The process of certification, recertification, and maintenance of certification is mandated by the American Board of Urology as a member Board of the American Board of Medical Specialties. The history of maintenance of certification parallels that of private regulation of medical schools and postgraduate medical education (residency) and other nonmedical areas in which public trust is involved. Current trends in information technology that allow data gathering that measure medical practice and recognition of failure mandate that urologists practice with current knowledge. This will be documented in the maintenance of certification process.
The upward spiral
Renewal is the principle—and the process—that empowers us to move on an upward spiral of growth and change, of continuous improvement. …[As] we grow and develop on this upward spiral, we must show diligence in the process of renewal by educating and obeying our conscience. An increasingly educated conscience will propel us along the path of personal freedom, security, wisdom, and power. Moving along the upward spiral …to keep progressing…we must learn, commit, and do…and learn, commit, and do again.
When Steven Covey published “The 7 Habits of Highly Effective People” in 1989, he was not speaking to the medical community but was addressing people as a management guru on personal development. Since that time, we have had our own medical spiral and some may believe it has been down rather than up. The rapidity of changes over the past two decades is enormous. Although many medical practitioners feel that regulation and compliance issues are directed only at the medical profession as a part of this, this is not the case. The medical community is one of many areas in which regulation has occurred.
The United States is a leader in medicine, but this was not always the case, and some may argue that it is not the case of the present or future. The pre-eminent position of American medicine is related to the regulation of medical education and specialization that occurred in the early part of the twentieth century. It was not until the 1920s that “American medical education had evolved from the worst in industrialized civilization to the very best…the marvel of the industrial world.” In the early 1900s, US medical schools had few standards, and education in scientific practice and knowledge lagged behind European counterparts, especially Germany and France. Many medical schools were being run primarily for profit. Abraham Flexner pointed out these deficiencies in a report in 1910 entitled “Medical Education in the United States and Canada” (“the Flexner Report”) commissioned by the Carnegie Foundation for the Advancement of Teaching. Although such reports are usually dry reading, the Flexner Report instigated revolutionary change in medical education. This revolution resulted in standardization of medical school curricula.
Around this time, medical specialties also emerged, among which was urology. David Innes Williams, a renowned urologic surgeon at St. Peter’s Hospital and the Hospital for Sick Children at Great Ormond Street, has defined a specialty. “A speciality [sic] has both a technical and a social dimension. Technically, it is defined by an acknowledged territory, a corpus of relevant knowledge, and a range of skills not readily acquired by the profession at large. The emergence of a surgical specialty was most often triggered by the skills required after the invention of a new instrument or a new operative procedure. Socially, a specialty can be seen to exist when there is a body of practitioners who devote the greater part of their time to a limited field who are recognized by designated appointments as providing a special service and who organize specialist societies and journals.”
Although urology branched from general surgery in the United States and most of Europe, in Great Britain urology remained a subspecialty of general surgery. Before the turn of the century, urology was recognized as a specialty separate from general surgery in the United States and most of Europe. This interesting history of disparate urologic development is attributed to the differing administrative structure with a national health system dominated by consultants of the two Royal Colleges, strength of the General Practice sector, and lack of a supportive university system.
After the restructure and regulation of medical schools that occurred in response to the Flexner Report, medical specialty boards started to appear. The stated purpose of these Boards was to improve standards of training and protect the public from “superficial training and commercialism.” Before their appearance, postgraduate medical education (residencies) lacked uniformity of content, had varying supervision, and varied in duration from weeks to months to years. The American Board of Ophthalmology was established in 1917, followed by the American Board of Otolaryngology in 1924, the Board of Obstetrics and Gynecology in 1930, the Board of Urology in 1935 (along with Orthopaedic Surgery, Pediatrics, and Radiology the same year), and the American Board of Surgery in 1937. Currently, 24 incorporated Boards exist, all of which are members of the American Board of Medical Specialties (ABMS), and one or more of the current boards certifies almost 90% of practicing physicians.
The Liaison Committee for Graduate Medical was established in 1972 as a private regulatory body for graduate medical education. It was succeeded by the Accreditation Council of Graduate Medical Education, which was established by consensus of the academic medical community as an independent accrediting organization in 1981 for postgraduate residency programs in the United States. Although medical school and postgraduate residency growth was originally disorganized and somewhat chaotic, public notice produced private regulation.
As a specialty, urology continues to evolve, with its practitioners integrating medical, surgical, technologic, imaging, and pharmacologic discoveries into new means for diagnosis, management, treatment, and prevention of genitourinary problems. The core of urologic diagnostics, management, and treatment always has involved medical and surgical components, but these areas and components of imaging, pharmacology, chemotherapy, and endoscopy have advanced in complexity and scope. Urologic imaging is no longer limited to retrograde pyelography, intravenous urography, and voiding cystourethrograms but encompasses ultrasonography, nuclear renography, CT, MRI, positron emission tomography, and molecular imaging, with decision analysis for selecting the optimal studies for the occasion. Treatment of advanced prostate cancer is no longer limited to diethylstilbestrol and radiation but includes new surgical and chemotherapeutic options, hormonal manipulation, radiation, and cyberknife. Pharmacologic choices for infection, impotence, prostatic enlargement, and incontinence are numerous.
Further subspecialization continues. With the explosive advances in medical knowledge and technology, specialists in areas previously unrecognized, such as trauma, critical care, endovascular surgical neuroradiology, and molecular genetics pathology, are common and sometimes required for hospitals. The landscape that composes the corpus for urology is reflected in the recent American Board of Urology (ABU) listing of the scope of urology, which includes but is not limited to the following: cognitive areas, such as ethics and professionalism, evidence-based medicine, perioperative care, wound healing/management, adrenal disease, benign renal disease, endocrinology, calculus disease, benign prostate disease, infertility female pelvic medicine and surgery, geriatric urology, infectious disease, neurourology and voiding dysfunction, urethral and ureteral obstructions, oncology, pediatric urology, renovascular disease, sexual dysfunction (male/female), renal transplantation, trauma, basic genitourinary pathology, and relevant diagnostic and technical skills, such as imaging (physics, diagnostic and therapeutic), open surgical skills/techniques, endourology, shock wave lithotripsy, laparoscopy, and urodynamics.
Urologic specialty societies, such as pediatrics, oncology, endourology, sexual medicine, female and neurourology, basic science, genitourinary reconstructions, and transplantation and renal surgery, also reflect the expanded areas of practice and interest. This superspecialization trend represents further differentiation within urology. This is a normal response to growth of a body of knowledge that is subdivided into multiple areas of specialties. In Williams’ terms, each of these areas represents the embodiment of speciality with technical and social dimensions. The trend is apparent in the United States and Europe.
It is not surprising that more extensive regulation of the practitioner after certification has emerged to protect the public. In 1986, legislation created the National Practitioner Data Bank; in 1996, the Secretary of the US Department of Health and Human Services—acting through the Office of Inspector General—created the Healthcare Integrity and Protection Data Bank as directed by the Health Insurance Portability and Accountability Act to combat fraud and abuse in health insurance and health care delivery. Both acts were instigated by practitioners crossing state lines to avoid discovery, and some of the current interest in recertification and maintenance of certification requirements is probably the result of the emphasis on medical error recognition. The stated purpose for creating the National Practitioner Data Bank was the “increasing occurrence of medical malpractice litigation and the need to improve the quality of medical care had become nationwide problems that warranted greater efforts than any individual State could undertake. The intent was to improve the quality of health care by encouraging state licensing boards, hospitals and other health care entities, and professional societies to identify and discipline those who engage in unprofessional behavior; and to restrict the ability of incompetent physicians…to move from State to State without disclosure or discovery of previous medical malpractice payment and adverse action history.” Perhaps this is an example of rules being made after predecessors break a trust.
Others with less onerous responsibilities have a similar history of regulation. As a result of concerns not unlike those discussed, the regulation of truck drivers and airline pilots occurred with expansion of services and formation of the US Department of Transportation. In 1934, Lubin, a member of President Roosevelt’s Advisory Committee on Federal Coordination of Railroads, became interested in motor vehicles and trucking and warned that 8 hours or more of driving created hazardous driving circumstances. When addressing the American Trucking Association, ne noted that lack of self-regulation would lead to federal regulation. A 1982 study estimated that driver error was the major cause of truck accidents 80% of the time. Not until 1992 did truck drivers have to pass written and driving tests to meet minimum federal standards, and prior training ranged from 150 to 610 hours without standardized licensing. These changes were instigated by the fact that large truck drivers needed only a routine driver’s license in 18 states, and they could easily obtain licenses in multiple states and avoid suspensions by spreading violations among the different licenses.
Long before concerns for regulating or mandating educational updating were entertained, individuals interested in continuing medical education focused on why and how physicians continue to learn after completion of their formal training and the need for lifelong learning. In personal essays on those remarkable stars of medical practice, discovery, and innovation, Manning and DeBakey found that these individuals have a “passion” for learning. Dr. A. McGehee Harvey, former chairman of the department of medicine at The Johns Hopkins University School of Medicine and physician-in-chief of The Johns Hopkins Hospital, stated “To be a good physician…[It] is a matter of developing the habit of learning so that it becomes second nature an not something you turn on and off at certain times…Education must be pursued actively, not through the passive receipt of information distilled by someone else…A teacher can provide motivation and an environment for learning, but it is still up to the student to be an active learner.”
Dr. Michael DeBakey, internationally renowned cardiac surgeon, director of the DeBakey Heart Center, previous chairman of the department of surgery, chancellor of the Baylor School of Medicine, and chairman of President Johnson’s Commission on Heart Disease, Cancer, and Stroke, recalled an incident from his childhood. “When I was a very young boy, my Father took me on a hunting trip, and when he set me down in the field, he said, ‘Now stay right here; I won’t be far away.’ He would go a short distance…returning every little while to bring back the ducks that he had shot. On one such occasion…I had my hands behind my back, and he said, ‘What’s wrong with your hands?’…I had to reveal my hands, which were bloody. He was immediately alarmed and asked, ‘What did you do? Did you cut yourself?’ I confessed that I had taken a knife out …and had opened the ducks…’I wanted to find out how they fly,’ I explained. Shortly after, my Father read me a book about birds flying.” This episode emphasizes, however, that passion and active learning must reside in the learner, and support of a teacher is needed for the best learning.
Perhaps what does not reside in the learner is just as important. Research has documented that students who fail often lack self-reflection. Although there may be indicators of lacking knowledge or poor performance, these students may be unlikely to foresee it, although others may. Active and proscribed educational activities may need to be required for these individuals to acquire new knowledge or learn to perform at improved levels. Research on the adoption and diffusion of innovations and new knowledge shows that personal and environmental characteristics are important to this process. Individuals have varying degrees of resistance to change or adopting new ideas that may or may not be scientifically based. With adoption of any new idea or innovation, predictable categories of group behavior have been studied, and patterns of adoption fall into categories: innovators, early adopters, early majority, late majority, and laggards. Each of these categories has its own personality and behavioral characteristics, which is an issue that may create haphazard adoption of new practices.
Although past practitioners’ education after residency was from formal educational courses, organized educational meetings and conferences, and literature, current education has many additional formats, such as multimedia that include telephone, radio, television, cable, and Internet. These formats have increased our capabilities for improving knowledge and communication and have created a “flat world.” All of this potential education is based on self-motivation and personal willingness to learn and adopt new knowledge. Two trends, the first being the ability to track quality and results through information technology and second being the recognition that individual error and failure may be prevented, have created a need for improved surveillance of physician continuing medical education.
Although the ABU did not invent or ask for “maintenance of certification,” the concept maintains the original mission of the specialty Boards. Maintenance of certification is a concept that was created by the ABMS in 1999 in response to increasing public scrutiny and awareness that physicians keep up with medical advances. The concept encompasses recertification and several elements that document a practitioner’s continuing involvement in medical education. The ABMS is asking physicians to fulfill four components: evidence of professional standing, evidence of commitment to lifelong learning and involvement in periodic self-assessment processes, evidence of cognitive expertise, and evidence of evaluation and performance in practice. The ABU is judging professional standing by peer review and judging evidence of cognitive expertise with certification or recertification testing. Findings will be used as evidence of commitment to periodic self-assessment. As a result, the first two of these components—evidence of professional standing and cognitive expertise—are already accomplished in the initial ABU certification and recertification process. The latter two areas of regular periodic self-assessment processes and evidence of evaluation and performance in practice are the areas in which the ABMS is requesting more documentation. The ABU will be using practice assessment protocols based on current urologic clinical guidelines to perform evaluation of performance in practice. Diplomates will perform self-review of a series of their personal cases in a specific area and compare their practice to those managed according to accepted guidelines. Beginning in 2007, physicians with time-limited certificates will enter the maintenance of certification process in the year in which they recertify ( Table 1 ).