Physician Board Certification in the United States

The term “board certified” appears in almost every form of medical advertising.  An examination of its appropriate meaning is in order.  Where did the term originate and for what purpose should it be used?  Why are some boards members of the American Board of Medical Specialties (ABMS) and others are not?  The following is a primer on the concept of board certification including its history and current status in North America.

The English word “board” has several meanings, however, for the purposes of this discussion it denotes a group of persons having managerial, supervisory, investigatory or advisory powers.  Readers should be familiar with this concept in the form of a “Board of Directors” for a corporate entity such as a bank.  In the medical/surgical environment it is frequently encountered as a “Board of Examiners”.

In the United States the “Board of Examiners” concept coalesced for physicians in 1915 as the National Board of Medical Examiners  http://www.nbme.org/.  The medical community of the early twentieth century recognized the need for establishing high, minimum standards for any physician practicing in the United States.  Today, graduates of accredited medical  schools in the United States and Canada must pass Step 1, Step 2 CK and Step 2 CS of the United States Medical Licensing Examination http://www.usmle.org/ to obtain a proper license in a particular state or territory.  The Federation of State Medical Boards http://www.fsmb.org/index.html represents the seventy state medical and osteopathic boards of the United States and its territories.  All physicians, regardless of specialty, must complete the same process to obtain their state license to practice medicine.

Simultaneously, during the early 1900s, advances in medicine and surgery led to the concept of specialization.  The 1800s had been a time of foundational breakthrough in medical science.  Giants such as Louis Pasteur (1822-1895), Robert Koch (1843-1910), William Osler (1849-1919), William Halsted (1852-1922) and Harvey Cushing (1869-1939), to name but a few, had transformed the practice of medicine.  During this time specific disciplines such as gynecology, internal medicine, neurosurgery, general surgery, ophthalmology, otolaryngology and dermatology emerged.  William Halsted (1852-1922) is credited with being the father of our contemporary training system for medical school graduates.  These interns and resident physicians spent many years attached to a group of senior physicians learning the advanced techniques associated with a particular area of medicine.  Upon completion of this type of program the physician possessed a specialized knowledge base.  For a thorough history on the subject of specialization of medicine in the United States I direct you to this page on the ABMS website. http://www.abms.org/About_ABMS/ABMS_History/Extended_History/Specialty_Board_Movement.aspx

The story of board certification in the United States begins in 1933 with the creation of the American Board of Medical Specialties (ABMS).  I encourage you to visit their website at  http://www.abms.org/ to expand your perspective on this subject.

The official ABMS Member Boards and Associate Members are (year approved as an ABMS Member Board in parentheses):

  • Allergy and Immunology (1971)
  • Anesthesiology (1941)
  • Colon and Rectal Surgery (1949)
  • Dermatology (ABMS Founding Member)
  • Emergency Medicine (1979)
  • Family Medicine (1969)
  • Internal Medicine (1936)
  • Medical Genetics (1991)
  • Neurological Surgery (1940)
  • Nuclear Medicine (1971)
  • Obstetrics and Gynecology (ABMS Founding Member)
  • Ophthalmology (ABMS Founding Member)
  • Orthopaedic Surgery (1935)
  • Otolaryngology (ABMS Founding Member)
  • Pathology (1936)
  • Pediatrics (1935)
  • Physical Medicine and Rehabilitation (1947)
  • Plastic Surgery (1941)
  • Preventive Medicine (1949)
  • Psychiatry and Neurology (1935)
  • Radiology (1935)
  • Surgery (1937)
  • Thoracic Surgery (1971)
  • Urology (1935)

Most of the member “boards” joined ABMS in the 1930s and 1940s.  The later entries were added only if they could satisfy the strict rules of admission listed below.

  1. The differentiation of a new specialty must be based on major new concepts in medical science and represent a distinct and well-defined field of medical practice.
  2. A single standard of preparation for and evaluation of expertise in each specialty must be recognized by only one medical specialty board for each specialty.
  3. The training needed to meet certification requirements by the applicant must be distinct from that required for certification by approved ABMS Member Boards so that it is not included in established training programs leading to certification by approved ABMS Boards.
  4. A medical specialty board must demonstrate that candidates for certification will acquire, and its diplomats will maintain, capability in a defined area of medicine and demonstrate special knowledge and competencies in that field.
  5. Evidence must be presented that the new board will establish defined standards for training and that there is a system for evaluation of educational program quality.
  6. The applicant medical specialty board must demonstrate support from the relevant field of medical practice and broad professional support.

These six rules continue to be applied today and are a compelling reason why there are not more American Board of Medical Specialties “boards” today.

Now back to my first paragraph.  There are in existence today many “boards” that are not sanctioned by the American Board of Medical Specialties. These other “boards” are autonomous entities that serve their membership, however, they do not conform to the strict criteria set forth by the American Board of Medical Specialties.  An example, germain to this author, would be the American Board of Cosmetic Surgery.  One of the requirements set forth by the American Board of Cosmetic Surgery is that each member must have already obtained certification in one of the member boards of the  American Board of Medical Specialties.  This means that physicians denoting their certification  by the American Board of Cosmetic Surgery were initially trained and then certified by ABMS boards such as, but not limited to, Otolaryngology, Obstetrics and Gynecology, Ophthalmology, Dermatology and General Surgery.

I will address the subject of the distinction between the American Board of Plastic Surgery and the American Board of Cosmetic Surgery in a future posting.  To do so now would be a digression from my original subject, that is, an exploration of the term “board certified”.

Any group of like minded individuals is free to create their own board.  Membership, however, in the venerable American Board of Medical Specialties is restricted by a strict set of criteria.  Before the casual reader concludes that the American Board of Medical Specialties is a political tool used to suppress the aspirations of some distinct group of physicians let me demonstrate by an example, unrelated to cosmetic surgery.

Let us revisit the requirements for the creation of an additional board by ABMS.  The first of the six criteria for inclusion of a new board into the American Board of Medical Specialties states:

The differentiation of a new specialty must be based on major new concepts in medical science and represent a distinct and well-defined field of medical practice.

Microsurgery is surgery performed using a device to magnify the surgeon’s view of the operative field thus permitting intricate dissection and suturing of tissue not possible with the naked eye.  Microsurgery is taught to residents in training for, and in the practice of, plastic surgery, neurosurgery, hand surgery and in some programs of otolaryngology.  It is a ubiquitous tool in all of these specialties and is none other than a technique used in the dissection and repair of small nerves, arteries and veins as well as in the auto-transplantation of tissue for reconstruction of the hand, head and neck and breast.  As the reader can imagine, microsurgery covers several anatomical territories and surgical specialties.  This is one reason why there is no such thing as the American Board of Microsurgery.  A proposal for an American Board of Microsurgery would find itself in conflict with the first rule set forth by the American Board of Medical Specialties.

Another example to illustrate this concept is surgery of the hand.  Any physician can suture simple lacerations to the hand or treat a simple fracture.  More complicated issues are usually referred to a plastic surgeon or orthopedic surgeon.  Burns and soft tissue problems are usually the domain of the plastic surgeon and complicated fractures of the digits, wrist and forearm fall to the orthopedic surgeon.  As the complexity of the patient’s problems increase the treatment is usually provided by a physician with advanced training in hand surgery.  Fellowships are offered in surgery of the hand.  Graduates of training programs in plastic surgery, orthopedic surgery and general surgery may choose to spend several years learning more advanced surgery of the hand than they learned in their residencies.

Upon completion of an accredited hand fellowship the surgeon may obtain certification in Hand Surgery through one of three established boards of the American Board of Medical Specialties.  These include the American Board of Surgery, the American Board of Orthopedic Surgery and the American Board of Plastic Surgery.  Although surgery of the hand can be practiced in a highly specialized fashion by practitioners with advanced training there is no American Board of Hand Surgery.  There is rather a cooperative effort between three boards within the American Board of Medical Specialties to certify applicants with added training in hand surgery.

Now that the reader has digested the concept of microsurgery and hand surgery relative to the American Board of Medical Specialties let us now consider the term “cosmetic surgery”.  Cosmetic surgery refers to the enhancement of normal tissue to improve appearance.  Strictly speaking, this can cover everything from a plastic surgeon performing a face lift to a gynecologist performing a labiaplasty.  Enhancement of normal tissue (cosmetic surgery) can be performed on just about any body part visible to the human eye and as such can be performed by a plethora of surgical disciplines.  The technique of cosmetic surgery includes a fundamental knowledge of anatomy, gentle handling of soft tissue, respect for the regional blood supply, an understanding of tension and careful suturing of soft tissue.  This “technique” is fundamental to all surgery.  Cosmetic surgery is albeit the use of highly refined yet fundamental surgical technique for other means, that is, enhancement of normal tissue.  Therein lies one reason why the American Board of Cosmetic Surgery has not become a member of the American Board of Medical Specialties.

So why does all this matter?  The prospective patient (consumer) could easily be led to assume that a physician promoting their certification by the American Board of Cosmetic Surgery had been classically and fundamentally trained to perform their wanted procedure when in fact that physician may have subsequent to their core area of training had one year of general surgery training and one year of additional cosmetic surgery training in a program accredited by the The American Academy of Cosmetic Surgery (AACS).  Compare this to the plastic surgeon certified by the American Board of Plastic Surgery who has completed either four or five years of general surgery and then two or three years of full time training in the art of managing both cosmetic and reconstructive problems.  Is one pathway fundamentally superior to another?  I will leave that to the pundits.  Are there fundamental differences between the two?  This is a question for the patient to answer.

This explanation of the basics of board certification in North America should not be misconstrued as a polemic against any physician or physician board. Both of the educational pathways have produced masterful surgeons, each contributing to the collective whole of surgical knowledge. I do not wish to denigrate anyone but merely wish to point out the facts about what “board certification” means.  There is a traditional meaning to the term which has its roots in the American Board of Medical Specialties.  In the past few decades there have emerged certain specialty boards that have ultimately not been recognized by the American Board of Medical Specialties.  I am afraid that in the contemporary patient’s mind all “board certified” surgeons are thought to derive their certified status from a singular source.  This may create a layer of confusion for the consumer.  In all but a few states, in the United States, is this distinction in boards (ABMS vs. non-ABMS board certification) regulated in the advertising arena.  Efforts to legislate this type of transparency is met with vigorous opposition underscoring how powerful the term “board certified” is in advertising.

In summary, the prospective patient must advocate for themselves and investigate the board status of their clinician.  Although being “board certified” by a member board of the American Board of Medical Specialties  is a signal to the world that the physician passed all the requisite tests, it does not guarantee competence. It does mean, however, that the physician has been classically and fundamentally trained to do what they say they do.  Whether choosing a plastic surgeon or a family practitioner it is incumbent upon each patient to investigate the physician’s credentials and experience.  With rare exception, the best way to choose a physician is by word of mouth confirmed by an opportunity to observe their bedside manner.  Ask deliberate questions as to their experience and training.  If you are contemplating having your procedure in an office based operating room or ambulatory surgery facility, make certain that your physician has privileges to perform your procedure at and admit patients to an accredited hospital nearby in case of complications.

By applying a little common sense, doing your homework and listening to your instincts you should be able to find the right physician for you.

 

 

 

 

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