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 NUMBER
22 AMERICAN BOARD OF NEUROLOGICAL
SURGERY 2003
NEUROLOGICAL
SURGERY
is a discipline of medicine and that
specialty of surgery that provides
the operative and non-operative management
(i.e. prevention, diagnosis, evaluation,
treatment, critical care, and rehabilitation)
of disorders of the central, peripheral,
and autonomic nervous systems, including
their supporting structures and vascular
supply; the evaluation and treatment
of pathological processes that modify
the function or activity of the nervous
system, including the hypophysis;
and the operative and non-operative
management of pain. As such, Neurological
Surgery encompasses the surgical,
non-surgical, and stereotactic radiosurgical
treatment of adult and pediatric patients
with disorders of the nervous system:
disorders of the brain, meninges,
skull, and skull base, and their blood
supply, including the surgical and
endovascular treatment of disorders
of the intracranial and extracranial
vasculature supplying the brain and
spinal cord; disorders of the pituitary
gland; disorders of the spinal cord,
meninges, and vertebral column, including
those that may require treatment by
fusion, instrumentation or endovascular
techniques; and disorders of the cranial
and spinal nerves throughout their
distribution.
The broad aim of the
AMERICAN BOARD OF NEUROLOGICAL SURGERY
is to encourage the study, improve
the practice, elevate the standards,
and advance the science of neurological
surgery, and thereby to serve the
cause of public health.
TRANSITION FROM RECERTIFICATION
TO MAINTENANCE OF CERTIFICATION
DAVID G. PIEPGRAS, MD IMMEDIATE
PAST CHAIRMAN
RALPH G. DACEY, JR.,
MD SECRETARY
VOLKER K. H. SONNTAG,
MD CHAIRMAN, MAINTENANCE OF CERTIFICATION
COMMITTEE
ARTHUR L. DAY, MD
TREASURER
TRANSITION
FROM RECERTIFICATION TO MAINTENANCE
OF CERTIFICATION DAVID G. PIEPGRAS,
MD IMMEDIATE PAST CHAIRMAN
Background
For the young specialist, completion
of postgraduate specialty training
remains a landmark that deserves recognition
as having achieved a high level of
expertise. As early as 1908 the first
specialty group, the American Academy
of Ophthalmology and Otolaryngology,
proposed a process for assessing specialists
in their field. In 1917 the nationally
recognized Medical Specialty Board
of Ophthalmology was established.
Otolaryngology followed in 1924 with
their program of required training
and certifi- cation. Neurosurgery
incorporated the ABNS in 1940 with
the broad aim to encourage the study,
to improve the practice, to elevate
the standards, to advance the science,
and to serve the cause of public health.
As specialty and subspecialty medicine
flourished, a need was seen for an
umbrella organization to coordinate
and facilitate the common purposes
and activities of the Boards. That
role was met in 1933 by the formation
of the Advisory Board for Medical
Specialties. In 1970 it was re-organized
and incorporated as the American Board
of Medical Specialties with the stated
mission to maintain and improve the
quality of medical care by assisting
member Boards in their efforts to
develop professional and educational
standards for evaluation and certification
of physician specialists. The mission
statement goes on to state that the
intent of certification is to provide
assurance to the public that a Diplomate
certified by a member Board has successfully
completed an approved educational
program and evaluation process that
assesses the knowledge, skills, and
experience required to provide quality
patient care in that specialty.
The process of certification is voluntary.
For the neurosurgeon it consists of
verification of having met basic training,
professional, and practice standards.
This is affirmed by passage of a cognitive
examination on basic knowledge relative
to the neurosciences, and finalized
through passage of an oral examination
con- firming the neurosurgeon’s
possession of fundamental clinical
knowledge and sound judgment.
Recertification
There has been a growing awareness
in the medical profession, as well
as the public, that initial certification
is not enough to assure a high level
of care throughout one’s career.
Over the past several decades there
has been a call for periodic recertification
of specialists. At the outset recertification
was envisioned as an impetus for physicians
to keep up with new knowledge. The
American Board of Family Practice
has issued seven-year time-limited
certificates since its inception in
1969; recertification requires an
evaluation of office practice and
cognitive knowledge, along with Continuing
Medical Education (CME) credits. Other
Boards followed suit as it became
recognized that updating knowledge
and basic skills is essential to maintaining
high quality patient care. Recertification
was affirmed by ABMS policy statements
dating back to 1973, and in 1993 the
ABMS adopted as policy: “the
goal of recertification is to evaluate
the continuing competence of a Diplomate
in the specialty in which he/she was
initially certified”. By 1998
most member Boards had recertification
in place, primarily based on passing
an examination, maintaining licensure,
and meeting CME requirements. Neurosurgery
was slow to join the movement and
had the somewhat ignominious distinction
of being the last Board to adopt a
plan. The first ABNS tenyear time-limited
certificates were issued in May 1999.
Meanwhile expectations were changing.
Quality of medical care, incompetent
physicians, and consumer protection
had become issues of broad concern
on a national level. There was growing
recognition that a test of factual
knowledge every ten years is inadequate
to assure a continuum of high level
knowledge and skills. In response
to the demand for improvement, task
forces, private and presidential commissions,
and the Institute of Medicine Committee
were formed to examine the quality
of health care in the U.S. Dr. Kenneth
Shine, President of the Institute
of Medicine, challenged physicians
by stating that demonstration of competence
and verification of performance are
the expectations for the future.
MOC
In recognition of the need to satisfy
the public, payers, other health care
organizations, governmental agencies,
and the profession itself, in 1998
the ABMS created the Task Force on
Competence to assure that specialists
maintain satisfactory up-to-date knowledge
and skills throughout the span of
their careers. In essence, in the
words of then ABMS President Dr. Leo
Dunn, “to do what we say we
do.” ABMS leadership espoused
that recertification programs should
transform from a periodic examination
and meeting CME requirements to a
continuing process of updating and
maintaining knowledge and skills through
ongoing learning and improvement in
practice. In March 2000 ABMS Boards
adopted a commitment to evolving their
current or planned programs for recertification
into programs for MOC.
The MOC movement has gained momentum
and been embraced in the policies
of not only the ABMS, but also the
Accreditation Council of Graduate
Medical Education (ACGME) and Association
of American Medical Colleges. The
expectation is that training and acquisition
of knowledge and skills in medical
practice will begin in medical school,
be enhanced and honed to the specialty
in residency, and maintained throughout
a specialist’s career.
Admittedly the designation of “competence”
has been troublesome for ABMS Boards.
All Boards share the belief that their
Diplomates possess “requisite
or adequate ability or qualities”;
however, they and their legal counsels
are reluctant, indeed unwilling, to
accept the responsibility that the
certification process verifies “competence”
in all aspects of practice at all
times. The Task Force on Competence
defined physician competence as follows:
“The competent physician should
possess the medical knowledge, judgment,
professionalism, and clinical and
communication skills to provide high
quality patient care. Patient care
encompasses the promotion of health,
prevention of disease, diagnosis,
treatment, and management of medical
conditions with compassion and respect
for patients and their families.”
In concert with the ACGME, six general
“competencies” have been
identified as key elements for the
full spectrum of MOC. Thus, although
neither the ABNS nor its sister Boards
purports to certify competence, it
strives to evaluate competence with
respect to knowledge and practice.
The components, appropriate to the
specialty, form the foundation for
physician and resident training; the
basis for credentialing, both primary
certification and future MOC; and
the accreditation standards against
which residency programs are assessed
in their teaching and performance
by Residency Review Committees (RRC).
They are:
Medical Knowledge:
Know and critically evaluate current
general and practice specific medical
information; understand and incorporate
evidence- based decision making.
Patient Care:
Improve performance skills, including
medical interviews and physical
examinations; incorporate a synthesis
of clinical data.
Interpersonal and Communication
Skills: Communicate effectively
with patients and families, other
professionals, and team members;
maintain comprehensive legible medical
records.
Professionalism: Demonstrate
self-awareness and knowledge of
limits, high standards of ethical
and moral behavior, reliability
and responsibility, respect for
patient dignity and autonomy
Practice-Based Learning
and Improvement: Engage
in ongoing learning to improve knowledge
and skills; analyze one’s
practice to recognize strengths
and deficiencies; seek input to
improve practice and quality care.
Systems-Based Practice:
Promote patient safety within the
system; provide value for patients
through cost effective care; promote
health and prevention of disease
and injury; demonstrate effective
practice management.
ABNS MOC
The ABNS is giving careful thought
and study to the methodology of an
MOC program. Certain principles governing
the plan are already established,
whereas others are just taking shape.
The overriding principle is that the
process must evaluate the six basic
competencies and evolve into a continuous,
rather than periodic, process. The
ABNS envisions that its primary certification
program will remain as it currently
functions: verification of credentials,
evaluation by peers, review of practice
data, and examinations. MOC will necessarily
conform to the model adopted by the
ABMS with assessment of four components.
A proposal for assessment of the first
components has been submitted to the
ABMS for approval.
For evidence of professional standing,
all ABMS Boards will require an unrestricted
license to practice medicine. The
ABNS will likely also include input
from peers and perhaps co-workers
and even patients.
Evidence of cognitive expertise will
be met by a secure examination, undoubtedly
multiple choice, administered at test
centers around the country. It is
the only part of MOC that will be
pass/fail. The Examination Committee,
with input from the Extra-Mural Subspecialty
Item Writing Committee, is already
assembling a bank of questions to
generate an examination that will
test fundamental knowledge, as well
as practice related current clinically
valid knowledge. Additionally it will
cover information relating to the
practice environment, such as quality
assurance, safety, ethics, and economic
issues. Diplomates will be given the
option to be examined completely in
general neurosurgery or partially
in complex spine surgery or pediatric
neurosurgery. The fact that the examination
will be practice related should allay
fears regarding esoteric question.
Also there will be no limit on retaking
it.
The requirement for evidence of participation
in lifelong learning and self-assessment
is challenging. Traditional CMEs will
be part of this but less weighty than
practice related selfstudy and analysis.
The Self-Assessment in NeuroSurgery
(SANS) program holds promise as an
important element, as well as valuable
in preparing Diplomates for the secure
examination.
Involvement in a program for evidence
of evaluation of practice assessment
has the potential to bring about significant
improvement in practice. A web-based
analysis of key cases relative to
management methods and procedural
outcomes will likely be used here.
The ABNS will proceed slowly in developing
these programs and look to the cumulative
experience of other surgical Boards
and the ABMS for direction. Methods
for assessment and feedback relative
to performance in the six areas will
undoubtedly evolve and ultimately
become most meaningful.
Many Diplomates will regard MOC with
trepidation or even outright hostility,
which is understandable. I reassure
you, however, that the ABNS is committed
to the program with the realization
that “its time has come”,
and it is “the right thing to
do” for our patients and our
specialty. The goal is an MOC process
that is not onerous or expensive but,
instead, meaningful and enhancing
to the practice and competence of
neurosurgeons.
Click
here if you would like to respond
to the article above
RALPH G.
DACEY, JR., MD SECRETARY
The Directors of the American Board
of Neurological Surgery have been
busy during the past year with several
initiatives important to all Diplomates.
In this edition of the Newsletter,
Drs. David G. Piepgras, Volker K.
H. Sonntag, and Arthur L. Day describe
some of that work.
Dr. Piepgras, immediate past ABNS
Chairman and a member of the executive
committee of the American Board of
Medical Specialties (ABMS), provides
the background and rationale for Maintenance
of Certification (MOC).
Dr. Sonntag, ABNS Vice Chairman and
chair of the MOC Committee, describes
the work of his Committee, its accomplishments,
and areas for continued effort.
Finally Dr. Day, ABNS Chairman and
immediate past Treasurer, describes
the development of NEURO-LOG, improvements
in the operations of the Board, and
the status of its finances.
Click
here if you would like to respond
to the article above
VOLKER K.
H. SONNTAG, MD CHAIRMAN, MAINTENANCE
OF CERTIFICATION COMMITTEE
The MOC Committee continues to be
very active, having met several times
since the last Newsletter. In association
with its Diplomates and organized
neurosurgery, the ABNS is working
hard to develop a meaningful process
that conforms to ABMS standards. The
ABNS application for its MOC process
has now been submitted to the ABMS.
The four components of MOC consist
of:
- Evidence of professional standing,
- Evidence of life-long learning
and self-assessment,
- Evidence of cognitive knowledge,
and
- Evidence of performance in practice.
Evidence of professional
standing is the only component
completed at the present time. It
will require a full, unrestricted
license to practice medicine in all
jurisdictions in which the Diplomate
practices. The neurosurgeon must also
have unencumbered hospital admitting
privileges to practice neurosurgery,
and a letter of recommendation from
the chief of staff of the primary
hospital will need to be submitted.
Evidence of fulfillment of these requirements
must be submitted to the ABNS every
two years. The MCO Committee is also
working on how individuals who are
not practicing full time can participate
in the process.
Although not finalized, the following
is planned for the other three components.
Evidence of life-long learning
and self-assessment will
require Diplomates to submit evidence
of completion of 100 hours of CMEs
over a two year cycle: 40 hours of
Category 1 and 60 hours of Category
II or a mix of both. Tracking of credits
will be done in conjunction with the
American Association of Neurological
Surgeons. The component will also
include an open book examination to
be taken every two years. This will
be carried out in conjunction with
the Congress of Neurological Surgeons.
Evidence of cognitive knowledge
will consist of a secure, web-based
examination to be completed every
ten years. The examination will consist
of 200 questions, with three test
modules available: general neurosurgery,
spine surgery, and pediatric neurosurgery.
For the complex spine and pediatric
examinations, 150 questions will be
from general neurosurgery and 50 from
the subspecialty.
Evidence of performance in
practice will consist of
submission of ten key cases by Diplomates
every two years. The cases will be
selected from a list of procedures
covering all subspecialties. In addition,
Diplomates will track six months of
operative cases. This should help
to develop a practice profile for
Diplomates and hopefully provide feedback
about outcomes, possibly compared
to national benchmarks.
The ABNS acknowledges that adopting
an MOC program and processes will
signifi- cantly change professional
requirements, which could generate
considerable frustration. The Board,
however, is committed to making the
program accessible, affordable, and
professionally enhancing and, thereby,
meaningful for Diplomates, patients
and the general public. The ABNS welcomes
the input of its Diplomates in the
MOC process.
Click
here if you would like to respond
to the article above
ARTHUR L.
DAY, MD TREASURER
ABNS yearly revenues are derived
from several sources, including the
annual membership assessment, fees
for written and oral examinations,
and return on investments. Yearly
expenditures include office expenses
(salaries, benefits, rent, and supplies,
etc) and the activities of Directors
in their various Committee functions
(development and delivery of examinations,
and development of MOC, etc.). In
years past, expenses have generally
run slightly lower than revenues,
thus enabling the Board to establish
a reserve operational fund.
The ABNS is addressing several major
issues that have required restructuring
of its finances.
- Meeting frequency and length
is one of these. Faced with increasingly
complex issues, Directors each year
now hold a third meeting, which
is regularly scheduled in the winter
and dedicated to a specific focus.
- MOC will require the Board to
review practice data from its Diplomates
periodically throughout the life
of their practices. In order to
facilitate this, the ABNS developed
a web-based logging system called
NEURO-LOG to compile and manage
data from residents, primary certification
applicants, and MOC candidates.
The goal of the database project
was originally to standardize and
digitize candidate practice data
submission. NEURO-LOG goes beyond
this by offering HIPAA compliant
technology that merges the ABNS
requirements with those of the RRC
for Neurological Surgery and creates
a seamless system useful from residency
to retirement with a similar data
submission format for all levels.
In addition, once implemented and
used for several years, the database
should be quite useful in evaluating
practice patterns. NEURO-LOG will
be released later this summer. It
will be supported by DataHarbor
and the ABNS office. Details can
be found at www.ABNS.org.
- The Board office has made much
needed upgrades in important electronic
and communications capabilities
in order to prepare for the future
and increase its workload.
The fee for the 2003 written Primary
Examination was $410 and currently
$2250 for the oral examination. The
yearly contribution asked of actively
practicing Diplomats is $125. These
fees, increased by vote in fiscal
year 2002, cover the costs of activities
as they currently exist but may not
take care of future expenses, for
instance those associated with MOC
and increased legal costs associated
with ensuring Diplomate conformity
to Board standards.
The ABNS Investment Portfolio is
divided equally between equities and
bonds. Like all similar funds, it
diminished in value over the past
few years, but fortunately by the
end of June 2003 the Portfolio had
recovered substantially. The Board
expects that the budget for 2003,
as was the case for 2002, will balance
(income vs. expenditures) without
dipping into reserves.
The fourteen Directors of the American
Board of Neurological Surgery hope
this Newsletter has been of interest
to you. If you have any questions,
advice, or comments, please write
to the office or e-mail us at abns@tmh.tmc.edu.
Notices of change of address are always
appreciated, and it is helpful to
learn of change of status to retired
since assessment statements are sent
only to active practitioners. Diplomates
overwhelmingly continue to support
the Board’s commitment to continuing
improvement of the certification process
and the search for an acceptable MOC
process through the voluntary dues
program. Thank you.
Click
here if you would like to respond
to the article above
The fourteen Directors
of the American Board of Neurological
Surgery hope this Newsletter has been
of interest to you. If you have any
questions, advice, or comments, please
write to the office or e-mail us at
abns@tmh.tmc.edu. Notices of change
of address are always appreciated,
and it is helpful to learn of change
of status to retired since assessment
statements are sent only to active
practitioners. Diplomates overwhelmingly
continue to support the Board’s
commitment to continuing improvement
of the certification process and the
search for an acceptable MOC process
through the voluntary dues program.
Thank you.
THE AMERICAN BOARD OF NEUROLOGICAL
SURGERY
Officers
Chairman
ARTHUR L. DAY, M.D. Boston,
Massachusetts
Vice-Chairman
VOLKER K. H. SONNTAG, M.D.
Phoenix, Arizona
Secretary
RALPH G. DACEY, JR., M.D.
St. Louis, Missouri
Treasurer
MARC R. MAYBERG, M.D. Cleveland,
Ohio
Administrator
MARY LOUISE SANDERSON
DIRECTORS
H. HUNT BATJER, M.D.
Chicago, Illinois
KIM J, BURCHIEL, M.D.
Portland, Oregon
WILLIAM F. CHANDLER, M.D.
Ann Arbor, Michigan
M. SEAN GRADY, M.D.
Philadelphia, Pennsylvania
HAL L. HANKINSON, M.D.
Albuquerque, New Mexico
ROBERT L. MARTUZA, M.D.
Boston, Massachusetts
RICHARD B. MORAWETZ, M.D.
Birmingham, Alabama
A. JOHN POPP, M.D.
Albany, New York
JON H. ROBERTSON, M.D.
Memphis Tennesse
ROBERT A. SOLOMON, M.D.
New York, New York
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