SUBSPECIALTY CERTIFICATION IN PEDIATRIC UROLOGY

0022-5347/05/1736-1845/0 THE JOURNAL OF UROLOGY® Copyright © 2005 by AMERICAN UROLOGICAL ASSOCIATION

Vol. 173, 1845–1846, June 2005 Printed in U.S.A.

DOI: 10.1097/01.ju.0000163662.01660.df

Editorials SUBSPECIALTY CERTIFICATION IN PEDIATRIC UROLOGY Initial efforts to achieve subcertification in the field of pediatric urology began more than 25 years ago. During the last quarter century the pediatric urological community has endeavored to differentiate itself to meet and exceed the standards required for formal subspecialty certification. Like other sub-disciplines in urology, pediatric urology is a disease based subspecialty. However, it is also a distinct population based subspecialty. The European Union of Medical Specialists, European Board of Urology and European Board of Pediatric Surgery have already approved formal subspecialty recognition of pediatric urology in Europe. In May 2000 the Pediatric Urology Coordinating Council, representing the combined leadership of 4 major pediatric urological organizations (American Academy of Pediatrics Section on Urology, Society for Pediatric Urology, Society for Fetal Urology and American Association of Pediatric Urologists) petitioned the American Board of Urology (ABU) to establish the Pediatric Urology Advisory Council. Following approval by the ABU, the advisory council met annually with the ABU Trustees to discuss issues of mutual interest to the ABU and pediatric urology, including training programs, research funding efforts, expert legal testimony and subcertification. These discussions culminated in a formal proposal in July 2003 to the ABU for a Certificate of Added Qualification (CAQ) in Pediatric Urology which was endorsed by the American Academy of Pediatrics and the American Board of Pediatrics. In February 2004 the ABU Trustees voted to “support and approve the concept of creating a Certificate of Added Qualification in Pediatric Urology.” In September 2004 the ABU Trustees voted to submit an application to the American Board of Medical Specialties for a CAQ in pediatric urology. As stated in the policy statement of the American Board of Medical Specialties (ABMS) The intent of the certification of physicians is to provide assurance to the public that a physician specialist certified by a Member Board of the ABMS has successfully completed an approved educational program and an evaluation process which includes an examination designed to assess the knowledge, skills, and experience required to provide high quality patient care in that specialty. It is the policy of the ABMS that recognition of subspecialty certification should be primarily for individuals who are devoting a major portion of their time and efforts to that restricted special field. Subspecialty certification should only be granted after education and training or experience in addition to that required for general certification in the discipline.1 Although concerns have been raised that subspecialty certification would adversely impact or in some way restrict the practice of the general urologist, historically this has not been the case in other fields that have subspecialty certification. For example, in the field of pediatrics, which currently awards 16 different subspecialty certificates, two-thirds of pediatricians are not subspecialty trained and yet almost 20% of these pediatricians spend some time in a subspecialty even without formal subspecialty training.2 Furthermore, as specifically stated in the following excerpts from the 2004 ABMS Annual Report and Reference Handbook: There is no requirement or necessity for a diplomat in a recognized specialty to hold a special certification in

subspecialty of that field in order to be considered qualified to include aspects of that subspecialty within a specialty practice. Under no circumstances should a diplomat be considered unqualified to practice within an area of subspecialty solely because of lack of subspecialty certification. Specialty certification in a subspecialty field is of significance for physicians preparing for careers in teaching, research, or practice restricted to that field. Such special certification is recognition of exceptional expertise and experience and has not been created to justify a differential fee schedule or to confer other professional advantages over other diplomats not so certified.1 The ABMS has established and published the formal criteria for subspecialty certification,1 and pediatric urology has achieved or exceeded these criteria. 1. “Documentation of the professional and scientific status of this field includes (a) the existence of a body of scientific medical knowledge which is in large form, or more detailed than, that of other areas in which primary certification is offered.” There were 2 major textbooks in pediatric urology with international authorship published in 2002;3, 4 2 surgical atlases devoted to the field of pediatric urology;5, 6 the only subspecialty in urology with a separate section of The Journal of Urology with its own designated editorial board; the only subspecialty in urology with a separate in-service examination; a designated pediatric urology representative on the American Board of Urology; consecutive representation on the Urology Residency Review Committee for more than the last 15 years; and the only subspecialty in urology with Accreditation Council for Graduate Medical Education (ACGME) accredited fellowship (residency) programs. “(b) The existence of a group of physicians concentrating their practice in the proposed area, the number of such physicians and the annual rate of increase in the past decade, and their geographical distribution at present.” There are approximately 250 full-time pediatric urologists in active practice in the United States. There are approximately 350 urologists with a strong interest in pediatric urology evidenced by active membership in the Society for Pediatric Urology. The geographical distribution is widespread throughout the United States. The annual rate of new trainees in pediatric urology during the last decade has averaged 12 per year. “(c) The existing national societies, the principal interest of which is in the proposed area.” There are currently 4 existing national societies (with overlapping membership) devoted exclusively to education and research in the field of pediatric urology, including the Society for Pediatric Urology (⬃280 active members); American Academy of Pediatrics Section on Urology, (⬃270 active members in the United States and Canada, and 70 foreign affiliates); Society of Fetal Urology (⬃250 members); and American Association of Pediatric Urologists (⬃100 active members). The vast majority of the members of these associations hold academic degrees affiliated with university teaching programs including full, associate and assistant professorships. Several members serve as Chair of Urology Departments or Divisions at major teaching universities/medical schools. “(d) Numerical and geographic distribution of medical school and hospital departments, divisions, or other units in

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which the principal educational effort is devoted to the area proposed for special certification.” Virtually every ACGME approved residency program in urology and every freestanding children’s hospital in the United States has a pediatric urologist. The vast majority of medical school urology programs have a Section or Division of Pediatric Urology with a designated chief or director. Pediatric urology is a required area of specialty training for ACGME approved urology residency programs. 2. “The number and names of institutions providing residency and other acceptable educational programs in the specialty, the total number of positions available, and the number of trainees completing training annually.” Currently there are 17 ACGME approved residency (fellowship) programs in pediatric urology. There is 1 additional residency (fellowship) program in Toronto, Canada that is approved by the Canadian Royal College of Surgeons. Approximately 12 have available positions each year. Of the 17 programs 13 offer a 2-year curriculum (1 year research, 1 year clinical), 3 offer a 3-year curriculum (2 years research, 1 year clinical) and 1 offers a 1-year clinical program. The curriculum for the clinical year must meet the requirements of the ACGME approved curriculum in pediatric urology. Three additional programs are currently seeking ACGME accreditation for a fellowship (residency) in pediatric urology. There appears to be sufficient training programs to accommodate new applicants and to meet the national demand for pediatric urologists. 3. “The cost of the required special training.” The primary costs of the required special training are the annual salary (⬃$50,000 to $55,000) and fringe benefits for the pediatric urology resident (fellow). Additional administrative costs are ⬃$5,000 per year and travel costs to meetings are ⬃$2,000 per year. The costs of the research projects vary significantly from institution to institution and generally are not included in the ACGME accredited clinical year. Research costs are covered by grants in many programs. Since all 17 American fellowship programs are already approved by the ACGME, the CAQ in pediatric urology should not add significant costs to the required special training currently in progress. The costs of examination for a CAQ in pediatric urology after the completion of training would be borne primarily by the applicants. 4. “The needs for and effect of the new certification on the existing patterns of specialty practice including . . . quality of care . . . and costs.” The need for a CAQ in pediatric urology is based on multiple issues. 1) The CAQ would provide parents and pediatricians with a legitimate means to identify

those individuals who have completed additional specialized training in pediatric urology and who have committed their practices to the care of children. 2) It formally recognizes the additional training and commitment to the subspecialty practice of those individuals who successfully qualify for a CAQ. 3) It would allow and/or improve access of parents to pediatric urologists when it has been denied by managed care organizations because of the lack of formal certification in pediatric urology. Regarding the impact on existing practice patterns, a Gallup Poll conducted by the American Urological Association revealed that the vast majority of urologists do not believe that a CAQ in pediatric urology would adversely affect their practice. This finding was also reflected in a review by the ABU of the recertification logs that confirmed that most general urologists do little, if any, pediatric urology. It is anticipated that a CAQ in pediatric urology would lower overall health care costs by streamlining the evaluation of children with urological problems and by optimizing the outcomes of the urological treatment. The approval of CAQ signals an important commitment that the ABU and the Pediatric Urology Coordinating Council made to ensure that pediatric urologists remain a significant component of organized urology and do not splinter from their parent organization as some pediatric surgical subspecialties have done. The proposal from the ABU will require review and approval by the Executive Committee of the ABMS, the Committee on Certification, Subcertification and Recertification, and the 24 parent boards of the ABMS. It is anticipated that the first written examination could be given as early as 2006. H. Gil Rushton Assistant Editor 1. American Board of Medical Specialties 2004 Annual Report and Reference Handbook. Evanston, Illinois: American Board of Medical Specialties, 2004 2. Brotherton, S. E.: Pediatric subspecialty training, certification, and practice: who’s doing what. Pediatrics, 94: 83, 1994 3. Belman, A. B., King, L. R. and Kramer, S. A.: Clinical Pediatric Urology, 4th ed. London: Taylor & Francis Group, 2002 4. Gearhart, G. J., Rink, R. and Moriquand, P. D. E.: Pediatric Urology. Totowa, New Jersey: Humana Press, 2001 5. Frank, J. D., Gearhart, J. P. and Snyder, H. M.: Operative Pediatric Urology. London: Churchill Livingston, 2002 6. Hinman, F., Jr.: Atlas of Pediatric Urology Surgery. Philadelphia: W. B. Saunders Co., 1994