August 2001 Bulletin

CAQs divisive issue for orthopaedic surgery

AAOS opposes proposal for subspecialty certification for orthopaedic sports medicine

By Lowry Jones Jr., MD

Intense and sometimes emotional debate about Certificates of Added Qualifications (CAQs) is back with us again. The American Orthopaedic Society for Sports Medicine (AOSSM) has announced its plan to seek approval by the American Board of Medical Specialties (ABMS) for its own subspecialty CAQ just as it did in 1994. In response, the Board of Directors of the American Academy of Orthopaedic Surgeons has reaffirmed the Academy’s strong opposition to the issuance of additional CAQs.

The rationale for this position is based on several factors.

CAQs are divisive. A proliferation of CAQs in orthopaedic surgery may result in fragmentation of our profession. Our profession could become a collection of small groups of narrowly focused super-specialists. In an effort to control costs, payers and institutions might even require an orthopaedic surgeon to possess a CAQ in order to be reimbursed for commonly performed targeted procedures. We need to focus our energy on activities that serve to unite us. There are many forces outside our profession that have long sought to weaken us. It is not wise for us divide the house of orthopaedics for them.

CAQs undermine our position that orthopaedic surgeons are the best-qualified physicians for the treatment of the entire musculoskeletal system. They are out of step with the movement in medical care away from subspecialist myopia and toward a more holistic approach to patient care. At the present time, the vast majority of sports injuries are well treated by orthopaedists who have not had specific specialty training in sports medicine. Their excellent clinical results and the fact that they have successfully completed their boards in orthopaedic surgery serve as sufficient proof that they are qualified to treat these conditions. Further proof of added qualification is redundant and unnecessary.

The AOSSM recognizes that "general orthopaedic training includes a sports medicine component and orthopaedists are in the best position to determine what services they are comfortable providing." AOSSM also says it recognizes and supports the right of all orthopaedists to continue providing sports medicine services in the team, clinical and surgical settings. If this were true, then why would a CAQ be of value? According to the AOSSM, a CAQ would serve to formally acknowledge those who have completed a fellowship. But do these orthopaedists require recognition beyond a diploma?

Even 30 percent of the members of the AOSSM who were surveyed by their leadership were opposed to the establishment of a new CAQ in sports medicine. In addition, multiple surveys of the AAOS membership consistently revealed overwhelming support of the Academy’s position opposing the issuance of further CAQs. The Board of Councilors surveyed AAOS members in July 2000 and found that 78.8 percent of the almost 3,000 respondents were opposed to the expansion of the concept of CAQs or Certificates of Special Qualifications.

The position of the membership has been documented many times. In 1989, 1990, 1995, 1996 and 2000 the AAOS fellowship approved or reaffirmed resolutions rejecting the creation of additional CAQs.

The Board of Councilors approved a resolution in April 2001, specifically opposing the AOSSM proposal to establish a subspecialty certification in orthopaedic sports medicine. The Councilors also asked the AAOS Board of Directors to send a strong letter of opposition to the American Board of Orthopaedic Surgeons (ABOS), the ABMS and the AOSSM. At its meeting in May, the AAOS Board approved sending such a letter to AOSSM.

Finally, the ABMS and the ABOS are presently re-examining the tools they use to measure competency. It seems premature to launch another CAQ until this re-examination is complete especially if it is a tool, which is unnecessary and worse, could even be harmful.

Lowry Jones Jr., MD, is chairman-elect of the Board of Councilors

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