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Serving the public by serving the profession.

This year's "hot topic" in health care, as it was last year and is apt to be in 1990, is quality-how to define it, how to measure it, and how to evaluate it. While the issue of quality in the provision of health care services lies largely unresolved, the pressures to gain a handle on the subject increase inexorably. Providers, payers, regulators, and the public alike are clamoring for workable responses to the cost/quality equation. Although there is no single definition of quality in health care, any more than there is a single definition of quality in any field, certain elements are consistently found in most quality measurement schemes that have been advanced to date. Perhaps the most important element in health care quality is the competence of the professionals who provide care. And because they are still the key actors in the health care melodrama, physicians and their competence must head the list for this element of quality. For nearly three-quarters of a century now, the most commonly accepted indicator of clinical competence within the medical profession has been board certification. Those physicians who are board-certified are viewed as having special competence in a clinical specialty, of representing a higher level of professional quality. According to Donald G. Langsley, MD, the Executive Vice President and Secretary of the Board of the American Board of Medical Specialties, a primary purpose of the certification process is to assure the public of the high quality of the practitioners they select for their care. The policy statement of the ABMS is clear in the subject. "The intent of the certification process ... is to provide assurance to the public that a certified medical specialist has successfully completed an approved educational program and an evaluation, including an examination process designed to assess the knowledge, experience, and skills requisite to the provision of high quality patient care in that specialty." There can be no doubt, if this policy statement is the source of one's definition, that certification is aimed at the public and that it is essentially a quality tool. Because they are asked to make decisions that affect patient care delivery in its more global ramifications, the professional quality of physician executives is no less a concern than that of clinical practitioners. The medical profession will want to assure the public that medical managers who are at critical points in the decision making structure of the health care field have the requisite credentials. As a hospital or other health care organization is anxious to demonstrate the competence of its clinical staff, so will it want assurances that its physician executives meet the highest possible standards of medical management. On January 1 of this year, the American College of Physician Executives created the American Board of Medical Management. This board will undertake the certification activities that had been handled by the American College of Physician Executives. The purpose of the new board, as it is for the other medical specialty boards, will be to establish and enforce standards of practice and techniques for their measurement. That process will begin immediately, but the longer term goal will be to seek formal recognition by the American Board of Medical Specialties. To understand the nature of that goal, it is necessary to understand the workings of the ABMS. A Historical Digression The first specialty board, incorporated in 1917, was what is now called the American Board of Ophthalmology. The second, founded in 1924, was the American Board of Otolaryngology, followed by the American Board of Obstetrics and Gynecology in 1930 and the American Board of Dermatology and Syphilology in 1932. In each case, the Board was established by the professional association for the medical specialty, but the boards were entirely independent. Each had as its purpose to ensure the education and competence of physicians seeking specialty status and to judge the quality of educational programs in the specialty. The American Board of Medical Specialties was founded by the four existing specialty boards, the American Hospital Association, the Association of American Medical Colleges the Federation of State Medical Boards, the American Medical Association Council on Medical Education and Hospitals, and the National Board of Medical Examiners at a meeting in 1933. The original name of the ABMS was the Advisory Board for Medical Specialties, which was changed in 1970. Since 1934, recognition of medical specialty boards has been a joint effort of the ABMS and the AMA. In 1948, these efforts were formalized through the creation of the Liaison Committee for Specialty Boards (LCSB) and the publication of Essentials for Approval of Examining Boards in Medical Specialties. The latter, with revisions that have been made over the years, remains the standard by which recognition is given to specialty boards. By 1948, the number of recognized boards had reached 18 (see table 1 below for all specialty boards and their dates of incorporation.) Then, for the next 20 years, no new boards were approved by the Liaison Committee for Specialty Boards. The ice was broken in 1969 with the approval of the American Board of Family Practice. In 1970, the American Board of Thoracic Surgery became a member board. In that same year, the designation conjoint board" was adopted, and in 1971 the American Board of Allergy and Immunology and the American Board of Nuclear Medicine were formed as conjoint boards. (A conjoint board is jointly sponsored by at least two primary member boards. The conjoint board's members must be approved by the sponsoring boards, and its policies are in conformity with policies jointly established by the sponsoring boards.) The American Board of Emergency Medicine became a conjoint board (modified) in 1979, the last time there was an addition to the membership of the ABMS. (A conjoint board, modified, is established under the sponsorship of five or more primary boards. Some of its members are nominated by the sponsors, and its policies are subject to review and comment by the sponsors, with final responsibility resting with the conjoint board, modified.) During the 1940s, provision was made for subsidiary boards of the ABMS. In subsequent years, these subspecialty boards increased greatly in number. At present, the 23 member boards of the ABMS provide certificates in 31 areas of general speciablization and certificates of special or added qualifications in 51 areas. The specialization and subspecialization breakdowns are shown in table 2, page 6. The American Board of Medical Specialties staff is headed by Donald G. Langsley, MD, a board certified psychiatrist and long-time medical educator. Dr. Langsley says that his interest in the ABMS stems partly from his lifelong interest in medical education. "The job of the ABMS," he says, "is primarily one of evaluation of medical qualifications. We work with both academicians and practitioners in establishing standards and in monitoring the certification process, but it is the degree to which medical education has been absorbed that is at issue on the certification process." by the American College of Physician Executives. The purpose of the new board, as it is for the other medical specialty boards, will be to establish and enforce standards of practice and techniques for their measurement. That process will begin immediately, but the longer term goal will be to seek formal recognition by the American Board of Medical Specialties. To understand the nature of that goal, it is necessary to understand the workings of the ABMS. A Historical Digression The first specialty board, incorporated in

ca the American Board of Ophthalmology. The second, founded in 1924, was the American Board of Otolaryngology, followed by the American Board of Obstetrics and Gynecology in 1930 and the American Board of Dermatology and Syphilology in 1932. In each case, the Board was established by the professional association for the medical specialty, but the boards were entirely independent. Each had as its purpose to ensure the education and competence of physicians seeing specialty status and to judge the quality of educational programs in the specialty. The American Board of Medical Specialties was founded by the four existing specialty boards, the American Hospital Association, the Association of American Medical Colleges the Federation of State Medical Boards, the American Medical Association Council on Medical Education and Hospitals, and the National Board of Medical Examiners at a meeting in 1933. The original name of the ABMS was the Advisory Board for Medical Specialties, which was changed in 1970. Since 1934, recognition of medical speciality boards has been a joint effort of the ABMS and the AMA. In 1948, these efforts were formalized through the creation of the Liaison Committee for Specialty Boards (LCSB) and the publication of Essentials for Approval of Examining Boards in Medical Specialties. The latter, with revisions that have been made over the years, remains the standard by which recognition is given to specialty boards. By 1948, the number of recognized boards had reached 18 (see table 1 below for all specialty boards and their dates of incorporation.) Then, for the next 20 years, no new boards were approved by the Liaison Committee for Specialty Boards. The ice was broken in 1969 with the approval of the American Board of Family Practice. In 1970, the American Board of Thoracic Surgery became a member board. In that same year, the designation conjoint board" was adopted, and in 1971 the American Board of Allergy and Immunology and the American Board of Nuclear Medicine were formed as conjoint boards. (A conjoint board is jointly sponsored by at least two primary member boards. The conjoint board's members must be approved by the sponsoring boards, and its policies are in conformity with policies jointly established by the sponsoring boards.) The American Board of Emergency Medicine became a conjoint board (modified) in 1979, the last time there was an addition to the membership of the ABMS. (A conjoint board, modified, is established under the sponsorship of five or more primary boards. Some of its members are nominated by the sponsors, and its policies are subject to review and comment by the sponsors, with final responsibilty resting with the conjoint board, modified.) During the 1940s, provision was made for subsidiary boards of the ABMS. In subsequent years, these subspecialty boards increased greatly in number. At present, the 23 member boards of the ABMS provide certificates in 31 areas of general specialization and certificates of special or added qualifications in 51 areas. The specialization and subspecialization breakdowns are shown in table 2, page 6. The American Board of Medical Specialties staff is headed by Donald G. Langsley, MD, a boardcertified psychiatrist and long-time medical educator. Dr. Langsley says that his interest in the ABMS stems partly from his lifelong interest in medical education. "The job of the ABMS," he says, "is primarily one of evaluation of medical qualifications. We work with both academicians and practitioners in establishing standards and in monitoring the certification process, but it is the degree to which medical education has been absorbed that is at issue on the certification process." Of course, the ABMS, as the "umbrella organization" for examining boards, also is a policy-setting organization. Dr. Langsley says that he and the ABMS staff work closely with the staffs of the member boards and with the voting representatives of those boards" in the setting of certifying policy. "The only real power that the ABMS has is to approve new types of certification, to approve the admission of new boards, and to approve new types of recertification. The boards set their own standards and their own training requirements, and they report some of that information to the ABMS. The policy of the boards is a matter of public discussion, but it is not a matter of authorization from the ABMS for board actions. The ABMS is not the master of the boards. In a very real sense, it is their servant." The ABMS also serves its member boards by providing a forum for discussion on issues of certification and by representing the boards in national, public forums. Dr. Langsley spends a good deal of his time in meetings with other organizations-the American Medical Association, the American Hospital Association, the Association of American Medical Colleges, the National Board of Medical Examiners, for instance, all of which are associate members of the ABMS. It also conducts educational meetings on the certification process and publishes the directories of specialists. In general, it represents the interests of its member boards. The ABMS is also actively involved in research, some on its own and some in collaboration with other groups. "We are involved in service to the boards in any ways that will make their functions easier and more useful. We are a member organization, and our members are the individual boards,"Dr.Langsley says. "In a sense, our constituency is the 370,000 medical specialists in the country, but we don't deal with them directly, except to obtain the information that goes in our directories of specialists." About 64 percent of all licensed physicians are board-certified in a specialty. (This comparcs with the nearly 90 percent of College members who are boardcertified in such specialties.) Dr. Langsley and the ABMS distinguish sharply between certification and licensure. "Licensure establishes standards very different from those of certification. Licensure is the standard established by government to try to ensure that a physician is relatively safe. Board certification involves a much higher level of confidencea level of excellence or consulting competence. We avoid ties between certification and licensure." Another reason for the separation of licensure and certification is to avoid licensure by specialty, which Dr. Langsley calls a potential "tragedy for the health care system." Because the ABMS is very much interested in the quality of specialist practitioners its research is quality- oriented. Dr. Langsley says that most of the ABMS's research projects are centered specifically on the certification process. It wants to know if certification makes a difference in the quality of care provided by physicians. He says that there is "some evidence of a connection. Several studies have shown that certified practitioners practice better medicine. For instance, board-certified surgeons have been shown to have lower rates of infection and lower morbidity and mortality rates than noncertified surgeons. There are studies that show that emergency physicians do better than their noncertified colleagues. A study shows that the peer ratings of certified internists are higher than those for noncertified internists." Another reason for looking at physician performance, Dr. Langsley says, is for recertification. "Boards are entering into an era of mandatory recertification. In the beginnings of board certification, there was encouragement of voluntary recertification. But that hasn't been effective. There isn't enough push behind it. Fifteen boards now have a requirement for time-limited certification. There is a date on the certificate. After that date, the physician is no longer board-certified unless there is recertification. Dr. Langsley says that there are still some problems to be solved in the recertification process. "Certification tests the knowledge and skills of a person who has finished a residency. It is essentially an evaluation of how well the person learned. Recertification is nowhere near that simple. Practitioners may and frequently do limit their practices even within subspecialties. Recertification has to get a handle on that narrow focus, not on how much they know about the overall specialty. In this regard, recertification may be viewed as a matter of performance assessment." To accommodate that practice diversity, far more variety in tests is required. But Dr. Langsley says that "we're in the early stages of developing tests that accurately gauge a practitioner's performance in a clinical specialty." The American Board of Family Practice has required recertification since its formation, according to Dr. Langsley. The board recertifies every seven years. The recertification test it administers is modular. Everyone takes a general section within the basic specialty. Then the practitioner seeking recertification must choose two other modules that represent areas in which he or she subspecializes. "The trick in recertification," Dr. Langsley says, "is to measure both knowledge and level of practice." So, he says, the American Board of Family Practice tests not only for level of educational depth but also for the range of competence in practice. It seeks a performance evaluation in its recertification. "After physicians pass the test," Dr. Langsley says, "they are recertified in their specialties. But they are not certified specifically in the modules that they chose to be tested in." The board continues to offer only the general and special certificates that are shown in table 2, he says. Dr. Langsley says that other special certificates may be added by this and other boards, but the demand could become limitedness. He believes that the boards win be more inclined to acknowledge increased specialization through increased use of the modular approach to certification examinations. Some states have moved to mandatory recertification, and New York requires periodic relicensure. The physician can be relicensed on the basis of recertification with a specialty board, although there are a couple of other avenues-a knowledge examination and a review of actual practice. The ABMS played an advisory role in the development of the New York system, Dr. Langsley says. The same kind of approaches are being considered elsewhere-Michigan, Massachusetts, California, and Pennsylvania, for instance. Dr. Langsley expects the trend to pick up speed. "There will be more states entering the fray. I predict that physicians will in the future be reviewed periodically for competence for both licensure and certification." Dr. Langsley makes it dear that the ABMS and its member boards have no special interest in standards of day- to-day practice. They are interested in standards for potential practice." They may become interested in medical practice as a matter of recertification, but the specialty societies, because of their focus on the medical specialty professions, are more likely to be interested in standards at the practice level. "Managed care organizations already call for this kind of standardization," Dr. Langsley says. "The relative value scale systems that have been proposed also support such standardization. When health care providers began to look at third parties for payment, those parties wanted to know what they were paying for. They wanted to have a say in the structure and operation of the health care system. There is an increasing demand from payers for national standards of necessity and efficacy in the provision of health care services. In spite of its interest in standards and in measurement of the quality of care, the ABMS has no lobbying role and does not envision one. It provides information to legislatures and other governmental agencies. But it isn't in the business of influencing legislation, Dr. Langsley says. "That is the business of the specialty societies. There is a distance between the certifying organizations and the professional societies because the ABMS and the boards are involved in the setting of standards that govern the professions. The societies represent the profession. The ABMS and the certifying boards represent the public. That might seem simplistic, but it isn't. That is how the boards and the ABMS see themselves." So where does this leave the medical management profession? The American Board of Medical Management seems a strange duck. Where does it fit in the certification process? What is the process by which a board receives recognition? "Starting a board is no problem," Dr. Langsley says. We could start a board of medical journalism this afternoon. With or without an examination. With or without any requirements. We could provide the certificates this afternoon. I have a list of 102 such self-designated boards. A small number of those boards are high quality, in that they have high standards and requirements and a very defensible evaluative system. But some of those boards will waive an examination, win waive the requirements for training. The only thing they won't waive is the fee. Those boards are not part of the establishment. In the beginning, the ABMS and the AMA formed what is called the Liaison Committee for Specialty Boards (LCSB). The purpose of the LCSB has always been to ensure that certification boards meet exacting standards. It has representatives from the AMA and the ABMS. It looks at proposed new boards and determines whether they should be granted official status for the certification of a specialty. An application for board recognition goes to the LCSB, which meets once a year and reviews these applications. The LCSB has a set of written standards for this determination. Those standards and their ammendment have to be approved by the legislature of ABMS and by the House of Delegates of the AMA. The standards are now in their 10th revision. The current version has been used for three years. If the specialty is truly new, is a new field of science, not just a new technique that cannot be included in an existing specialty, it could be approved. But it must be a national specialty and have a reasonable plan for educational requirements and for evaluation of candidates. So far, the recommendation of the LCSB has always been approved by AMA and ABMS. What are the chances for the American Board of Medical Management? Dr. Langsley doesn't have a vote, and no application has been received by the ABMS, he says. "There will need to be a demonstration of a body of knowledge, perhaps even science, in medical management. Where there may be some discussion is in educational requirements. There is no residency requirement for medical management. He believes that a key to the ultimate success of the ABMM will be the establishment of an educational base. So where does this leave the medical management profession in it quest for legitimacy? Will the ABMM remain just one of the 102 boards on the outside looking in? There clearly are no guarantees. The ABMS and the AMA have devised an exacting process that ensures that only the best survive-and reach membership status in the ABMS. Preparatory to the creation of the ABMM, the American College of Physician Executives, then the American Academy of Medical Directors, took many steps that place the ABMM in a good position to achieve recognition. A certifying examination has been tested four times. Formal educational programs are springing up around the country, and Academy courses are receiving attention from academia. Within the next few months, the ABMM will file its application for membership in the ABMS. As Dr. Langsley says, the goal of the ABMS is to ensure that a proposed medical specialty is a unique area of medical science and that the sponsoring board has designed and implemented testing and evaluative systems to ensure that physicians granted board certification meet exacting professional standards. There is no rush to judgment, so the process can be expected to take time. The last board to be approved for membership, the American Board of Emergency Medicine, was approved in 1979, after being incorporated in 1976. The ABMM can expect a similar examination in its drive for recognition.
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Title Annotation:American Board of Medical Specialties
Author:Curry, Wesley
Publication:Physician Executive
Article Type:Interview
Date:Mar 1, 1989
Words:3812
Next Article:The physician executive and professional grief.
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