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THE CLASSIC: EDITORIAL: Development of Certification in Hand Surgery

Omer, George, E, Jr; Graham, William, P, III

Clinical Orthopaedics and Related Research: August 2006 - Volume 449 - Issue - p 6-10
doi: 10.1097/01.blo.0000224023.18905.a9
SECTION I: SYMPOSIUM I: C. T. Brighton/ABJS Workshop on Orthopaedic Education
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Correspondence to: Henry H. Sherk, MD, Drexel University College of Medicine, Orthopaedic Surgery, 245 N. 15th St. 7th Floor (MS420), Philadelphia, PA 19102. Phone: 215-762-4471; Fax: 215-762-3442; E-mail: Henry.Sherk@DrexelMed.edu.

(This Classic Article is ©1989 and is reprinted with permission of Elsevier Science from Omer GE Jr, Graham WP 3rd. Development of certification in hand surgery. J Hand Surg Am. 1989;14:589-593.)

In 1971, the members of the American Society for Surgery of the Hand (ASSH) decided that the specialty of hand surgery justified establishing an American Board of Hand Surgery, which would certify individuals who had met certain requirements in that field. In 1989, 18 years later, they finally succeeded in doing so. Dr. George Omer and Dr. William Graham describe in this classic article what they and their fellow members in the ASSH went through to achieve ultimate success in this endeavor. The article outlines the organizational aspects of accreditation and certification and how the political interaction between specialty societies, agencies, and associations can affect the process.

Fig. 1

Fig. 1

Dr. Omer was born in Kansas City, Kansas and earned an undergraduate degree at Fort Hays Kansas State University. He attended medical school at the University of Kansas and graduated from there in 1950. He immediately went into active duty in the US Army at Brook Army Hospital in San Antonio, and entered an orthopaedic residency there soon after. He developed an interest in hand surgery early on and received specialty training in that field with Adrian Flatt in Iowa City and Dan Riordan in New Orleans in 1962 and 1964, respectively. He had a series of assignments in the Army thereafter and served in the military for 20 years.

In 1970, at the end of his Army career, he entered academic medicine at the University of New Mexico in Albuquerque. He organized and created the Department of Orthopaedics there and stayed on as department Chairman until 1990. He continued to practice for a time thereafter and still attends rounds and teaching conferences. He has had an outstanding 56 year career after medical school.

His co-author in writing this paper was Dr. William Graham, who practiced in Hershey and Carlisle, Pennsylvania.

Henry H. Sherk, MD

Reconstruction of traumatic injuries of the hand and upper extremity became a special area of surgery during World War II and stimulated the organization of the American Society for Surgery of the Hand (ASSH) in 1946.1,2 The major educational effort of the ASSH has been a program of continuing medical education (CME) for all physicians interested in the care of the hand and upper extremity. The CME program of the ASSH was accredited in 1975 by the Liaison Committee on Continuing Medical Education (LCCME),3 with subsequent designation of hand surgery as a surgical subspecialty by the American Medical Association (AMA).

Postgraduate fellowships in hand surgery developed because a progressively larger number of general, orthopaedic, and plastic surgeons desired special training after completion of their residency programs to improve their knowledge and capabilities in surgery of the hand. In 1970, the ASSH published an information booklet that identified 56 special training programs for hand surgery in the United States and Canada. However, there was no standardization of the educational experience in these programs.4 From 1970 through 1978, the ASSH developed committees to study the educational experience in a postgraduate fellowship in hand surgery, including guidelines, credentials, and on-site evaluation. These committees were consolidated into the Division of Graduate Education. Thirty-seven directors of hand surgery fellowships voluntarily initiated continuing on-site program evaluation in 1978.5 However, this evaluation process was not under the supervision of the Residency Review Committee (RRC), nor recognized by the Accreditation Council for Graduate Medical Education (ACGME).

In 1920, The AMA Council on Medical Education created 15 committees to recommend the preparation essential to secure expertness in each of the primary specialties. During the 1930s, graduate medical education programs were accredited by several organizations, including the AMA, the American College of Surgeons, and the primary specialty Boards. During the 1950s, Residency Review Committees (RRCs) were established for the primary specialties. The approved graduate medical education program that meets appropriate special requirements for content and experience is accredited by the RRC of the primary specialty, such as orthopaedic surgery, plastic surgery, or surgery.

Successful graduates of accredited programs may apply for certification by the related primary specialty Board, such as the American Board of Orthopaedic Surgery (ABOS), the American Board of Plastic Surgery (ABPS), or the American Board of Surgery (ABS). Certification occurs after satisfactory completion of any prerequisite and requirements of the Board and successful completion of the Board examination process. The RRCs provide accreditation through the ACGME and the primary Boards are members of the American Board of Medical Specialties (ABMS).

In 1933, representatives of the existing primary Boards, the American Hospital Association, the Association of American Medical Colleges, the AMA Council on Medical Education, the Federation of State Medical Boards, and the National Board of Medical Examiners created the Advisory Board for Medical Specialties. This became the ABMS in 1970.

Early in the history of specialty Boards, the major disciplines of medicine and surgery began to develop sub-specialties. The American Board of Internal Medicine was incorporated in 1936, and since has developed 12 Certificates of Special Competence in subspecialties such as cardiovascular disease and rheumatology. The American Board of Surgery was incorporated in 1937, after five primary surgical specialty boards, including Orthopaedic Surgery, had been organized. Since 1937, four additional primary surgical specialty boards, including Plastic Surgery, have been organized. The autonomy and independence characteristic of the surgical specialties changed in 1975 when a Certificate of Special Competence in Pediatric Surgery was sponsored by the ABS.

During the past 5 years (1983 to 1988), there have been 18 new types of certificates authorized by the ABMS; at the present time there are 11 new types of certificates on file; and at least 3 more are pending.6 Over the past 10 years, subspecialty certificates have been awarded in approximately 45 categories, with approximately 20% of all certificates awarded in a subspecialty.7 None have been awarded by the ABOS or ABPS.

Formal discussions concerning certification in hand surgery began in 1971 when the Surgical Council of the ABMS wrote the Secretary of the ASSH inquiring about “the possibility of a Board in hand surgery, perhaps supported by the ABS, the ABOS, and the ABPS.”8 Correspondence was initiated with all three primary boards regarding a Conjoint Board of Hand Surgery, but in February 1972, the ABMS placed a moratorium on the formation of additional primary, subsidiary, or conjoint boards.9 In 1973, the bylaws of the ABMS were revised to provide certificates of special competence. Subsequently, the ASSH wrote all three primary boards and requested a joint sponsorship, but in 1974 the three primary boards declined to endorse subspecialty certification.

In 1978, the chairman of the Liaison Committee on Graduate Medical Education (later the ACGME) was contacted by the President of the ASSH for guidance concerning appropriate educational requirements for a fellowship hand surgery. The response recommended that subspecialty certification should be obtained before accreditation of fellowship programs.10 In response, the Executive Director of the ABMS was invited to participate in the September 1978 mid-year meeting of the ASSH, and all three primary boards were contacted again. In July 1979, a meeting was held with representatives of the ASSH, ABMS, ABOS, ABPS, and ABS; it was agreed that recognition of hand surgery was desirable, but the mechanism by which that recognition should occur could not be determined.

A survey of the frequency and the cost of upper extremity disorders in the United States was conducted by Jennifer L. Kelsey, PhD, and colleagues at Yale University. The results of this major impact study, which was financed by the ASSH, were published in 1980.11

Utilizing this material, data for the three primary boards were prepared as outlined in Section 9.4, Article VIII, Bylaws of the ABMS.12 A certificate of Special Qualifications indicates the possession of knowledge, skill, and training in a special field over and above that required for general certification. A Certificate of Added Qualifications reflects additional training of at least 1 year and satisfactory completion of an examination in a special field. The proposal was presented to the ABPS in November 1980 by G. E. Omer, Jr., MD, and by G. E. Omer, Jr., MD, and R. J. Smith, MD, to the ABOS in March 1981. The final meeting of this tripartite presentation was July 1981 with the ABS. There was unanimous agreement by the three primary boards that discussions concerning a Certificate of Added Qualifications in Hand Surgery should continue and that an ad hoc Joint Committee for Surgery of the Hand should be organized with representatives from each of the three primary boards, the ASSH, and the American Association for Hand Surgery (AAHS). The first meeting was held May 31, 1982. The representatives of the five organizations selected Stanley J. Dudrick, MD (ABS) as chairman and Philip D. Wilson, Jr., MD (ABOS) as secretary. After almost 2 years of study, the ad hoc committee recommended a permanent committee and the Articles of Agreement were signed in March and April of 1984 by all five organizations. The permanent committee was designated the Joint Committee on Surgery of the Hand (JCSH). Instrumental in bringing this stage of development to fruition was the guidance and advice of James Humphreys, MD, who as executive director of the ABS, had experience in other similar programs.

The JCSH was charged to serve as an advisory committee to the three primary Boards (ABOS, ABPS, ABS), and to develop, administer, and score individual examinations for subspecialty certification. The first meeting was held September 1, 1984. George E. Omer, Jr., MD (ABOS) has served as Chairman, Stanley J. Dudrick, MD (ABS) and Basil A. Pruitt, Jr., MD (ABS) have served as Vice-Chairmen, and William P. Graham III, MD (ABPS and ASSH) has served as Secretary; the ABOS was designated as the Administrative Agent for the first 5 years.

The Advisory Council for Orthopaedic Resident Education (ACORE), in conjunction with its parent organizations (ABOS, American Orthopaedic Association, Association of Orthopaedic Chairmen, and the American Academy of Orthopaedic Surgeons), sponsored a workshop on Orthopaedic Fellowships on November 11 through 13, 1982. One recommendation was that a mechanism for approval of fellowships should be patterned after current accreditation processes.13 After the 1982 ACORE meeting, the RRC for Orthopaedic Surgery identified a need to establish a mechanism that incorporated current accreditation procedures for residency programs with additional procedures for Accreditation of postgraduate fellowship education in orthopaedic surgery.14

During the second meeting of the JCSH, a working relationship was established with the RRC for Orthopaedic Surgery through Donald B. Kettelkamp, MD, who was a representative to both committees from the ABOS. The RRC for Orthopaedic Surgery developed general requirements for all fellowships in orthopaedic surgery, which were subsequently approved by the ACGME. The Special Requirements for Hand Surgery were then developed by the RRC for Orthopaedic Surgery while Donald B. Kettelkamp, MD, served as Chairman.15 The Special Requirements for Hand Surgery were reviewed by James Callison, MD, Chairman of the RRC for Plastic Surgery, and Hiram Polk, MD, Chairman of the RRC for Surgery. After appropriate impact studies, the identical Special Requirements for Hand Surgery were agreed on by all three Residency Review Committees. The ACGME approved Special Requirements in Hand Surgery for orthopaedic surgery based on fellowships on June 3, 1985, and for plastic surgery based fellowships on February 17, 1986. These special requirements were first published in the 1986-1987 Directory of Residency Training Programs (Green Book), as accredited by the ACGME. The accreditation status of the basic residency program (orthopaedic surgery, plastic surgery, or surgery) will determine the eligibility of the postgraduate fellowship for accreditation.

There will be an on-site inspection of a postgraduate fellowship program in conjunction with the RRC evaluation. The forms and methodology of the site visits are still under development and may utilize documents developed by the ASSH in the voluntary evaluation program initiated in 1978.5 The fellowship should be at least 1 year and structured to provide basic and advanced education in hand surgery, as well as personal operative experience to develop diagnostic, procedural, and technical skills. Adequate postoperative follow-up and rehabilitative experience are also essential. It is anticipated that accreditation of postgraduate fellowships in hand surgery will be initiated in 1989.

Number 449 August 2006 During 1984, the Joint Committee on Surgery of the Hand developed an application for a Certificate of Added Qualifications in Hand Surgery. The application was prepared by a task force of the JCSH, headed by Richard J. Smith, MD. The application form includes an Impact Statement regarding the anticipated changes within primary disciplines. The application was presented by the JCSH to all three primary Boards, and approved by ABOS on July 16, 1985, by ABPS on November 11, 1985, and ABS on November 20, 1985. The joint application was reviewed and endorsed by the Executive Committee of the ABMS. On March 20, 1986, the full Assembly of the ABMS unanimously approved the joint application from the three primary Boards (ABOS, ABPS, ABS) for a Certificate of Added Qualifications in Hand Surgery, thus providing an appropriate mechanism for certification of hand surgeons.16 Staff members of the ABMS commented that this type of cooperative endeavor among overlapping fields should serve as a model for future programs.

The requirements that must be met for the Certificate of Added Qualifications in Hand Surgery are as follows17:

  1. Each candidate must be a Diplomate of the primary Board (ABOS, ABPS, or ABS), and have been in the active practice of surgery of the hand for at least 2 years after the completion of any formal training
  2. Must have currently registered full and unrestricted license to practice medicine in the United States, a United States jurisdiction, a Canadian province, or be engaged in full-time practice in the Federal Government
  3. Must have an ethical standing in the profession and moral status in the community acceptable to the primary Board
  4. Must be actively engaged in the practice of surgery of the hand as indicated by holding full operating privileges in a hospital approved by the Joint Commission of Accreditation of Hospitals
  5. Effective July 1, 1994, must have satisfactorily completed a fellowship in surgery of the hand approved by the RRC of the specialty sponsoring the fellowship and accredited by the ACGME
  6. Must submit lists of cases managed during a consecutive 12-month period within the 3 years preceding application. The case list must include at least 125 cases fulfilling at least six of the following categories:
  7. TABLE

    TABLE

  8. Candidates who do not fulfill the practice requirements may petition the Committee on Credentials of the primary Board for individual consideration. This consideration will take into account other contributions and dedications to the discipline of surgery of the hand, such as (1) teaching, (2) publications, (3) administration, and (4) research.
  9. Must pass any and all examinations prescribed by the primary Board (ABOS, ABPS, and ABS). The examination will be administered periodically, starting in 1989. The examination will include questions designed to evaluate cognitive knowledge of clinical surgery of the hand and basic science relevant to surgery of the hand.

The JCSH selected the American Board of Surgery Examination Division as the initial contractor to provide the examination. The process has two major components: (1) meeting the standards for eligibility, including peer review, and (2) evaluation of cognitive knowledge. The entire examination must be developed and administered by the same standards as the certification examinations of the primary Boards. The matrix of the first examination is based in part on a Role Delineation Study by the American College Testing Program (ACT) and financed by AAHS and ASSH in 1985. The ACT study was developed with a joint AAHS-ASSH task force, chaired by Graham D. Lister, MD, and provides a profile of clinical activities done by a hand surgeon. The JCSH Committee on Examinations conducted a field trial in 1987.

On May 7, 1988, the American Board of Plastic Surgery formally withdrew from the Joint Committee for Surgery of the Hand, and with that action also withdrew from the Certificate of Added Qualifications in Hand Surgery.

Surgery of the hand is an established subspecialty of surgery. Appropriate educational requirements (accreditation) and standards of individual competence (certification) have been established to achieve optimal patient care. A cooperative effort has been made in the establishment of the Certificate of Added Qualifications in Hand Surgery.

The first examination for the Certificate of Added Qualifications in Surgery of the Hand was held January 30, 1989. There were 510 examinees-412 (81%) Diplo-mates of the American Board of Orthopaedic Surgery and 98 (19%) Diplomates of the American Board of Surgery. There was an overall failure rate of 7.6% for this initial evaluation. Significant relationships were demonstrated between examination performance and several variables, such as percentage of practice in hand surgery, hand fellowship, and annual caseload.

In May 1989, the American Board of Plastic Surgery rejoined the Joint Committee for Surgery of the Hand.

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REFERENCES

1. Barsky AJ. History of The American Society for Surgery of the Hand. Am Soc Surg Hand 1977;1-3, 255.
2. Bell JL. American Society for Surgery of the Hand, 25 years: 1945-1970. Am Soc Surg Hand 1970;47.
3. Letter dated March 21, 1975, from C.H. William Ruhe. Secretary, Council on Medical Education, to George E. Omer, Jr., Coordinator of Education, The American Society for Surgery of the Hand.
4. Goldner JL. Hand surgery training: Presidential address, American Society for Surgery of the Hand. J Bone Joint Surg 1970;52A: 1061-5.
5. Omer GE, Jr. Postgraduate education and the American Society for Surgery of the Hand-Presidential address. J HAND SURG 1979;4: 274-8.
6. Langsley D. Letter dated May 18, 1988, from American Board Medical Specialties to Omer GE, Jr. American Board of Orthopaedic Specialties.
7. Omer GE, Jr. Recertification and subcertification. AOA News 1988;20:25-6.
8. Letter dated August 21, 1971, from Beattie EJ, Jr. Surgical Council, American Board Medical Specialties to Milford L, Secretary, American Society for Surgery of the Hand.
9. Omer GE. The Joint Committee For Surgery of the Hand. J HAND SURG 1982;7:221-3.
10. Letters dated May 22, 1978, and June 14, 1978 from Hamilton WK, Chairman, Liaison Committee on Graduate Education to Omer GE, President, American Society for Surgery of the Hand.
11. Kelsey JL, Pastides H, Kreiger N, Harris C, Chernow RA. Upper extremity disorders. A survey of their frequency and cost in the United States. St. Louis: The CV Mosby Company, 1980:71.
12. American Board of Medical Specialties. Annual report and reference handbook, 1988. Evanston, Illinois: American Board of Medical Specialties. 80-84.
13. Minutes, American Board of Orthopaedic Surgery, dated March 15-16, 1983. Chicago.
14. Statement of justification of the special requirements for postgraduate fellowship in the subspecialties of orthopaedic surgery. Residency Review Committees for Orthopaedic Surgery, June 1985.
15. Kettelkamp DB. Correspondence newsletter 1985-79. American Society for Surgery of the Hand; 1985: June 26.
16. Letter dated March 21, 1986, from Langsley DG, Executive Vice President, American Board Medical Specialties to American Board of Orthopaedic Surgery, ABPS, and American Board of Surgery.
17. The American Board of Orthopaedic Surgery. The certificate of added qualifications in surgery of the hand, 1988. In: Information about requirements and examination, The American Board of Orthopaedic Surgery.
18. Letter dated May 10, 1988, from Woods JE, Chairman American Board of Plastic Surgery.
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