine. J Thorac Cardiovasc Surg 64:179-185, 1972.
interest in at least one particular specialty, though that interest often changes. Today 97% of entering medical students plan to become a specialist and more than 90% of graduates of Liaison Committee for Medical Education (LCME) accredited schools do complete a residency, though only about 70% of them are eventually certified. The basic purpose of certification is to protect the interest of the public through the establishment and maintenance of standards for the physician who renders specialized care. The result has been a vast improvement in medicaI care since the turn of the century. The basic goal of specialization is excellence (the motto of the American Board of Medical Specialties [ABMS] is "excellence," supported by skill, ethics, and honor). In contrast, the goal of licensure is to establish the minimal level o f competence to protect the public safety, health, and property. At least three agencies could serve as the specialist certifying group: teaching hospitals could certify, but they are subject to a conflict of interest; government agencies could certify, but they represent political and economic influences; the medical profession is the best-qualified group be911
912
Journal of the American Academyof Dermatology
Ferguson and Langsley
Abbreviations used AAMC Association of American Medical Colleges ABMS American Board of Medical Specialties ACGME Accreditation Council on Graduate Medical Education ACCME Accreditation Council on Continuing Medical Education AMA American Medical Association AHA American Hospital Association AHME Association for Hospital Medical Education CMSS Council of Medical Specialty Societies COCERT Committee on Certification, Subcertification and Recertification COSEP Committee on the Study of Evaluation Procedures FSMB Federation of State Medical Boards LCME Liaison Committee for Medical Education LCSB Liaison Committee on Specialty Boards NBME National Board of Medical Examiners
cause it places responsibility in the hands of those best qualified to evaluate competence.
History of the A B M S The medical specialty societies were the basic impetus to specialty education and certification. Groups o f physicians especially interested in certain diseases, age groups, or styles of practice banded together out o f their interest in mutual education and improvement in their practice. The concept o f a specialty board was proposed in 1908 by the president of a specialty society. Dr. Derrick T. Vail, in his presidential address to the American Academy o f Ophthalmology and Otolaryngology, proposed requiring an educational program of sufficient length to assure proper training and passing an examination given by a certifying board before being able to practice as a specialist in ophthalmology. In 1915, a joint committee from the American Ophthalmological Society, the Section of Ophthalmology of the American Medical Association ( A M A ) , and the Academy of Ophthalmology published a report recommending the establishment o f a board to "anange, control and supervise examinations to test the preparation of those who design to enter on the special or exclusive practice of ophthalmology". The report called for such a board to fix requirements that included completion o f medical school at least 2 years prior to the examination, adequate study of ophthalmology and allied subjects, and payment of an examination fee. The board was to prepare
lists of approved medical schools, hospitals, and private instructors deenred competent to give the required instruction in the specialty. The board was officially incorporated in 1917. It was almost a decade before the second board was formed. The American Board of Otolaryngology was incorporated in 1924; the third, in obstetrics and gynecology, was established in 1930. The fourth specialty board to be formed was in dermatology. For dermatology, a 1931 meeting of the American Dermatological Association saw the appointment of a committee to determine the advisability of forming a board in dermatology. A similar committee was appointed by the AMA Section on Dermatology and Syphilology. Both committees recommended the formation of a board and in 1932 it was started with both groups as sponsors. In 1939 a third sponsor, the American Academy of Dermatology, was added. The board corresponded with the other specialty boards, obtaining information that was useful in setting the arrangements for the examinations. The first written examination in 1933 was an essay type test. The first oral examination was held later that year. By 1949, the written examination was changed from essay type to multiple choice questions. In 1976, the oral examination was replaced by an examination based on answers to prepared questions following the viewing of projected photographic slides and microscopic examinations of histopathologic sections. ~ By 1933, after four boards were formed, it had
Volume 11 Number 5, Part 1 November, 1984
become apparent that new specialties were developing and that national standards should be established for the recognition o f the specialists with the use of a certification system that would set educational requirements and assure the public that a candidate had passed an examination given by experts. At a conference attended by the four original "founding" specialty boards, the American Hospital Association (AHA), the Association of American Medical Colleges (AAMC), the AMA Council on Medical Education and Hospitals, the Federation of State Medical Boards (FSMB) and the National Board of Medical Examiners (NBME), it was resolved that: the examination and certification of specialists is best carried out by the National Boards (specialty boards) . . .; second, that the efficacy of these boards will be brought to their best level by the formation of an advisory committee or council created by two delegated representatives from the official specialty boards now in existence or in the process of formation and the other organizations at the meeting.* Thus was the Advisory Board on Medical Specialties established on Sept. 2, 1933. At that time it was also recommended that individual specialty boards should be established in at least the twelve recognized specialties of that era. Within 5 years, twelve boards had been established and consideration had begun for the recognition of subspecialties. By 1948 there was a total of eighteen board members of ABMS. No new specialty boards were formed during the period 1949 to 1969. In the next decade, the remaining five boards were approved. Presently there are twenty-three. With the formal organization of the Advisory Board, 1933, Louis B. Wilson was elected president, J. S. Rodman, vice-president, and Paul Titus, secretary-treasurer. Although the AMA was not a founding member of the ABMS in 1933, there have been continuing cooperation and collaborative establishment of the Liaison Committee on Specialty Boards (LCSB). From 1933 to 1970, the Advisory Board oper* From American Board of Medical Specialties: Annual report and reference handbook. Evanston, 1983, American Board of Medical Specialties.
Fif0' years o2I"medical specialS" certification
913
ated as a federation and met annually to discuss items of concern. By 1969 efforts at reorganization to make the ABMS a more useful organization had begun, and in 1970 the members voted to reorganize as the American Board of Medical Specialties. With the reorganization of 1970, the member boards vested more authority in the ABMS, especially authority for the approval of new boards and new forms of certification. In July 1970, with the retirement of Dr. Louis Buie (who had served for 12 years as part-time secretarytreasurer), Dr. John C. Nunemaker was employed as full-time executive director. Dr. Glen R. Leymaster succeeded him in 1975 and Dr. Donald G. Langsley, in 1981. Activities of the ABMS Governance. The Assembly, a group of 113 voting representatives plus alternates, governs itself through a committee structure and meets in plenary session semiannually. The standing committees include an executive committee, a committee to review applications for certification and recertification (COCERT), a research-oriented committee to study evaluation procedures (COSEP), and the usual organizational committees for nominations, finance, and bylaws. Four representatives to the Accreditation Council on Graduate Medical Education (ACGME) and three representatives to the Accreditation Council on Continuing Medical Education (ACCME) are also elected. Certification. A major responsibility of the ABMS is to approve new forms of certification and new specialty boards. Through its assembly (which consists of voting representatives of twenty-three member boards in proportion to the number of certificates issued, five associate members, and three public members), the ABMS considers applications to issue new forms of certification such as Certificates of Special Qualifications (formerly called Certificates of Special Competence). During the 1940s, subspecialty certification was attempted through subsidiary boards formed under the aegis of existing specialty boards. By 1970, the numbers of subspecialty areas had doubled and by 1980 they had quadrupled. The ABMS (after various reviews) decided that subspecialty certification should be arranged by pri-
914
Ferguson and Langsley
mary boards (which could act jointly with other primary boards) to develop certification for subspecialties (special competence or qualifications). Recertifieation. The concept that certification did not suggest lifelong competence was mentioned as far back as the 1936 annual meeting when one item on the agenda was "reregistration at stipulated intervals." In 1940, a report was published by the Commission on Graduate Medical Education called "Time Limit on Certificat i o n . " The report included the statement: Many persons argue that certification of a specialist indicates that he is up-to-date and competent at the time of examination but this does not prove that he continues indefinitely thereafter to be competent and aware of all important new knowledge in his field. This is obviously true and, as the certifying boards become established and as they complete the examination of the large group of physicians already practicing the specialties, they may find it desirable to issue certificates that are valid for a stated period only. In 1969, the American Board of Internal Medicine and the American Board of Family Practice adopted policies of recertification, the former voluntary and the latter mandatory. By 1973, all the members of ABMS had adopted the principle o f recertification, and in 1975 guidelines on recertification were punished. In 1974, the American Board o f Internal Medicine was the first board to examine diplomates for recertification. By 1980, twelve boards had received ABMS approval o f their recertification plans, and by 1982, nine boards had administered recertification examinations. In 1981, the first recertification plan was approved for a subspecialty (pediatric surgery) and by 1983, seven boards had established time-limited certification (mandatory recertification) for those certified after the time limit. However, recertification has not been universally accepted. A m o n g some groups it has been an issue that rouses the ire o f many practitioners. They are threatened by another examination (along with the threat o f loss of the status of being a certified specialist) and by increasing external control. E d u c a t i o n a l activities. The specialty boards (acting through the ABMS) have been involved in
Journal of the American Academyof Dermatology
establishing national accreditation standards and procedures for graduate medical education (residency programs) and for continuing medical education. Joining with the AAMC, the AHA, the AMA, and the Council of Medical Specialty Societies (CMSS), the ABMS is one of the sponsors of the ACGME, the organization for accreditation of residency programs. Each of the individual specialty boards is a co-sponsor of the Residency Review Committee in that specialty. The ABMS is also one of the sponsors of the ACCME, along with the AAMC, AHA, AMA, CMSS, the Association for Hospital Medical Education (AHME), and the FSMB. Specialty boards exert influence on the quality of graduate medical education by establishing educational requirements for eligibility for certification. They influence the content and length of the residency programs by these requirements. Through the ACGME they also have an influence on the standards by which residency programs are accredited (called "special requirements"). Along with its indirect influence on medical education, the ABMS has sponsored direct education through a series of ABMS conferences. Those conferences have been for both ABMS members and other interested parties. The conferences have been on topics related to the evaluation of medical skills, such as validation of the certification process, oral examinations, noncognitive skills, recertification, and legal aspects of certification and accreditation. The papers from these conferences formerly were duplicated and distributed as proceedings to those who attended, but in 1982 ABMS initiated a book publishing program that uses papers from such conferences plus other invited contributions as the contents of a series of case-bound books sold to a wide audience. Four such books were published in 1982-1983, and at least one more (on computer applications in evaluating physicians) is scheduled for 1984. As part of its educational responsibilities, ABMS is charged by its bylaws to publish a list of diplomates certified by the specialty boards. Beginning in 1939, this was done by arrangement with Marquis' Who's Who, and the Directot~y of Medical Specialists was published approximately every 2 years. It is presently in its twenty-first
Volume 11 Number 5, Part 1 November, 1984
edition. However, ABMS also recognized the usefulness of individual specialty directories and in 1983 began the publication of a series of them. Seven were published during 1983 and included emergency medicine, nuclear medicine, neurological surgery, ophthalmology, plastic surgery, thoracic surgery, and urology. Dermatology and eight others are scheduled for 1984, and by the end of 1985 all specialties will be represented in this series. The directories are published using an on-line computerized data base in the ABMS offices developed during 1983. These directories serve as a source of information about certified specialists for the professional and the public. This data base will be of help to member boards and to research studies on medical specialist manpower. ABMS provides information to its members and to others in the general fields of medical education and medical practice through its periodical publications. An Annual Report and Reference Handbook updates information on the medical specialty certification movement each year. It is distributed to approximately 5,000 persons and institutions. A monthly publication called the ABMS Record is sent to approximately a thousand persons. It contains information on meetings and activities of groups involved in graduate medical education and also information on legislation, regulations, and judicial matters related to certification. Another monthly publication called the Evaluation Exchange goes to the same thousand persons. It abstracts recent publications on technologic developments within the field of evaluation and measurement likely to be of interest to specialty boards and others in graduate and continuing medical education. Research. In 1971, ABMS established a Committee on the Study of Evaluation Procedures (COSEP). This committee was charged with 1. the development of educational conferences and programs 2. the accumulation of information and statistics about evaluation technics and procedures 3. the coordination of activities leading to improvement in content, construct, criterion, and predictive validity of certification examinations 4. the organization and coordination of high priority research and the development of such activities
Fif~ years of medical specialty certification 915
5. assisting specialty boards in developing specific projects and grant proposals It has provided consultation on evaluation, particularly on concerns about the validation of examination procedures. Three specific research projects involving collaboration o f several boards are underway. COSEP has developed an Advisory Council with representation from each board. There is widespread recognition that the improvement and validation of specialty examination procedures are a major priority for ABMS and that the collaboration and resources of individual boards plus the coordination of COSEP can enhance progress in this area. Problems and issues A major concern for ABMS is the proliferation of certificates of special qualifications (subspecialties) and its potential for the fragmentation of m e d i c a l c a r e . a,4 Subspecialists tend to identify with their subspecialist colleagues and subspecialty organizations rather than with their primary specialty. The argument in favor of subspecialization is that it provides better care. However, the move toward increasing numbers of subspecialties is also a threat to the value of a primary board certificate. Can we logically expect one to be both a superspecialist and an all-purpose clinician.'? Another problem is that the proliferation of subspecialties promotes jurisdictional problems. It may increase the cost of medical education and the cost of medical care and may make it difficult for the general public to find the right practitioner for a specific problem. The pendulum swings from the depth and competence of the subspecialist to the breadth of the generalist. Does superspecialization represent "too much science and too little caring for the patient"? is the question asked by Paul Beeson. ~ The American College of Surgeons (in 1983) approved a position stating that programs of special interest education are expected to be developed to train surgeons to teach, advance research, and provide sophisticated care for certain groups. Training programs may be developed in institutions that have the capability. Review (accreditation) mechanisms may be established by appropriate bodies. The recognition of completion may be awarded by the institution, but special in-
916
Journal of the American Academy of Dermatology
Ferguson and Langsley
terest should not be recognized b y formal certification or special competence certificates. Another issue has been the effort of hospital medical staff committees to seek a national standard for awarding practice privileges. However, A B M S does not view certification as the only valid claim of competence, especially with reference to privileges to practice in hospitals. Such decisions should be made by local committees by evaluating a variety of information about a specific individual practitioner. Certification is considered only one of these criteria. Still, the tendency to try to use certification for privileging and for compensation by third party payers is a problem. The issue of knowledge versus performance is one that has concerned the ABMS for many years. Knowledge and skill are prerequisites to competent performance, but no guarantor. The basic issue is really one o f predictive validity. The question o f whether board certification examinations truly predict performance is an issue that is presently under intensive study. A B M S is presently studying previous efforts to test predictive validity and is preparing a long-term program project that will attempt to investigate the many facets of this key question. Another issue is that of self-designated boards. It is a fact that any person or organization can claim the title of a board. There are several dozen such organizations--some of them organized by highly excellent and ethical individuals and some of them that seem to be willing to sell a certificate! Unless such boards claim to be recognized by A B M S , there is little that can be done about them except education of the public and the involved professions. Indeed, there is positive value
in public education because a diplomate of an A B M S - a p p m v e d board has met high standards. One of the challenges for ABMS is to make the public more aware of the certification process and the usefulness of it. An issue that will be more prominent in the future has to do with nonmedical health care professionals. The ABMS member boards now certify only physicians (with the single exception that the American Board of Radiology certifies Ph.D. radiological physicists). In this world of changing roles and rules when hospitals are increasingly giving independent admission and treatment privileges to nonphysicians (as required by the Joint Commission on the Accreditation of Hospitals), ABMS may one day rethink that position. This is not to suggest that nonphysicians should automatically be included in the certification process, but rather that ABMS will eventually have to consider whether there is usefulness in considering the certification of limited disciplines that have a special relationship to physicians as the radiological physicist has a special relationship to the radiologist. REFERENCES
1. Hanlon CR: Specialization in medicine. J Thorac Cardiovasc Surg 64:179-185, 1972. 2. Livingood CS: History of the American Board of Dermatology 1932-82. J AM ACADDERMATOL7:821-850, 1982.
3. Meyers R: A critical look at medical education in the United States with comments on the role of specialty boards. Perspect Biol Med 1:48-68, 1957. 4. Rosen G: Changing attitudes of the medical profession to specialization. Bull Hist Med 12:343-354, 1942. 5. Beeson PB: The natural history of medical subspecialties. Ann Intern Med 93:624-626, 1980.