The explosion of new information in neurology has accelerated the trend in superspecialization. As our field mushrooms into disciplines as differentiated as endovascular stroke care, neurointensive care, and neurorehabilitation medicine, the call to validate new areas with credentialing and certification has grown. But for practicing neurologists, and particularly generalists, difficult questions arise: Will the movement preserve or threaten our turf? Will it place neurologists, already poorly reimbursed for cognitive services, in even greater financial jeopardy? Will it cause payers to stratify payment based on credentials or will that threat, like the one to electromyography years ago, never materialize? And the biggest question of all: Will it improve patient care?
Historically, there has been one imprimatur that matters in terms of certification: The American Board of Medical Specialties (ABMS) and its offshoot, the American Board of Psychiatry and Neurology (ABPN). Until 1990, the only certifications in the field of neurology were for psychiatry, neurology, and neurology with special qualification in child neurology. That year, the American Board of Medical Specialties first offered subspecialty certifications in neurology when clinical neurophysiology was approved as an added qualification. Sleep, for example, did not earn ABPN validation until March 2005, and neuromuscular medicine was only approved in September.
INDEPENDENT BOARDS: HOW DO THEY COMPARE?
Perhaps because the ABPN is so slow to embrace new subspecialties, independent boards have sprung up to certify specialties such as pain management and neuroimaging. It is not clear if certification by these other non-ABPN boards means anything to anyone other than neurologists. But, say some experts, they deserve recognition because independent boards have more rigorous certification requirements and exams than the ABPN.
Marc R. Nuwer, MD, PhD, Professor of Neurology and Director of the EEG Lab at the University of California-Los Angeles, contends that ABPN subspecialties do not demand the same in-depth training as the independent boards. The American Board of Clinical Neurophysiology, the former American Electroencephalographic Society, for example, is recognized as having higher standards, signifying a substantially greater degree of expertise in EEG than the ABMS/ABPN subspecialty board in clinical neurophysiology, Dr. Nuwer said.
“One could major in EMG, take some sleep studies, but have no experience reading EEGs – and then take and pass the ABMS exam – and not even qualify to sit for the American Board of Clinical Neurophysiology, which requires one year experience in actual supervised EEG reading,” he added. If your child had an EEG test, which person would you want to read the study?” Although others share this opinion, a few other states, including California, limit the public use of the term board certified to only ABMS or equivalent boards. “The law was established,” Dr. Nuwer explained, “to prevent people from getting what are called ‘Las Vegas’ boards – pay your $1,000, take a trivial test, and get your certificate.”
INCREASING SUBSPECIALTY TRAINING: WHAT DOES IT MEAN FOR THE FIELD?
Meanwhile, subspecialty training continues unabated. Currently, 75 percent of neurology residents take some kind of subspecialty fellowship. In response to this rising tide, both the ABPN and the United Council for Neurological Subspecialties (UCNS), a new organization established in 2003, have set out to standardize certification requirements. (See “The Certifying Organizations for Neurology.”)
“The idea for accreditation of training programs is to provide a high standard for training modeled after the strict curricular demands of the Residency Review Committee,” said UCNS Chair Leslie A. Morrison, MD.
It is not yet possible to determine the ultimate impact of this new organization on our specialty. The forecast varies depending on the perspective and agenda of neurologists – both generalists and specialists.
Headache specialists, for example, differ in their responses. Alan M. Rapoport, MD, Founder and Director of the New England Headache Center in Stamford, CT, plans to take the new UCNS headache medicine examination later this year. He hopes that certification will allow him to say that he is specialized in headache, (even though he has been so for 27 years) and that it may make it clear to the lay public how he differs from the neurology generalist.
Neurologist Frederick R. Taylor, MD, Treasurer of the National Board for Certification in Headache Management, an independent certifying headache specialty board formed by the National Headache Foundation, also intends to take the UCNS certification examination for headache, and agrees that this development is beneficial for his specialty. Dr. Taylor, who serves as Associate Editor for the Headache Subsection for the Cochrane Library systematic reviews, contends that certification legitimizes the field by acknowledging the practitioner's expertise. “Many neurologists consider the treatment of headache as required, but not necessarily desirable, and some do not even consider it legitimate neurology,” he said.
But some neurologists simply don't see the point of taking yet another examination. Headache specialist Randolph W. Evans, MD, of Houston, TX, thinks that for those completing headache fellowships, taking an exam and obtaining certification seems reasonable, but he wonders about those neurologists already in practice. “Many have been promoting headache clinics with varying degrees of expertise for years,” he said, “and will continue to do so, with or without subspecialty certification.”
Although he suspects that full-time academicians may gain stature from formal certification, he thinks that their departmental value is more likely to depend on whether they can sustain headache clinics and provide related revenue. He also conceded that there may be a benefit for those who need an incentive to study, but Dr. Evans, who spends much “free time” researching and writing headache textbooks, chapters, and articles already, said, “I would not feel very motivated to just take a test.”
THE EFFECT ON PRACTICE
But if new diplomas affect revenues, motivations may change among practicing neurologists. Many express fears that subspecialty certification may stratify our payment from insurers, shift referral patterns in our communities, and affect privileges at hospitals.
Christiansburg, VA, neurologist R. James Hawley, MD, certified in both the non-ABPN American Board of Sleep Medicine, and the ABMS Clinical Neurophysiology Boards, has had his share of experience with other specialists attempting to restrict his privileges. “While it is true that insurers and hospitals have not yet required subspecialty certification,” he said, “the competitive struggle between physicians will cause them to do so eventually, as physicians continue their turf battles and appeal to insurers and hospitals for exclusive control of income-producing turf.”
These issues may most threaten general neurologists, who are struggling to sustain private practice in a climate of declining reimbursements and rising overhead. Carl Billian, MD, a neuromuscular and neurorehabilitation specialist in Rome, GA, views the problem of declining reimbursement on cognitive services as a more imminent threat than the trend towards superspecialization. “I am not sure if there will always be room for general neurologists,” said Dr. Billian, “If they can't be compensated commensurate with the value of their services, they many not survive economically.” Moreover, he expresses concern that infighting outside and within our specialty may get nastier as the size of the pie continues to shrink.
Dr. Morrison pointed out that it is too early to predict fall-out at this time as subspecialty certification is still in its infancy. She said, “While it is obvious that certification means that a person has achieved a certain level of training, we still don't know what this means in terms of insurance companies or medical malpractice liability.”
DOES IT SERVE OUR PATIENTS?
In the final analysis, perhaps we should be asking what would best serve our patients. This trend is unlikely to make a difference to primary care doctors outside academic centers who don't usually consider subspecialty expertise in their referral patterns. Furthermore, they are, to a large degree, tethered to the provider books, most of which don't acknowledge subspecialization. And, patients, who just want someone in their network, may not get it at all. Dr. Evans observed: “Botulinum toxin (Botox), our one headache procedure, is performed by dermatologists or nurses in shopping malls, so why would patients care whether we are subspecialty certified?”
But even if patients are oblivious to diplomas, it is our responsibility to keep the patient's best interests in mind. “In medicine, our patients' needs are our highest priority and as physicians we have pledged to serve those needs when appropriate,” Dr. Taylor said. “Certification assists in assuring a legitimate bottom or at least a minimum qualification to call oneself a headache specialist.” Nevertheless, some would suggest that it is arguable whether or not subspecialty certification actually improves the quality of the medical care that neurologists deliver.
Many practitioners assert that general neurologists should be able to attend to stroke, epilepsy, headache, Parkinson disease, multiple sclerosis, and other common conditions after completing their training. “If they don't, the training has failed them,” said William A. Tosches, MD, a Hopedale, MA, general neurologist.
Dr. Tosches, an epilepsy expert who has been in practice for 29 years, opposes the shift towards additional boards. “Don't tell me that a resident who does one year of certification in stroke has more experience or knowledge on how to handle acute strokes than a non-certified general neurologist with years of experience who has seen all the permutations and varieties of stroke, he said. Despite all the controversy, the process will likely move forward. Dr. Hawley predicted: “Subspecialty boards are more than an adornment in Fair Academe already; those who run programs to train others in a subspecialty with boards, usually need these boards themselves to run an accredited program…Viva laissez faire capitalism, competition, and social Darwinism.”
THE CERTIFYING ORGANIZATIONS IN NEUROLOGY
The American Board of Medical Specialties recognizes 24 approved medical specialty boards, including the American Board of Psychiatry and Neurology (ABPN). The ABPN, founded in 1934, offers three primary certifications: psychiatry, neurology, and neurology with special qualification in child neurology; and five subspecialty certifications for diplomats in neurology: clinical neurophysiology, pain medicine, vascular neurology, sleep (approved in March 2005), and neuromuscular medicine (approved in September 2005).
At present, independent boards certify a variety of conditions including sleep (American Board of Sleep Medicine), electrodiagnostic medicine (American Board of Electrodiagnostic Medicine), neuroimaging (American Society of Neuroimaging), pain (American Board of Pain Medicine), clinical neurophysiology (American Board of Clinical Neurophysiology), and neurorehabilitation (American Society of Neurorehabilitation).
The United Council for Neurologic Subspecialties (UCNS) comprises five organizations: The American Academy of Neurology, The American Neurological Association, The Association of University Professors of Neurology, The Child Neurology Society, and The Professors of Child Neurology. The UCNS currently provides certification in five subspecialties: behavioral neurology and neuropsychiatry, clinical neuromuscular pathology, headache medicine, neurointensive care, and neuro-oncology. The whole comprises the parts.
WHAT DO AAN, UCNS, AND ABPN LEADERS HAVE TO SAY?
The sought-after ABPN moniker helps to distinguish vanity boards from ABMS boards. However, subspecialty certifications have a short history with the organization. Steven C. Scheiber, MD, Executive Vice President of the ABPN, said, “The ABPN did not begin to certify subspecialty fields in neurology until the 1990's. Since then, there have been a number of superspecialties in neurology that simply did not meet the ABMS criteria – for example, there were too few training programs, or too few specialists to merit certification.”
The need for standardization and a higher level of validation for independent boards led to the creation of The United Council for Neurological Subspecialties (UCNS) in 2003. “We believed that it was necessary to recognize added competence and to assist subspecialties that had matured to the point at which accreditation of training programs and certification of graduates was appropriate,” said AAN President-Elect Steven M. Sergay, MD, first Chair of the UCNS.
AAN Enterprises Chair Steven P. Ringel, MD, who is also Associate Editor-in-chief of Neurology Today, agrees that standardization of fellowship training should improve care. However, he is concerned that the unintended consequences of the subspecialty certification trend will involve additional expenses and greater time commitment for neurologists who seek these added qualifications.
“For example, a neuromuscular specialist might have to pay fees and take recertification tests in three ABPN (neurology, neurophysiology, clinical neuromuscular), one UCNS (neuromuscular pathology), and the AANEM (EMG) board exams if they see patients, do EMGs, and read biopsies.” This could amount to thousands of dollars with no immediate return on investment.” He believes that in the final analysis neurologists will vote with their wallets: “I certainly wouldn't want to make that investment with falling reimbursement and no guarantee of added income with such credentials.”