Robert W. Bucholz, MD
Maintaining control of certification/recertification process
While recently representing the Academy at the annual British Orthopaedic Association (BOA) meeting in Manchester, England, I was provided some insights into the value of independent, rigorous certification of physicians. Unlike in the United Kingdom (UK), in the United States, certification is voluntary and granted through the American Board of Medical Specialties (ABMS) and its 24 member-specialty boards, such as the American Board of Orthopaedic Surgery (ABOS).
By setting minimum standards for certification in each medical and surgical specialty, these legitimate Boards provide the American public some assurance that board-certified physicians and surgeons are competent. The board certification process is not perfect in this country, but it commands the respect and support of the public and the government.
The rapidly accelerating expansion of medical science and technology make the concept of career-long certification based on a one-time evaluation untenable. Recertification and time-limited certificates replaced lifelong certification in most specialties 15 to 20 years ago. Continuous evaluation through a maintenance of certification (MOC) process is currently being developed under the direction of the ABMS. The purpose of this report is to emphasize the importance of an independent, effective MOC process developed and administered by our profession and not by the government.
The UK medical profession and the British government are engaged in a bitter battle over its certification system. The current training scheme for orthopaedic surgeons in the UK involves two years of general graduate medical education clinical training (formerly known as Basic Surgical Training) followed by six years as an orthopaedic registrar. Orthopaedic trainees sit for the Intercollegiate Fellowship of the Royal College of Surgeons (RCS) examination in trauma and orthopaedics (FRCS T&Orth) after a minimum of four years of specialist training.
After obtaining the FRCS T&Orth and successfully completing the training program, which is subject to annual assessment by interview, the trainee receives a Certificate of Completion of Specialist Training, becomes eligible for Consultant appointment and is placed on the Specialist Registrar. Specialist fellowships are encouraged in the fifth or sixth year of training. Largely for financial reasons, the British government is interested in gaining control of the standard-setting process and shortening the training period. The RCS and BOA vigorously oppose such moves and are diligently trying to maintain the high standards of British orthopaedic surgeons.
As in America, British physicians are grappling with the issue of maintaining competence among current practitioners. The Royal Colleges of Surgeons (one Irish, two Scottish, and one English) concluded that they do not possess the staff or resources to assume responsibility for a continuing assessment system. Annual appraisals of performance and skills are therefore now conducted through the government-controlled National Health Service (NHS). The medical directors at individual NHS hospitals coordinate annual appraisals of scope of practice, research, education and clinical outcomes. Either orthopaedists or non-orthopaedists, such as anesthesiologists and radiologists, are assigned to appraise by interview and discussion the annual portfolios produced by each consultant orthopaedist.
This system rarely disciplines individuals, and public concerns about its validity and effectiveness abound. A process, which rightfully should be developed and directed by the profession through the RCS, has been relinquished to non-orthopaedic bodies. The approximate 2,000 orthopaedic consultants of the UK unfortunately have insufficient resources to regain control of this process.
The implications of this loss of control have been driven home lately with a new governmental program to employ non-British orthopaedists. The NHS has unacceptably long waiting lists for a number of surgical procedures, most notably total joint arthroplasty. Obstinately confident of its role as standard-setter and health care provider, the Labor government has invested large sums of public funds into creating free-standing treatment centers that provide arthroplasty and other operations to waiting list patients performed by imported orthopaedists from Europe, South Africa and the United States. The credentialing and approval of these foreign surgeons will be conducted independently of the RCS and the BOA. Indeed, British orthopaedists are explicitly excluded from participation in these treatment centers. However, they are expected to provide patient after-care and to treat complications once the foreign orthopaedic surgeons have returned home.
This program has caused much dissatisfaction between the department of health and the orthopaedic surgical community. The surgeons want to increase capacity through more investment in the NHS along with preservation of standards.
Our maintenance of certification program
Under the direction of the ABMS, the ABOS is in the final phase of developing the orthopaedic MOC process. For orthopaedic surgeons with time-limited certificates, the MOC process will consist of four components.
First, professional standing will be assessed by a comprehensive peer review similar to the recertification program. Requirements include a valid, unrestricted license; hospital privileges at a Joint Commission on Accreditation for Healthcare Organizations-approved hospital; a three-month case list (or a maximum of 75 consecutive cases) and favorable appraisals by colleagues and hospital administrators.
Second, a commitment to life-long learning and to periodic self-assessment will be documented in the Continuing Medical Education (CME) cycle. Currently, physicians are required to document 120 hours of Category I CME during the three years prior to recertification. The MOC process will require documentation of two three-year cycles of CME during the 10 years that a certificate is valid. As part of CME, two self-assessment examinations (SAE) will be required. The results of these SAE, which will be developed by the Academy and specialty societies, are reported only to the candidate, who can use them to guide an individual CME plan. Courses on patient safety, professionalism, ethics, cultural competency, and communication will likely be part of the orthopaedic curriculum.
The third MOC component—cognitive expertise—will be tested through a secure, proctored, computer-based, multiple-choice examination or through the oral examination process. Subspecialty written examinations in adult reconstructive surgery, spine surgery, sports medicine and hand surgery will likely be expanded to other subspecialty areas. All subspecialty examinations, including those for hand and sports medicine certification, will continue to include questions in general orthopaedics.
Finally, practice performance, the fourth component of MOC, will be assessed through a combination of peer review and patient surveys. Patient surveys on patient satisfaction (developed by the Academy) and on patient communication (developed by the ABMS) will be available and compared to national norms by the ABOS and returned to the candidates for use in their own quality improvement programs. During a recent informal survey of the AAOS Board of Councilors (BOC), it was noted that more than 50 percent of the BOC members already use comparable patient surveys in their practices.
Candidates who fail the credentialing process or who fail to complete the practice performance component may be directed to take an oral examination for MOC. Candidates who choose to take an oral examination will have slightly different requirements for practice performance. The needs of the non-operating orthopaedic surgeon are recognized and pathways to fulfill MOC will be made available.
Maintaining control of the profession
While the new MOC program may sound complex, the time-consuming components of the program, above what is currently required with recertification, are few. Compared to the detailed programs implemented by other specialty boards, the ABOS has attempted to minimize the costly regulatory demands in this MOC program. The self-evaluation program and patient satisfaction surveys actually provide useful practice management data for the individual practitioner.
Several state licensure boards have threatened to institute general medical examinations for all physicians who refuse or fail to comply with an ABMS MOC program. The U.S. government might intervene if we fail to set these new standards. The new MOC process is surely less onerous and costly than alternative pathways that might be introduced by governmental bodies.
More importantly, however, we must retain control of our professional standards. As professionals in orthopaedic surgery, we are expected by the American public to set, measure, and test the competency standards for orthopaedic surgery. Failure to do so may result in a situation comparable to the problems now confronting the British orthopaedic community. He who sets the standards controls the future of a profession. The very life of our orthopaedic profession hinges on our setting high standards for ourselves.
Robert W. Bucholz, MD