1151
after 5 years (beginning in 1994), but the "renewable" principle was dropped. Yet the main planks of the system remain in place. The confidentiality with which reviews are conducted would be inappropriate for a secret service, let alone a public service. Theoretically, consultants can look at the list of people with awards, but the public, press, and GPs cannot. There are three levels of selection: district, regional, and national. District representatives work in widely different ways. Some just observe, others consult with senior colleagues, and others hold formal meetings of all award holders in a district to consider the record of each non-award holder. The system is open to abuse, with the award-holder who has a prejudice against a colleague being in a powerful position to veto an award. Ask a consultant whether there should be performancerelated pay, and you will get a loud and predictable no. The last annual meeting of the BMA said it would be impossible. It then went on to endorse the present system of distinction awards, which are performance-related bonuses under a different guise. Performance-related pay is okay so long as it is decided within the profession. In a more democratic age in which all public services are being made more accountable, the long-term decline of the system looks inevitable. Malcolm Dean
Round the World USA: New AIDS definition After a year of controversy and deliberation, the Centers for Disease Control (CDC) intends to publish in December a new definition of AIDS that will include all those who are seropositive for HIV and have a CD4 T-lymphocyte count of less than 200/ltl, irrespective of clinical manifestation. new Three AIDS-indicator diseases-pulmonary recurrent bacterial pneumonia, and invasive tuberculosis, cervical cancer will be added to the existing list of 23. The new definition should become effective from Jan 1, 1993. According to CDC the new definition could increase AIDS cases in the US by about 160 000. The current number of reported cases is 248 146. CDC first announced its decision to change the definition in November, 1991. The three new AIDS-indicator diseases were added to the existing 23 after public response to the 1991 meeting and a Sept 2,1992, meeting with experts and AIDS activists. Critics of the current definition pointed to the increased prevalence of some severe manifestations of HIV infection, such as tuberculosis and cervical cancer, among women and injecting drug users-expanding groups that are disproportionately Afrian-American and Hispanic. Activists say that the omission of these diseases has resulted in an underestimation of the impact of the epidemic on these populations and has hindered access of these groups to federal medical programmes and social security. Public health and CDC officials have maintained that the casedefinition was developed for public health notifiable disease reporting systems, rather than for determining insurance reimbursement or as a criterion for disability. Most activists favour the new definition but fear that the increased reliance on CD4 count might result in a weakening of confidentiality. CDC said that there have been no breaks in confidentiality among the cases reported so far and that confidentiality would continue to be strictly maintained. Extrapulmonary tuberculosis has been an indicator disease since August, 1987. The addition of the pulmonary
form, CDC said, may increase the completeness of reporting of persons with both tuberculosis and HIV infection and the
understanding of the relation between HIV and tuberculosis epidemics. Also, public health attention can be focused on communities where prophylaxis and treatment for these diseases are most needed. Recurrent pneumonia was included as an AIDSindicator disease on grounds that the risk of multiple episodes in a 12-month period is about 19.6 times higher among persons with CD4 count below 200/ul than among those with a higher CD4 count. The yearly incidence of bacterial pneumonia among HIV-infected intravenous drug users without AIDS is 97/1000, or five times that of
non-infected drug users. Whilst the incidence of cervical cancer was rarely listed among HIV deaths in women of reproductive age in the US in 1987, one New York study indicated that the incidence of invasive cervical cancer increased from 0-5 to 3-2 per 1000 young women admitted to hospital with HIV infection between 1988 and 1991.
Harry Nelson
USA:
Compulsory recertification
for internists
Thousands of internists have received the first issue of a new semiannual newsletter of the American Board of Internal Medicine (ABIM). It contains an account of the Board’s recent policy on time-limited certification and recertification-"obligations of an accountable profession", according to the Board. All diploma-holders who passed the certifying examination after 1989 will be required to take recertifying exams at least every ten years to maintain their Board-certified status. Older colleagues are encouraged to seek recertification. The ABIM action was not unforeseen. Recertification has been an issue since the 1940s, when it was first proposed by the American Board of Medical Specialties (ABMS), but little action has been taken. Recertification was largely subsumed by the need for organised medicine to devote attention to postgraduate courses as States began to require continuing education as prerequisites for licensure. The issue was revived in 1969 when the American Board of Family Practice became the first member of the ABMS to demand recertification. Shortly thereafter, the ABIM cautiously announced its own voluntary programme of recertification. From the start, recertification--even voluntary-was extremely unpopular. "In pursuing the subject the board members have had some of the feelings of a hunter going into tall grass after a wounded Cape buffalo", one ABIM member wrote in 1970. Despite these trepidations, the ABIM policy prevailed and the first recertifying exam was offered in 1974. Upon announcing the test, the president of the American College of Physicians assured fellow internists that the recertification procedure would not be punitive and that all unsuccessful exam results would be kept strictly confidential. "I will take the recertification examination of the ABIM in October 1974 at age 57 years", he wrote. "I hope you will join me." Few did. In fact, the proportion of Board-certified internists taking the exam dwindled over the next decade to under 10%. In 1987, despite the promise of a "handsome" certificate of Advanced Achievement in Internal Medicine, and warnings that it might represent "the last gasp of
Perspective,
after 5 years (beginning in 1994), but the "renewable" principle was dropped. Yet the main planks of the system remain in place. The confidentiality with which reviews are conducted would be inappropriate for a secret service, let alone a public service. Theoretically, consultants can look at the list of people with awards, but the public, press, and GPs cannot. There are three levels of selection: district, regional, and national. District representatives work in widely different ways. Some just observe, others consult with senior colleagues, and others hold formal meetings of all award holders in a district to consider the record of each non-award holder. The system is open to abuse, with the award-holder who has a prejudice against a colleague being in a powerful position to veto an award. Ask a consultant whether there should be performancerelated pay, and you will get a loud and predictable no. The last annual meeting of the BMA said it would be impossible. It then went on to endorse the present system of distinction awards, which are performance-related bonuses under a different guise. Performance-related pay is okay so long as it is decided within the profession. In a more democratic age in which all public services are being made more accountable, the long-term decline of the system looks inevitable. Malcolm Dean
Round the World USA: New AIDS definition After a year of controversy and deliberation, the Centers for Disease Control (CDC) intends to publish in December a new definition of AIDS that will include all those who are seropositive for HIV and have a CD4 T-lymphocyte count of less than 200/ltl, irrespective of clinical manifestation. new Three AIDS-indicator diseases-pulmonary recurrent bacterial pneumonia, and invasive tuberculosis, cervical cancer will be added to the existing list of 23. The new definition should become effective from Jan 1, 1993. According to CDC the new definition could increase AIDS cases in the US by about 160 000. The current number of reported cases is 248 146. CDC first announced its decision to change the definition in November, 1991. The three new AIDS-indicator diseases were added to the existing 23 after public response to the 1991 meeting and a Sept 2,1992, meeting with experts and AIDS activists. Critics of the current definition pointed to the increased prevalence of some severe manifestations of HIV infection, such as tuberculosis and cervical cancer, among women and injecting drug users-expanding groups that are disproportionately Afrian-American and Hispanic. Activists say that the omission of these diseases has resulted in an underestimation of the impact of the epidemic on these populations and has hindered access of these groups to federal medical programmes and social security. Public health and CDC officials have maintained that the casedefinition was developed for public health notifiable disease reporting systems, rather than for determining insurance reimbursement or as a criterion for disability. Most activists favour the new definition but fear that the increased reliance on CD4 count might result in a weakening of confidentiality. CDC said that there have been no breaks in confidentiality among the cases reported so far and that confidentiality would continue to be strictly maintained. Extrapulmonary tuberculosis has been an indicator disease since August, 1987. The addition of the pulmonary
form, CDC said, may increase the completeness of reporting of persons with both tuberculosis and HIV infection and the
understanding of the relation between HIV and tuberculosis epidemics. Also, public health attention can be focused on communities where prophylaxis and treatment for these diseases are most needed. Recurrent pneumonia was included as an AIDSindicator disease on grounds that the risk of multiple episodes in a 12-month period is about 19.6 times higher among persons with CD4 count below 200/ul than among those with a higher CD4 count. The yearly incidence of bacterial pneumonia among HIV-infected intravenous drug users without AIDS is 97/1000, or five times that of
non-infected drug users. Whilst the incidence of cervical cancer was rarely listed among HIV deaths in women of reproductive age in the US in 1987, one New York study indicated that the incidence of invasive cervical cancer increased from 0-5 to 3-2 per 1000 young women admitted to hospital with HIV infection between 1988 and 1991.
Harry Nelson
USA:
Compulsory recertification
for internists
Thousands of internists have received the first issue of a new semiannual newsletter of the American Board of Internal Medicine (ABIM). It contains an account of the Board’s recent policy on time-limited certification and recertification-"obligations of an accountable profession", according to the Board. All diploma-holders who passed the certifying examination after 1989 will be required to take recertifying exams at least every ten years to maintain their Board-certified status. Older colleagues are encouraged to seek recertification. The ABIM action was not unforeseen. Recertification has been an issue since the 1940s, when it was first proposed by the American Board of Medical Specialties (ABMS), but little action has been taken. Recertification was largely subsumed by the need for organised medicine to devote attention to postgraduate courses as States began to require continuing education as prerequisites for licensure. The issue was revived in 1969 when the American Board of Family Practice became the first member of the ABMS to demand recertification. Shortly thereafter, the ABIM cautiously announced its own voluntary programme of recertification. From the start, recertification--even voluntary-was extremely unpopular. "In pursuing the subject the board members have had some of the feelings of a hunter going into tall grass after a wounded Cape buffalo", one ABIM member wrote in 1970. Despite these trepidations, the ABIM policy prevailed and the first recertifying exam was offered in 1974. Upon announcing the test, the president of the American College of Physicians assured fellow internists that the recertification procedure would not be punitive and that all unsuccessful exam results would be kept strictly confidential. "I will take the recertification examination of the ABIM in October 1974 at age 57 years", he wrote. "I hope you will join me." Few did. In fact, the proportion of Board-certified internists taking the exam dwindled over the next decade to under 10%. In 1987, despite the promise of a "handsome" certificate of Advanced Achievement in Internal Medicine, and warnings that it might represent "the last gasp of
Perspective,
