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Board Certification
Board Certification The Global Perspective Susan H. Day, MD This article reviews globalization of quality standards in medicine, with emphasis on accreditation and certification. In conjunction with the 100th anniversary of the American Board of Ophthalmology, the author explores globalization movements, standards of quality, expectations of others seeking certification, the American Board of Medical Specialties (ABMS) International, interrelationships with the ABMS, and considerations both pragmatic and philosophical in addressing globalization of standards. Ophthalmology 2016;123:S50-S54 ª 2016 by the American Academy of Ophthalmology.
Why Globalization? Globalization is a result of many factors. Ease of transportation and communication greatly facilitate the transfer of knowledge. Businesses identify new markets, students identify new schools, and entertainers identify new audiences. In medical education, a growing number of allopathic medical schools now have international campuses; eye institutes including Wilmer, Cleveland Clinic, and Moorfields have a presence in Saudi Arabia, Abu Dhabi, and Dubai, respectively. Other aspects of our profession have been slower to join the globalization trend. Standards underpinning quality of caredand, in particular, accreditation and certificationdare lacking. Cultural differences impact physician behavioral norms and hence standards. Disease prevalence may differ dramatically, as do economic and technological capabilities. Physicians in more developed countries may view globalization as a threat to job security. Yet there are elements of our professional responsibilities that warrant a careful assessment of this issue. Expansion of knowledge and technology, as well as ease of access and communication, has driven globalization efforts in other disciplines. One compelling reason is the profession’s fundamental commitment to improve health. Historically, this responsibility has been related to the individual patient. Increasingly, the onus for improving health worldwide highlights the medical profession’s responsibility for a broader societal health. This call reflects the ethical pillar known as distributive justice. Improved standards must center on society’s needs. Patients learn about better care whether they reside in the shadows of a medical center or the shadows of a rain forest. Word of mouth and simple communication systems spread the word. Dr. Govindappa Venkatasamy, founder of the Aravind Eye Hospital in India, noted that “the villages demand good care” (Miller M, personal communication, February 14, 2016). Countless other examples exist in
S50
2016 by the American Academy of Ophthalmology Published by Elsevier Inc.
countries challenged with economic, transport, and geographic barriers. Quality speaks for itself. This article reviews aspects of globalization from the perspective of quality physician education (accreditation) and of the validation of that education (certification) with the central theme of the improvement of global health care. It does acknowledge that so-called “brain drain” often is driven by the desire for quality education and the pursuit of improved lifestyle.1
Global Standards of Quality Good care can be found in virtually all parts of the world. Excellent training centers exist in remote corners of the world, often designed as a traditional mentoreapprentice model of education. Physiciansdparticularly those seeking specialty trainingdalso leave their homelands to receive quality education. Distance learning has created new avenues for some aspects of the educational process. But the availability of quality educationdand hence, of quality caredis not as consistent in most regions of the world as in places such as the United States. The continuum of medical educationdnot simply graduate medical educationdreflects many inconsistencies. In fact, one must define in a more general sense what is meant by the term doctor. In China, for instance, more than 10 million doctors exist, but less than 50% have the equivalent of a university-level degree.2 Clear distinctions of educational background are not made apparent to the public. As a consequence, this vast country also suffers from an unusually high incidence of violence against physicians and health care workers, with more than 17 000 incidents occurring in 20103 and close to 30 annual assaults by patients or their families per hospital in 2012.4 Patients do not trust their doctors. China’s government is now prioritizing improvement of quality and sees the education (accreditation) and Statement of Potential Conflict of Interest and Funding/Support: See page S54. http://dx.doi.org/10.1016/j.ophtha.2016.06.007 ISSN 0161-6420/16
Day
Global Perspective on Board Certification
individual validation (certification) process as central to improving health for its citizens. As incredulous as the China story may sound, its current status of variable training and care are reminiscent of what existed in the United States before the Flexner report. After this report, both certification and accreditation became important processes where quality was improved in large part by raising the minimally acceptable standard. The importance of accreditation and certification standards as an indicator for quality also can be seen in the phenomenon of physician migration. As viewed from the physicians’ perspective, international migration (so-called brain drain) research provides evidence that educational incentives often are at the root for movement across borders.1 The United States has a unique model in which a peerdriven process exists for both accreditation and certification; this privilege is one that the profession of medicine must balance with an assumption of responsible action. In most countries, responsibility for standard setting rests with ministries or their governmental equivalents. There is variance on whether a ministry of health or a ministry of education is responsible for defining the quality of education. When governmental agencies are in charge of a certification process, it is the ministry of health that typically is responsible. Many countries rely on specialist societies to assist in setting such standards. In discussing matters of education and quality, it is critical to understand and define terms. We assume that words such as “doctor,” “medical school,” “accreditation,” and “certification” have universal meaning. In the international arena, they do not. In large part, these words are defined in a country-specific manner. Attempts have been made to identify a consensus understanding by the World Federation for Medical Education (WFME). It has defined standards across the medical continuum.5 In contrast, a more unified approach already exists for hospital accreditation, as well as for accreditation of ambulatory and behavioral health care facilities, home care, laboratory services, and nursing care centers. The Joint Commission, having established national patient safety goals,6 also founded in 1994 an international arm, the Joint Commission International.7 The Joint Commission International now accredits facilities in more than 90 countries. It has identified its role further in raising standards in resource-restricted countries through its SafeCare program,8 along with PharmAccess Foundation of The Netherlands and the Council for Health Service Accreditation of Southern Africa. The Joint Commission, the Joint Commission International, and SafeCare are accredited by the International Society for Quality in Health Care, the so-called accreditor of the accreditors.9 One of the greatest difficulties in comparing and identifying medical school quality in some countries is in identifying where medical schools are located.10 This becomes even more complex when trying to define where graduate medical education programs exist. An equally complex challenge is defining the component parts of the educational program. Many so-called residencies mimic a mentoreapprentice model in which training has no structure or system, but in which a good student and keen teacher can result in a good outcome. For our specialty, the International Council of Ophthalmology has created a standardized
curriculum representing input from 150 ophthalmologists worldwide.11 It also has created an examination process that in 2016 already has received more than 7000 applications. This examination is not intended as a certification process, but rather as one that assesses cognitive knowledge (Golnik K, personal communication, February 28, 2016). One effort to standardize education for ophthalmologists has occurred in conjunction with the creation of international accreditation granted by the ACGME International, an LLC of the Accreditation Council for Graduate Medical Education. As such, both foundational12 and advanced specialty13 requirements for ophthalmology have been created.
Expectations of and Reasons for Seeking Certification Countries (ministries), institutions, physicians, and patients are coalescing around the shared need for improved quality. These various perspectives are important in identifying why a certification process is being sought as well as in understanding expectations for improved outcomes. In general, countries, through their ministries, seek assistance when either a quality issue or manpower issue is identified; both qualitative and quantitative outcomes are sought to serve the needs of society better. Ironically, it is finding such assistance that is the greatest challenge. Increasingly, the outreach is to others internationally who have created a mechanism to provide a systematic approach. In some cases, the need is for more primary care; in others, for specialty care. Another governmental perspective pertains to a desire to prevent brain drain. Absence of opportunity for graduate medical education and certification systems often is seen as an underlying factor for this phenomenon. Finally, competitiondparticularly regionaldmay be at play for asking for assistance, because both residents and faculty are attracted to places with a clearer definition of quality standards. Institutions often see standardization of accreditation and certification as a means to provide quality to the institution itself. In the international arena, better job opportunities for graduates often are seen as a potential benefit as careers are developed, as well as the benefit of having produced quality physicians that often become local or regional leaders. What are the physicians’ perspectives on the value of specific standards? Physicians want to provide good care as well as to better themselves and their opportunities for both career and personal development. In many regions, a recognized certification process results in enhanced position, salary, or both. Certification by a process as robust as the American Board of Medical Specialties (ABMS) process is highly regarded internationally. This esteem surely reflects the psychometrics with its consequent validity, the patientcentric emphasis, security measures for examination content, and the peer-driven emphasis on its examinations. Less rigorous assessment processes not only lack these elements, but also often reflect an arbitrary, if not capricious, process for examination and certification. The relationship between the educational process (accreditation) and the certification processdas is found in the United Statesdalso validates in a reciprocal fashion what an individual physician expects
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Ophthalmology Volume 123, Number 9, Supplement, September 2016 from a certifying examination. In essence, a physician gains comfort in knowing that individual validation of quality is coupled with a standardized programmatic content, both of which are designed to ensure good care for patients. For patients, what is needed is attention to their needs by a physician who upholds his or her professional responsibility to patients. Board certification is designed to provide this assurance. In the United States, the tradition of board certification by the ABMS has resulted in a uniform expectation by the public that the care received will be appropriate and sufficient. The patient may not consciously associate board certification with quality. Conversely, the greater variability of quality internationally results in the need for alternative means of defining quality. As with Aravind Eye Hospital’s reputation, word of mouth regarding quality is a powerful, consistent force in defining where a patient will seek help. Patient-to-doctor violence in China is one manifestation of the confusion and lack of trust that occurs in the absence of robust quality indicators. Patients demand quality. As globalization enhances communication among the world’s citizens, this demand will increase.
American Board of Medical Specialties and American Board of Medical Specialties International The validity of the ABMS examinations has benefitted from century-old efforts to design a process that is fair, thorough, and reproducible. It entails an objective measurement of knowledge and validates the ABMS assessment tools. The science of psychometrics, as it has evolved, has provided ABMS boards the ability to deliver a robust product that can withstand challenges from multiple directions. This science of testing has played a significant role in garnering public trust in the years since the Flexner report. The American board certification process also has benefitted from less quantifiable concepts, but possibly equally important outcomes. First, the ABMS has unified the disciplines across medicine and surgery. The imprimatur of ABMS certification may define those eligible to join a medical staff during a credentialing process, who may seek further specialty training, and who is eligible to participate in organizations that provide access to a patient population. Although a voluntary process, some aspects of professional activity may be limited if an individual does not become board certified. A second factor contributing to the value of the ABMS certification process is peer involvement in the creation of such examinations. The sheer quantity of available and willing volunteers has benefitted the ABMS enormously in fulfilling its mission to protect the public. Each board has in place a process to focus further on the quality of the individuals it calls on to assist in board activities. Finally, ABMS boards benefit from both volunteer effort and certification fees. Many boards engage volunteer specialists to assist with item writing, and with an average of 100 000 physicians newly eligible for certification on an annual basis and with annual income from continual certification activities, the costs of producing valid examination processes can be budgeted. As currently exists, such fees are regarded by those
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involved in the certification process as a necessary step in securing credentials required for practicing medicine. Without board certification, access to medical staff, patients, and membership organizations becomes far more difficult. The international community does not enjoy the luxury of evolving a process over a 100-year period. It is divided into smaller population bases and as such cannot use quantity to offset cost. The tradition of volunteers willing to assist with standard setting also is not in place. The international community first reached out to the United States for accreditation standards. Singapore’s Ministry of Health reached agreement with the Accreditation Council for Graduate Medical Education in 2009 to create an international process of accreditation. The ACGME-I thus was created as a limited liability corporation of the parent organization. This process has accredited institutions and programs in Qatar, Abu Dhabi, Oman, and the American University of Beirut, with additional contracts with Saudi Arabia (King Khaled Eye Specialist Hospital), Haiti (Hospital de Mirebalais), and Panama (University of Panama) for accreditation services. In conjunction with the formation of ACGME-I after Singapore’s request, the ABMS was petitioned similarly. As a result, the ABMS International (ABMSI) was created in 2011 and has collaborated with the Singapore Ministry of Health in developing an assessment system reflecting locally relevant health care needs. The first examinations were administered in 2013. Thus far, 7 ophthalmologists have become certified through this process; the process is limited to a written examination and includes neither an oral examination nor a maintenance-of-certification process. Currently, all graduates of ACGME-I-accredited residencies in Singapore are required to sit for this examination. The American Board of Ophthalmology provides items for the Singapore examination as well as participates in the examination development activities. When ABMS-I was conceived, at least 3 hurdles were identified: the small pool of graduating candidates, the financial constraints of examination development, and the regional disparities in disease demographics as well as cultural variations. The concept of providing regional examinations thus was introduced. Currently, discussions with individuals representing Qatar, Abu Dhabi, Oman, and the American University of Beirut are being carried out regarding a regional examination suitable to the 4 countries.
Global Standards: Identical, Equivalent, or Regional? For certification to be meaningful, it must serve society. This service takes many forms: ability to diagnose, ability to communicate, ability to work within a team of care, ability to use technology, ability to keep current with knowledge, and ability to demonstrate cultural sensitivity. A global standard is driven by the availability of knowledge; the migratory nature of existing society; and (in many cases) Westernization of cultures, with a shift in types of disease demographically. Yet differences do remain. For example, how does one counsel a dying patient and family? How does one define responsibilities of surrogacy? Of informed
Day
Global Perspective on Board Certification
consent? How does one prepare for diseases prevalent in tropical countries? In frigid countries? How does one respect diet-specific conditions? How does one deal with various forms of trauma? Despite international trends for expanded disease burdens of trauma, cardiovascular disease, and oncologic conditions, there remain significant differences in the societies we serve, and hence in the type of doctor who is to provide care. Within our own specialty, international differences in care also can be found. In some countries, esotropia is a mark of beauty. The treatment of glaucoma internationally is modulated by the complexities inherent when interventional surgery not only may have little apparent benefit to patients, but also may be associated with further loss of vision. In countries where there is a strong belief system that divine will supersedes all, cultural approaches to malignant conditions may influence treatment preference. As movements toward international quality standards have increased, the prevailing mind-set is that there is significant overlap of common necessary actions and behaviors, and a smaller but nevertheless significant country- or region-specific element requiring validation. This concept has been called the 80e20 rule, where 80% of the information is universal and 20% is country or region specific. Even with the catholic majority, a rewriting of items may be indicated when culturally centric elements are included, such as reference to particular sports. As such, successful candidates will have passed an examination not identical to that of ABMS certification. Hence, there is at this time no reciprocity that in turn would result in an individual’s ability to use an international ABMS model interchangeably with an ABMS examination.
Moving Forward Reflecting on the history of United States movements, the roles of accreditation and certification are predicted to be essential for improving quality in health care internationally. Without such systems in place, education has a tremendous potential to be haphazard, the potential for uneven opportunity among a cohort of residents is immense, the responsibilities of meeting every patient’s needs may lead to a clash between service and education motives, and associated economic and political factions of health care may dominate education- or patient-centric endeavors. The existing United States model of ensuring proper education has found success when it embraces each resident and advocates for his or her education with subsequent board eligibility. The public’s needs are served when the resident’s educational needs are served. There is clear evidence that the habits learned in residency translate into lifelong habits of clinical practice as measured not only by quality of outcomes,14,15 but also by economic factors.16 Internationally, ministries, institutions, and individuals are recognizing the imperative of welltrained individuals to improve societal health. Furthermore, the growing demand for subspecialization has enhanced young physicians’ need for access to the equivalent of fellowship training; often, this is only available in
countries such as the United States, and competition as well as eligibility standards are increasingly rigorous. Should international involvement fall within the scope and mission of the ABMS? How would international work affect the responsibilities of ABMS and its board directors? What are the financial impacts? Is the current model of ABMS-I certification affordable for our international colleagues? Will equivalentdas opposed to identicald standards withstand a legal challenge centered on the interchangeability of multiple certification processes? What outcomes measures should be studied? How can trust be quantified in a meaningful manner? How does one keep individual certification data secure when globalization occurs? If not ABMS-I, then who? As American standards-setting entities such as the American Board of Ophthalmology and the ABMS seek answers, a focus on mission must serve as an inevitable guide. Businesses have deemed globalization as a striking new opportunity, and have reaped the benefits and grappled with the risks. The profession of medicine is less responsive. Much of medicine’s emphasis has been placed on the medical pillars of ethics that are individually patient centric: autonomy, beneficence, nonmaleficence, and truth telling. The fifth pillar, distributive justice, remains true to patient centricity, but in a manner that looks at benefit to all. It is this ethical principle that warrants a concerted assessment of globalization of quality standards.
References 1. Norcini J, Masmanian P. Physician migration, education, and health care. J Contin Educ Health Prof 2005;25:4–7. 2. National Health and Family Planning Commission. China Health and Family Planning Statistical Digest 2015. Peking: Union Medical College Press; 2015. 3. Violence against doctors: heartless attacks. The Economist July 21, 2012. 4. Burkitt L. Violence against doctors on the rise in China. The Wall Street Journal. August 16, 2013. 5. World Federation for Medical Education Task Force. Global standards for quality improvement in medical education. Copenhagen: World Federation for Medical Education; 2007. 6. Joint Commission. National patient safety goals effective January 1, 2016. Available at: http://www.join tcommission.org/npsg.presentation. Accessed February 24, 2016. 7. Joint Commission International. Who is the Joint Commission International? Available at: http://www.join tcommissioninternational.org/about-jci/who-is-jci. Accessed February 24, 2016. 8. SafeCare. Basic healthcare standards. Available at: http://www. safe-care.org/index.php?page¼standards. Accessed February 24, 2016. 9. International Society for Quality in Healthcare. ISQuadwho we are. Available at: http://www.isqua.org/who-we-are. Accessed February 24, 2016. 10. Mullan F, Frehywot S, Omaswa F, et al. Medical schools in sub-Saharan Africa. Lancet 2011;377:1113–21. 11. International Council of Ophthalmology. Residency curriculum. Available at: http://www.icoph.org/refocusing_education/ curricula.html. Accessed March 1, 2016.
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Ophthalmology Volume 123, Number 9, Supplement, September 2016 12. ACGME International. Foundational program requirements for graduate medical education. Available at: http://www.acgmei. org/Portals/AboutUs/FoundInternational.pdf. Accessed March 1, 2016. 13. ACGME International. Advanced specialty program requirements for graduate medical education in ophthalmology. Available at: http//:www.acgmei.org/Portals/0/ Specialties/Ophthalmology/ophthalmology.pdf. Accessed March 1, 2016.
14. Asch D, Nicholson S, Srinivas S, et al. Evaluating obstetrical residency programs using patient outcomes. JAMA 2009;302:1277–83. 15. Sirovich B, Lipner R, Johnson M, Holmboe E. The association between residency training and internists’ ability to practice conservatively. JAMA Intern Med 2014;174:1640–8. 16. Chen C, Patterson S, Phillips R, et al. Spending patterns in region of residency training and subsequent expenditures for care provided by practicing physicians for Medicare beneficiaries. JAMA 2014;312:385–93.
Footnotes and Financial Disclosures Originally received: April 18, 2016. Final revision: June 3, 2016. Accepted: June 3, 2016.
Analysis and interpretation: Day Manuscript no. 2016-790.
ACGME International, Chicago, Illinois. Presented at: American Board of Ophthalmology 100th Anniversary Symposium, March 2016, San Francisco, California. Financial Disclosure(s): The author(s) have made the following disclosure(s): S.H.D.: Employee e ACGME International, Chicago, Illinois The opinions expressed are those of the author. Author Contributions: Conception and design: Day
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Data collection: Day Obtained funding: none Overall responsibility: Day Abbreviations and Acronyms: ABMS ¼ American Board of Medical Specialties; ABMS-I ¼ American Board of Medical Specialties International. Correspondence: Susan H. Day, MD, ACGME International, 401 North Michigan Avenue, Suite 2000, Chicago, IL 60611. E-mail: [email protected].
Why Globalization? Globalization is a result of many factors. Ease of transportation and communication greatly facilitate the transfer of knowledge. Businesses identify new markets, students identify new schools, and entertainers identify new audiences. In medical education, a growing number of allopathic medical schools now have international campuses; eye institutes including Wilmer, Cleveland Clinic, and Moorfields have a presence in Saudi Arabia, Abu Dhabi, and Dubai, respectively. Other aspects of our profession have been slower to join the globalization trend. Standards underpinning quality of caredand, in particular, accreditation and certificationdare lacking. Cultural differences impact physician behavioral norms and hence standards. Disease prevalence may differ dramatically, as do economic and technological capabilities. Physicians in more developed countries may view globalization as a threat to job security. Yet there are elements of our professional responsibilities that warrant a careful assessment of this issue. Expansion of knowledge and technology, as well as ease of access and communication, has driven globalization efforts in other disciplines. One compelling reason is the profession’s fundamental commitment to improve health. Historically, this responsibility has been related to the individual patient. Increasingly, the onus for improving health worldwide highlights the medical profession’s responsibility for a broader societal health. This call reflects the ethical pillar known as distributive justice. Improved standards must center on society’s needs. Patients learn about better care whether they reside in the shadows of a medical center or the shadows of a rain forest. Word of mouth and simple communication systems spread the word. Dr. Govindappa Venkatasamy, founder of the Aravind Eye Hospital in India, noted that “the villages demand good care” (Miller M, personal communication, February 14, 2016). Countless other examples exist in
S50
2016 by the American Academy of Ophthalmology Published by Elsevier Inc.
countries challenged with economic, transport, and geographic barriers. Quality speaks for itself. This article reviews aspects of globalization from the perspective of quality physician education (accreditation) and of the validation of that education (certification) with the central theme of the improvement of global health care. It does acknowledge that so-called “brain drain” often is driven by the desire for quality education and the pursuit of improved lifestyle.1
Global Standards of Quality Good care can be found in virtually all parts of the world. Excellent training centers exist in remote corners of the world, often designed as a traditional mentoreapprentice model of education. Physiciansdparticularly those seeking specialty trainingdalso leave their homelands to receive quality education. Distance learning has created new avenues for some aspects of the educational process. But the availability of quality educationdand hence, of quality caredis not as consistent in most regions of the world as in places such as the United States. The continuum of medical educationdnot simply graduate medical educationdreflects many inconsistencies. In fact, one must define in a more general sense what is meant by the term doctor. In China, for instance, more than 10 million doctors exist, but less than 50% have the equivalent of a university-level degree.2 Clear distinctions of educational background are not made apparent to the public. As a consequence, this vast country also suffers from an unusually high incidence of violence against physicians and health care workers, with more than 17 000 incidents occurring in 20103 and close to 30 annual assaults by patients or their families per hospital in 2012.4 Patients do not trust their doctors. China’s government is now prioritizing improvement of quality and sees the education (accreditation) and Statement of Potential Conflict of Interest and Funding/Support: See page S54. http://dx.doi.org/10.1016/j.ophtha.2016.06.007 ISSN 0161-6420/16
Day
Global Perspective on Board Certification
individual validation (certification) process as central to improving health for its citizens. As incredulous as the China story may sound, its current status of variable training and care are reminiscent of what existed in the United States before the Flexner report. After this report, both certification and accreditation became important processes where quality was improved in large part by raising the minimally acceptable standard. The importance of accreditation and certification standards as an indicator for quality also can be seen in the phenomenon of physician migration. As viewed from the physicians’ perspective, international migration (so-called brain drain) research provides evidence that educational incentives often are at the root for movement across borders.1 The United States has a unique model in which a peerdriven process exists for both accreditation and certification; this privilege is one that the profession of medicine must balance with an assumption of responsible action. In most countries, responsibility for standard setting rests with ministries or their governmental equivalents. There is variance on whether a ministry of health or a ministry of education is responsible for defining the quality of education. When governmental agencies are in charge of a certification process, it is the ministry of health that typically is responsible. Many countries rely on specialist societies to assist in setting such standards. In discussing matters of education and quality, it is critical to understand and define terms. We assume that words such as “doctor,” “medical school,” “accreditation,” and “certification” have universal meaning. In the international arena, they do not. In large part, these words are defined in a country-specific manner. Attempts have been made to identify a consensus understanding by the World Federation for Medical Education (WFME). It has defined standards across the medical continuum.5 In contrast, a more unified approach already exists for hospital accreditation, as well as for accreditation of ambulatory and behavioral health care facilities, home care, laboratory services, and nursing care centers. The Joint Commission, having established national patient safety goals,6 also founded in 1994 an international arm, the Joint Commission International.7 The Joint Commission International now accredits facilities in more than 90 countries. It has identified its role further in raising standards in resource-restricted countries through its SafeCare program,8 along with PharmAccess Foundation of The Netherlands and the Council for Health Service Accreditation of Southern Africa. The Joint Commission, the Joint Commission International, and SafeCare are accredited by the International Society for Quality in Health Care, the so-called accreditor of the accreditors.9 One of the greatest difficulties in comparing and identifying medical school quality in some countries is in identifying where medical schools are located.10 This becomes even more complex when trying to define where graduate medical education programs exist. An equally complex challenge is defining the component parts of the educational program. Many so-called residencies mimic a mentoreapprentice model in which training has no structure or system, but in which a good student and keen teacher can result in a good outcome. For our specialty, the International Council of Ophthalmology has created a standardized
curriculum representing input from 150 ophthalmologists worldwide.11 It also has created an examination process that in 2016 already has received more than 7000 applications. This examination is not intended as a certification process, but rather as one that assesses cognitive knowledge (Golnik K, personal communication, February 28, 2016). One effort to standardize education for ophthalmologists has occurred in conjunction with the creation of international accreditation granted by the ACGME International, an LLC of the Accreditation Council for Graduate Medical Education. As such, both foundational12 and advanced specialty13 requirements for ophthalmology have been created.
Expectations of and Reasons for Seeking Certification Countries (ministries), institutions, physicians, and patients are coalescing around the shared need for improved quality. These various perspectives are important in identifying why a certification process is being sought as well as in understanding expectations for improved outcomes. In general, countries, through their ministries, seek assistance when either a quality issue or manpower issue is identified; both qualitative and quantitative outcomes are sought to serve the needs of society better. Ironically, it is finding such assistance that is the greatest challenge. Increasingly, the outreach is to others internationally who have created a mechanism to provide a systematic approach. In some cases, the need is for more primary care; in others, for specialty care. Another governmental perspective pertains to a desire to prevent brain drain. Absence of opportunity for graduate medical education and certification systems often is seen as an underlying factor for this phenomenon. Finally, competitiondparticularly regionaldmay be at play for asking for assistance, because both residents and faculty are attracted to places with a clearer definition of quality standards. Institutions often see standardization of accreditation and certification as a means to provide quality to the institution itself. In the international arena, better job opportunities for graduates often are seen as a potential benefit as careers are developed, as well as the benefit of having produced quality physicians that often become local or regional leaders. What are the physicians’ perspectives on the value of specific standards? Physicians want to provide good care as well as to better themselves and their opportunities for both career and personal development. In many regions, a recognized certification process results in enhanced position, salary, or both. Certification by a process as robust as the American Board of Medical Specialties (ABMS) process is highly regarded internationally. This esteem surely reflects the psychometrics with its consequent validity, the patientcentric emphasis, security measures for examination content, and the peer-driven emphasis on its examinations. Less rigorous assessment processes not only lack these elements, but also often reflect an arbitrary, if not capricious, process for examination and certification. The relationship between the educational process (accreditation) and the certification processdas is found in the United Statesdalso validates in a reciprocal fashion what an individual physician expects
S51
Ophthalmology Volume 123, Number 9, Supplement, September 2016 from a certifying examination. In essence, a physician gains comfort in knowing that individual validation of quality is coupled with a standardized programmatic content, both of which are designed to ensure good care for patients. For patients, what is needed is attention to their needs by a physician who upholds his or her professional responsibility to patients. Board certification is designed to provide this assurance. In the United States, the tradition of board certification by the ABMS has resulted in a uniform expectation by the public that the care received will be appropriate and sufficient. The patient may not consciously associate board certification with quality. Conversely, the greater variability of quality internationally results in the need for alternative means of defining quality. As with Aravind Eye Hospital’s reputation, word of mouth regarding quality is a powerful, consistent force in defining where a patient will seek help. Patient-to-doctor violence in China is one manifestation of the confusion and lack of trust that occurs in the absence of robust quality indicators. Patients demand quality. As globalization enhances communication among the world’s citizens, this demand will increase.
American Board of Medical Specialties and American Board of Medical Specialties International The validity of the ABMS examinations has benefitted from century-old efforts to design a process that is fair, thorough, and reproducible. It entails an objective measurement of knowledge and validates the ABMS assessment tools. The science of psychometrics, as it has evolved, has provided ABMS boards the ability to deliver a robust product that can withstand challenges from multiple directions. This science of testing has played a significant role in garnering public trust in the years since the Flexner report. The American board certification process also has benefitted from less quantifiable concepts, but possibly equally important outcomes. First, the ABMS has unified the disciplines across medicine and surgery. The imprimatur of ABMS certification may define those eligible to join a medical staff during a credentialing process, who may seek further specialty training, and who is eligible to participate in organizations that provide access to a patient population. Although a voluntary process, some aspects of professional activity may be limited if an individual does not become board certified. A second factor contributing to the value of the ABMS certification process is peer involvement in the creation of such examinations. The sheer quantity of available and willing volunteers has benefitted the ABMS enormously in fulfilling its mission to protect the public. Each board has in place a process to focus further on the quality of the individuals it calls on to assist in board activities. Finally, ABMS boards benefit from both volunteer effort and certification fees. Many boards engage volunteer specialists to assist with item writing, and with an average of 100 000 physicians newly eligible for certification on an annual basis and with annual income from continual certification activities, the costs of producing valid examination processes can be budgeted. As currently exists, such fees are regarded by those
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involved in the certification process as a necessary step in securing credentials required for practicing medicine. Without board certification, access to medical staff, patients, and membership organizations becomes far more difficult. The international community does not enjoy the luxury of evolving a process over a 100-year period. It is divided into smaller population bases and as such cannot use quantity to offset cost. The tradition of volunteers willing to assist with standard setting also is not in place. The international community first reached out to the United States for accreditation standards. Singapore’s Ministry of Health reached agreement with the Accreditation Council for Graduate Medical Education in 2009 to create an international process of accreditation. The ACGME-I thus was created as a limited liability corporation of the parent organization. This process has accredited institutions and programs in Qatar, Abu Dhabi, Oman, and the American University of Beirut, with additional contracts with Saudi Arabia (King Khaled Eye Specialist Hospital), Haiti (Hospital de Mirebalais), and Panama (University of Panama) for accreditation services. In conjunction with the formation of ACGME-I after Singapore’s request, the ABMS was petitioned similarly. As a result, the ABMS International (ABMSI) was created in 2011 and has collaborated with the Singapore Ministry of Health in developing an assessment system reflecting locally relevant health care needs. The first examinations were administered in 2013. Thus far, 7 ophthalmologists have become certified through this process; the process is limited to a written examination and includes neither an oral examination nor a maintenance-of-certification process. Currently, all graduates of ACGME-I-accredited residencies in Singapore are required to sit for this examination. The American Board of Ophthalmology provides items for the Singapore examination as well as participates in the examination development activities. When ABMS-I was conceived, at least 3 hurdles were identified: the small pool of graduating candidates, the financial constraints of examination development, and the regional disparities in disease demographics as well as cultural variations. The concept of providing regional examinations thus was introduced. Currently, discussions with individuals representing Qatar, Abu Dhabi, Oman, and the American University of Beirut are being carried out regarding a regional examination suitable to the 4 countries.
Global Standards: Identical, Equivalent, or Regional? For certification to be meaningful, it must serve society. This service takes many forms: ability to diagnose, ability to communicate, ability to work within a team of care, ability to use technology, ability to keep current with knowledge, and ability to demonstrate cultural sensitivity. A global standard is driven by the availability of knowledge; the migratory nature of existing society; and (in many cases) Westernization of cultures, with a shift in types of disease demographically. Yet differences do remain. For example, how does one counsel a dying patient and family? How does one define responsibilities of surrogacy? Of informed
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consent? How does one prepare for diseases prevalent in tropical countries? In frigid countries? How does one respect diet-specific conditions? How does one deal with various forms of trauma? Despite international trends for expanded disease burdens of trauma, cardiovascular disease, and oncologic conditions, there remain significant differences in the societies we serve, and hence in the type of doctor who is to provide care. Within our own specialty, international differences in care also can be found. In some countries, esotropia is a mark of beauty. The treatment of glaucoma internationally is modulated by the complexities inherent when interventional surgery not only may have little apparent benefit to patients, but also may be associated with further loss of vision. In countries where there is a strong belief system that divine will supersedes all, cultural approaches to malignant conditions may influence treatment preference. As movements toward international quality standards have increased, the prevailing mind-set is that there is significant overlap of common necessary actions and behaviors, and a smaller but nevertheless significant country- or region-specific element requiring validation. This concept has been called the 80e20 rule, where 80% of the information is universal and 20% is country or region specific. Even with the catholic majority, a rewriting of items may be indicated when culturally centric elements are included, such as reference to particular sports. As such, successful candidates will have passed an examination not identical to that of ABMS certification. Hence, there is at this time no reciprocity that in turn would result in an individual’s ability to use an international ABMS model interchangeably with an ABMS examination.
Moving Forward Reflecting on the history of United States movements, the roles of accreditation and certification are predicted to be essential for improving quality in health care internationally. Without such systems in place, education has a tremendous potential to be haphazard, the potential for uneven opportunity among a cohort of residents is immense, the responsibilities of meeting every patient’s needs may lead to a clash between service and education motives, and associated economic and political factions of health care may dominate education- or patient-centric endeavors. The existing United States model of ensuring proper education has found success when it embraces each resident and advocates for his or her education with subsequent board eligibility. The public’s needs are served when the resident’s educational needs are served. There is clear evidence that the habits learned in residency translate into lifelong habits of clinical practice as measured not only by quality of outcomes,14,15 but also by economic factors.16 Internationally, ministries, institutions, and individuals are recognizing the imperative of welltrained individuals to improve societal health. Furthermore, the growing demand for subspecialization has enhanced young physicians’ need for access to the equivalent of fellowship training; often, this is only available in
countries such as the United States, and competition as well as eligibility standards are increasingly rigorous. Should international involvement fall within the scope and mission of the ABMS? How would international work affect the responsibilities of ABMS and its board directors? What are the financial impacts? Is the current model of ABMS-I certification affordable for our international colleagues? Will equivalentdas opposed to identicald standards withstand a legal challenge centered on the interchangeability of multiple certification processes? What outcomes measures should be studied? How can trust be quantified in a meaningful manner? How does one keep individual certification data secure when globalization occurs? If not ABMS-I, then who? As American standards-setting entities such as the American Board of Ophthalmology and the ABMS seek answers, a focus on mission must serve as an inevitable guide. Businesses have deemed globalization as a striking new opportunity, and have reaped the benefits and grappled with the risks. The profession of medicine is less responsive. Much of medicine’s emphasis has been placed on the medical pillars of ethics that are individually patient centric: autonomy, beneficence, nonmaleficence, and truth telling. The fifth pillar, distributive justice, remains true to patient centricity, but in a manner that looks at benefit to all. It is this ethical principle that warrants a concerted assessment of globalization of quality standards.
References 1. Norcini J, Masmanian P. Physician migration, education, and health care. J Contin Educ Health Prof 2005;25:4–7. 2. National Health and Family Planning Commission. China Health and Family Planning Statistical Digest 2015. Peking: Union Medical College Press; 2015. 3. Violence against doctors: heartless attacks. The Economist July 21, 2012. 4. Burkitt L. Violence against doctors on the rise in China. The Wall Street Journal. August 16, 2013. 5. World Federation for Medical Education Task Force. Global standards for quality improvement in medical education. Copenhagen: World Federation for Medical Education; 2007. 6. Joint Commission. National patient safety goals effective January 1, 2016. Available at: http://www.join tcommission.org/npsg.presentation. Accessed February 24, 2016. 7. Joint Commission International. Who is the Joint Commission International? Available at: http://www.join tcommissioninternational.org/about-jci/who-is-jci. Accessed February 24, 2016. 8. SafeCare. Basic healthcare standards. Available at: http://www. safe-care.org/index.php?page¼standards. Accessed February 24, 2016. 9. International Society for Quality in Healthcare. ISQuadwho we are. Available at: http://www.isqua.org/who-we-are. Accessed February 24, 2016. 10. Mullan F, Frehywot S, Omaswa F, et al. Medical schools in sub-Saharan Africa. Lancet 2011;377:1113–21. 11. International Council of Ophthalmology. Residency curriculum. Available at: http://www.icoph.org/refocusing_education/ curricula.html. Accessed March 1, 2016.
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Ophthalmology Volume 123, Number 9, Supplement, September 2016 12. ACGME International. Foundational program requirements for graduate medical education. Available at: http://www.acgmei. org/Portals/AboutUs/FoundInternational.pdf. Accessed March 1, 2016. 13. ACGME International. Advanced specialty program requirements for graduate medical education in ophthalmology. Available at: http//:www.acgmei.org/Portals/0/ Specialties/Ophthalmology/ophthalmology.pdf. Accessed March 1, 2016.
14. Asch D, Nicholson S, Srinivas S, et al. Evaluating obstetrical residency programs using patient outcomes. JAMA 2009;302:1277–83. 15. Sirovich B, Lipner R, Johnson M, Holmboe E. The association between residency training and internists’ ability to practice conservatively. JAMA Intern Med 2014;174:1640–8. 16. Chen C, Patterson S, Phillips R, et al. Spending patterns in region of residency training and subsequent expenditures for care provided by practicing physicians for Medicare beneficiaries. JAMA 2014;312:385–93.
Footnotes and Financial Disclosures Originally received: April 18, 2016. Final revision: June 3, 2016. Accepted: June 3, 2016.
Analysis and interpretation: Day Manuscript no. 2016-790.
ACGME International, Chicago, Illinois. Presented at: American Board of Ophthalmology 100th Anniversary Symposium, March 2016, San Francisco, California. Financial Disclosure(s): The author(s) have made the following disclosure(s): S.H.D.: Employee e ACGME International, Chicago, Illinois The opinions expressed are those of the author. Author Contributions: Conception and design: Day
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Data collection: Day Obtained funding: none Overall responsibility: Day Abbreviations and Acronyms: ABMS ¼ American Board of Medical Specialties; ABMS-I ¼ American Board of Medical Specialties International. Correspondence: Susan H. Day, MD, ACGME International, 401 North Michigan Avenue, Suite 2000, Chicago, IL 60611. E-mail: [email protected].