Independent practice should require thoracic board certification
2022; Elsevier BV; Volume: 164; Issue: 3 Linguagem: Inglês
10.1016/j.jtcvs.2022.04.019
ISSN1097-685X
AutoresDavid Howard Adams, Dimosthenis Pandis, Shaf Keshavjee,
Tópico(s)Radiology practices and education
ResumoCentral MessageThe American Board of Thoracic Surgery or an equivalent International Board Certification should be a prerequisite to credentialing independent practice of Thoracic Surgery in the United States.See Commentary on page 1021. The need for specialty boards gained impetus during a period of sweeping transformations in medical education and clinical practice during the 20th century.1Starr P. The Social Transformation of American Medicine: The Rise of a Sovereign Profession and the Making of a Vast Industry.2nd ed. Basic Books, 2017Google Scholar The overarching tenet of establishing specialty boards, independent from professional societies, was to define the high standards in clinical knowledge and competence afforded to board-certified physicians,2Cassel C.K. Holmboe E.S. Professionalism and accountability: the role of specialty board certification.Trans Am Clin Climatol Assoc. 2008; 119: 295-303PubMed Google Scholar with the dual intention to demonstrate accountability through self-regulation and, by extension, build public credibility through leadership in advancing quality and transparency in clinical practice. The first discussions around certification boards for thoracic surgeons occurred at the American Association for Thoracic Surgery (AATS) Annual Meeting in 1936 and was later revisited at the direction of the 25th AATS President, Claude Beck, in 1945.3The American Board of Thoracic SurgeryHistory of the board.https://www.abts.org/ABTS/About/About ABTS/ABTS/Public/About/History.aspxDate accessed: August 19, 2021Google Scholar Originally an affiliate of the American Board of Surgery (ABS), the Board of Thoracic Surgery was founded in 1948. The first thoracic specialty written examination took place on August 1, 1949, with a pass rate of 78% (22/28), followed by the first oral examination in Chicago in October the same year, with a pass rate of 75% (15/20). The Board of Thoracic Surgery later evolved into an independent primary member of the American Board of Medical Specialties in 1971, re-established as the American Board of Thoracic Surgery (ABTS).3The American Board of Thoracic SurgeryHistory of the board.https://www.abts.org/ABTS/About/About ABTS/ABTS/Public/About/History.aspxDate accessed: August 19, 2021Google Scholar For the next 3 decades, ABTS certification requirements included ABS certification, at least 2 years of additional training in an ABTS-approved residency program, and successful completion of written (cognitive) and oral (practical) examinations overseen by the ABTS. More recently, significant efforts toward the development of a core curriculum led to the establishment of an integrated 6-year program or alternatively a 4/3 model, with elimination of the ABS board requirement. Completion of an accredited thoracic surgery program deems a residency graduate “eligible” for ABTS board certification within 7 years from completion of his/her residency training. The first step toward certification is to pass the written (“qualifying”) ABTS examination, traditionally given annually in the fall. Candidates are allowed up to 3 attempts (once per year) to pass the qualifying examination. Successful candidates then sit for the oral (“certifying”) ABTS examination, traditionally given annually in the spring. Candidates are again allowed 3 attempts to successfully complete the certifying examination (once per year). During the ABTS-certification process, recent graduates have always practiced independently with varying degrees of supervision, although the latter is mostly voluntary. In the information provided by the ABTS, the primary purpose of the of the Board is stated to “protect the public by establishing and maintaining high standards in thoracic surgery.”4The American Board of Thoracic Surgery. BOOKLET OF INFORMATION.https://www.abts.org/ABTS/CertificationWebPages/Related Policies.aspxDate: 2021Date accessed: August 19, 2021Google Scholar The ABTS clearly defines its board certification to “provide evidence of a physician's qualifications for specialty practice recognized by his or her peers” and “is not intended to define requirements for membership on hospital staffs” or “to gain special recognition or privileges for its Diplomates.” ABTS certification is not currently part of initial practice credentialing and privileging of thoracic surgeons in the majority of hospitals in the United States. Interestingly, the issue of board certification and independent cardiothoracic surgery practice is viewed quite differently in most other developed countries. As an example, in the United Kingdom, the National Health Service position is explicit: “At the end of this [cardiothoracic surgery] training, you can then apply for consultant posts. However, before you can do this you must take further examinations leading to specialty fellowship of the Royal College of Surgeons. To work in the UK as a consultant (independent practice) you need a Certificate of Completion of Training (CCT).”5NHS: training and development (cardiothoracic surgery).https://www.healthcareers.nhs.uk/explore-roles/doctors/roles-doctors/surgery/cardiothoracic-surgery/training-and-developmentDate accessed: August 19, 2021Google Scholar Likewise in Japan, “No trainees are allowed to operate independently before obtaining Japanese Board of Cardiovascular Surgery certification.”6Tanemoto K. Yokoyama H. Okita Y. Ueda Y. Takamoto S. Yaku H. et al.Cardiovascular surgery training in Japan.J Thorac Cardiovasc Surg. 2022; 163: 166-175.e5Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar The same can be said for other countries we reviewed (Australia and New Zealand,7Shi W.Y. Oldfield Z. Tam R. Cochrane A.D. Smith J.A. Cardiothoracic surgery training in Australia and New Zealand.J Thorac Cardiovasc Surg. 2018; 156: 718-725Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar Canada,8Noly P.E. Rubens F.D. Ouzounian M. Quantz M. Shao-Hua W. Pelletier M. et al.Cardiac surgery training in Canada: current state and future perspectives.J Thorac Cardiovasc Surg. 2017; 154: 998-1005Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar,9The Royal College of Physicians and Surgeons of Canadahttps://www.royalcollege.ca/rcsite/home-eDate accessed: August 19, 2021Google Scholar France, and Germany10Wick A. Beckmann A. Nemeth A. Conradi L. Schäfer A. Reichenspurner H. et al.Cardiac surgery residents training in Germany—status quo and future prospects.J Thorac Cardiovasc Surg. 2020; 159: 579-587Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar). After finishing an accredited training program in all these countries, successful completion of specialty board certification is mandatory to become eligible for independent practice. Many factors point to the need to revisit the current status of requirements for independent practice of cardiothoracic surgery in the United States. Residency training has changed significantly, with shorter training programs. In addition, mandatory 80-hour workweeks, and the continuous expansion of therapies to be proficient, puts pressure on trainees to be ready for independent practice after only 6 years. Patients have also changed over time and now cardiothoracic surgeons operate on sicker and frailer patients as well as younger (asymptomatic) patients with increasing frequency. Both populations present special challenges to cardiothoracic surgeons, particularly early in their career. Finally, expectations have changed dramatically. Unsupervised “learning curves” are now intolerable, in large part due to public reporting and the recognized importance of patient outcomes on institutional ranking. Insurance payers and regulatory bodies also provide much more oversight around quality in recent years.11Brennan T.A. Horwitz R.I. Duffy F.D. Cassel C.K. Goode L.D. Lipner R.S. The role of physician specialty board certification status in the quality movement.JAMA. 2004; 292: 1038-1043Crossref PubMed Scopus (241) Google Scholar,12Chen C. Chung Y. Petterson S. Bazemore A. Changes and variation in Medicare Graduate Medical Education payments.JAMA Intern Med. 2020; 180: 148-150Crossref PubMed Scopus (14) Google Scholar There are also increasing calls from policy makers and health law experts to sanction quality measures such as this: “Furthermore, the Federal Government must acknowledge through legislation that the public is best served when the delivery of specialty health care is provided by board certified physicians. For example, physicians unable to successfully meet the requirements of the Board of Thoracic Surgery should not be allowed to perform open heart surgery, and physicians without board certification in neurosurgery should not perform brain surgery.”13Gunnar W. The scope of a physician's medical practice: is the public adequately protected by State Medical Licensure, peer review, and the National Practitioner Data Bank?.Ann Health Law. 2005; 14Google Scholar Finally, the emphasis on informed consent and transparency in medicine has evolved enormously in the past decade,14Bobinski M.A. Autonomy and privacy: protecting patients from their physicians.Univ Pittsburgh Law Rev. 1993; 55: 291-388Google Scholar and there would be little argument that a patient deserves to know through a clear informed consent process if their surgeon is board certified or not (whether by the ABTS or an equivalent Specialty Board in another country). The most recently available examination results from the ABTS show very high pass rates (exceeding 95%) on the written examination, confirming training programs are excelling in providing trainees with cognitive knowledge; interestingly, the pass rate for the oral examination (around 75 percent) has not changed appreciably since the inception of the ABTS.15American Board of Thoracic Surgery5-year pass rate.https://www.abts.org/ABTS/CertificationWebPages/Initial_Certification_Page.aspxDate accessed: August 19, 2021Google Scholar,16Moffatt-Bruce S.D. Ross P. Williams T.E. American Board of Thoracic Surgery examination: fewer graduates, more failures.J Thorac Cardiovasc Surg. 2014; 147: 1464-1469Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar Clearly, many young cardiothoracic surgeons are still in need of gaining practical experience to apply their knowledge safely in real-life patient care settings, and this is evident when examined by qualified examiners skilled in identifying such deficiencies. The AATS has historically led the advocacy for the safe practice of thoracic surgery since its early leadership in leading the discussion around the need for an independent Thoracic Surgery Board.3The American Board of Thoracic SurgeryHistory of the board.https://www.abts.org/ABTS/About/About ABTS/ABTS/Public/About/History.aspxDate accessed: August 19, 2021Google Scholar It is currently not the role of the ABTS to decide when a thoracic surgery residency graduate is ready for independent practice. Rather, the ultimate responsibility lies with the surgeon administrative leadership working within the boundaries of their own hospital-credentialing process, often impacted by state codes and regulations. The AATS has led the discussion around the importance of certification from the early day of our specialty and should continue to do so. A potential path forward is to establish an AATS committee to develop a consensus statement recommending hospitals and, when necessary, states adopt a requirement for ABTS or equivalent International Board Certification before credentialing independent practice of Thoracic Surgery in the United States (Figure 1). During the certification process, candidates that have successfully completed their training programs could join the faculty or staff and take on increasing responsibilities, but always under the proctorship of a board-certified surgeon, disclosed to the patient and family. In addition to assuring patients receive the highest-quality care we can offer, such a path forward would also give recent graduates time to gain more experience in a monitored setting for at least several months after completion of training and before ABTS certification. This would address a recognized concern that due to the aforementioned highlighted reasons, many trainees do not feel ready to assume completely independent practice immediately after completion of residency training.17Bergquist C.S. Brescia A.A. Watt T.M.F. Pienta M.J. Bolling S.F. Super fellowships among cardiothoracic trainees: prevalence and motivations.Ann Thorac Surg. 2021; 111: 1724-1729Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar Finally, this direction would reinforce the ongoing responsibility of all of us as stewards of cardiothoracic surgery to invest in our newest faculty members to assure their successful matriculation through the ABTS certification process. The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest. The authors thank the following cardiothoracic surgeons for their feedback on certification requirements: Richard Bunton (Australia and New Zealand), Robin Varghese (Canada), Farzan Filsoufi (France), Michael Borger (Germany), Tohru Asai (Japan), and Clifford Barlow (UK). Commentary: Board certification as a prerequisite for independent practice: Who is to say?The Journal of Thoracic and Cardiovascular SurgeryVol. 164Issue 3PreviewAdams and colleagues1 suggest that completion of the certification process should be a prerequisite to begin independent practice in cardiothoracic surgery. The authors' suggestion is provocative but raises questions as to under whose authority could such a mandate originate. The American Board of Thoracic Surgery does not have the power to limit practice. The Board's function is to promote lifelong learning and practice improvement among its diplomates and to certify that a physician's qualifications for the practice of thoracic surgery are recognized by his or her peers. Full-Text PDF
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