Point/Counterpoint
The Value of Maintaining Primary Board Certification in Physical Medicine and Rehabilitation CASE SCENARIO D. B. is a 49-year-old physiatrist. He is board certified in physical medicine and rehabilitation (PM&R) and also holds a subspecialty certification in spinal cord injury (SCI) medicine. He is an attending physician in the SCI unit at a Veterans Affairs hospital, where he has practiced exclusively since completing his residency 19 years ago. His 10-year Maintenance of Certification (MOC) cycle requires retaking both PM&R and SCI recertification examinations next year to stay board certified. D. B. recently became aware of the new policy from the American Board of Physical Medicine and Rehabilitation (ABPMR) that he no longer has to maintain primary PM&R board certification to keep his SCI subspecialty certification. D. B. believes that it is essential to be board certified; however, because his practice is entirely focused on SCI medicine, he is wondering if he should continue to maintain his primary board certification in PM&R in addition to his SCI certification. James Crew, MD, will argue that maintaining subspecialty certification in SCI is sufficient, and Michelle Gittler, MD, will argue that maintaining primary board certification is essential for D. B. Please note: These views do not represent the views of the American Academy of Physical Medicine and Rehabilitation or the ABPMR, and this discussion is intended for educational purposes.
Guest Discussants: James Crew, MD Department of Physical Medicine and Rehabilitation, Santa Clara Valley Medical Center, San Jose, CA Disclosure: nothing to disclose
Michelle Gittler, MD Department of Physical Medicine and Rehabilitation, Schwab Rehabilitation Hospital, Chicago, IL Disclosures outside this publication: consultancy for case review, payment to residency; expert testimony, payment to residency
Feature Editor: David J. Kennedy, MD Department of Orthopaedics, Stanford University, Redwood City, CA. Address correspondence to: D.J.K.; e-mail:djkenned@ stanford.edu Disclosure: nothing to disclose
James Crew, MD, Responds The case of D. B. is relevant and timely because the American Board of Physical Medicine and Rehabilitation (ABPMR) recently announced the option to allow subspecialists to forego primary PM&R certification maintenance [1]. D. B. is faced with a dilemma that many ABPMR diplomats will have to contemplate: what is the value of primary board certification maintenance for a physician who has already subspecialized? Debate may arise on this issue, depending on the scope of one’s clinical practice as well as one’s personal and professional value on keeping primary PM&R certification. D. B. is board certified in spinal cord injury (SCI) medicine and has been practicing within this subspecialty exclusively for his 19-year career. As such, it is my opinion that D. B. has no need to maintain his primary PM&R board certification but should focus exclusively on maintaining his expertise in SCI medicine. The following points will aim to illustrate that maintaining subspecialty SCI medicine certification is not only sufficient but most appropriate for D. B. To address one of the fundamental issues on this topic, a brief review of the evolution of our current practice in board certification maintenance is relevant. The American Board of Medical Specialties (ABMS) changed from traditional periodic recertification testing in PM&R 1934-1482/14/$36.00 Printed in U.S.A.
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favor of a continuous learning program for physicians to maintain specialty certification within their field. This new dynamic program, known as ABMS MOC (Chicago, IL), developed criteria for demonstrating active lifelong engagement within a given specialty rather than recertifying physicians based solely on passing an examination. MOC was created in 2000 by the ABMS in response to a variety of pressures. These pressures included consumer demand and quality assurance because the lack of standardized physician competency assessments after initial licensure was noted as one of many areas for potential health care improvement by the Institute of Medicine in 1999 [2]. There are 4 ABMS MOC components: professional standing, lifelong learning and self-assessment, cognitive experience, and practice improvement. These MOC components altogether are meant to encompass the 6 core clinical competencies: medical knowledge, patient care, interpersonal skills, professionalism, practice-based learning, and systems-based practice [3]. The ABPMR, as an ABMS member since 1947, is responsible for integrating the ABMS components into MOC for primary PM&R as well as the 6 ABPMR subspecialties (soon to be 7, with brain injury medicine to be added later this year). The ª 2014 by the American Academy of Physical Medicine and Rehabilitation Vol. 6, 650-655, July 2014 http://dx.doi.org/10.1016/j.pmrj.2014.06.007
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purpose of MOC is to ensure that physicians who are board certified are keeping current and advancing their knowledge within the specialty and/or subspecialty that reflects their practices. In essence, MOC is meant to be a quality safeguard for health care consumers and a more objective measure to validate certification. Because quality patient care is the primary consideration in MOC, one must ponder whether D. B. or his patients are well served by maintaining primary PM&R certification. More importantly, how does specialization affect patient care? Specialization does matter, both in terms of patient outcomes and the public perception of expertise. For example, the inpatient mortality rate after acute myocardial infarction has been shown to be significantly lower in patients treated by a board-certified cardiologist instead of a general internist [4]. Board certification in surgery was associated with improved mortality after colon resection [5], and a lack of board certification among anesthesiologists was linked with worse clinical outcomes [6]. Further, in the state of California, disciplinary action has been shown to be more likely to involve physicians who are not board certified [7]. Admittedly, there are studies that looked at this topic that have failed to show a link between physician specialization and quality of care. However, a systematic review of the literature revealed a positive correlation between board certification and patient outcomes in the majority of methodologically sound studies [8]. In addition, patient survey data from the American Board of Internal Medicine collected through the Gallup organization (Gallup Inc, Washington, DC) found that the majority of patients would switch physicians if theirs was not board certified and that a boardcertified physician or specialist was more desirable than a noncertified physician recommended by family or friends [3]. Hence, board certification is important because it represents clinical expertise and is valued by the public. Yet, there is little meaning to this expertise if the physician is not practicing in the specialty or subspecialty in which he or she holds board certification. For example, a boardcertified internal medicine specialist would not be considered an expert cardiologist, despite some cardiac training. Similarly, would D. B. be the best physician to prescribe a prosthesis for a below knee amputee, manage a spondylolysis in a competitive adolescent athlete, or treat an adult with a severe traumatic brain injury? My opinion is a resounding, “no.” Certainly, a case can be made for a general PM&R physician with a broad scope of practice being able to appropriately manage these 3 clinical scenarios. Yet, it is hard to support D. B. having relevant, updated knowledge and expertise in these other PM&R areas, given his exclusive SCI medicine practice for 19 years. Many physicians have very focused practices, and the case of D. B. is representative of a shift in medicine as it becomes not only specialized but subspecialized. Before 1970, there were a total of 10 ABMS subspecialty certifications. This number grew to 74 by 1996, and today there are 145 ABMS subspecialty certifications [9].
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As physicians focus on their subspecialty, the expertise that they had elsewhere in the primary specialty becomes diluted and outdated. More importantly, primary board certification loses relevance if the physician is practicing only in his or her subspecialty area; such is the case for D. B. The ABPMR is not alone in moving away from requiring primary specialty MOC for subspecialists. In fact, the American Board of Internal Medicine does not require internal medicine MOC for the majority of its subspecialties, and the American Board of Surgery does not require general surgery MOC to maintain surgical subspecialty certification [10,11]. It is not clear that D. B. would improve his clinical practice by attempting to maintain his non-SCI medicine PM&R knowledge. Is it a good idea for D. B. to focus time on continuing education or board examination review on areas of PM&R that are not relevant for his current practice? This would not seem like time well spent for D. B. Rather, he would be better suited clinically and professionally by maintaining and improving his knowledge by attending an SCI conference on the use of functional electrical stimulation after SCI or by creating a practice improvement project aimed at decreasing urinary tract infection rates in his inpatient rehabilitation unit. More importantly, D. B.’s patients would be better served because these endeavors would have a higher yield on the quality of care and education that D. B. will be able to provide. As noted by the ABPMR, “this new policy ensures that physicians stay updated in their areas of expertise without taking time away from patient care to study for and take the primary PM&R exam, which includes 16 topic areas, many of which subspecialists no longer encounter in their practice” [1]. For D. B., his SCI medicine practice represents one-sixteenth of these areas, which accounts only for approximately 6% of the primary PM&R MOC examination. Discussing the PM&R MOC examination is extremely important here, insofar as it is the only MOC component in question for this debate. The ABPMR has reciprocity between primary and subspecialty PM&R MOCs with the other 3 MOC components [12]. (Aside from pediatric rehabilitation medicine for which there is reciprocity across all 4 components.) That is, the professional standing, continuing medical education, self assessments, and practice improvement projects count toward both the primary PM&R and SCI medicine MOCs. In other words, D. B. does not have to do double the work to maintain his 2 board certifications in these areas. Cognitive expertise, as demonstrated by passing a recertification examination, is the lone MOC component that does not have reciprocity, and the ABPMR requires it in both the primary and subspecialty areas to keep certification [12]. The ABPMR has afforded D. B. the power of choice, and it ultimately comes down to whether D. B. should take another test. To be fair, choosing to take the PM&R primary MOC examination would likely not take much time away from his patients or threaten his SCI medicine expertise. Yet, as mentioned, any time that D. B. would spend away from clinical care to prepare and complete the primary PM&R
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MOC examination could be used in ways that would better serve the patient population that D. B. manages. Similarly, cost also is a consideration, albeit a minor one. However, is it rational for D. B. to spend $745 to take an examination that includes approximately 6% relevance for his clinical practice, or could this money be better spent elsewhere for his subspecialty professional development? Ultimately, this is the question that D. B. must ask himself. Moreover, if it is only taking the test every 10 years that grants D. B. ongoing primary PM&R board certification, it does not seem to be very meaningful in terms of expertise. Again, it is worth noting that, because there is reciprocity between primary and subspecialty ABPMR areas in all MOC components except the examinations, all that D. B. has to do for general PM&R knowledge is take and pass a test every 10 years. As such, it seems that maintaining his primary certification only represents his ability to pass a periodic examination, which was the previous recertification process that fell under scrutiny and led to MOC in the first place [2]. I admit that there are a few qualifications to these arguments. First, D. B. may have aspirations of moving into a more generalized PM&R practice. In this case, clearly, it would make sense for D. B. to focus also on his general PM&R knowledge outside of SCI medicine and maintain his primary certification. Second, one might argue that the scope of the SCI medicine MOC examination does not adequately evaluate all the relevant PM&R areas of practice (eg, pain management, musculoskeletal disorders) as well as the primary PM&R MOC examination. To that end, this would only suggest that reevaluation and amendment of the SCI medicine MOC examination is critical over time. Third, D. B. may want to carry the primary PM&R certification for personal reasons because he likes to be “double boarded” or that it helps with marketing his practice. Nonetheless, in the case of D. B., given the relative clinical irrelevance of the examination, the potential benefits with him using time and money elsewhere,
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and the lack of meaningful expertise if D. B. were to pass the primary PM&R MOC examination, the objective answer is that he should not maintain his primary PM&R certification but instead focus on his SCI medicine subspecialty.
REFERENCES 1. Tarvestad, AM. ABPMR news release: ABPMR announces new options to maintain primary and subspecialty certificates. February 26, 2013. Available at http://www.abpmr.org/documents/Press%20Release.pdf. Accessed June 16, 2014. 2. Kohn L, Corrigan J, Donaldson M. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 1999,141-148. 3. Brennan TA, Horowitz RI, Duffy DF. The role of physician specialty board certification status in the quality movement. JAMA 2004;293: 1038-1043. 4. Norcini JJ, Kimball HR, Lipner RS. Certification and specialization: Do they matter in the outcome of acute myocardial infarction? Acad Med 2000;75:1193-1198. 5. Prystowsky JB. Patient outcomes for segmental resection according to surgeon’s training, certification, and experience. Surgery 2002;132: 663-670. 6. Silber JH, Kennedy SK, Even-Shoshan O, et al. Anesthesiologist board certification and patient outcomes. Anesthethesiology 2002;96: 1044-1052. 7. Kohatsu ND, Gould D, Ross LK, et al. Characteristics associated with physician discipline. Arch Intern Med 2004;164:653-658. 8. Sharp LK, Bashook PG, Lipsky MS, et al. Specialty board certification and clinical outcomes: The missing link. Acad Med 2002;77:534-542. 9. American Board of Medical Specialties. Expansion of Specialties and Growth of Subspecialties. Available at http://www.abms.org/About_ ABMS/ABMS_History/Extended_History/Expansion.aspx. Accessed June 16, 2014. 10. American Board of Internal Medicine Board Certification by Specialty Guide. Available at http://www.abim.org/specialty/default. aspx. Accessed June 16, 2014. 11. American Board of Surgery. MOC Q & A. Updated June 2014. Available at http://www.absurgery.org/default.jsp?exam-mocqa. Accessed June 16, 2014. 12. Maintenance of Certification: Booklet of Information 2013-2014. ABPMR; 2013. Available at: https://www.abpmr.org/boi/MOC_BOI. pdf. Accessed July 10, 2014.
Michelle Gittler, MD, Responds Board certification through the ABMS is one mechanism (albeit imperfect) that the general public uses as an indicator of competency. In February 2013, the ABPMR announced that, beginning in 2015, physicians who hold time-limited subspecialty certificates would no longer be required to maintain their primary certification in physical medicine and rehabilitation. The rationale behind this new policy is to eliminate the time burden necessary for physiatrists to prepare for and take the primary PM&R recertification examination. However, I firmly believe that, regardless of clinical practice or subspecialty certification, all physiatrists should maintain a primary PM&R certification for several reasons. First, one must consider what defines and unifies physicians as PM&R specialists. PM&R is an enormously diverse
field, which encompasses musculoskeletal medicine, SCI, electrodiagnosis, pediatrics, chronic pain management and interventional pain management, neuromuscular disease, brain injury, orthotics and prosthetics, sports medicine, hospice and palliative care, and impairments attendant to medically complex patients. Physiatrists also provide care in multiple settings and professional groups: inpatient, postacute, and outpatient, private practice, hospital-based practice (including the Veterans Affairs), specialty group, and multispecialty practices. Despite this diversity, physiatry is unified as the medical specialty: collectively diagnosing and treating patients with painful or functionally limiting conditions, managing comorbidities and/or impairments, and possibly using injections or electrodiagnostic procedures, all
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while emphasizing prevention of secondary complications from disability. Given the diversity of the field and lack of a clear centrum, it may be very tempting to don their subspecialty blinders and, for instance, consider themselves only as sports medicine or a pain medicine physicians. In my opinion, this is clearly a mistake; they should consider themselves physiatric sports medicine or physiatric pain medicine physicians. All physiatrists, regardless of subspecialty certification, have completed a PM&R residency-training program. This background is essential because it separates a physiatrist from other physicians who also may maintain a similar subspecialty certificate. The physiatric sports medicine physician brings a wealth of knowledge on the functional consequences of concussion, just as the physiatric pain medicine specialist has a unique and strong background in working in multidisciplinary teams. The PM&R background allows the physiatric sports medicine physician to be just as comfortable taking care of the wheelchair athlete as the aging athlete, the Special Olympian, and the weekend warrior. The physiatric pain medicine specialist must be able to interpret electrodiagnostic studies and integrate the study results with the actual concerns of specific patients. By virtue of training in PM&R, the physiatric pain specialist is already competent in electrodiagnosis. The physiatric pain specialist will have a deeper understanding of neuropathic pain in both amputees and persons with spinal cord disorders. Thus, patients who see subspecialists benefit immensely from the physiatric background training, and they deserve a physician who maintains a certain level of competency in general PM&R as demonstrated by maintaining primary board certification in PM&R. This is even more apparent in the case scenario of this point/counterpoint discussion. D. B. is an SCI specialist. Given the nature of this particular condition, how could he not maintain a level of competence on the basics of PM&R? It would be short sighted as an SCI physician to not maintain competency in brain injury medicine as well as the musculoskeletal complications of relying on a manual wheelchair. The competent physiatrist, regardless of subspecialty training, is a function-based physician. Michael Furman, MD, summarized it well in a recent PM&R point/counterpoint column when he stated, “regardless of our individual skill sets and biases, we should recognize that musculoskeletal interventions, spasticity management, and inpatient team rounds (physician rounds on hospitalized patients) are equivalently ‘physiatric’ because they lead to improved patient function and quality of life” [1]. In addition to the simple fact that it is nearly impossible to be so subspecialized so as to never need to maintain a minimal level of competency in PM&R, there are additional reasons to maintain primary certification. First, PM&R is a small field that is unified in its position in treating individuals with disabling conditions. The additional unifying bond of primary board certification allows for greater advocacy for our patients. There is no other cohort of
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physicians dedicated to advocating for individuals with disabling conditions. No matter the area of expertise or the practice venue, physiatrists advocate for access to habilitative and rehabilitative therapy service; access to specialty care and interventions; and access to medical equipment, adaptive equipment, and/or assistive devices. Second, although it may be tempting to drop primary certification to avoid taking the general rehabilitation examination, physicians who do so will no longer be recognized as board-certified physiatrists. This also is true for American Board of Anesthesiology (ABA) diplomats, who may choose to maintain only their subspecialty certification. However, the ABA strongly encourages diplomates to maintain their primary certification. The ABA recommends that diplomates “consider any imponderable repercussions before choosing to let their primary certification in anesthesiology expire” [2]. Other medical boards, such as the American Board of Family Medicine and the American Board of Internal Medicine, both require physicians to maintain their primary certification to maintain subspecialty certification. The reason that the American Board of Family Medicine and the American Board of Internal Medicine require their diplomates to maintain primary certification and why ABA strongly encourages diplomates to also maintain their primary certification, is because their respective leadership recognizes the inherent value of maintaining primary board certification for their diplomates. This value includes specialty awareness and cohesive legislative action, both of which are of paramount importance for PM&R in the rapidly evolving medical marketplace. In addition, there may be significant repercussions with no longer being board certified in the primary specialty. These may include legal issues in malpractice cases, insurance qualifications, and/or hospital privileging. For individuals who currently provide expert witness testimony, the Federation of State Medical Boards has delineated an expert witness as only a physician who is “certified by the same American board in the same specialty” [3]. There also may be ramifications in hospital privileges, especially for those hospitals that require board certification for admitting and consultative privileges. Insurance reimbursement for patients with multiple diagnoses or those seeking out of coverage care may also be at risk. These may be acceptable risks for some practitioners, but they must be carefully considered. From a practical standpoint, the hurdles to MOCs are not insurmountable. Maintenance of board certification, regardless of subspecialty or primary certification, consists of 4 parts. MOC1 (professionalism) requires maintaining an active medical license. MOC2 (self-assessment) involves taking periodic ABPMR approved self-assessment examinations, such as those offered by the American Academy of Physical Medicine and Rehabilitation. MOC3 (examination) requires passing a written examination every 10 years, and MOC4 (practice improvement) involves completing a practice improvement project. For all subspecialty boards recognized by
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the ABPMR, the only additional step to maintain dual certification is the completion of the multiple choice recertification examination (MOC3) for both boards. I understand that this examination may require extra time to study to refresh one’s knowledge on topics outside of his or her subspecialty. But, on review of the MOC3 outline, most topics comprise 4%-5% of the examination and are thus clearly targeted toward high yield and important topics. Therefore. I believe that, for most subspecialty certified physiatrists, preparing for the examination may not require much time at all, and, further, the updated knowledge gained should result in enhanced patient care. The specialty of PM&R was “patient centered” before the rest of the world knew what patient centered meant. We have used the team approach to coordinate patient care as a fundamental part of our training. Educating and counseling patients and families, and having family and team meetings regarding life-changing effects of disability and sequelae are hardwired into our practice. PM&R pioneered systems
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concepts in health care, including working in various health care delivery settings, coordinating patient care within the health care system, and advocating for quality patient care and optimal patient care systems. Interestingly, these are all now requirements in the milestones for all specialties. It, therefore, is imperative that all PM&R practitioners, regardless of their subspecialty training, continue to demonstrate these principles by unifying under the banner of “board certified physiatrist.” It is only through our solidarity that we can continue to promote excellence in medicine that is represented by PM&R.
REFERENCES 1. Furman MB, Melvin JL. Do physiatric procedures represent a value or liability? PM R 2014;6:85-91. 2. American Board of Anesthesiology. Available at: http://www.theaba.org/ home. Accessed June 23, 2014. 3. Federation of State Medical Boards Expert Witness Qualifications Board by Board overview. Available at: http://library.fsmb.org/pdf/GRPOL_ ExpertWitness.pdf. Accessed June 23, 2014.
James Crew, MD, Rebuts Clearly, the field of PM&R is unique in focusing on improving quality of life. Indeed, physiatrists are trained experts in optimizing function in patients with a wide array of disabling conditions. Dr Gittler reminds us of our common strengths as physiatrists and offers an inspired view of PM&R being ahead of the curve in taking a patient-centered multidisciplinary team approach to providing care, one that is entrenched in our training and practice. I agree completely with these points and appreciate her enthusiasm for our specialty. Despite this, I remain unconvinced that D. B. should maintain primary certification in PM&R. Dr Gittler argues for D. B. maintaining primary certification based on the need to keep current PM&R principles that are often involved in the care of those with SCI, such as managing concomitant brain injury and treating musculoskeletal sequelae of wheelchair use. This is a valid concern, but mistakenly assumes that MOC in his particular subspecialty, SCI medicine, does not account for such principles. In fact, the ABPMR SCI medicine examination does incorporate these topics and other areas of PM&R relevant to SCI [1]. Moreover, such is also the case for the other ABPMR subspecialties because the examination topic weights suggest that a general PM&R competency is required as it relates to the subspecialty. Correctly, Dr Gittler points out that, for D. B., the extra step to maintain primary certification in PM&R is only of taking and passing the primary PM&R MOC examination, given the reciprocity for the other 3 MOC components. In addition, we both note that studying for and taking this examination every 10 years is not a major commitment. However, we disagree on the meaningfulness of the primary
PM&R MOC examination for D. B. Dr Gittler proposes that studying the PM&R topics covered in the examination would fortify D. B.’s foundation as a physiatrist. Yet, it appears that many of these high-yield topics are included in the SCI medicine examination. I argue that D. B.’s time would be better spent updating his knowledge and honing his practice in SCI medicine. In addition, it bears repeating that MOC was borne from a consumer demand for a more robust process than just periodic recertification testing, and this is all that remains for D. B. Thus, there seems little objective value to D. B. keeping his primary PM&R certification if he is to focus solely on SCI care. As Dr Gittler suggests, there may be consequences to not maintaining primary board certification in PM&R. Yet, it is unclear what these may be, nor if any would be relevant regarding D. B.’s clinical practice or privileges in caring for persons with SCI. Also, one could ask whether D. B. should be seen as an expert for legal testimony or otherwise in the areas of PM&R outside of SCI medicine, given this is not his focus. D. B. has focused solely on the subspecialty of SCI medicine, and the ABPMR has carefully constructed MOC to support his practice and continued growth by not requiring him to focus time elsewhere. Regardless of his choice, D. B. would still be an ABPMR board-certified specialist capable of caring for his patients by using his physiatry background.
REFERENCES 1. American Board of Physical Medicine and Rehabilitation. Spinal Cord Injury Medicine Examination Outline. Available at https://www.abpmr. org/subspecialties/sci/documents/SCIM_ExamOutline_Weights_Heading. pdf. Accessed June 16, 2014.
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Michelle Gittler, MD, Rebuts One of the interesting aspects of subspecialization in PM&R is that one is never truly only practicing exclusively in that subspecialty area. Over my career, I have learned that the more subspecialized physicians become, the more they realize the value of their general PM&R training. For instance, following up an individual with spinal cord dysfunction through a lifetime absolutely guarantees that one will address issues related to musculoskeletal and neuropathic pain; secondary neurologic and medical issues related to aging, such as a stroke, heart disease, cancer; and entrapment neuropathies and peripheral neuropathies. It is the integrated knowledge of spinal cord dysfunction together with these other issues that will enable the practitioner to differentiate peripheral neuropathy from syrinx or recognize unilateral weakness as a stroke, and not a new Brown Séquard syndrome. It is true that SCI medicine represents approximately 6% of the PM&R MOC examination. However, when considering all the relevant content areas for SCI medicine, including the secondary conditions and complications attendant to SCI medicine, then a minimum of 69% of this examination is relevant for the practitioner. I wholeheartedly agree that studying for the primary PM&R MOC recertification examination would not at all take much time away from patient care, nor would it threaten SCI expertise. In my opinion, it would only enhance his SCI medicine expertise because SCI medicine is not focused on just an organ system but a field of medicine that follows up individuals with spinal cord dysfunction throughout the life span.
Although it seems that maintaining primary certification may only represent an ability to pass a periodic (once per decade!) examination, there may be other important issues to consider. Some hospitals do require primary certification for admitting privileges as well as for patient care. If D. B. is part of a rehabilitation practice group, he may be required to periodically round on the other inpatients without SCI or even do admissions if he is covering for a colleague. It would certainly be ironic if an individual with SCI subspecialization were unable to see patients in the acute setting and/or trauma unit, and thus unable to assist in the acute management of newly acquired spinal cord dysfunction because he did not have privileges at the hospital due to a lack of maintaining primary board certified in PM&R. This attending physician would not only be unable to assist his colleagues, he may be unable to even admit his own patients to the rehabilitation unit! PM&R as a field is quite broad; there is vast array of knowledge and skills one must acquire to become board certified. It is precisely for this reason, that it has been so difficult for our specialty to speak with a single voice and to unite in advocacy for our field as well as for our patients. I believe that the minimal effort required to complete the primary PM&R MOC examination is far outweighed by the need for physiatrists to actually identify first as physiatrists. It is only after we identify as physiatrists first that we have the credibility, in turn, to expect other health care providers to value patient function and quality of life.
Web Poll Question For the case scenario presented in this Point/Counterpoint, which approach would you recommend? a. maintain subspecialty certification only b. maintain primary PM&R certification To cast your vote, visit www.pmrjournal.org
Results of May’s Web Poll For the case scenario presented in Should Antiplatelet Medications Be Held Before Cervical Epidural Injections, should antiplatelet medications be withheld before cervical ESI? 25% proceed with ESI while the patient continues to take clopidogrel 75% stop clopidogrel before the procedure
The Value of Maintaining Primary Board Certification in Physical Medicine and Rehabilitation CASE SCENARIO D. B. is a 49-year-old physiatrist. He is board certified in physical medicine and rehabilitation (PM&R) and also holds a subspecialty certification in spinal cord injury (SCI) medicine. He is an attending physician in the SCI unit at a Veterans Affairs hospital, where he has practiced exclusively since completing his residency 19 years ago. His 10-year Maintenance of Certification (MOC) cycle requires retaking both PM&R and SCI recertification examinations next year to stay board certified. D. B. recently became aware of the new policy from the American Board of Physical Medicine and Rehabilitation (ABPMR) that he no longer has to maintain primary PM&R board certification to keep his SCI subspecialty certification. D. B. believes that it is essential to be board certified; however, because his practice is entirely focused on SCI medicine, he is wondering if he should continue to maintain his primary board certification in PM&R in addition to his SCI certification. James Crew, MD, will argue that maintaining subspecialty certification in SCI is sufficient, and Michelle Gittler, MD, will argue that maintaining primary board certification is essential for D. B. Please note: These views do not represent the views of the American Academy of Physical Medicine and Rehabilitation or the ABPMR, and this discussion is intended for educational purposes.
Guest Discussants: James Crew, MD Department of Physical Medicine and Rehabilitation, Santa Clara Valley Medical Center, San Jose, CA Disclosure: nothing to disclose
Michelle Gittler, MD Department of Physical Medicine and Rehabilitation, Schwab Rehabilitation Hospital, Chicago, IL Disclosures outside this publication: consultancy for case review, payment to residency; expert testimony, payment to residency
Feature Editor: David J. Kennedy, MD Department of Orthopaedics, Stanford University, Redwood City, CA. Address correspondence to: D.J.K.; e-mail:djkenned@ stanford.edu Disclosure: nothing to disclose
James Crew, MD, Responds The case of D. B. is relevant and timely because the American Board of Physical Medicine and Rehabilitation (ABPMR) recently announced the option to allow subspecialists to forego primary PM&R certification maintenance [1]. D. B. is faced with a dilemma that many ABPMR diplomats will have to contemplate: what is the value of primary board certification maintenance for a physician who has already subspecialized? Debate may arise on this issue, depending on the scope of one’s clinical practice as well as one’s personal and professional value on keeping primary PM&R certification. D. B. is board certified in spinal cord injury (SCI) medicine and has been practicing within this subspecialty exclusively for his 19-year career. As such, it is my opinion that D. B. has no need to maintain his primary PM&R board certification but should focus exclusively on maintaining his expertise in SCI medicine. The following points will aim to illustrate that maintaining subspecialty SCI medicine certification is not only sufficient but most appropriate for D. B. To address one of the fundamental issues on this topic, a brief review of the evolution of our current practice in board certification maintenance is relevant. The American Board of Medical Specialties (ABMS) changed from traditional periodic recertification testing in PM&R 1934-1482/14/$36.00 Printed in U.S.A.
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favor of a continuous learning program for physicians to maintain specialty certification within their field. This new dynamic program, known as ABMS MOC (Chicago, IL), developed criteria for demonstrating active lifelong engagement within a given specialty rather than recertifying physicians based solely on passing an examination. MOC was created in 2000 by the ABMS in response to a variety of pressures. These pressures included consumer demand and quality assurance because the lack of standardized physician competency assessments after initial licensure was noted as one of many areas for potential health care improvement by the Institute of Medicine in 1999 [2]. There are 4 ABMS MOC components: professional standing, lifelong learning and self-assessment, cognitive experience, and practice improvement. These MOC components altogether are meant to encompass the 6 core clinical competencies: medical knowledge, patient care, interpersonal skills, professionalism, practice-based learning, and systems-based practice [3]. The ABPMR, as an ABMS member since 1947, is responsible for integrating the ABMS components into MOC for primary PM&R as well as the 6 ABPMR subspecialties (soon to be 7, with brain injury medicine to be added later this year). The ª 2014 by the American Academy of Physical Medicine and Rehabilitation Vol. 6, 650-655, July 2014 http://dx.doi.org/10.1016/j.pmrj.2014.06.007
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purpose of MOC is to ensure that physicians who are board certified are keeping current and advancing their knowledge within the specialty and/or subspecialty that reflects their practices. In essence, MOC is meant to be a quality safeguard for health care consumers and a more objective measure to validate certification. Because quality patient care is the primary consideration in MOC, one must ponder whether D. B. or his patients are well served by maintaining primary PM&R certification. More importantly, how does specialization affect patient care? Specialization does matter, both in terms of patient outcomes and the public perception of expertise. For example, the inpatient mortality rate after acute myocardial infarction has been shown to be significantly lower in patients treated by a board-certified cardiologist instead of a general internist [4]. Board certification in surgery was associated with improved mortality after colon resection [5], and a lack of board certification among anesthesiologists was linked with worse clinical outcomes [6]. Further, in the state of California, disciplinary action has been shown to be more likely to involve physicians who are not board certified [7]. Admittedly, there are studies that looked at this topic that have failed to show a link between physician specialization and quality of care. However, a systematic review of the literature revealed a positive correlation between board certification and patient outcomes in the majority of methodologically sound studies [8]. In addition, patient survey data from the American Board of Internal Medicine collected through the Gallup organization (Gallup Inc, Washington, DC) found that the majority of patients would switch physicians if theirs was not board certified and that a boardcertified physician or specialist was more desirable than a noncertified physician recommended by family or friends [3]. Hence, board certification is important because it represents clinical expertise and is valued by the public. Yet, there is little meaning to this expertise if the physician is not practicing in the specialty or subspecialty in which he or she holds board certification. For example, a boardcertified internal medicine specialist would not be considered an expert cardiologist, despite some cardiac training. Similarly, would D. B. be the best physician to prescribe a prosthesis for a below knee amputee, manage a spondylolysis in a competitive adolescent athlete, or treat an adult with a severe traumatic brain injury? My opinion is a resounding, “no.” Certainly, a case can be made for a general PM&R physician with a broad scope of practice being able to appropriately manage these 3 clinical scenarios. Yet, it is hard to support D. B. having relevant, updated knowledge and expertise in these other PM&R areas, given his exclusive SCI medicine practice for 19 years. Many physicians have very focused practices, and the case of D. B. is representative of a shift in medicine as it becomes not only specialized but subspecialized. Before 1970, there were a total of 10 ABMS subspecialty certifications. This number grew to 74 by 1996, and today there are 145 ABMS subspecialty certifications [9].
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As physicians focus on their subspecialty, the expertise that they had elsewhere in the primary specialty becomes diluted and outdated. More importantly, primary board certification loses relevance if the physician is practicing only in his or her subspecialty area; such is the case for D. B. The ABPMR is not alone in moving away from requiring primary specialty MOC for subspecialists. In fact, the American Board of Internal Medicine does not require internal medicine MOC for the majority of its subspecialties, and the American Board of Surgery does not require general surgery MOC to maintain surgical subspecialty certification [10,11]. It is not clear that D. B. would improve his clinical practice by attempting to maintain his non-SCI medicine PM&R knowledge. Is it a good idea for D. B. to focus time on continuing education or board examination review on areas of PM&R that are not relevant for his current practice? This would not seem like time well spent for D. B. Rather, he would be better suited clinically and professionally by maintaining and improving his knowledge by attending an SCI conference on the use of functional electrical stimulation after SCI or by creating a practice improvement project aimed at decreasing urinary tract infection rates in his inpatient rehabilitation unit. More importantly, D. B.’s patients would be better served because these endeavors would have a higher yield on the quality of care and education that D. B. will be able to provide. As noted by the ABPMR, “this new policy ensures that physicians stay updated in their areas of expertise without taking time away from patient care to study for and take the primary PM&R exam, which includes 16 topic areas, many of which subspecialists no longer encounter in their practice” [1]. For D. B., his SCI medicine practice represents one-sixteenth of these areas, which accounts only for approximately 6% of the primary PM&R MOC examination. Discussing the PM&R MOC examination is extremely important here, insofar as it is the only MOC component in question for this debate. The ABPMR has reciprocity between primary and subspecialty PM&R MOCs with the other 3 MOC components [12]. (Aside from pediatric rehabilitation medicine for which there is reciprocity across all 4 components.) That is, the professional standing, continuing medical education, self assessments, and practice improvement projects count toward both the primary PM&R and SCI medicine MOCs. In other words, D. B. does not have to do double the work to maintain his 2 board certifications in these areas. Cognitive expertise, as demonstrated by passing a recertification examination, is the lone MOC component that does not have reciprocity, and the ABPMR requires it in both the primary and subspecialty areas to keep certification [12]. The ABPMR has afforded D. B. the power of choice, and it ultimately comes down to whether D. B. should take another test. To be fair, choosing to take the PM&R primary MOC examination would likely not take much time away from his patients or threaten his SCI medicine expertise. Yet, as mentioned, any time that D. B. would spend away from clinical care to prepare and complete the primary PM&R
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MOC examination could be used in ways that would better serve the patient population that D. B. manages. Similarly, cost also is a consideration, albeit a minor one. However, is it rational for D. B. to spend $745 to take an examination that includes approximately 6% relevance for his clinical practice, or could this money be better spent elsewhere for his subspecialty professional development? Ultimately, this is the question that D. B. must ask himself. Moreover, if it is only taking the test every 10 years that grants D. B. ongoing primary PM&R board certification, it does not seem to be very meaningful in terms of expertise. Again, it is worth noting that, because there is reciprocity between primary and subspecialty ABPMR areas in all MOC components except the examinations, all that D. B. has to do for general PM&R knowledge is take and pass a test every 10 years. As such, it seems that maintaining his primary certification only represents his ability to pass a periodic examination, which was the previous recertification process that fell under scrutiny and led to MOC in the first place [2]. I admit that there are a few qualifications to these arguments. First, D. B. may have aspirations of moving into a more generalized PM&R practice. In this case, clearly, it would make sense for D. B. to focus also on his general PM&R knowledge outside of SCI medicine and maintain his primary certification. Second, one might argue that the scope of the SCI medicine MOC examination does not adequately evaluate all the relevant PM&R areas of practice (eg, pain management, musculoskeletal disorders) as well as the primary PM&R MOC examination. To that end, this would only suggest that reevaluation and amendment of the SCI medicine MOC examination is critical over time. Third, D. B. may want to carry the primary PM&R certification for personal reasons because he likes to be “double boarded” or that it helps with marketing his practice. Nonetheless, in the case of D. B., given the relative clinical irrelevance of the examination, the potential benefits with him using time and money elsewhere,
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and the lack of meaningful expertise if D. B. were to pass the primary PM&R MOC examination, the objective answer is that he should not maintain his primary PM&R certification but instead focus on his SCI medicine subspecialty.
REFERENCES 1. Tarvestad, AM. ABPMR news release: ABPMR announces new options to maintain primary and subspecialty certificates. February 26, 2013. Available at http://www.abpmr.org/documents/Press%20Release.pdf. Accessed June 16, 2014. 2. Kohn L, Corrigan J, Donaldson M. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 1999,141-148. 3. Brennan TA, Horowitz RI, Duffy DF. The role of physician specialty board certification status in the quality movement. JAMA 2004;293: 1038-1043. 4. Norcini JJ, Kimball HR, Lipner RS. Certification and specialization: Do they matter in the outcome of acute myocardial infarction? Acad Med 2000;75:1193-1198. 5. Prystowsky JB. Patient outcomes for segmental resection according to surgeon’s training, certification, and experience. Surgery 2002;132: 663-670. 6. Silber JH, Kennedy SK, Even-Shoshan O, et al. Anesthesiologist board certification and patient outcomes. Anesthethesiology 2002;96: 1044-1052. 7. Kohatsu ND, Gould D, Ross LK, et al. Characteristics associated with physician discipline. Arch Intern Med 2004;164:653-658. 8. Sharp LK, Bashook PG, Lipsky MS, et al. Specialty board certification and clinical outcomes: The missing link. Acad Med 2002;77:534-542. 9. American Board of Medical Specialties. Expansion of Specialties and Growth of Subspecialties. Available at http://www.abms.org/About_ ABMS/ABMS_History/Extended_History/Expansion.aspx. Accessed June 16, 2014. 10. American Board of Internal Medicine Board Certification by Specialty Guide. Available at http://www.abim.org/specialty/default. aspx. Accessed June 16, 2014. 11. American Board of Surgery. MOC Q & A. Updated June 2014. Available at http://www.absurgery.org/default.jsp?exam-mocqa. Accessed June 16, 2014. 12. Maintenance of Certification: Booklet of Information 2013-2014. ABPMR; 2013. Available at: https://www.abpmr.org/boi/MOC_BOI. pdf. Accessed July 10, 2014.
Michelle Gittler, MD, Responds Board certification through the ABMS is one mechanism (albeit imperfect) that the general public uses as an indicator of competency. In February 2013, the ABPMR announced that, beginning in 2015, physicians who hold time-limited subspecialty certificates would no longer be required to maintain their primary certification in physical medicine and rehabilitation. The rationale behind this new policy is to eliminate the time burden necessary for physiatrists to prepare for and take the primary PM&R recertification examination. However, I firmly believe that, regardless of clinical practice or subspecialty certification, all physiatrists should maintain a primary PM&R certification for several reasons. First, one must consider what defines and unifies physicians as PM&R specialists. PM&R is an enormously diverse
field, which encompasses musculoskeletal medicine, SCI, electrodiagnosis, pediatrics, chronic pain management and interventional pain management, neuromuscular disease, brain injury, orthotics and prosthetics, sports medicine, hospice and palliative care, and impairments attendant to medically complex patients. Physiatrists also provide care in multiple settings and professional groups: inpatient, postacute, and outpatient, private practice, hospital-based practice (including the Veterans Affairs), specialty group, and multispecialty practices. Despite this diversity, physiatry is unified as the medical specialty: collectively diagnosing and treating patients with painful or functionally limiting conditions, managing comorbidities and/or impairments, and possibly using injections or electrodiagnostic procedures, all
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while emphasizing prevention of secondary complications from disability. Given the diversity of the field and lack of a clear centrum, it may be very tempting to don their subspecialty blinders and, for instance, consider themselves only as sports medicine or a pain medicine physicians. In my opinion, this is clearly a mistake; they should consider themselves physiatric sports medicine or physiatric pain medicine physicians. All physiatrists, regardless of subspecialty certification, have completed a PM&R residency-training program. This background is essential because it separates a physiatrist from other physicians who also may maintain a similar subspecialty certificate. The physiatric sports medicine physician brings a wealth of knowledge on the functional consequences of concussion, just as the physiatric pain medicine specialist has a unique and strong background in working in multidisciplinary teams. The PM&R background allows the physiatric sports medicine physician to be just as comfortable taking care of the wheelchair athlete as the aging athlete, the Special Olympian, and the weekend warrior. The physiatric pain medicine specialist must be able to interpret electrodiagnostic studies and integrate the study results with the actual concerns of specific patients. By virtue of training in PM&R, the physiatric pain specialist is already competent in electrodiagnosis. The physiatric pain specialist will have a deeper understanding of neuropathic pain in both amputees and persons with spinal cord disorders. Thus, patients who see subspecialists benefit immensely from the physiatric background training, and they deserve a physician who maintains a certain level of competency in general PM&R as demonstrated by maintaining primary board certification in PM&R. This is even more apparent in the case scenario of this point/counterpoint discussion. D. B. is an SCI specialist. Given the nature of this particular condition, how could he not maintain a level of competence on the basics of PM&R? It would be short sighted as an SCI physician to not maintain competency in brain injury medicine as well as the musculoskeletal complications of relying on a manual wheelchair. The competent physiatrist, regardless of subspecialty training, is a function-based physician. Michael Furman, MD, summarized it well in a recent PM&R point/counterpoint column when he stated, “regardless of our individual skill sets and biases, we should recognize that musculoskeletal interventions, spasticity management, and inpatient team rounds (physician rounds on hospitalized patients) are equivalently ‘physiatric’ because they lead to improved patient function and quality of life” [1]. In addition to the simple fact that it is nearly impossible to be so subspecialized so as to never need to maintain a minimal level of competency in PM&R, there are additional reasons to maintain primary certification. First, PM&R is a small field that is unified in its position in treating individuals with disabling conditions. The additional unifying bond of primary board certification allows for greater advocacy for our patients. There is no other cohort of
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physicians dedicated to advocating for individuals with disabling conditions. No matter the area of expertise or the practice venue, physiatrists advocate for access to habilitative and rehabilitative therapy service; access to specialty care and interventions; and access to medical equipment, adaptive equipment, and/or assistive devices. Second, although it may be tempting to drop primary certification to avoid taking the general rehabilitation examination, physicians who do so will no longer be recognized as board-certified physiatrists. This also is true for American Board of Anesthesiology (ABA) diplomats, who may choose to maintain only their subspecialty certification. However, the ABA strongly encourages diplomates to maintain their primary certification. The ABA recommends that diplomates “consider any imponderable repercussions before choosing to let their primary certification in anesthesiology expire” [2]. Other medical boards, such as the American Board of Family Medicine and the American Board of Internal Medicine, both require physicians to maintain their primary certification to maintain subspecialty certification. The reason that the American Board of Family Medicine and the American Board of Internal Medicine require their diplomates to maintain primary certification and why ABA strongly encourages diplomates to also maintain their primary certification, is because their respective leadership recognizes the inherent value of maintaining primary board certification for their diplomates. This value includes specialty awareness and cohesive legislative action, both of which are of paramount importance for PM&R in the rapidly evolving medical marketplace. In addition, there may be significant repercussions with no longer being board certified in the primary specialty. These may include legal issues in malpractice cases, insurance qualifications, and/or hospital privileging. For individuals who currently provide expert witness testimony, the Federation of State Medical Boards has delineated an expert witness as only a physician who is “certified by the same American board in the same specialty” [3]. There also may be ramifications in hospital privileges, especially for those hospitals that require board certification for admitting and consultative privileges. Insurance reimbursement for patients with multiple diagnoses or those seeking out of coverage care may also be at risk. These may be acceptable risks for some practitioners, but they must be carefully considered. From a practical standpoint, the hurdles to MOCs are not insurmountable. Maintenance of board certification, regardless of subspecialty or primary certification, consists of 4 parts. MOC1 (professionalism) requires maintaining an active medical license. MOC2 (self-assessment) involves taking periodic ABPMR approved self-assessment examinations, such as those offered by the American Academy of Physical Medicine and Rehabilitation. MOC3 (examination) requires passing a written examination every 10 years, and MOC4 (practice improvement) involves completing a practice improvement project. For all subspecialty boards recognized by
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the ABPMR, the only additional step to maintain dual certification is the completion of the multiple choice recertification examination (MOC3) for both boards. I understand that this examination may require extra time to study to refresh one’s knowledge on topics outside of his or her subspecialty. But, on review of the MOC3 outline, most topics comprise 4%-5% of the examination and are thus clearly targeted toward high yield and important topics. Therefore. I believe that, for most subspecialty certified physiatrists, preparing for the examination may not require much time at all, and, further, the updated knowledge gained should result in enhanced patient care. The specialty of PM&R was “patient centered” before the rest of the world knew what patient centered meant. We have used the team approach to coordinate patient care as a fundamental part of our training. Educating and counseling patients and families, and having family and team meetings regarding life-changing effects of disability and sequelae are hardwired into our practice. PM&R pioneered systems
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concepts in health care, including working in various health care delivery settings, coordinating patient care within the health care system, and advocating for quality patient care and optimal patient care systems. Interestingly, these are all now requirements in the milestones for all specialties. It, therefore, is imperative that all PM&R practitioners, regardless of their subspecialty training, continue to demonstrate these principles by unifying under the banner of “board certified physiatrist.” It is only through our solidarity that we can continue to promote excellence in medicine that is represented by PM&R.
REFERENCES 1. Furman MB, Melvin JL. Do physiatric procedures represent a value or liability? PM R 2014;6:85-91. 2. American Board of Anesthesiology. Available at: http://www.theaba.org/ home. Accessed June 23, 2014. 3. Federation of State Medical Boards Expert Witness Qualifications Board by Board overview. Available at: http://library.fsmb.org/pdf/GRPOL_ ExpertWitness.pdf. Accessed June 23, 2014.
James Crew, MD, Rebuts Clearly, the field of PM&R is unique in focusing on improving quality of life. Indeed, physiatrists are trained experts in optimizing function in patients with a wide array of disabling conditions. Dr Gittler reminds us of our common strengths as physiatrists and offers an inspired view of PM&R being ahead of the curve in taking a patient-centered multidisciplinary team approach to providing care, one that is entrenched in our training and practice. I agree completely with these points and appreciate her enthusiasm for our specialty. Despite this, I remain unconvinced that D. B. should maintain primary certification in PM&R. Dr Gittler argues for D. B. maintaining primary certification based on the need to keep current PM&R principles that are often involved in the care of those with SCI, such as managing concomitant brain injury and treating musculoskeletal sequelae of wheelchair use. This is a valid concern, but mistakenly assumes that MOC in his particular subspecialty, SCI medicine, does not account for such principles. In fact, the ABPMR SCI medicine examination does incorporate these topics and other areas of PM&R relevant to SCI [1]. Moreover, such is also the case for the other ABPMR subspecialties because the examination topic weights suggest that a general PM&R competency is required as it relates to the subspecialty. Correctly, Dr Gittler points out that, for D. B., the extra step to maintain primary certification in PM&R is only of taking and passing the primary PM&R MOC examination, given the reciprocity for the other 3 MOC components. In addition, we both note that studying for and taking this examination every 10 years is not a major commitment. However, we disagree on the meaningfulness of the primary
PM&R MOC examination for D. B. Dr Gittler proposes that studying the PM&R topics covered in the examination would fortify D. B.’s foundation as a physiatrist. Yet, it appears that many of these high-yield topics are included in the SCI medicine examination. I argue that D. B.’s time would be better spent updating his knowledge and honing his practice in SCI medicine. In addition, it bears repeating that MOC was borne from a consumer demand for a more robust process than just periodic recertification testing, and this is all that remains for D. B. Thus, there seems little objective value to D. B. keeping his primary PM&R certification if he is to focus solely on SCI care. As Dr Gittler suggests, there may be consequences to not maintaining primary board certification in PM&R. Yet, it is unclear what these may be, nor if any would be relevant regarding D. B.’s clinical practice or privileges in caring for persons with SCI. Also, one could ask whether D. B. should be seen as an expert for legal testimony or otherwise in the areas of PM&R outside of SCI medicine, given this is not his focus. D. B. has focused solely on the subspecialty of SCI medicine, and the ABPMR has carefully constructed MOC to support his practice and continued growth by not requiring him to focus time elsewhere. Regardless of his choice, D. B. would still be an ABPMR board-certified specialist capable of caring for his patients by using his physiatry background.
REFERENCES 1. American Board of Physical Medicine and Rehabilitation. Spinal Cord Injury Medicine Examination Outline. Available at https://www.abpmr. org/subspecialties/sci/documents/SCIM_ExamOutline_Weights_Heading. pdf. Accessed June 16, 2014.
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Michelle Gittler, MD, Rebuts One of the interesting aspects of subspecialization in PM&R is that one is never truly only practicing exclusively in that subspecialty area. Over my career, I have learned that the more subspecialized physicians become, the more they realize the value of their general PM&R training. For instance, following up an individual with spinal cord dysfunction through a lifetime absolutely guarantees that one will address issues related to musculoskeletal and neuropathic pain; secondary neurologic and medical issues related to aging, such as a stroke, heart disease, cancer; and entrapment neuropathies and peripheral neuropathies. It is the integrated knowledge of spinal cord dysfunction together with these other issues that will enable the practitioner to differentiate peripheral neuropathy from syrinx or recognize unilateral weakness as a stroke, and not a new Brown Séquard syndrome. It is true that SCI medicine represents approximately 6% of the PM&R MOC examination. However, when considering all the relevant content areas for SCI medicine, including the secondary conditions and complications attendant to SCI medicine, then a minimum of 69% of this examination is relevant for the practitioner. I wholeheartedly agree that studying for the primary PM&R MOC recertification examination would not at all take much time away from patient care, nor would it threaten SCI expertise. In my opinion, it would only enhance his SCI medicine expertise because SCI medicine is not focused on just an organ system but a field of medicine that follows up individuals with spinal cord dysfunction throughout the life span.
Although it seems that maintaining primary certification may only represent an ability to pass a periodic (once per decade!) examination, there may be other important issues to consider. Some hospitals do require primary certification for admitting privileges as well as for patient care. If D. B. is part of a rehabilitation practice group, he may be required to periodically round on the other inpatients without SCI or even do admissions if he is covering for a colleague. It would certainly be ironic if an individual with SCI subspecialization were unable to see patients in the acute setting and/or trauma unit, and thus unable to assist in the acute management of newly acquired spinal cord dysfunction because he did not have privileges at the hospital due to a lack of maintaining primary board certified in PM&R. This attending physician would not only be unable to assist his colleagues, he may be unable to even admit his own patients to the rehabilitation unit! PM&R as a field is quite broad; there is vast array of knowledge and skills one must acquire to become board certified. It is precisely for this reason, that it has been so difficult for our specialty to speak with a single voice and to unite in advocacy for our field as well as for our patients. I believe that the minimal effort required to complete the primary PM&R MOC examination is far outweighed by the need for physiatrists to actually identify first as physiatrists. It is only after we identify as physiatrists first that we have the credibility, in turn, to expect other health care providers to value patient function and quality of life.
Web Poll Question For the case scenario presented in this Point/Counterpoint, which approach would you recommend? a. maintain subspecialty certification only b. maintain primary PM&R certification To cast your vote, visit www.pmrjournal.org
Results of May’s Web Poll For the case scenario presented in Should Antiplatelet Medications Be Held Before Cervical Epidural Injections, should antiplatelet medications be withheld before cervical ESI? 25% proceed with ESI while the patient continues to take clopidogrel 75% stop clopidogrel before the procedure
