While the debate continues over whether it is in the best interest of medicine for specialties to develop their own self-appointed boards, recent developments indicate that a growing number of them are nevertheless choosing to do so, hoping to gain recognition for their highly specialized skills and enhance their specialty’s ability to meet the growing needs of the medical consumer.
Supporters of this trend argue that certifying subspecialty boards are integral to their particular, dynamic subspecialty and that they are the inevitable result of an expanding knowledge base, technological advancements and biomedical developments. They firmly believe that such boards provide them with a mechanism for recognition, as well as give third-party payers a means to identify those physicians with reimbursable expertise.
Those opposed to subspecialty boards disagree. They argue that such boards will result in the fragmentation of too many medical disciplines and may actually limit a patient’s access to care. They fear that certified subspecialty boards will negate the role of the generalist and, in turn, place those who choose not to subspecialize at an unfair market advantage.
Following are some highlights from a recent interview conducted with Peter A. Adamson, MD, President of the American Board of Facial Plastic and Reconstructive Surgery (ABFPRS). The ABFPRS is an example of a medical specialty that reluctantly, but for compelling reasons, chose to establish its own specialty certifying board to provide its colleagues and the public with a recognizable landmark for identifying surgeons with particular training and experience in facial plastic surgery.
Q: What do you view as the driving force behind subspecialty boards?
A: Subspecialty boards are a natural outgrowth of rapidly expanding medical technology and knowledge. To deliver the benefits of new medical technology and knowledge to patients, doctors often find they must focus their practices in narrower, deeper areas of their primary training. Although their primary training is certified by member boards of the American Board of Medical Specialties (ABMS), doctors who further focus their training and practice often desire to undergo examinations to verify their additional training and experience. They understandably reason that subcertification will enable patients to identify more readily the subspecialists who frequently perform the procedures patients want and need, with good result.
For example, otolaryngologists, whose residencies include as much or more training than do plastic surgery residencies in facial plastic surgery, for years had difficulty explaining to patients and colleagues the true nature of that training. Language often compounded the problem, since older certifying boards have Greek names and younger boards have English names. Surveys have shown that patients have no idea what a certificant of the American Board of Otolaryngology actually does, and the ABMS has prevented the certification board from adding “Head-and-Neck Surgery” to its name.
Emerging specialties typically take some years to become ABMS members. They grow up, meanwhile, outside the ABMS. They may be perfectly legitimate boards, but for a variety of reasons, they are not initially welcome under the ABMS umbrella. They may not fit the ABMS technical definition of a subspecialty. They may be opposed by some in the parent specialty board who fear the splintering of the medical specialty. Or, an incumbent ABMS board may feel its “turf ” is threatened.
All of these factors, at one time or another, stalled the development of an ABMS pathway for subcertification of otolaryngology-trained facial plastic surgeons. In response, these surgeons established their own subspecialty board, the American Board of Facial Plastic and Reconstructive Surgery.
Since the ABFPRS’s establishment in 1986, the board has earnnned universal recognition as a board equivalent to the ABMS primary boards. Although this action has prompted the ABMS into trying to develop an alternative subcertification pathway, the ABFPRS continues to be the only board that certifies surgeons exclusively in facial plastic and reconstructive surgery. Although outside the ABMS fold, the ABFPRS has become, de facto, the con joint board for the two primary ABMS specialties that have long competed for the same “medical turf ” — plastic surgery and otolaryngology.
Q: Who wants subspecialty boards and why?
A: This question might better be phrased, “Who doesn’t want subspecialty boards and why?” After all, what could possibly be objectionable about subspecialty boards, if they give patients an easier way to identify doctors who perform procedures they need, and give third-party payers a means of more readily recognizing reimbursable expertise?
Those who don’t want subspecialty boards include some within the ABMS. Although the ABMS has carried out its task of defining specialties, facial plastic surgery’s experience has suggested that ABMS’s policies may not have kept up with the rapid growth of emerging specialties.
Because the strong forces driving subspecialization continue whether the ABMS chooses to recognize them or not, many physicians practicing non-ABMS subspecialties, like facial plastic surgeons, have been forced to establish their own boards. The ABMS disapproves of these competing boards, but we should remember that many ABMS boards began their life as “self-designated” boards, including the otolaryngology board (which was formed before there was an ABMS) and the plastic surgery board (which was formed in 1937, but did not earn approval until 1941).
In the case of otolaryngology, all the specialty societies have actively supported subspecialization for the reasons I have stated above. Fragmentation has not been a real problem.
Q: What do you see as the competitive effects of subspecialty boards in the medical community?
A: If science develops the technology for a new specialty or subspecialty, it will happen and any “competitive effects” will be inevitable. We ought to be about providing useful, truthful information to patients about such specialties in terms they can understand. If consumers gain such information about subspecialization, they will cast their economic ballots in the marketplace more efficiently. Who could legitimately be opposed to that?
Q: What does the growth of “self-designated” boards mean at the state level and on hospital credentialing?
A: Because the ABMS has not dealt effectively with legitimate new boards in some emerging specialties like facial plastic surgery and pain medicine, state medical regulators have been forced to adopt regulations to determine which are “legitimate” or “equivalent” to ABMS boards.
The ABFPRS has been found equivalent to primary boards of the ABMS in every state that has reviewed it for such equivalence.
Hospitals, like many other medical institutions, will also have to recognize those specialties. If the ABMS lags behind or is held back by the politics of its incumbent boards, hospitals will have to make their decisions without ABMS definition. Science will move on with or without the ABMS.
Legitimate boards, whether in or out of the ABMS, are easily recognizable. All require accredited residencies and a rigorous psychometrically validated examination. Hospital staffs should have no problem recognizing legitimate boards.
For more information on the ABFPRS’s journey toward subspecialization, please contact:
Peter A. Adaammson, MD
President, American Board of Facial
Plastic and Reconstructive Surgery
One Prince Street, Suite 310
Alexandria, Virginia 22314
Phone: (703) 549-3223
Fax: (703) 549-3357