Hand surgery emerged as a subspecialty during World War II when it was recognized that reconstruction of traumatic injuries to the hand and upper extremity required a specific body of knowledge that crossed several disciplines including orthopaedic, general, and plastic surgery.4
This was a time when surgical specialization was in its infancy with the establishment of the American Board of Orthopaedic Surgery (ABOS) in 1934, the American Board of Surgery (ABS) in 1937, and the American Board of Plastic Surgery (ABPS) in 1941. To meet the educational and scientific needs of these three specialties, the American Society for Surgery of the Hand (ASSH) emerged in 1946. The ASSH developed a well-organized program of continuing medical education and later was to become the major promoter of hand surgery as a distinct subspecialty.
Justification for Subspecialty Certification in Hand Surgery
Omer3 noted a medical subspecialty is an identifiable area in a recognized specialty to which a physician devotes considerable time and study. Smith,5 in a guest editorial in the Journal of Hand Surgery, pointed out by the 1970s, certain crucial elements and considerations existed that allowed consideration of the development of subspecialty certification in hand surgery.
The first is the prevalence of upper extremity disorders. In 1980, Kelsey et al2 in an epidemiologic survey using data from the United States National Health Survey of the National Center for Health Statistics noted there are annually 16 million upper extremity injuries sufficiently severe to bring about restriction of activity or a visit to a physician. The total annual cost of upper extremity injuries was in excess of $10 billion including medical expenses, lost earnings, and indirect costs of injury. Additionally, in the mid-1970s there were nearly 25 million people with arthritis, the second most common medical condition for which worker disability allowance was granted. Finally, in 1976, 3.2 million people in the United States reported upper extremity impairment.
Second, hand surgery is a distinct body of knowledge required to handle a major medical need. Hand surgery is not a discipline of special interests or skills. Although the three parent Boards require knowledge in hand surgery to receive primary certification, subspecialty certification in hand surgery encompasses an in-depth and discrete body of knowledge with elements contributed by all three Boards.
On the other hand, it was believed by some that sub specialty certification could cause fragmentation of the parent Boards (Orthopaedic, Plastic, and General Surgery). As subspecialty certification in hand surgery evolved, it was never the intent of its advocates to create an independent Board. The three primary Boards, from which subspecialty certification is granted, are all members of the American Board of Medical Specialties (ABMS), the umbrella organization for the 24 federally recognized certifying Boards. To qualify to sit for the sub specialty certification examination, one must hold a valid certificate from his or her primary Board.
Furthermore, some were concerned that pressure from the academic or legal community could result in certificate holders being the only physicians permitted to practice hand surgery. By implication such surgeons might be viewed as able to render better patient care for hand disorders. In reality, any physician who has received their primary Board certification is deemed qualified and competent to practice hand surgery. Moreover, the volume of hand disorders is great; a small group of physicians would only be able to care for a fraction of the problems. One intent of subspecialty certification is to allow the public and medical colleagues to know a certificate holder has met Board standards and is qualified to manage complex problems of the hand and upper extremity. Restraint of trade should not be, and is not, the stimulus for hand surgery subspecialty certification.
Smith5 also noted that there was concern that practitioners in other fields of special interest, such as sports medicine, hip surgery, and microsurgery, might request subspecialty certification. He felt that if a discipline could demonstrate that it represented a substantial body of knowledge and not merely a special interest or skill, there was merit in developing subspecialty certification. Twenty-five years later (2007), the first sports medicine subspecialty certification examination will be administered by the ABOS.
Another concern discussed by Smith5 was that subcertification in hand surgery would dilute or damage hand surgery training in residency programs. He argued that hand fellowships with separate clinics, conferences, laboratories, and teaching aids would raise the bar for resident education. He felt that fellows would assume the role of junior staff surgeons and would actively teach the residents.
One might argue de facto certification already exists and membership in the ASSH or the American Association of Hand Surgery is enough to demonstrate one's qualifications to practice hand surgery. In reality, medical societies and Boards serve different purposes. Medical societies are educational and advocacy associations, whereas medical Boards set requirements and standards for certification. Boards serve the public to ensure competence in a specific discipline.
History of Subspecialty Certification in Hand Surgery4
The development of subspecialty certification was a long and convoluted process that began in 1971 with dialogue between the ASSH and the ABMS. In 1973, the bylaws of the ABMS were revised to permit subspecialty certification. In 1974, the ASSH contacted the three parent Boards; however, they declined to lend their support to subspecialty certification. Finally, in 1979, at a joint meeting of the ABMS, ABOS, ABS, ABPS, and the ASSH it was agreed recognition of hand surgery was desirable, but the mechanism was yet to be determined. The ABMS bylaws defined a Certificate of Special Qualifications as reflecting the possession of knowledge, skill, and training in a special field over and above what is required for general certification. By 1981, the three Boards not only endorsed the certificate but agreed the certificate holder must receive a year of additional specialty training and successfully pass an examination. In 1984, the Joint Committee for Surgery of the Hand (JCSH) was formed with representation from the three Boards. Its charge was to develop, administer, and score examinations for subspecialty certification. The second part of the equation was to establish fellowship requirements for hand surgery. This was done with the approval of the Accreditation Council for Graduate Medical Education (ACGME) in conjunction with the residency review committees of orthopaedic, plastic, and general surgery. Requirements were identical for each of the three Boards.
In 1986, a joint application for subspecialty certification was filed with the ABMS and was unanimously approved. The ABMS staff complimented the three Boards on their cooperative effort and noted it should be a model for future programs.
Highlights of the requirement for subspecialty certification in hand surgery include: (1) candidates must pass his or her primary Board (ABOS, ABPS, ABS); (2) candidates must have a currently registered, full, and unrestricted license and full and unrestricted privileges at his or her hospital; (3) they must have an ethical standing in the profession and moral status in the community acceptable to the primary Board; (4) they must be actively engaged in the practice of hand surgery as indicated by holding full operating privileges in a hospital or surgery center approved by the Joint Commission on Accreditation of Heath Care Organizations; (5) they must satisfactorily complete a 1-year ACGME accredited hand surgery fellowship; and (6) they must submit a consecutive list of hand surgery cases from a 1-year period within 2 years of the application.
During a so-called grandfather period from 1989 to July 1994 there were no fellowship requirements to sit for the examination. Those surgeons who actively engaged in the practice of hand surgery and had not necessarily completed a 1-year hand surgery fellowship but had met other requirements, such as peer review and case volume, were permitted to sit for the examination. Effective July 1994, candidates were required to have satisfactorily completed a 1-year fellowship in hand surgery, and beginning July 1999 the fellowship had to be accredited by the ACGME. Linking accreditation and certification has always been an ABMS tradition.1 Additionally, a consecutive list of hand surgery cases from a 1-year period had to be submitted with a minimum of 125 cases from six of nine categories.
In 1989, the first hand surgery subspecialty examination was administered as a 10-year time-limited certificate.1 It was given to 510 candidates, with 81% holding ABOS certificates and 19% with ABS certificates (the ABPS did not participate until the following year). The overall failure rate was 7.6%. As of 2004, 2601 individuals have taken the certifying examination with an overall 14.5% failure rate (Table 1). Of note is an ABOS failure rate of 3.1%.
Unpublished data collected from examination exit surveys shows that success on the examination correlates with one's primary Board (orthopaedic surgery), case volume (> 300 hand cases per year), and devoting more than 75% of one's practice to hand surgery. If one meets these three criteria, passage is almost a given.
With the subspecialty certificate in hand surgery being time limited, recertification was first offered in 1996. The requirements for recertification include evidence of continuing medical education, peer review and/or licensure, and successful passage of an examination. To maintain subspecialty certification in hand surgery a computer-administered examination (identical to the primary certification examination in hand surgery) must be passed. Since 1996, 980 surgeons have been recertified and 916 have met with success (an overall failure rate of 6.5%; Table 2). For physicians receiving certification from the ABOS, 623 have recertified with a 2% failure rate.
Before 2004, orthopaedic surgeons holding a 10-year time-limited certificate in orthopaedic surgery and a certificate of subspecialty qualifications in hand surgery could recertify in both by merely passing the hand surgery recertification. However, beginning in 2004, board-certified orthopaedic surgeons with time-limited certificates in orthopaedic surgery and subspecialty certification in hand surgery who chose to recertify in both by the computer examination were required to take an examination consisting of 160 hand subspecialty certification questions and 80 general orthopaedic questions. The ABOS rationale for this change was that hand surgeons who recertified in orthopaedic surgery must possess basic knowledge in general orthopaedic surgery to validate to the public and profession that they were truly Board certified in orthopaedic surgery. Furthermore, all other orthopaedic colleagues who recertified are required to pass an examination that contains general orthopaedic questions to maintain certification. Therefore, the addition of the 80 general orthopaedic questions “leveled the playing field.” In the fall of 2004, 56 individuals completed the computer-based combined General Orthopaedic and Hand Recertification examination. The mean percent correct for the 80 general orthopaedic items was 79% and the mean percent correct for the 168 hand recertification items was 80%. A passing level of 67.5% correct was set. This resulted in no failures for the first combined examination. In 2005, 88 candidates took the combined general orthopaedic and hand subspecialty certification examination. Three candidates failed.
Subspecialty Certification and the American Society for Surgery of the Hand
Shortly after the hand subspecialty examination was initiated, the ASSH amended its bylaws to require those individuals applying for active membership to possess a sub-specialty certificate in hand surgery. From my perspective, this amendment leveled the playing field for ASSH membership. No longer is membership in the ASSH a privilege. If a surgeon meets the requirements to sit for the subspecialty examination and passes, ASSH membership is likely.
Under the auspices of the ABMS, recertification for the 24 ABMS boards is moving toward a process called maintenance of certification (MOC). With the rapid changes in medical care coupled with demands from the government, industry, and the public for quality care, physicians must demonstrate continuously they are proficient in their specialty. As mandated by the ABMS, physicians who elect to maintain certification must: (1) undergo a review of their professional standing (credentialing and licensure); (2) participate in continuing medical education; (3) pass a recertification examination; and (4) have their performance in practice assessed. Assessment methods are evolving and will probably include patient communication and satisfaction surveys, peer review, and a case list.
I believe subspecialty certification in hand surgery has benefited our specialty and the public. Holding such a certificate does not-and was never intended to-bestow special privileges related to the practice of hand surgery. Additionally, it does not translate to better patient care. Rather, it allows the public and our professional colleagues to know the certificate holder has met Board standards and is qualified to manage problems related to the hand and upper extremity.