During the last twenty years, an increasing number of orthopaedic surgeons
have chosen to subspecialize. As such, there has been an increased interest in
subspecialty certification.
In 1990, 44% of orthopaedic surgeons viewed themselves as general
orthopaedists and 21%, as specialists. Currently, those numbers are largely
reversed, with 31% who consider themselves general orthopaedists and 35% who
view themselves as specialists (Fig.
1).
The average age of orthopaedic subspecialists is forty-nine years, and the
average age of general orthopaedic surgeons is fifty-four years
(Fig. 2).
Therein, the anticipated trend is that, with time, an even higher
percentage of orthopaedic surgeons will be subspecialists, and the number
practicing general orthopaedic surgery will shrink to the point at which
general orthopaedic surgeons will be a dramatically smaller percentage of the
specialty than those who either exclusively practice a subspecialty or have a
strong interest in a subspecialty.
There are advantages and disadvantages to subspecialty certification. The
process of accomplishing acceptance of the subspecialty certification by the
American Board of Orthopaedic Surgery (ABOS) and the American Board of Medical
Specialties (ABMS) is a long, time-consuming one, as documented by the
certification processes for hand surgery and sports medicine. The preparation
of the examination is very time-consuming and expensive.
The main purpose of subspecialty certification is to establish a body of
knowledge within that field and, ultimately, to improve the quality of
medicine being practiced within that subspecialty.
The concerns about subspecialty certification include the time and effort
involved with the process, both by those who lead the process to accomplish
subspecialty certification and by those who take the examination. Most
orthopaedic surgeons do not want to take more examinations. Furthermore,
subspecialty certification can be perceived as a threat to those who have not
finished an accredited fellowship and who do not practice that particular
subspecialty in a substantial quantity. Hand subspecialty certification has
existed for many years now. Sports-medicine certification has just arrived,
and the first examination is about to be administered. Spine-spinal deformity
subspecialty certification is currently being investigated and is in its early
stages. Accomplishing agreement across societies and disciplines outside
orthopaedic surgery is also an obstacle.
The purpose of this article is to provide an informative review. However,
we are not able to provide answers with regard to the overall effect of
subspecialty certification on the whole of practicing orthopaedic
surgeons.
Hand surgery emerged during World War II, when it was recognized that
reconstruction of traumatic injuries to the hand and upper extremity required
a specific body of knowledge that crossed several disciplines, including
orthopaedic, general, and plastic
surgery1. This was a
time when surgical specialization was in its infancy with the establishment of
the ABOS in 1934, the American Board of Surgery (ABS) in 1937, and the
American Board of Plastic Surgery (ABPS) in 1941. To meet the educational and
scientific needs of these three specialties, the American Society for Surgery
of the Hand (ASSH) emerged in 1946. The ASSH developed a well-organized
program of continuing medical education and later was to become the major
promoter of hand surgery as a distinct subspecialty.
Justification for Subspecialty Certification in Hand Surgery
Omer2 noted that
a medical subspecialty is an identifiable area within a recognized specialty
to which a physician devotes considerable time and study.
Smith3, in a guest
editorial in the Journal of Hand Surgery, pointed out that, by the
1970s, there were certain crucial elements that allowed consideration of the
development of subspecialty certification in hand surgery.
1. Prevalence of Upper Extremity Disorders
In 1980, Kelsey et
al.4, in an
epidemiologic survey using data from the United States National Health Survey
of the National Center for Health Statistics, noted that the annual number of
upper-extremity injuries that were of sufficient severity to lead to
restriction of activity or a visit to a physician was sixteen million. The
total annual cost of upper-extremity injuries, including medical expenses,
lost earnings, and indirect costs of injury, was in excess of ten billion
dollars. Furthermore, in the mid-1970s, there were nearly twenty-five million
people with arthritis, the second most common medical condition for which
worker disability allowance was granted. Finally, in 1976, 3.2 million people
in the United States reported an upper-extremity impairment.
2. Fragmentation of the Parent Boards (Orthopaedic, Plastic, and
General Surgery) by Subspecialty Certification
As subspecialty certification in hand surgery evolved, it was never the
intent of its advocates to create an independent board. The three primary
boards from which subspecialty certification is granted are all members of the
ABMS, the umbrella organization for the twenty-four federally recognized
certifying boards. To qualify to sit for the subspecialty certification
examination, one must hold a valid certificate from his or her primary
board.
3. A Distinct Body of Knowledge
Hand surgery is not a discipline of special interests or skills; rather, it
is a distinct body of knowledge that is required to handle a major medical
need. While the three parent boards require knowledge in hand surgery to
receive primary certification, subspecialty certification in hand surgery
encompasses an in-depth and discrete body of knowledge with elements
contributed by all three disciplines.
4. Exclusivity and/or Better Care
There was concern that pressure from the academic or legal community could
result in a situation in which certificate holders would be the only
physicians permitted to practice hand surgery and, by implication, such
surgeons would be thought to render better patient care for hand disorders. In
reality, diplomates of all three primary boards are deemed qualified and
competent to practice hand surgery. Furthermore, the volume of hand disorders
is so great that a small group of physicians would be able to care for only a
fraction of the problems. One intent of subspecialty certification is to
inform the public and medical colleagues that a certificate holder has met
board standards and is qualified to manage complex problems of the hand and
upper extremity. Restraint of trade should not and is not the stimulus for
hand surgery subspecialty certification.
5. De Facto Certification
One might argue that membership in the ASSH or the American Association of
Hand Surgery is enough to demonstrate one's qualifications to practice hand
surgery. In reality, medical societies and boards serve different purposes.
Medical societies are educational and advocacy associations, while medical
boards set requirements and standards for certification. Boards serve the
public to ensure competence in a specific discipline.
History of Subspecialty Certification in Hand Surgery
The development of subspecialty certification was a long and convoluted
process that began in 1971 with a dialogue between the ASSH and the
ABMS1. In 1973, the
bylaws of the ABMS were revised to permit subspecialty certification. In 1974,
the ASSH contacted the three parent boards; however, these boards declined to
lend their support to subspecialty certification. Finally, in 1979, at a joint
meeting of the ABMS, the three surgical boards, and the ASSH, it was agreed
that recognition of hand surgery was desirable, but the mechanism was yet to
be determined. The ABMS bylaws defined a Certificate of Special Qualifications
as reflecting the possession of knowledge, skill, and training in a special
field over and above that required for general certification. By 1981, the
three boards not only endorsed the certificate but agreed that the certificate
holder must receive a year of additional specialty training and successfully
pass an examination. In 1984, the Joint Committee for Surgery of the Hand was
formed with representation from the three boards. Its charge was to develop,
administer, and score examinations for subspecialty certification. The second
part of the equation was to establish fellowship requirements for hand
surgery. This was done with the approval of the Accreditation Council for
Graduate Medical Education (ACGME) in conjunction with the Residency Review
Committees of orthopaedic, plastic, and general surgery. The requirements were
identical for each of the three boards.
In 1986, a joint application for subspecialty certification was filed with
the ABMS and was unanimously approved. The ABMS staff complimented the three
boards on their cooperative effort and noted that it should be a model for
future programs.
Highlights of the Requirement for Subspecialty Certification in Hand
Surgery
Candidates must:
Be a diplomate of his or her primary board: orthopaedic surgery, plastic
surgery, or surgery.Have a currently registered, full, and unrestricted license and full and
unrestricted privileges at his or her hospital.Have an ethical standing in the profession and moral status in the
community acceptable to the primary board.Be actively engaged in the practice of hand surgery as indicated by holding
full operating privileges in a hospital or surgery center approved by the
Joint Commission on Accreditation of Healthcare Organizations.Submit a consecutive list of hand surgery cases from a one-year period
within two years of the application. The case list must include a minimum of
125 cases from six of nine categories.
Be a diplomate of his or her primary board: orthopaedic surgery, plastic
surgery, or surgery.
Have a currently registered, full, and unrestricted license and full and
unrestricted privileges at his or her hospital.
Have an ethical standing in the profession and moral status in the
community acceptable to the primary board.
Be actively engaged in the practice of hand surgery as indicated by holding
full operating privileges in a hospital or surgery center approved by the
Joint Commission on Accreditation of Healthcare Organizations.
Submit a consecutive list of hand surgery cases from a one-year period
within two years of the application. The case list must include a minimum of
125 cases from six of nine categories.
From 1989 until July 1994, there were no fellowship requirements to sit for
the examination. This was the so-called "grandfather" period.
Surgeons actively engaged in the practice of hand surgery who had not
necessarily completed a one-year hand-surgery fellowship but met other
requirements, such as peer review and case volume, were permitted to sit for
the examination. Effective in July 1994, candidates were required to take a
one-year fellowship in hand surgery, and, effective in July 1999, candidates
had to satisfactorily complete a one-year ACGME-accredited hand-surgery
fellowship. It should be noted that the linkage of accreditation and
certification has always been an ABMS
tradition5.
In 1989, the first subspecialty examination for hand surgery was
administered as a ten-year time-limited
certificate5. It was
given to 510 candidates, with 81% holding ABOS certificates and 19% holding
ABS certificates (the ABPS did not participate until the following year). The
overall failure rate was 7.6%. As of 2004, 2601 individuals had taken the
certifying examination, with an overall failure rate of 14.6%
(Table I). It is of note that
the ABOS candidate failure rate is 3.1%.
Success on the examination correlates with one's primary board (orthopaedic
surgery), case volume (>300 hand cases per year), and devoting more than
75% of one's practice to hand surgery. If one meets these three criteria,
passage is almost a given.
Recertification
With the subspecialty certificate in hand surgery being time-limited,
recertification was first offered in 1996. The requirements for
recertification include evidence of continuing medical education, peer review
and/or licensure, and successful passage of an examination. The examination
component can be accomplished by either a computer-administered examination or
an oral examination based on cases selected from the applicant's practice.
Since 1996, 980 surgeons have recertified and 916 have met with success, for
an overall failure rate of 6.5% (Table
II). For the diplomates of the ABOS, 623 have recertified with a
3.4% failure rate.
Beginning in 2004, board-certified orthopaedic surgeons who held a hand
subspecialty certificate and chose to recertify in both orthopaedic surgery
and hand surgery by the computer-based pathway were required to take an
examination consisting of 160 hand subspecialty certification questions and
eighty general orthopaedic questions. Interestingly, the percentage of
questions that were correctly answered for both the hand and general
orthopaedic sections was nearly identical.
Subspecialty Certification and the ASSH
Shortly after the hand subspecialty examination was initiated, the ASSH
amended its bylaws to require individuals applying for active membership to
possess a subspecialty certificate in hand surgery. Some hand surgeons believe
that this amendment leveled the playing field for ASSH membership. No longer
is membership in the ASSH a privilege. If a surgeon meets the requirements to
sit for the subspecialty examination and passes, ASSH membership is quite
likely.
The Future
Under the auspices of the ABMS, recertification for the twenty-four ABMS
boards is moving toward a process called Maintenance of Certification. With
the rapid changes in medical care coupled with demands from the government,
industry, and the public for quality care, physicians must demonstrate
continuously that they are proficient in their specialty. As mandated by the
ABMS, physicians who elect to maintain certification must:
Undergo a review of their professional standing (credentialing and
licensure).Participate in continuing medical education.Pass a recertification examination.Have their performance in practice assessed. The assessment methodology is
evolving and will probably include patient communication and satisfaction
surveys, peer review, and a case list.
Undergo a review of their professional standing (credentialing and
licensure).
Participate in continuing medical education.
Pass a recertification examination.
Have their performance in practice assessed. The assessment methodology is
evolving and will probably include patient communication and satisfaction
surveys, peer review, and a case list.
In conclusion, it is the author's opinion that most hand surgeons believe
subspecialty certification in hand surgery has benefited our specialty and the
public. Holding such a certificate does not, and was never intended to, bestow
special privileges related to the practice of hand surgery. Furthermore, it
does not translate into better patient care. Rather, it allows the public and
our professional colleagues to know that the certificate holder has met board
standards and is qualified to manage problems related to the hand and upper
extremity.
This section describes the story of subspecialty certification in sports
medicine as it has unfolded over the last seventeen years.
Background
Subspecialty certification (formerly a Certificate of Added Qualification
or CAQ) was established by the ABMS to recognize new medical science and
practice patterns that evolve over time in the various
specialties6.
Orthopaedics is one of the twenty-four member boards in the ABMS. The main
purpose of all member boards 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...."6
Currently, there are ninety subspecialty certificates (with a range of two to
seventeen per specialty) offered by the various boards. Of the nine surgical
boards, five offer subspecialty certificates (with a range of two to five
certificates per board). Orthopaedics now has two subspecialty certificates in
hand and sports medicine.
Why?
For each subspecialty, there are different issues and reasons to pursue or
not to pursue subspecialty certification. The process is not easy, it is
time-consuming (seventeen years for the Certificate of Added Qualification in
Surgery of the Hand), and it is potentially very costly. Therefore, the
decision to proceed must be carefully and clearly defined. For orthopaedic
sports medicine, this process started in 1988. After extensive discussions,
meetings, surveys, and debates (see history section below), it was agreed on
by the leadership that sports medicine has a unique body of knowledge and an
area of practice worthy of subspecialty status. It was also thought that this
body of knowledge was becoming more complex, distinct, and difficult to obtain
in a five-year general orthopaedic residency. This position is further
supported by data on subspecialty selection by graduating orthopaedic surgery
residents. Over the last several years, approximately one-third of residents
(approximately 200 per year) have pursued a sports-medicine fellowship. The
reason for this is probably multifactorial, including scientific interests,
personal interests, or economics. Finally, it was thought, given the large
number of programs (currently ninety-five) and fellows graduating per year
(203 in 2004), that "raising the bar" and unifying the educational
experience were important. Currently, sixty-three of the ninety-five programs
are accredited by the ACGME (in 2004, fifty-five were accredited).
History
In 1988, an ad hoc committee chaired by John Bergfeld, MD, was formed by
the American Orthopaedic Society for Sports Medicine (AOSSM) to begin the
process. The initial application was drafted in 1989. Concurrently, the
Orthopaedic Sports Medicine Member and Fellowship Curriculum (which defined
the "body of knowledge") was being
formulated7. During
the ensuing thirteen years, there were ongoing discussions between the
American Academy of Orthopaedic Surgeons (AAOS) and the AOSSM. The AAOS
position during this time was in opposition to subspecialty certification. In
1992, the ABMS awarded certification status for primary-care sports medicine
to four member boards (Family Practice, Pediatrics, Internal Medicine, and
Emergency Medicine). Subsequently in 1994, the AOSSM submitted its first draft
of the application to the ABOS for review. The ABOS made significant
recommendations on the initial application, which spurred a whole new
reevaluation by the AOSSM. In 1996, John Bergfeld stepped down as Chair of the
ad hoc committee and I (C.D.H.) was appointed. Major modifications in the
application were made, and ongoing discussions with leaders and members of
AOSSM were conducted. These included publications, debates, and a survey in
1999 of 555 AOSSM members (42% responded) and 612 nonmembers (57%
responded)8. From
this survey, it was determined that:
The majority of those who participated favored subspecialty
certification.When the data were adjusted for age, a substantial majority of younger
members favored certification.The main reason for supporting certification was to establish a universal
higher standard of training.The main reason for opposition is the "burden" of
certifying.
The majority of those who participated favored subspecialty
certification.
When the data were adjusted for age, a substantial majority of younger
members favored certification.
The main reason for supporting certification was to establish a universal
higher standard of training.
The main reason for opposition is the "burden" of
certifying.
Clearly, the majority who took the survey (members and nonmembers) believed
that there was a unique body of knowledge and area of practice
(Fig. 3) and would pursue
certification if it was offered (Fig.
4)9.
In October 2000, the AOSSM Board voted to submit the new application to the
ABOS. In September 2001, the ABOS voted to forward this new application to the
ABMS with only minor modifications. In the spring of 2002, the ABMS returned
the application with minor modifications. Finally, in March 2003, the ABMS
voted unanimously to approve Subspecialty Certification in Orthopaedic Sports
Medicine.
Where Are We?
The examination is now being constructed by the ABOS. This process will be
directly supervised and monitored by the National Board of Medical Examiners
(NBME), which also administers the United States Medical Licensing Examination
(USMLE) Steps 1, 2, and 3 and the Orthopaedic Surgery Part-I certification
examination. The examination (approximately 200 multiplechoice questions) will
be based on the Fellowship
Curriculum7. The
questions will be written at a content level that a graduating fellow is
expected to know. There will be a substantial percentage of questions in the
areas of evaluation and nonoperative management. Since sports medicine is a
cross-disciplinary subspecialty with overlapping knowledge in other
specialties and subspecialties, the examination will include a considerable
number of questions in these areas. The content breakdown (and approximate
percentages) is as follows:
General principles (research methodology, study design, statistics, ethics,
and professionalism) 5%Medical aspects of sports20%Musculoskeletal system 75% Upper extremity 30% Lower extremity 40% Spine
5%
General principles (research methodology, study design, statistics, ethics,
and professionalism) 5%
Medical aspects of sports20%
Musculoskeletal system 75% Upper extremity 30% Lower extremity 40% Spine
5%
The timeline for the examination has been outlined by the ABOS and NBME.
The initial Question Writing Task Force was chosen by the ABOS in the summer
of 2004 and consists of sixteen experienced individuals from academic and
private practice programs. In February 2005, the Question Writing Task Force
wrote and approved 400 questions for the next phase. Over the next two years,
the examination will go through numerous different task forces and committees
so that it will be developed into a high-quality, reproducible (precise and
reliable), and accurate (valid) examination. It is being carefully constructed
so that it will reflect the "body of knowledge" of the
subspecialty. The estimated date for the first test will be in the fall of
2007.
Recently, the ABOS approved the requirements for sitting for the
examination. This includes educational requirements (continuing medical
education), license requirements (state), board certification, and practice
requirements. Within the practice requirements, examinees will have to have
performed 115 sports-medicine-related surgical cases and ten nonoperative
cases and document that they have a practice in orthopaedic sports medicine.
For the first five years after initiation of the examination, all those who
meet the basic requirements will be eligible to take the examination.
Beginning in the sixth year (2012), examinees will have to graduate from an
ACGME-accredited fellowship program.
Conclusions
Subspecialty certification is a by-product of expanding medical knowledge.
It is not easy to achieve, and each subspecialty must decide whether it is
worth the effort. For orthopaedic sports medicine, the reasons for pursuing or
not pursuing it were carefully debated before proceeding with the process. In
the end, it was decided that orthopaedic sports medicine did encompass a
unique body of knowledge and area of practice that could not be achieved in a
five-year general orthopaedic residency. Finally, it was thought that
subspecialty certification for sports medicine would achieve the
following:
Raise the educational "bar" for sports-medicine fellowship
programs.Achieve a common high standard of education for fellows.Provide for the long-term growth and health of the subspecialty.Serve as an educational standard and not a practice standard.
Raise the educational "bar" for sports-medicine fellowship
programs.
Achieve a common high standard of education for fellows.
Provide for the long-term growth and health of the subspecialty.
Serve as an educational standard and not a practice standard.
It is important to note that, at this time, subspecialty certification is
not a requirement to become a member of the AOSSM (unlike the Hand Society).
See the requirements at
.
When patients try to identify a spine surgeon, they run into a conflict.
There are two basic paths to spine surgery. The ABOS recognizes spinal surgery
as a component of its requirement for certification in orthopaedic surgery.
Spinal surgery also falls into the domain of the American Board of
Neurological Surgery. The challenge is in the actual practice of spinal
surgery. Some orthopaedic surgeons exclusively do spinal surgery, and some,
perhaps the majority, do no spinal surgery. Similarly for neurosurgeons, most
do some spinal surgery, but not all do spinal surgery. Also, for the
orthopaedic spine surgeons and neurological spine surgeons, there are types of
cases that some do and that others do not and vice versa. Therefore, it is a
confusing environment for patients as well as for referring physicians, who
need to know what kind of spine problem to refer to what kind of surgeon.
In the past, there was a typical relationship between neurological surgeons
and orthopaedic surgeons, in which neurosurgeons would do spinal decompression
and orthopaedic surgeons would do spinal stabilization. Often, in such cases,
the orthopaedic and neurological surgeons worked as cosurgeons. What has
happened more recently, because of a variety of factors, is that it is now
common for orthopaedic surgeons to do decompressive surgeries, and it is more
common for neurosurgeons to do spinal stabilization surgeries. There are
certain classic boundaries, such as the treatment of intradural tumors being
done only by neurosurgeons and scoliosis or spinal deformity surgery being
done only by orthopaedic surgeons, but those boundaries are being crossed in
both directions. So, this establishes the dilemma faced by both the patients
and the medical community.
In this fertile ground has blossomed the discussion about subspecialty
certification. There have been a myriad of efforts to come together to define
the spine surgeon, but to date they have floundered on the rocky shores of the
many considerations of both disciplines. The North American Spine Society was
initially founded as an attempt to bring together these two specialties.
However, the North American Spine Society involved many nonsurgical
specialties. As a result, it represents a society of those involved in spine
care, but it is not a spine surgeon society. The Scoliosis Research Society
has existed since 1966 and has been actively involved with organized
orthopaedic surgery. Similarly, the Cervical Spine Research Society was
founded by and has been under the auspices of the AAOS for many years, but it
has been a meeting ground for both orthopaedic surgery and neurosurgery. The
International Society for Study of the Lumbar Spine may also represent a
similar meeting ground of orthopaedic surgery, neurosurgery, and other
disciplines. However, a strictly surgically oriented spine society addressing
the whole impact of the spine has been somewhat limited to date. Some of the
frustration with the process of organized medicine toward the definition of
spine surgery as a particular discipline (be it a subspecialty expertise or a
certificate of added qualification) has resulted in the development of an
organization outside the ABMS. Specifically, it has led to the development of
the American College of Spine Surgery and the American Board of Spine Surgery.
This is not an ABMS-recognized board; however, it has been recognized by the
legislature in the state of California in part because of the challenges noted
above.
Similarly, within the field of neurological surgery, there has been a
growing recognition of the demands of the field of spine surgery as being
different from routine neurosurgery residency training. This has led to
increased activity at the Joint Section meeting, which is the combined meeting
of the Congress of Neurological Surgeons and the American Association of
Neurological Surgeons, which has several breakout groups. These include
peripheral nerve surgery and spine surgery. Currently, there has been
increasing attendance, especially among young neurosurgeons at the joint
section, and there has been a changing agenda based on their desire to further
understand the complexities of spinal deformity and spinal instrumentation.
This has led to a substantial number of orthopaedic spine surgeons being
invited as faculty members and lecturers for this meeting in order to share
ideas and understanding about the spine.
Within organized orthopaedics, it was recognized that defining spine
surgery as a subspecialty ran into all of the problems of the interaction with
neurosurgery. Ronald
DeWald10, in an
effort to both side-step this dilemma and advance the recognition of this
domain of expertise, sought to establish what he thought would be a less
controversial subspecialty certification process, that of spinal deformity
surgery. Spinal deformity surgery has been more recognized as a domain falling
within the field of orthopaedics, since our name, which implies "to
straighten the child," is well exemplified in the care of patients with
scoliosis. Dr. DeWald has trained a great number of spinal deformity surgeons
as well as many leaders within the field of orthopaedics. He recognized from
the start that, in order to define a field of subspecialty expertise, a
curriculum is a key and critical component. With the support of the Scoliosis
Research Society, he developed a comprehensive textbook of spinal deformity
surgery. This textbook has been quite well received throughout the field as
representing a comprehensive treatise on the field of spinal deformity
surgery. Necessarily, it includes basic spine anatomy and pathophysiology, as
well as more extensive discussion on spinal deformity care. He attempted to
move this body of knowledge forward under the auspices of the Scoliosis
Research Society. While it was initially well received, there was a perception
among pediatric orthopaedic surgeons that this appeared to be an attempt to
disenfranchise them. In fact, this was not the case. The proposal was defined
quite broadly in order to allow pediatric orthopaedic surgeons with spine
surgery training to become certified as spinal deformity surgeons. After
extensive debate by the Scoliosis Research Society Board of Directors, the
decision was made to support the concept and move forward to the ABOS with a
request for subspecialty certification in the area of spinal deformity
surgery. Upon review, the board believed that the body of knowledge was not
adequately defined and that, before the board acted on it, it would require
the concurrence of all possible parties involved, including pediatric
orthopaedics and neurosurgery. Interestingly, this throws the problem back
into the same dilemma that to date has been irreconcilable between the
specialties of orthopaedic surgery and neurosurgery.
Data from the 2003 ABOS recertification process indicated that 693 surgeons
took the examination by means of one of multiple pathways. Of those,
fifty-five (approximately 8%) chose the spine-based computerized
examination.
From the perspective of the ABOS, there is the issue of the cost associated
with the development and administration of a subspecialty certification
examination. It takes about 500 to 600 questions in order to rotate through
200 questions per session and still keep the examination secure.
Question-writing and validation typically costs about $2500 per question. So
the minimum cost would be $1,250,000, with a maximum of $1,500,000. There are
also costs associated with examination administration. As someone who has
written and reviewed questions for the AAOS spine self-assessment examination,
I (D.W.P. Jr.) cannot say with certainty that there are 600 questions on spine
deformity that can be written and validated. Certainly, there are many more
questions that can be asked, but evidence-based answers are more elusive.
Opinion runs strong, but consensus answers are more difficult to find. Simply
asking a group of spinal deformity surgeons to select fusion levels and
provide a basis for their decisions results in an interesting dialogue.
In the recognition of real-world forces, it is clear that orthopaedic
chairmen and neurosurgery chairmen do not want to give up the revenue stream
associated with spine surgery. There is a requirement for this education
process in both fields, but there is also a desire to have at least some
control of or access to this revenue steam. This has made it difficult to move
forward on a content-based approach in general.
With the development of newer generations of neurosurgeons and orthopaedic
spine surgeons, previous stereotypical thoughts about skill sets from the
parent-discipline training may no longer apply. There have been fellowship
programs that accept both orthopaedic surgery and neurosurgery-trained
residents. There have even been combined orthopaedic-neurosurgery spine
surgery services developing across the country with combined fellowship
programs. I personally believe that both disciplines are strengthened when the
two efforts are brought together. The neurosurgical understanding of
intradural processes, as well as handling of problems such as dural leaks,
exceeds that of the conventional orthopaedic training. Similarly, the
orthopaedic training and teaching about overall musculoskeletal function and,
specifically, the understanding of bone biology as well as instrumentation
bring much to the table as well.
So the dilemma that must be resolved remains. How does the patient identify
who is a spine surgeon? Is he or she the person who simply appends that logo
to his or her name in the yellow pages? How does a referring physician
identify who is a spine surgeon? He or she is not necessarily an orthopaedic
surgeon or a neurosurgeon. If organized medicine is unable to help make this
definition, then there will be rogue efforts outside organized medicine that
may obviate the role of the ABMS. This may or may not be a good thing, but a
definition is needed whether we establish it within organized medicine or have
it established for us.
When this topic was presented as a symposium at the Annual Meeting of the
American Orthopaedic Association (AOA) in Huntington Beach, California, on
June 25, 2005, there was extensive discussion with considerable interaction
between the audience and panel. A series of audience response questions was
presented before and after the lectures and discussion.
It appeared that a plurality of the audience recognized that the main
purpose of subspecialty certification is to improve the educational standards
and offerings of that subspecialty. Approximately 20% still believed that the
purpose was to limit the number of those practicing in the subspecialty to
those who have completed a fellowship.
Fifty-four percent of the audience seemed to think that the biggest
drawback to subspecialty certification was fragmentation of the profession of
orthopaedic surgery. Those of us on the panel believe that the biggest
drawback is the time, energy, and expense of achieving subspecialty
certification and administering the examination.
What we do not know is the makeup of the audience attending this symposium.
We do know that, in general, the older and more "generalist" the
orthopaedic surgeon was, the more unfavorable the response was toward
subspecialty certification. The younger and more "subspecialist"
the orthopaedic surgeon was, the more likely the response was to be
favorable.
Clearly, "time will tell" with regard to opinions on
sports-medicine subspecialty certification. It appeared that the negative
views were related to concerns about the fragmentation of orthopaedic surgery
and the potential effect of limiting the number of those practicing in the
subspecialty to those who have completed a fellowship. Two-thirds believed
that hand subspecialty certification has been positive. The audience was split
50-50 on whether spine subspecialty certification should proceed.
Ultimately, the issue of subspecialty certification raises questions about
an "educational standard" compared with a "practice
standard." Although the intent is to provide an ultimate
"educational standard," the result inevitably translates into some
form of "practice standard."
There may be distinctions among hand, sports, and spinal surgery. Most
members of the AOA perceive hand and spine surgery to be more
"specialized." Non-fellowship-trained surgeons are performing more
"sports" procedures than hand and spine procedures. Furthermore,
sports surgery is more clearly identified with orthopaedics than with hand and
spine surgery, which are substantially practiced by plastic reconstructive
surgeons and neurosurgeons, respectively. This is not to say that subspecialty
certification is not appropriate for sports surgery, but there is more
apparent "sports" controversy about whether subspecialization is
fragmenting or improving orthopaedic surgery.
This symposium cannot answer the question: "Are we fragmenting or
improving orthopaedic surgery?" On the basis of the opinions of the
authors of this article and the audience response to questions at the AOA
symposium, it appears that what we are seeing in association with subspecialty
certification is an improvement in the "educational standards" but
also further fragmentation of orthopaedic surgery. This does not answer the
question of whether it is more important to improve the educational standards
or to limit fragmentation of the specialty. In order to answer this question
in the future, the AOA might consider a task force to assemble a survey of AOA
and AAOS members to shed further light on this controversy. It is certainly
our hope that this evolutionary process does not antiquate or discourage the
generalist.
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