Accreditation of vascular training programs and certification of vascular surgeons
1996; Elsevier BV; Volume: 23; Issue: 6 Linguagem: Inglês
10.1016/s0741-5214(96)70221-5
ISSN1097-6809
Autores Tópico(s)Vascular Procedures and Complications
ResumoThe bylaws of The Society for Vascular Surgery (SVS), as accepted at its founding in 1947, included in its objects, “To encourage hospitals to develop special training for young surgeons in this field.” It is commendable that our forefathers recognized the importance of the training of residents in vascular surgery. During the first 22 years of our history, however, little can be found in the minutes of our society or in the presentations at the annual meetings regarding the training of vascular surgeons, and even less can be found about the certification of vascular surgeons. During the first 22 years, considerable changes had occurred in vascular surgery. For example, the only operative procedures discussed at the first meeting of the SVS in 1947 were femoral vein ligations, ligation and stripping of the greater saphenous vein, portacaval shunts, lumbar and thoracolumbar sympathectomies, and correction of coarctation of the aorta. In 1969 papers were presented on distal tibial bypasses, aortoiliac endarterectomies, femorofemoral and axillofemoral bypasses, microsurgical operations, thoracic and abdominal aortic aneurysm resections, carotid endarterectomies, and splenorenal shunts. A survey was made of the number of arterial operations performed in American Hospital Association hospitals in 1969.11970 Special Hospital Services for Cardiovascular Disease Patients. 2 vols. : Health Services and Mental Health Administration, Washington, D.C1971Google Scholar The estimated numbers of operations performed were 20,000 femoropopliteal, 17,000 aortoiliac, 16,000 carotid, 16,000 aortic aneurysms, and 4000 renovascular, for a total of 73,000 procedures; almost none of these procedures were being performed in 1947. C. Rollins Hanlon chose “Standards in Vascular Surgery” for the title of his presidential address to the SVS in June of 1969.2Hanlon CR. Presidential address: standards in vascular surgery.Surgery. 1970; 67: 1-4PubMed Google Scholar He stated, “As specialists we are characteristically striving for individual excellence in our specialty, which implies rigid standards for entry into the profession, stern demands on training programs and rejection of individuals who fall below the norms during or after the course of their training.” Hanlon's remarks suggested that some surgeons were falling below norms, and challenged us to “strive toward the incredible standards of excellence of our forebears.” Edwin J. Wylie, as president of the North American Chapter of the International Cardiovascular Society (NAICVS) and future president of the SVS, gave his address on “Vascular Surgery: A Quest for Excellence” at the NAICVS meeting in 1970.3Wylie EJ. Vascular surgery: a quest for excellence.Arch Surg. 1970; 101: 645-648Crossref PubMed Scopus (31) Google Scholar His speech was based on his experience as a pioneer vascular surgeon, teacher of general surgical residents and vascular fellows, chief of a vascular fellowship, consultant for peer-group review committees, and replies from questions to former residents, former fellows, and surgeons from other regions in the country. He identified three groups of surgeons who performed vascular surgery. The first group included those whose formal training included extensive experience in vascular surgery or older surgeons already in practice at the beginning of the current era of vascular surgery who acquired the necessary skills by dedicating a major segment of their practice to vascular surgery. The second group were self-declared vascular surgeons who were motivated by self-interest rather than acquired skills. The third group included surgeons proficient in general surgery who only occasionally performed vascular operations. Dr. Wylie believed that in both the second and third groups surgical indications were often ill-founded and that the frequency of disastrous complications was appreciably higher than in his own practice. Dr. Wylie suggested that the standards of excellence for vascular surgery could be reached by the establishment of residency training programs within or after a general surgical residency, the criteria of which were established by members of the vascular societies. “Those criteria would identify centers whose graduates when certified by the American Board of Surgery (ABS), would also be certified as proficient in vascular surgery.” Jack A. Cannon, in his NAICVS presidential address in 1971, recorded examples of poor judgment in the surgical management of patients with peripheral vascular, coronary artery, and carotid artery diseases, which he attributed to lack of proper training or an operation by an “occasional vascular surgeon.”4Cannon JA. Surgical judgment in vascular surgery.Arch Surg. 1971; 103: 521-524Crossref PubMed Scopus (10) Google Scholar He supported Dr. Wylie's recommendation that training programs in vascular surgery should be established. During the latter part of the 1960s, many people, including President Lyndon B. Johnson, believed that there was a need to improve the quality of medical care in the United States. The major target was on patients with cancer, heart disease, and stroke. A law was passed in 1965 that established the Regional Medical Program Service. This service supported the establishment of the Inter-Society Commission for Heart Disease Resources (ICHD) under the auspices of the American Heart Association. The ICHD was charged with the development of guidelines for medical facilities in the prevention, treatment, and rehabilitation of patients with cardiovascular diseases. In 1969 a committee consisting of Drs. William Blaisdell, John H. Foster, and myself was asked by the ICHD to identify the optimal resources required for the performance of high-quality vascular surgery. The first draft of the report was circulated to more than 54 consultants, of whom 25 had been, were, or later became presidents of the SVS or the NAICVS. Their comments and suggestions were very helpful to the committee. The committee believed that the presidential addresses of Wylie and Cannon and the numerous discussions with the consultants and other surgeons had provided ample evidence that a considerable amount of suboptimal vascular surgery was being performed in the United States.3Wylie EJ. Vascular surgery: a quest for excellence.Arch Surg. 1970; 101: 645-648Crossref PubMed Scopus (31) Google Scholar, 4Cannon JA. Surgical judgment in vascular surgery.Arch Surg. 1971; 103: 521-524Crossref PubMed Scopus (10) Google Scholar A survey of the American Hospital Association that documented that fewer than 10 of the common vascular operations per year were being performed in 63% to 88% of hospitals provided a possible reason for these suboptimal results.11970 Special Hospital Services for Cardiovascular Disease Patients. 2 vols. : Health Services and Mental Health Administration, Washington, D.C1971Google Scholar In addition, good evidence existed that most general surgery residencies did not provide adequate experience in vascular surgery. With the cooperation of the Conference Committee on Graduate Education, the operative records of 83 residents who completed their general surgical residencies in 22 major university hospitals or clinics in 1969 were reviewed. Only 19 residents from nine institutions believed that they assumed enough responsibility that they were the surgeon on 40 or more arterial reconstructive procedures.5DeWeese JA. Training and certification of vascular surgeons.Surg Clin North Am. 1974; 54: 3-12PubMed Google Scholar In addition, 50 residents performed fewer than 20 vascular reconstructions during their training, and 31 had performed fewer than 10. For all of these reasons, it was the committee's opinion that “The factors most responsible for the quality of vascular surgery are the judgment and technical skill of the surgeon, both developed through properly supervised training and experience.”6DeWeese JA Blaisdell FW Foster JH. Optimal resources for vascular surgery.Circulation. 1972; 46: A305-A324PubMed Google Scholar The “essentials” for a vascular surgical training program were defined. The committee's recommendation was that the certifying bodies (the ABS and the American Board of Thoracic Surgery [ABTS] or a subboard of either or both boards “develop examinations for competency in vascular surgery as the most objective way of assessing qualifications for this surgical specialty.” The executive council of the SVS met in Philadelphia June 17, 1971, with Dr. F. Henry Ellis presiding. The council had discussed the desires of Dr. Ellis, Dr. Jack A. Cannon, president of the NAICVS, and Edwin J. Wylie, past president of the NAICVS, to “find out what is being done in establishing standards for training and proficiency in Vascular Surgery.” After a discussion, Dr. Ellis appointed Dr. Keith Reemtsma from the SVS to join Dr. Wylie, who was appointed by the NAICVS, to study the problem. The committee on optimal resources for vascular surgery communicated frequently with Dr. Wylie and Dr. Reemtsma during the preparation of their report. An abstract of the completed report was submitted and accepted for the regular program of the 1972 meeting, with the knowledge that the full report would appear in Circulation in August 1972. Dr. Richard Warren published the report in the December 1972 issue of the Archives of Surgery. In the foreword, Dr. Warren explained his actions with the statement, “As he peruses it, the reader will understand why. Its message needs the widest circulation possible.”7DeWeese JA Blaisdell FW Foster JH. Optimal resources for vascular surgery.Arch Surg. 1972; 105: 948-961Crossref PubMed Scopus (42) Google Scholar The 1972 council meeting of the SVS was held in Carmel, Calif., and for the first time was attended by President Charles Rob and Secretary John Foster of the NAICVS as guests. Keith Reemtsma submitted the report of the vascular surgery committee. He indicated that 1 week earlier the ABS had approved a mechanism for certifying special competence in specific disciplines and intended to apply it to pediatric surgery. He presented a resolution that he and Jack Wylie had prepared. The resolution, which was discussed and eventually approved by both Societies, stated: Whereas: the rapid expansion of the field of vascular surgery and its broad range of special expertise have reached a dimension difficult to encompass in the scope of many four-year programs in general surgery, and whereas: the acquisition of particular skills in diagnostic methods and surgical technique are necessary prerequisites for the delivery of optimum care in vascular surgery, and whereas: the IHCD through its vascular surgery subcommittee has now defined standards of training and experience to assure optimum delivery of surgical care in this specialty, and whereas: the ABS and the American Board of Internal Medicine have set a precedent for certifying special competence in specific disciplines and whereas: the American Surgical Association (ASA) has in 1972 resolved that other areas of surgical endeavor require specialized training and has recommended that proficiency in the areas be recognized under the aegis of the ABS by the issuance of certificates of special competence; Therefore be it resolved that the Society for Vascular Surgery recommend and endorse a certification method for recognition of special competence in vascular surgery under the aegis of the ABS and that the secretary of the society be instructed to convey this recommendation to the American Board of Surgery, the American College of Surgeons (ACS) and the American Surgical Association (ASA). A committee for “Certification of Special Competence in Vascular Surgery” to follow through on this resolution was appointed by the two presidents, to be chaired by Dr. Wylie and to include Drs. Cannon, DeWeese, Foster, and Szilagyi. As requested in the resolution, letters were sent to the ABS, ACS, and ASA. On November 27, 1972, a letter was received from C. Rollins Hanlon, Director of the ACS, stating, “I am pleased to inform you that the Regents approved `in principle' the establishment of such a certificate for individuals who have been fully trained in general surgery and recommended that this be kept under the aegis of the ABS.” A letter was received dated March 30, 1973, from G. Tom Shires, Secretary of the ASA, stating that, “Its council `has recommended to the ABS that consideration be given to a solution which will provide a model for granting such certification.'” The ABS discussed the resolution at its June 1973 meeting and appointed Dr. George Zuidema as the Board's liaison member to work with members of the vascular community. Dr. Wylie was invited to present a proposal to the June 12, 1973, meeting of the Board. Because of the overlapping interest of vascular surgery with cardiac surgery, Dr. Russell M. Nelson, as a representative of the ABTS, participated in the development of the proposal. Dr. Wylie presented a report of his meeting with the ABS at the June 21, 1973, executive council meeting of the SVS in Toronto, chaired by president Wiley F. Barker. Dr. Jesse E. Thompson, president, and Dr. John H. Foster, secretary of the NAICVS, also attended as ex officio members, as initiated by a constitutional amendment passed by the SVS in 1972. Dr. Wylie was pleased to report that the Board approved the resolution in principle. However, they returned the proposal to Dr. Wylie for a more detailed proposal, particularly regarding the “essentials for a training program in vascular surgery.” During the scientific program of the meeting in 1973, a panel discussion on vascular surgery training was presented.8DeWeese JA Crawford ES Dale WA Wylie EJ Reemtsma K Vascular surgical training—a panel discussion.Surgery. 1973; 74: 803-823PubMed Google Scholar The panel consisted of Drs. Crawford, Dale, Wylie, and Reemtsma, with Dr. DeWeese as moderator. There were presentations by the panel and by several discussants, including Drs. Julian, Wesolowski, William Baker, Evans, Curi, Fogarty, Rich, LeVeen, John Davis, Robicsek, Connolly, and Alfred Humphries. There were descriptions of many active training programs in which vascular surgery was taught, including those with general surgical and thoracic surgical training programs, fellowships and residencies in hospitals with surgical training programs, and those without general surgical training programs. Dr. Dale reported on the results of a questionnaire sent to 550 members of the two societies, of whom 304 responded. There were 46 fellowships or residencies for advanced training in vascular surgery described. There was an active discussion of numbers of cases necessary for a resident to perform, ranging from 50 to 500. It was believed that the discussion would be helpful to Dr. Wylie and his committee in their preparation of guidelines for “the essentials of training programs in vascular surgery” to be presented to the ABS. Dr. Wylie presented the revised “essentials” to the ABS on June 12, 1974. The Board was still not prepared to proceed with establishing certification of vascular surgeons. Instead, they established a standing committee to be known as the “Committee for Vascular Surgery.” The purpose of the committee was to improve the quality of vascular surgery training and practice in the United States by upgrading training in this discipline working through the ABS and the related residency review committees. The committee members were John H. Davis (Chairman); George D. Zuidema and David B. Skinner (ABS); D. Emerick Szilagyi, Jesse E. Thompson, and E. J. Wylie (SVS and NAICVS); and Sterling W. Edwards (ABTS). The committee was to consider the appropriateness of and the mechanism for recognition of competence in vascular surgery and make their recommendations to the ABS. Despite what appeared to be a setback to some members, the councils of the two societies reaffirmed the position that it should cooperate with the ABS in hopes of improving vascular surgical training and establishing certification for vascular surgery. A council meeting of the SVS was held in Boston in June 1975. For the first time, a joint council meeting of the SVS and NAICVS was also held. The joint council was chaired by Presidents Russell Nelson of the SVS and Allan Callow of the NAICVS. The ABS had taken no further actions. In May 1976, the vascular surgical subcommittee of the ICHD again indicated the need for recognition of quality training programs in vascular surgery and for the examination and certification of surgeons with special competence in this important surgical discipline.9DeWeese JA Blaisdell FW Foster JH Garrett HE DeWolfe VG Optimal resources for vascular surgery—a supplement.Circulation. 1976; 53: A39-A50Google Scholar The report was prepared by Drs. DeWeese, Blaisdell, Foster, Garrett, and DeWolfe. At the time, Dr. Wylie was a member of the executive council of the ICHD. A joint council meeting was held on June 17, 1976, and was chaired by Presidents Worthington Schenk (SVS) and Frank Spencer (NAICVS). Because of the lack of action by the ABS, it was decided that the joint council should appoint its own committee on vascular surgical training. The committee was appointed and consisted of Drs. Callow (Chairman), Blaisdell, Reemtsma, Thompson, Edwards, and DeWeese. It was learned subsequently that the ABS on June 24, 1976, approved the report of the Committee on Vascular Surgery of the ABS, which had recommended that “vascular surgery training could be best upgraded by examining and certifying (accrediting) programs which meet certain minimum standards of training.” These recommendations were to be forwarded to the Resident Review Committee (RRC) for general surgery. The ABS also decided that discussions of certification of special competence in vascular surgery were premature and should not be considered at this time. Although this was another setback, it did clarify the actions of the vascular societies. Three years had been spent in developing guidelines for training programs, which were really in the province of the RRC, not the ABS. At the joint council meeting on June 15, 1977, in Rochester, chaired by Presidents Jesse E. Thompson (SVS) and John E. Connolly (NAICVS), F. William Blaisdell, a member of the ABS and RRC, reported that the RRC had accepted in principle the recommendations of the ABS and ACS and appointed a committee to make the appropriate recommendations. The committee was chaired by Dr. Blaisdell and also consisted of Dr. Hassan Najafi as a representative of the RRC for thoracic surgery and Dr. Jesse Thompson as a representative of the joint council. Their report included a revised “Essentials of a Training Program in Vascular Surgery.” Vascular surgery training could be obtained through three types of programs: (1) As a 12 month component of an accredited general surgery program in which the year of residency in vascular surgery is preceded by a minimum of 31/2 years of residency in general surgery and must be in addition to the minimum requirements for qualification by the American Board of Surgery. (2) A vascular surgery residency combined with cardiothoracic training the time requirement being in addition to the minimal requirements for qualification by the American Board of Thoracic Surgery. (3) A 12 month free standing supplemental program in vascular surgery after the completion of an accredited residency in general surgery or thoracic surgery . . .. The resident should have a senior or chief resident responsibility in the operative management of a wide range of cases — in the range of 11/2 to 2 major operations per week. The report was approved by the RRC for general surgery to be submitted to the appropriate involved governing bodies for their approval. The joint meeting of the Societies in June 1978 in Los Angeles was chaired by Drs. James A. DeWeese (SVS) and Sterling Edwards (NAICVS). In his presidential address, Dr. DeWeese noted that the guidelines may not be perfect but could be modified with further discussion. “My plea is for the early orderly acceptance of vascular training programs of which there are many already in existence — because it is my belief that vascular surgery is different.”11DeWeese JA Vascular surgery—is it different?.Surgery. 1978; 84: 733-738PubMed Google Scholar The joint council meeting of the SVS and NAICVS was held June 27, 1979, in Nashville and was chaired by Presidents F. William Blaisdell (SVS) and William S. Blakemore (NAICVS). In his presidential address, Dr. Blaisdell reported that the “essentials” and “guidelines” had been forwarded to the RRC's parent bodies, the ABS, ACS, and the AMA's Liaison Committee for Graduate Medical Education (LCGME). The LCGME tabled the document on the basis of an objection from the ABTS that they believed that the guidelines should be more flexible for methods of training vascular surgeons in thoracic surgery programs. Dr. Blaisdell stated the it was the recommendation of both the ABS and RRC for general surgery that the joint council consider initiating a mechanism for accrediting training programs themselves.12Blaisdell FW. Vascular surgery training: quo vadis.Surgery. 1979; 86: 783-790PubMed Google Scholar The pediatric surgeons had used a similar approach that eventually led to accreditation of their training programs by the RRC for general surgery and certification of special qualifications in pediatric surgery by the ABS.12Blaisdell FW. Vascular surgery training: quo vadis.Surgery. 1979; 86: 783-790PubMed Google Scholar The vascular committee of the joint council, which consisted of Drs. Jack Wylie (Chairman), Emerick Szilagyi, Jesse Thompson, and Sterling Edwards, also recommended that the societies proceed with accreditation of training programs using the revised “essentials” that they had prepared. The joint council and membership voted to proceed with the accreditation of vascular surgical training programs. A vascular credentials committee was appointed by the two Society presidents. It consisted of Drs. Wiley (Chairman), DeWeese, Edwards, Garrett, and Thompson. Subsequently, the committee was officially named the “Program Evaluation and Endorsement Committee” (PEEC). At the meeting of the Joint Council in Chicago in June 1980, which was chaired by presidents E. J. Wiley (SVS) and Wiley Barker (NAICVS), Dr. Wiley reported on the activities of the PEEC. Twenty-seven applications had been received, and 17 programs had been visited by one or two members of the committee and had their applications evaluated. By 1982, the PEEC had approved 52 programs.13Garrett HE. Presidential address: evaluation and endorsement of vascular training programs and certificate of qualification in general vascular surgery.Surgery. 1982; 92: 915-920PubMed Google Scholar, 14Evaluation of training programs in vascular surgery.Surg. 1983; 93: 117-120Google Scholar In the fall of 1980 the climate had changed, and when a meeting took place between John A. Mannick (president of SVS), W. Andrew Dale (president NAICVS), H. Edward Garrett, and representatives of the ABS, ABTS, and the RRCs for general surgery and thoracic surgery, modified guidelines for training programs were unanimously approved.15Mannick JA Presidential address: vascular surgery—“A part of the main.”.Surgery. 1981; 90: 927-931PubMed Google Scholar It was also agreed that members of the RRC for thoracic surgery would participate in discussions of vascular surgery training programs with the RRC for general surgery. In addition, representatives of the ABTS would serve on the vascular committee and credentials committee of the ABS when applicants for certification in vascular surgery were being discussed. These guidelines were approved by the appropriate boards and committees. The final approval came from the Accrediting Council for Graduate Medical Education (ACGME), formerly the LCGME, in November 1982. The RRC began reviewing programs in 1983 and accredited its first programs in 1984. As of June 1995, 71 training programs had been approved for the training of 92 residents. The ABS had tabled consideration of certifying vascular surgeons in 1974. In June 1977, however, they voted to accept the principle that certificates could be issued by the board in subspecialties within general surgery.15Mannick JA Presidential address: vascular surgery—“A part of the main.”.Surgery. 1981; 90: 927-931PubMed Google Scholar Directors of the ABS at that time included Drs. Mannick, Blaisdell, Fry, Connolly, Griffen, and Greenfield. The vascular surgical committee of the ABS was reactivated in 1978 under the chairmanship of Dr. Wylie and also included Drs. Szilagyi, Edwards, and Thompson.16Griffen WO Humphreys Jr, JW Folse JR. Vascular surgery and accreditation.Ann Surg. 1986; 203: 231-235Crossref PubMed Scopus (2) Google Scholar Dr. Wylie appeared before the American Board of Medical Specialties (ABMS) for the ABS on March 19, 1982. Dr. Wylie overcame the resistance of competing societies with gentle persuasion, and the ABMS approved the application of the ABS with representation from the ABTS to grant “Certificates of Special Qualifications in General Vascular Surgery.” During the negotiations with the ABS and the ABMS, two changes were made in the name of the certificate. “Qualifications” replaced “competence,” and “general” was placed before “surgery.” According to Ward Griffen, no examination process can measure competence but only proper training and knowledge. It is assumed that such training and knowledge will be translated into competence, and thus the certificate is one of special qualifications, not special competence.16Griffen WO Humphreys Jr, JW Folse JR. Vascular surgery and accreditation.Ann Surg. 1986; 203: 231-235Crossref PubMed Scopus (2) Google Scholar He also said, “it was necessary to add the word \`general' to be assured that several other specialty boards would vote to approve the certificate.”16Griffen WO Humphreys Jr, JW Folse JR. Vascular surgery and accreditation.Ann Surg. 1986; 203: 231-235Crossref PubMed Scopus (2) Google Scholar The concerned specialties were apparently urology and neurosurgery. On June 20, 1982, 14 members of the ABTS, ABS, and the vascular committee of the ABS passed a test prepared by the ABS and became certified. Included in this group were Drs. Wylie, Thompson, Connolly, Fry, Garrett, Greenfield, Hiebert, Liddle, Malt, Najafi, Stiles, Trunkey, and Urschel. It is only fitting that Edwin J. Wylie's certificate is numbered “1” (Fig. 1.) It was a well-deserved recognition of his 11 years of tireless efforts to attain certification of qualified vascular surgeons. Unfortunately, his untimely death a few weeks later, on September 2, 1982, prevented him from observing the positive effects of his contribution. Jesse Thompson, whose certificate is numbered “2,” was also very instrumental in establishing certification and has continued to contribute to vascular surgery. Yearly written examinations have been given since 1983, and since 1986 oral examinations have been given. As of June 1995, 1527 diplomates have received certificates of either Special (895) or Added (632) Qualifications in General Vascular Surgery. Written recertifying examinations have been given since 1991, and as of October 1995, 543 diplomates have been recertified. For 11 years, the SVS and the North American Chapter of the International Society for Cardiovascular Surgery (ISCVS-NA; in 1981 the International Cardiovascular Society name was changed) had worked toward the accreditation of vascular surgery training programs and the certification of vascular surgeons. During the time that the ABS and RRCs first began certifying and accrediting, there were significant growing pains. A joint council meeting was held in San Francisco in June 1983 and was chaired by presidents John J. Bergan (SVS) and William J. Fry (ISCVS-NA). A number of concerns regarding the process for granting accreditation and certification were expressed. As a result, an ad hoc committee on vascular training and certification was appointed under the chairmanship of Dr. Andrew Dale and consisted of Drs. Veith, Ehrenfeld, Fry, and Mannick. The committee reported to a special meeting of the joint council on October 22, 1984, chaired by Anthony M. Imparato (SVS) and James A. DeWeese (ISCVS-NA). The committee expressed great concern regarding: (1) representation on the ABS and RRC; (2) the regulation that did not allow a general surgical resident and a vascular surgical resident on the same service; (3) the use of case numbers to determine qualifications for taking the certifying examination and not allowing all residents from accredited programs to take examinations. They requested submission of an early report on the joint council's actions to the membership of the two societies before the annual meeting because of the generalized concerns of the members. A letter was sent to Dr. Hiram C. Polk, Chairman of the RRC, on January 2, 1985, from the two presidents and described the concerns of the vascular community. As a result, Drs. Imparato and DeWeese were invited to attend the RRC meeting on February 16 in Dallas. There were also communications with directors of the ABS (Drs. Garrett, Thompson, and Sheldon) and the recently appointed Secretary of the ABS, Ward O. Griffen, Jr., who was also a member of the SVS and ISCVS-NA. Drs. Imparato and DeWeese were also invited to a meeting of the credentials committee of the ABS in April 1985. A special meeting of the joint council was held on April 27 in New Orleans for discussions of the status of accreditation and certification as well as the new Journal. As requested by Dr. Dale's committee, a report on the status of their concerns was sent to the membership on May 24, 1985, to acquaint them with the status of the joint council's negotiations with the ABS and RRC.17DeWeese JA Presidential address: the
Referência(s)