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Report of the American Board of Surgery

Report of the American Board of Surgery The American Board of Surgery met in Cancun, Mexico, for 5 days under the direction of Russell Postier, MD, Chair. The following issues were addressed (Table). Table. View LargeDownload American Board of Surgery Summary of 2008-2009 Examinations Modular (Focused Practice) Recertification The American Board of Internal Medicine has proposed to the American Board of Medical Specialties (ABMS) that a new procedure for the recognition of expertise in a focused area of practice be developed for use in maintenance of certification. This would be specifically targeted to areas in which expertise is developed after residency as a result of a specific practice environment and would allow explicit recognition of subspecialty areas of practice for which the focus has narrowed. Such areas would be distinguished from, and would not overlap with, areas in which subspecialty certificates are offered, because they would not necessarily require additional fellowship training after residency, nor would any subspecialty examination be given. The principal impetus for this has come from medical hospitalists within the American Board of Internal Medicine, who normally receive no training beyond basic medical residency but who limit their practice to the hospital environment. The ABMS held a 2-day task-force meeting in early December to discuss whether to proceed with this initiative, and several problems became evident. The initiative was considered to be a way of providing recognition for specific expertise that develops as a result of practice, rather than fellowship training, but the task force also felt that it would be confusing to the public and would be difficult to distinguish from subspecialty certification. The ABMS has not yet taken a final stance on the issue. This issue was the subject of a retreat held on January 11, 2009, and was subsequently discussed at the main meeting on January 14. Several pros and cons were identified, and it was specifically noted that of the 4 parts of maintenance of certification, the issues of focused practice are already possible in regard to part II (continuing medical education and self-assessment) and part IV (performance in practice). Part I is generic, relating to licensure and professionalism, and hence is not subject to focused practice, which leaves only part III (the secure examination) as a real focus. The issue then is whether a diplomate should be able to recertify him or herself by taking a modular examination concentrated in a narrower area of surgery than that in which the general examination is customarily given. There are significant problems in doing this, in both finding sufficient questions in a narrow area, eg, breast surgery, to allow a psychometrically valid examination and in having a sufficient number of diplomates to take the examination to give statistically adequate results. Lastly, there is the philosophical issue of whether it is a good idea to recertify a diplomate in surgery on the basis of an examination that is not targeted to the broad range of surgical subjects. The opinion was expressed by a number of directors that allowing a focused examination to be taken for recertification would only encourage fragmentation of surgery, when in fact the principal need is for more generalists. Attendees of the retreat also agreed that any attempt to identify a subspecialty area of focused practice on the certificate would be extremely confusing to the public in regard to differentiating it from subspecialty certification as it already exists. After extensive discussion and an expression of the range of opinions on this issue, the board voted, and on a split vote (18-13) decided not to proceed with the possibility of modular recertification. The board agreed, as noted above, that parts II and IV already may be focused on a modular area but that the secure examination, which is not extremely difficult for an active practitioner to prepare for, should not be changed. Institute of Medicine Report and Response The recently released report from the Institute of Medicine regarding resident work hours was the subject of extensive discussion, in both formal and informal sessions. The report has recommended that the 80-hour limit remain unchanged but that a maximum shift length of 16 hours be allowed, after which at least 5 hours of uninterrupted sleep be required. Total shift length is limited to 30 hours. The universal opinion of directors was that the proposal is unworkable in the context of surgical residency and that it cannot be implemented effectively in the real world, where residents are required to give patient care. In addition, there was great concern that the entire area of work-hours restriction was giving residents the message that their sleep cycles are more important than patient welfare. There have already been multiple reported examples of residents who violate present work-hours restrictions because of their personally perceived obligations to care for patients and provide continuity of care. The board formally requested that the staff prepare a white paper to address the problems of the Institute of Medicine's proposals in regard to surgical residency and to provide this to the Accreditation Council for Graduate Medical Education before their scheduled symposium on March 3 and 4, when this issue will be addressed. Several directors volunteered to be part of the writing committee if needed. Public Members The board decided at the June meeting to add 2 public members, and the directors have nominated several individuals. There was discussion of the desirable credentials at the meeting and additional nominations were solicited (to be sent to the board office within a week after the conclusion of the meeting). All names, with short biographies, will be compiled and then mailed to all directors for evaluation and prioritization. Once a prioritized list is available, the individuals will be approached and asked if they would be willing to participate as public members, with the obligation to attend at least 2 meetings per year. American Board of Radiology Proposal for Vascular Interventional Radiology Primary Certificate The American Board of Radiology has sent a proposal to the ABMS (Committee on Certification and Recertification) asking that a primary certificate in vascular interventional radiology that is separate from the present certificate in diagnostic radiology be created. This would entail 5 years of residency and begin with 1 year of surgical residency, followed by 18 months of diagnostic radiology and 24 months of interventional radiology, as well as 6 months of additional clinical time involving complex patient management. The Vascular Surgery Board reviewed this proposal in depth and prepared a critique of the proposal, which primarily focused on the disparity between the level of clinical skills envisioned and the amount of clinical training required. The intent of the certificate is to prepare an interventional radiologist who can individually provide pretreatment and evaluation, interventional radiology treatment, and posttreatment follow-up. It was the strong opinion of the Vascular Surgery Board that the amount of clinical training provided in the application for the certificate was insufficient to prepare a radiologist to evaluate and adequately plan management of these complex patients and that 18 months of clinical time would not in fact provide adequate background. The board also felt that the certificate would alter the role of interventional radiology as it currently functions in the management of vascular patients and that it was not clear that the training outlined would be sufficient to allow this level of change in responsibilities. As a result, the Vascular Surgery Board and subsequently the full board took a strong opposing position, and this opinion will be transmitted to the Committee on Certification and Recertification prior to its meeting in February, when this certificate will have its first reading. Certification in Surgical Oncology The Surgical Oncology Advisory Council discussed in depth a white paper that they have prepared outlining the pros and cons of proposing to the board that a new certificate in surgical oncology be created. The Surgical Oncology Advisory Council is not yet prepared to move ahead with this but anticipates that they may have this prepared by the June 2009 meeting of the board and if so will present the proposal at that time. The board has discussed this issue at recent meetings, and there are divided opinions as to whether the creation of a surgical oncology certificate would be desirable or whether it would result in the exclusion of general surgeons who could not qualify but have a significant degree of oncology in their practices. No formal proposal was brought forward at this time, and the Surgical Oncology Advisory Council will discuss this further with the membership of the Society of Surgical Oncology before finalizing the proposal. ABMS Proposals for Maintenance of Certification Standards The Committee on Maintenance of Certification of ABMS has published the second draft of their proposed standards for maintenance of certification and has formally asked for comments to be submitted by January 31. The Diplomates Committee and subsequently the full board reviewed the request and felt that it contained several unworkable and excessively expensive proposals. In particular, a proposal that Consumer Assessment of Healthcare Providers and Systems surveys be required of all diplomates at 5-year intervals, that all diplomates be required to complete a 20-hour patient safety course, and that all diplomates undergo 360° evaluations at 5-year intervals were all thought to be unworkable and unproven in regard to their beneficial effect on patient safety or quality of care. The expense of each is also high and, if implemented, would at least double the present cost of recertification. As a result, the Diplomates Committee strongly recommended that the American Board of Surgery oppose the recommendations as drafted and so inform the Committee on Maintenance of Certification prior to the deadline for comment. It is anticipated that the Committee on Maintenance of Certification will evaluate the feedback and make final recommendations for the maintenance of certification standards at the March 2009 ABMS meeting. Board Certification for International Graduates The issue of allowing board certification for international graduates without requiring a period of residency training in the United States has been raised by various organizations and in particular has been discussed in conjunction with the Maintenance of Licensure initiative from the Federation of State Medical Boards. This was discussed in the Diplomates Committee, and it was felt that some method may be found for allowing highly qualified international graduates who have worked for some time in academic centers to qualify for board certification in the future. However, when trying to draft specific proposals that would clearly define candidates who were qualified for board certification, it was clear that this will be quite difficult to define narrowly enough to ensure that those allowed to proceed to certification actually have the necessary broad credentials. In particular, if there is no period of residency training, there are many characteristics of the individual in practice that cannot be evaluated, and the quality and breadth of training programs in various countries are extremely variable. Thus, the diplomates felt that we should proceed slowly in this area and not loosen the restrictions prematurely, as it would be nearly impossible to reverse an action once it was taken. New Directors The following new directors have been elected to serve a 6-year term starting July 1, 2009: Stephen Evans, MD, American Medical Association Ronald Hirschl, MD, American Pediatric Surgical Association Selwyn Vickers, MD, American Surgical Association Douglas Hanto, MD, American Society of Transplant Surgeons Dr Evans will replace Dr Postier; Dr Hirschl will replace Marshall Schwartz, MD; Dr Vickers will replace Carlos Pellegrini, MD; and Dr Hanto will replace James Schulak, MD; all of the members listed second are completing their terms of office. It should also be noted that the term of office of Larry Kaiser, MD, expired in June, and he was succeeded by Cameron Wright, MD, from the American Board of Thoracic Surgery. Necrology We were saddened to learn of the deaths of Clement A. Hiebert, July 3, 2008, and Lloyd M. Nyhus, December 15, 2008, senior members of the American Board of Surgery. Correspondence: Dr Lewis, American Board of Surgery, 1617 John F. Kennedy Blvd, Ste 860, Philadelphia, PA 19103 (flewis@absurgery.org). Financial Disclosure: None reported. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Surgery American Medical Association

Report of the American Board of Surgery

Archives of Surgery , Volume 144 (6) – Jun 15, 2009

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Publisher
American Medical Association
Copyright
Copyright © 2009 American Medical Association. All Rights Reserved.
ISSN
0004-0010
eISSN
1538-3644
DOI
10.1001/archsurg.2009.85
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Abstract

The American Board of Surgery met in Cancun, Mexico, for 5 days under the direction of Russell Postier, MD, Chair. The following issues were addressed (Table). Table. View LargeDownload American Board of Surgery Summary of 2008-2009 Examinations Modular (Focused Practice) Recertification The American Board of Internal Medicine has proposed to the American Board of Medical Specialties (ABMS) that a new procedure for the recognition of expertise in a focused area of practice be developed for use in maintenance of certification. This would be specifically targeted to areas in which expertise is developed after residency as a result of a specific practice environment and would allow explicit recognition of subspecialty areas of practice for which the focus has narrowed. Such areas would be distinguished from, and would not overlap with, areas in which subspecialty certificates are offered, because they would not necessarily require additional fellowship training after residency, nor would any subspecialty examination be given. The principal impetus for this has come from medical hospitalists within the American Board of Internal Medicine, who normally receive no training beyond basic medical residency but who limit their practice to the hospital environment. The ABMS held a 2-day task-force meeting in early December to discuss whether to proceed with this initiative, and several problems became evident. The initiative was considered to be a way of providing recognition for specific expertise that develops as a result of practice, rather than fellowship training, but the task force also felt that it would be confusing to the public and would be difficult to distinguish from subspecialty certification. The ABMS has not yet taken a final stance on the issue. This issue was the subject of a retreat held on January 11, 2009, and was subsequently discussed at the main meeting on January 14. Several pros and cons were identified, and it was specifically noted that of the 4 parts of maintenance of certification, the issues of focused practice are already possible in regard to part II (continuing medical education and self-assessment) and part IV (performance in practice). Part I is generic, relating to licensure and professionalism, and hence is not subject to focused practice, which leaves only part III (the secure examination) as a real focus. The issue then is whether a diplomate should be able to recertify him or herself by taking a modular examination concentrated in a narrower area of surgery than that in which the general examination is customarily given. There are significant problems in doing this, in both finding sufficient questions in a narrow area, eg, breast surgery, to allow a psychometrically valid examination and in having a sufficient number of diplomates to take the examination to give statistically adequate results. Lastly, there is the philosophical issue of whether it is a good idea to recertify a diplomate in surgery on the basis of an examination that is not targeted to the broad range of surgical subjects. The opinion was expressed by a number of directors that allowing a focused examination to be taken for recertification would only encourage fragmentation of surgery, when in fact the principal need is for more generalists. Attendees of the retreat also agreed that any attempt to identify a subspecialty area of focused practice on the certificate would be extremely confusing to the public in regard to differentiating it from subspecialty certification as it already exists. After extensive discussion and an expression of the range of opinions on this issue, the board voted, and on a split vote (18-13) decided not to proceed with the possibility of modular recertification. The board agreed, as noted above, that parts II and IV already may be focused on a modular area but that the secure examination, which is not extremely difficult for an active practitioner to prepare for, should not be changed. Institute of Medicine Report and Response The recently released report from the Institute of Medicine regarding resident work hours was the subject of extensive discussion, in both formal and informal sessions. The report has recommended that the 80-hour limit remain unchanged but that a maximum shift length of 16 hours be allowed, after which at least 5 hours of uninterrupted sleep be required. Total shift length is limited to 30 hours. The universal opinion of directors was that the proposal is unworkable in the context of surgical residency and that it cannot be implemented effectively in the real world, where residents are required to give patient care. In addition, there was great concern that the entire area of work-hours restriction was giving residents the message that their sleep cycles are more important than patient welfare. There have already been multiple reported examples of residents who violate present work-hours restrictions because of their personally perceived obligations to care for patients and provide continuity of care. The board formally requested that the staff prepare a white paper to address the problems of the Institute of Medicine's proposals in regard to surgical residency and to provide this to the Accreditation Council for Graduate Medical Education before their scheduled symposium on March 3 and 4, when this issue will be addressed. Several directors volunteered to be part of the writing committee if needed. Public Members The board decided at the June meeting to add 2 public members, and the directors have nominated several individuals. There was discussion of the desirable credentials at the meeting and additional nominations were solicited (to be sent to the board office within a week after the conclusion of the meeting). All names, with short biographies, will be compiled and then mailed to all directors for evaluation and prioritization. Once a prioritized list is available, the individuals will be approached and asked if they would be willing to participate as public members, with the obligation to attend at least 2 meetings per year. American Board of Radiology Proposal for Vascular Interventional Radiology Primary Certificate The American Board of Radiology has sent a proposal to the ABMS (Committee on Certification and Recertification) asking that a primary certificate in vascular interventional radiology that is separate from the present certificate in diagnostic radiology be created. This would entail 5 years of residency and begin with 1 year of surgical residency, followed by 18 months of diagnostic radiology and 24 months of interventional radiology, as well as 6 months of additional clinical time involving complex patient management. The Vascular Surgery Board reviewed this proposal in depth and prepared a critique of the proposal, which primarily focused on the disparity between the level of clinical skills envisioned and the amount of clinical training required. The intent of the certificate is to prepare an interventional radiologist who can individually provide pretreatment and evaluation, interventional radiology treatment, and posttreatment follow-up. It was the strong opinion of the Vascular Surgery Board that the amount of clinical training provided in the application for the certificate was insufficient to prepare a radiologist to evaluate and adequately plan management of these complex patients and that 18 months of clinical time would not in fact provide adequate background. The board also felt that the certificate would alter the role of interventional radiology as it currently functions in the management of vascular patients and that it was not clear that the training outlined would be sufficient to allow this level of change in responsibilities. As a result, the Vascular Surgery Board and subsequently the full board took a strong opposing position, and this opinion will be transmitted to the Committee on Certification and Recertification prior to its meeting in February, when this certificate will have its first reading. Certification in Surgical Oncology The Surgical Oncology Advisory Council discussed in depth a white paper that they have prepared outlining the pros and cons of proposing to the board that a new certificate in surgical oncology be created. The Surgical Oncology Advisory Council is not yet prepared to move ahead with this but anticipates that they may have this prepared by the June 2009 meeting of the board and if so will present the proposal at that time. The board has discussed this issue at recent meetings, and there are divided opinions as to whether the creation of a surgical oncology certificate would be desirable or whether it would result in the exclusion of general surgeons who could not qualify but have a significant degree of oncology in their practices. No formal proposal was brought forward at this time, and the Surgical Oncology Advisory Council will discuss this further with the membership of the Society of Surgical Oncology before finalizing the proposal. ABMS Proposals for Maintenance of Certification Standards The Committee on Maintenance of Certification of ABMS has published the second draft of their proposed standards for maintenance of certification and has formally asked for comments to be submitted by January 31. The Diplomates Committee and subsequently the full board reviewed the request and felt that it contained several unworkable and excessively expensive proposals. In particular, a proposal that Consumer Assessment of Healthcare Providers and Systems surveys be required of all diplomates at 5-year intervals, that all diplomates be required to complete a 20-hour patient safety course, and that all diplomates undergo 360° evaluations at 5-year intervals were all thought to be unworkable and unproven in regard to their beneficial effect on patient safety or quality of care. The expense of each is also high and, if implemented, would at least double the present cost of recertification. As a result, the Diplomates Committee strongly recommended that the American Board of Surgery oppose the recommendations as drafted and so inform the Committee on Maintenance of Certification prior to the deadline for comment. It is anticipated that the Committee on Maintenance of Certification will evaluate the feedback and make final recommendations for the maintenance of certification standards at the March 2009 ABMS meeting. Board Certification for International Graduates The issue of allowing board certification for international graduates without requiring a period of residency training in the United States has been raised by various organizations and in particular has been discussed in conjunction with the Maintenance of Licensure initiative from the Federation of State Medical Boards. This was discussed in the Diplomates Committee, and it was felt that some method may be found for allowing highly qualified international graduates who have worked for some time in academic centers to qualify for board certification in the future. However, when trying to draft specific proposals that would clearly define candidates who were qualified for board certification, it was clear that this will be quite difficult to define narrowly enough to ensure that those allowed to proceed to certification actually have the necessary broad credentials. In particular, if there is no period of residency training, there are many characteristics of the individual in practice that cannot be evaluated, and the quality and breadth of training programs in various countries are extremely variable. Thus, the diplomates felt that we should proceed slowly in this area and not loosen the restrictions prematurely, as it would be nearly impossible to reverse an action once it was taken. New Directors The following new directors have been elected to serve a 6-year term starting July 1, 2009: Stephen Evans, MD, American Medical Association Ronald Hirschl, MD, American Pediatric Surgical Association Selwyn Vickers, MD, American Surgical Association Douglas Hanto, MD, American Society of Transplant Surgeons Dr Evans will replace Dr Postier; Dr Hirschl will replace Marshall Schwartz, MD; Dr Vickers will replace Carlos Pellegrini, MD; and Dr Hanto will replace James Schulak, MD; all of the members listed second are completing their terms of office. It should also be noted that the term of office of Larry Kaiser, MD, expired in June, and he was succeeded by Cameron Wright, MD, from the American Board of Thoracic Surgery. Necrology We were saddened to learn of the deaths of Clement A. Hiebert, July 3, 2008, and Lloyd M. Nyhus, December 15, 2008, senior members of the American Board of Surgery. Correspondence: Dr Lewis, American Board of Surgery, 1617 John F. Kennedy Blvd, Ste 860, Philadelphia, PA 19103 (flewis@absurgery.org). Financial Disclosure: None reported.

Journal

Archives of SurgeryAmerican Medical Association

Published: Jun 15, 2009

Keywords: american board of surgery,surgical procedures, operative,diagnostic radiologic examination,institute of medicine (u.s.)

There are no references for this article.