ENVIRONMENTAL RESEARCH 59, 132-138 (1992)
What Is a Specialist? The Role of Board Certification in Occupational Medicine JEFFREY L. L E V I N 1 AND JOANNE L . PIZZINO Division of Occupational Medicine, Department of Medicine, The University of Texas Health Center at Tyler, P.O. Box 2003, Tyler, Texas 75710 Received May 15, 1992 A shortage of occupational medicine physicians exists for which a number of solutions have been proposed. The lack of board-certified specialists to address the increasingly complex issues encountered in this area of medicine has contributed to a Credibility and identity crisis within the occupational medicine community. This article will review the significance of board certification and its importance for enhancing and preserving the specialty of occupational medicine. © 1992AcademicPress,Inc.
INTRODUCTION
Occupational medicine has been practiced as a specialty, especially in the United States, since the industrial revolution at the turn of this century. In recent decades, the focus of practice has shifted from the treatment of work-related injuries to the recognition and prevention of disease associated with the work environment. With the rapid growth of chemical and physical hazards in the workplace accompanied by increasing administrative and regulatory complexities, the need for formally trained specialists in occupational medicine is clear. Challenges to the occupational physician in the year 2000 will be considerable and the viability of the specialty has been brought into question (Warshaw, 1990). This article will examine the significance of specialization and the role of board certification in occupational medicine for addressing these challenges. OCCUPATIONAL MEDICINE PHYSICIAN MANPOWER
The American Board of Preventive Medicine was first established in 1948 and was subsequently authorized by the Advisory Board of Medical Specialties to certify physicians beginning in 1953 (American Board of Preventive Medicine, 1987). This authorization was extended to occupational medicine beginning in 1955. Through 1990, the Board has certified approximately 1400 individuals in occupational medicine (Teichman and Goldstein, 1990). However, fewer than 1000 of these specialists are actively practicing today. Pransky has estimated that about 650 board-certified specialists were actively practicing at the time of a 1988 survey, with approximately half available to community physicians for consultation purposes (Pranksy, 1990). Less than two-thirds of recent residency graduates had pursued board certification at the time of the study. These small numbers To whom reprint requests should be addressed at Division of Occupational Medicine, The University of Texas Health Center at Tyler, P.O. Box 2003, Tyler, TX 75710. 132 0013-9351/92 $5.00 Copyright© 1992by AcademicPress, Inc. All rightsof reproductionin any formreserved.
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would suggest that a good deal of occupational medicine provided to and for workers comes from other providers. Few argue, based upon this information, that a shortage of specialists exists. The major points of dispute center around the extent of the shortage and the best approach to resolving it. Castorina and Rosenstock (1990) have recently reviewed the needs and supply of physicians in this field including estimates by the Graduate Medical Education National Advisory Committee (GMENAC), the American Medical Association (AMA), and the American College of Occupational Medicine (ACOM). The authors suggest a current deficit of 3100 to 5500 physicians. They correctly point out that most of these estimates are based upon self-selecting and self-reporting of physicians involved in the field. The majority of these physicians, however, have received no specialized certification in this area. In one survey of 942 physicians identified as preventive medicine specialists, fewer than half were board certified in any specialty and fewer than a quarter were board certified by the American Board of Preventive Medicine (Pearson et al., 1988). Approximately three-quarters of respondents had come to the field after a career change. A number of proposals exist to address the shortage of available occupational medicine expertise (Castorina and Rosenstock, 1990; Teichman and Goldstein, 1990; McCunney and Greaves, 1990). The two major targeted areas have been at the medical student level (to enhance interest in and understanding of this area) and at the postgraduate level. Ideally, the contribution of work factors to the development of disease should receive emphasis during medical school with adequate curriculum time allotted. Clearly, the formalized training of residents accompanied by board certification should serve as the desired method for increasing the availability of expertise. Although this may represent the preferred approach and has been financially supported through funding efforts spearheaded by the American College of Occupational and Environmental Medicine and by the National Institute of Environmental Health Sciences, it still may not adequately address the current shortage. This is particularly so in light of the small number of specialists who are board certified each year. The American College of Physicians has committed to the development of strategies to improve the knowledge of internists and primary caregivers in dealing with chemical and physical exposures and in preventing occupationally and environmentally induced disease (Kilbourne and Weiner, 1990). Some have suggested a formalized method of recognizing special competence among internists as a way to help address the problem of providing this type of health care at the community level (Castorina and Rosenstock, 1990). Certainly there is some validity to this approach as evidenced by case reports of exposures receiving treatment from internists with knowledge of occupational medicine (Vernon et al., 1991). Although this may address some short-term needs and improve the quality of care delivered to the individual worker, whether it will fill the void of experts for dealing with the increasingly complex issues in the practice of occupational medicine remains to be seen. Kipen (1991) has expressed concern over an attempt to impart competency and proficiency to internists without formalized training. He suggests that " a more modest and pragmatic expectation for the generalist
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may be to know when and how to use the identification of occupationalenvironmental issues that might be present for a patient as an indication for a more detailed history or other investigation. We do not expect all internists to do cardiac catheterizations or bronchoscopies, only to know when to refer to the specialist for further evaluation." While occupational medicine utilizes certain medical and surgical skills that are common to other specialties, there are, nonetheless, important differences in dealing with occupational disease. Residency training is clearly the most effective method for teaching these differences. Mini-residency programs and special competency certification do provide a useful stop-gap measure to disseminate information to the practitioners "in the trenches" and to help fill the considerable void of physicians with any understanding of the field. However, in-depth knowledge, such as can only be obtained by a 2- or 3-year immersion in the subject, is still needed to create understanding and confidence when dealing with the complexities and subtleties of the specialty. In the case of occupational medicine, this includes not only an understanding of the pathologic mechanisms of occupational disease, but of prevention, toxicology, epidemiology, risk assessment and a myriad of relationships including the physician, patient, employer, and other social groups. ONGOING IDENTITY CRISIS
Within the American College of Occupational and Environmental Medicine and among its approximately 5000 physician members (American College of Occupational Medicine, 1991), the vast majority have no certification credentials specifically for occupational medicine. The College actually represents a 1989 reorganization of the occupational medicine community with incorporation of the American Occupational Medicine Association (AOMA) and the American Academy of Occupational Medicine (AAOM) into a single entity. The major rationale for the merger was to establish a more unified, and hence, stronger voice for occupational medicine practitioners. The goals of the organization as set forth in its mission are to unite and support the interests of physicians who practice or are interested in occupational medicine, while at the same time educating and encouraging practitioners toward study and understanding of occupational disease processes. In so doing, the College presumably promotes professional standards among practitioners. In January of 1991, the membership voted overwhelmingly to once again change the name of the organization to the American College of Occupational and Environmental Medicine. There was a good deal of support for the concept that there were broad parallels between occupational medicine and environmental medicine, making the name change a natural and timely direction for the College to take (Gochfeld and Becker, 1990; DeHart, 1990; McDonagh et al., 1990). "Occupational medicine blends preventive concepts and clinical expertise with the important tools of toxicology, epidemiology, and exposure assessment to recognize and prevent exposure to hazards in the workplace environment" (Gochfeld and Becker, 1990). Likewise, it was argued that environmental medicine involved the application of similar skills to exposures beyond the work environment. Others
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argued that the definition of environmental medicine was not so clear (Ducatman et al., 1990) and that residency programs in occupational medicine would have to expand their scope in order to provide the necessary training elements (Cullen and Figueroa, 1990). The position of the American Board of Preventive Medicine, however, is that the concept of environmental medicine as a separate specialty is incorrect in that there are environmental issues encountered in each of the subspecialty areas of the Board (Tepper, 1990). The Board, therefore, feels that there is little current need to incorporate environmental medicine as a separate area of study and clinical practice into the medical specialty of occupational medicine. The Board suggests that dissatisfaction for this position would come primarily from those who view the situation as a "turf" battle with other medical specialties. WHAT IS A SPECIALIST AND WHY BE ONE?
The Flexner Report originally published in 1910 resulted in a more uniform model for medical education in American medical schools (Jonas, 1986). Since that time, there has been an explosion of medical knowledge with a resultant trend toward specialization in an attempt to make this growing body of information manageable. There are multiple factors which have guided the growth of various medical specialties, an elaboration of which is beyond the scope of this discussion. Common to almost all of the identifiable medical specialties, however, is a specified program of postgraduate training leading to eligibility for examination to be certified as a specialist. It is accepted that there is a discrete body of information tested by such an examination, of which the certified specialist will have an in-depth understanding. In an era of increased demand for measuring quality of care, such board certification represents an important mechanism for ensuring the credible provision of quality medical services. Many specialty boards now offer time-limited certification, requiring that diplomates be recertified on a periodic basis. The American Board of Family Practice has required recertification since its inception in 1969 (Glassock et al., 1991). After considerable deliberation, the American Board of Internal Medicine now offers a specialty certificate with a time-limited duration of validity for all candidates examined in 1990 and after. This decision was based upon the explosive growth of medical information, combined with evidence of decay in the knowledge and skills of certified practitioners, as well as increased public concern. The goal was to improve the quality of care by setting more stringent standards. The argument has also been made that all internists should undergo recertification regardless of when they were originally tested in order to meet this standard, much like family practitioners (Lifshitz, 1991). Beginning on January 1, 1984, graduates of medical or osteopathic schools are eligible for certification by examination in occupational medicine only after completion of an approved course of training in an accredited residency program (American Board of Preventive Medicine, 1987). The candidate must also complete at least 1 year of full-time special training, research, teaching, or practice in the field of preventive medicine. However, alternate or equivalency pathways still exist for pre-1984 graduates even though the experience required may be consid-
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erable. This experience in occupational medicine does not necessarily have to be supervised and evaluated. There is concern over the fact that the American Board of Preventive Medicine continues to allow an open-ended alternative pathway to certification (McDiarmid, 1990). This concern is justifiable not only from the standpoint of ensuring high quality and standards, as McDiarmid points out, but also because of poor appreciation by colleagues of the role of the occupational specialist. Many other specialists are not even aware that the specialty is different and separate from the component of rehabilitative medicine known as occupational therapy or that it has its own board and certification process. An enhanced position among other medical specialties leads to better dissemination of information and more appropriate consultation and referral. Such an open-ended alternative pathway to board certification weakens the credibility of occupational medicine as the only specialty among the American Board of Medical Specialties which allows certification by this route. It also serves little purpose for those physicians who wish to have this option available to them, but have not yet taken advantage of it. Certainly, the specialty of occupational medicine would expect that any physician making a career change would have to complete a proper course of training, just as any other specialty would require. No other specialist would embrace as a colleague a practitioner who had no formal training in their field. For instance, one cannot simply claim to have the detail and scope of knowledge of a dermatologist or cardiologist without some evidence of supervised training. This is contradictory to the whole system of medical specialization which has come about because of the need to manage a vast expl6'sion of knowledge in medical science. The credibility of trained specialists is weakened by the large number of practitioners who offer services in occupational medicine despite having no formal training in the field. Equally important is the issue of quality assurance and quality control. In an era in which practice parameters are becoming the standard of care, providers must apply uniform diagnostic and therapeutic principles and have a thorough academic knowledge of the area in which they purport to provide services. This allows industry and individual consumers to receive higher quality services and to make more informed decisions regarding their care. Additionally, from its inception, occupational medicine has had a somewhat different focus than most specialties. Since it is actually a specialty of preventive medicine, its main thrust has always been to avoid illness and injury, whereas most specialties must deal with the results of the failure or neglect of preventive modalities. This view of prevention, developed through knowledge of risk factors and identification of disease clusters, is most thoroughly developed in the atmosphere of supervised training. As our society becomes more aware of issues such as cost containment and quality of life, it is mandatory that we develop and encourage preventive sciences and support their credibility in order to truly bring about changes in lifestyles and policies. The response of the American College of Occupational Medicine and its membership regarding the incorporation of environmental medicine into the specialty demonstrates a similar lack of understanding and short-sightedness surrounding the importance of this credibility. Although there are many good reasons for this
ROLE OF BOARD CERTIFICATION
137
merger of disciplines, the largely uncredentialed group of self-identified occupational specialists has not yet even dealt with the issue of board certification. "Gaining turf" may represent an important motivation for this name change in a very competitive provider atmosphere. However, the College should first be pursuing its stated goals of excellence by encouraging board certification among its members, seeking to eliminate open-ended alternative pathways to such certification, and at the same time defining the realm of environmental medicine while establishing training protocols. Territorial battles are most likely to be won on the basis of credibility as other specialties have recognized. The proposal of a certificate of special competence • for internists, uniform pathways of board certification, as well as time-limited certification support this argument. At the political level, the College should insist that regulatory standards require that board-certified occupational medicine physicians perform medical surveillance and address health issues in the work environment. This would not only ensure quality of care, but also establish territorial boundaries for providers. CONCLUSION The foregoing discussion reviews a manpower shortage in occupational medicine for which a number of solutions have been proposed. Most have agreed that the increasing complexity of occupational medicine is best addressed in the longterm through formalized training and board certification. Short-term needs may require training and special certification for primary caregivers. Occupational medicine currently suffers an identity crisis, in part because of this lack of board-certified specialists. A move to change the name of the American College of Occupational Medicine to include the study and treatment of environmental illness is both reasonable and timely and can enhance the specialty's identity. However, occupational medicine and the College, as its major educational and political organization, must emphasize credibility to preserve its identity among the other medical specialties. Uniform minimum training requirements and encouragement toward board certification are two necessary aspects of creating this credibility. It is fitting in this issue of Environmental Research honoring the achievements of Dr. Selikoff and his contribution to the field of occupational medicine to insist upon this level of excellence. REFERENCES American Board of Preventive Medicine Incorporated (1987). "Booklet of Information," revised ed. American Board of Preventive Medicine, Dayton, OH. American College of Occupational Medicine (1991). "Membership Directory: 1991-1992." American College of Occupational Medicine, Arlington Heights, IL. Castorina, J. S., and Rosenstock, L. (1990). Physician shortage in occupational and environmental medicine. Ann. Intern. Med. 113, 983-986. Cullen, M. R., and Figueroa, S. T. (1990). Incorporating environmental medicine into training programs in occupational medicine. J. Occup. Med. 32, 1104-1107. DeHart, R. L. (1990). An opportunity lost, an opportunity regained: The challenge for an evolving specialty. J. Occup. Med. 32, 1110. Ducatman, A. M., Chase, K. H., Farid, I., LaDou, J., Logan, D. C., McCunney, R. J., Milroy,
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W. C., Mitchell, F., Monosson, I., and Sunderman, F. W. (1990). What is environmental medicine? J. Oecup. Med. 32, 1130-1132. Glassock, R. J., Benson, J. A., Copeland, R. B., Godwin, H. A., Johanson, W. G., Point, W., Popp, R. L., Scherr, L., Stein, J. H., and Taunton, O. D. (1991). Timeqimited certification and recertification: The program of the American Board of Internal Medicine. Ann. Intern. Med. 114, 59-62. Gochfeld, M., and Becker, C. E. (1990). What's in a name? Taking poetic license with occupational and environmental medicine. J. Oecup. Med. 32, 1108-1109. Jonas, S. (1986). Health manpower. In "Health Care Delivery in the United States," 3rd ed., pp. 54-89. Springer, New York. Kilbourne, E. M., and Weiner, J. (1990). Occupational and environmental medicine: The internist's role. Position paper of the American College of Physicians. Ann. Intern. Med. 113, 974-982. Kipen, H. (1991). Occupational medicine: Too much expected (letter)? Ann. Intern. Med. 114, 915. Lifshitz, E. (1991). Timeqimited certification (letter). Ann. Intern. Med. 114, 432. McCunney, R. J., and Greaves, W. (1990). Addressing the shortage of occupational physicians (letter). J. Occup. Med. 32, 1247-1248. McDiarmid, M. A. (1990). Occupational medicine board certification (letter). J. Occup. Med. 32, 949. McDonagh, T. J., DeHart, R. L., Gorkun, L. J., Harber, P. I., Peterson, K. W., and Shaptini, E. A. (1990). To change or not to change. J. Oceup. Med. 32, 1160A-1160B. Pearson, R. J., Kane, W. M., and Keimowitz, H. K. (1988). The preventive medicine physician: A national study. Am. J. Prey. Med. 4, 28%297. Pransky, G. (1990). Occupational medicine specialists in the United States: A survey. J. Occup. Med. 32, 985-988. Teichman, R. F., and Goldstein, M. D. (1990). Filling the void of well-trained occupational medicine physicians: A challenge for the 1990s. J. Occup. Med. 32, 124-126. Tepper, L. B. (1990). Environment and the American Board of Preventive Medicine. J. Occup. Med. 32, 1111. Vernon, S. W., Cooper, S. P., Morris, R. D., Buffier, P. A., Key, M. M., and Bradley, B. L. (1991). Physicians' management of health effects related to industrial exposures: Two case reports. Texas Med. 87, 83-87. Warshaw, L. J. (1990). Toward the year 2000: Challenges to the occupational physician. J. Occup. Med. 32, 524-528.
What Is a Specialist? The Role of Board Certification in Occupational Medicine JEFFREY L. L E V I N 1 AND JOANNE L . PIZZINO Division of Occupational Medicine, Department of Medicine, The University of Texas Health Center at Tyler, P.O. Box 2003, Tyler, Texas 75710 Received May 15, 1992 A shortage of occupational medicine physicians exists for which a number of solutions have been proposed. The lack of board-certified specialists to address the increasingly complex issues encountered in this area of medicine has contributed to a Credibility and identity crisis within the occupational medicine community. This article will review the significance of board certification and its importance for enhancing and preserving the specialty of occupational medicine. © 1992AcademicPress,Inc.
INTRODUCTION
Occupational medicine has been practiced as a specialty, especially in the United States, since the industrial revolution at the turn of this century. In recent decades, the focus of practice has shifted from the treatment of work-related injuries to the recognition and prevention of disease associated with the work environment. With the rapid growth of chemical and physical hazards in the workplace accompanied by increasing administrative and regulatory complexities, the need for formally trained specialists in occupational medicine is clear. Challenges to the occupational physician in the year 2000 will be considerable and the viability of the specialty has been brought into question (Warshaw, 1990). This article will examine the significance of specialization and the role of board certification in occupational medicine for addressing these challenges. OCCUPATIONAL MEDICINE PHYSICIAN MANPOWER
The American Board of Preventive Medicine was first established in 1948 and was subsequently authorized by the Advisory Board of Medical Specialties to certify physicians beginning in 1953 (American Board of Preventive Medicine, 1987). This authorization was extended to occupational medicine beginning in 1955. Through 1990, the Board has certified approximately 1400 individuals in occupational medicine (Teichman and Goldstein, 1990). However, fewer than 1000 of these specialists are actively practicing today. Pransky has estimated that about 650 board-certified specialists were actively practicing at the time of a 1988 survey, with approximately half available to community physicians for consultation purposes (Pranksy, 1990). Less than two-thirds of recent residency graduates had pursued board certification at the time of the study. These small numbers To whom reprint requests should be addressed at Division of Occupational Medicine, The University of Texas Health Center at Tyler, P.O. Box 2003, Tyler, TX 75710. 132 0013-9351/92 $5.00 Copyright© 1992by AcademicPress, Inc. All rightsof reproductionin any formreserved.
ROLE OF BOARD C E R T I F I C A T I O N
133
would suggest that a good deal of occupational medicine provided to and for workers comes from other providers. Few argue, based upon this information, that a shortage of specialists exists. The major points of dispute center around the extent of the shortage and the best approach to resolving it. Castorina and Rosenstock (1990) have recently reviewed the needs and supply of physicians in this field including estimates by the Graduate Medical Education National Advisory Committee (GMENAC), the American Medical Association (AMA), and the American College of Occupational Medicine (ACOM). The authors suggest a current deficit of 3100 to 5500 physicians. They correctly point out that most of these estimates are based upon self-selecting and self-reporting of physicians involved in the field. The majority of these physicians, however, have received no specialized certification in this area. In one survey of 942 physicians identified as preventive medicine specialists, fewer than half were board certified in any specialty and fewer than a quarter were board certified by the American Board of Preventive Medicine (Pearson et al., 1988). Approximately three-quarters of respondents had come to the field after a career change. A number of proposals exist to address the shortage of available occupational medicine expertise (Castorina and Rosenstock, 1990; Teichman and Goldstein, 1990; McCunney and Greaves, 1990). The two major targeted areas have been at the medical student level (to enhance interest in and understanding of this area) and at the postgraduate level. Ideally, the contribution of work factors to the development of disease should receive emphasis during medical school with adequate curriculum time allotted. Clearly, the formalized training of residents accompanied by board certification should serve as the desired method for increasing the availability of expertise. Although this may represent the preferred approach and has been financially supported through funding efforts spearheaded by the American College of Occupational and Environmental Medicine and by the National Institute of Environmental Health Sciences, it still may not adequately address the current shortage. This is particularly so in light of the small number of specialists who are board certified each year. The American College of Physicians has committed to the development of strategies to improve the knowledge of internists and primary caregivers in dealing with chemical and physical exposures and in preventing occupationally and environmentally induced disease (Kilbourne and Weiner, 1990). Some have suggested a formalized method of recognizing special competence among internists as a way to help address the problem of providing this type of health care at the community level (Castorina and Rosenstock, 1990). Certainly there is some validity to this approach as evidenced by case reports of exposures receiving treatment from internists with knowledge of occupational medicine (Vernon et al., 1991). Although this may address some short-term needs and improve the quality of care delivered to the individual worker, whether it will fill the void of experts for dealing with the increasingly complex issues in the practice of occupational medicine remains to be seen. Kipen (1991) has expressed concern over an attempt to impart competency and proficiency to internists without formalized training. He suggests that " a more modest and pragmatic expectation for the generalist
134
LEVIN AND PIZZINO
may be to know when and how to use the identification of occupationalenvironmental issues that might be present for a patient as an indication for a more detailed history or other investigation. We do not expect all internists to do cardiac catheterizations or bronchoscopies, only to know when to refer to the specialist for further evaluation." While occupational medicine utilizes certain medical and surgical skills that are common to other specialties, there are, nonetheless, important differences in dealing with occupational disease. Residency training is clearly the most effective method for teaching these differences. Mini-residency programs and special competency certification do provide a useful stop-gap measure to disseminate information to the practitioners "in the trenches" and to help fill the considerable void of physicians with any understanding of the field. However, in-depth knowledge, such as can only be obtained by a 2- or 3-year immersion in the subject, is still needed to create understanding and confidence when dealing with the complexities and subtleties of the specialty. In the case of occupational medicine, this includes not only an understanding of the pathologic mechanisms of occupational disease, but of prevention, toxicology, epidemiology, risk assessment and a myriad of relationships including the physician, patient, employer, and other social groups. ONGOING IDENTITY CRISIS
Within the American College of Occupational and Environmental Medicine and among its approximately 5000 physician members (American College of Occupational Medicine, 1991), the vast majority have no certification credentials specifically for occupational medicine. The College actually represents a 1989 reorganization of the occupational medicine community with incorporation of the American Occupational Medicine Association (AOMA) and the American Academy of Occupational Medicine (AAOM) into a single entity. The major rationale for the merger was to establish a more unified, and hence, stronger voice for occupational medicine practitioners. The goals of the organization as set forth in its mission are to unite and support the interests of physicians who practice or are interested in occupational medicine, while at the same time educating and encouraging practitioners toward study and understanding of occupational disease processes. In so doing, the College presumably promotes professional standards among practitioners. In January of 1991, the membership voted overwhelmingly to once again change the name of the organization to the American College of Occupational and Environmental Medicine. There was a good deal of support for the concept that there were broad parallels between occupational medicine and environmental medicine, making the name change a natural and timely direction for the College to take (Gochfeld and Becker, 1990; DeHart, 1990; McDonagh et al., 1990). "Occupational medicine blends preventive concepts and clinical expertise with the important tools of toxicology, epidemiology, and exposure assessment to recognize and prevent exposure to hazards in the workplace environment" (Gochfeld and Becker, 1990). Likewise, it was argued that environmental medicine involved the application of similar skills to exposures beyond the work environment. Others
ROLE OF BOARD CERTIFICATION
135
argued that the definition of environmental medicine was not so clear (Ducatman et al., 1990) and that residency programs in occupational medicine would have to expand their scope in order to provide the necessary training elements (Cullen and Figueroa, 1990). The position of the American Board of Preventive Medicine, however, is that the concept of environmental medicine as a separate specialty is incorrect in that there are environmental issues encountered in each of the subspecialty areas of the Board (Tepper, 1990). The Board, therefore, feels that there is little current need to incorporate environmental medicine as a separate area of study and clinical practice into the medical specialty of occupational medicine. The Board suggests that dissatisfaction for this position would come primarily from those who view the situation as a "turf" battle with other medical specialties. WHAT IS A SPECIALIST AND WHY BE ONE?
The Flexner Report originally published in 1910 resulted in a more uniform model for medical education in American medical schools (Jonas, 1986). Since that time, there has been an explosion of medical knowledge with a resultant trend toward specialization in an attempt to make this growing body of information manageable. There are multiple factors which have guided the growth of various medical specialties, an elaboration of which is beyond the scope of this discussion. Common to almost all of the identifiable medical specialties, however, is a specified program of postgraduate training leading to eligibility for examination to be certified as a specialist. It is accepted that there is a discrete body of information tested by such an examination, of which the certified specialist will have an in-depth understanding. In an era of increased demand for measuring quality of care, such board certification represents an important mechanism for ensuring the credible provision of quality medical services. Many specialty boards now offer time-limited certification, requiring that diplomates be recertified on a periodic basis. The American Board of Family Practice has required recertification since its inception in 1969 (Glassock et al., 1991). After considerable deliberation, the American Board of Internal Medicine now offers a specialty certificate with a time-limited duration of validity for all candidates examined in 1990 and after. This decision was based upon the explosive growth of medical information, combined with evidence of decay in the knowledge and skills of certified practitioners, as well as increased public concern. The goal was to improve the quality of care by setting more stringent standards. The argument has also been made that all internists should undergo recertification regardless of when they were originally tested in order to meet this standard, much like family practitioners (Lifshitz, 1991). Beginning on January 1, 1984, graduates of medical or osteopathic schools are eligible for certification by examination in occupational medicine only after completion of an approved course of training in an accredited residency program (American Board of Preventive Medicine, 1987). The candidate must also complete at least 1 year of full-time special training, research, teaching, or practice in the field of preventive medicine. However, alternate or equivalency pathways still exist for pre-1984 graduates even though the experience required may be consid-
136
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erable. This experience in occupational medicine does not necessarily have to be supervised and evaluated. There is concern over the fact that the American Board of Preventive Medicine continues to allow an open-ended alternative pathway to certification (McDiarmid, 1990). This concern is justifiable not only from the standpoint of ensuring high quality and standards, as McDiarmid points out, but also because of poor appreciation by colleagues of the role of the occupational specialist. Many other specialists are not even aware that the specialty is different and separate from the component of rehabilitative medicine known as occupational therapy or that it has its own board and certification process. An enhanced position among other medical specialties leads to better dissemination of information and more appropriate consultation and referral. Such an open-ended alternative pathway to board certification weakens the credibility of occupational medicine as the only specialty among the American Board of Medical Specialties which allows certification by this route. It also serves little purpose for those physicians who wish to have this option available to them, but have not yet taken advantage of it. Certainly, the specialty of occupational medicine would expect that any physician making a career change would have to complete a proper course of training, just as any other specialty would require. No other specialist would embrace as a colleague a practitioner who had no formal training in their field. For instance, one cannot simply claim to have the detail and scope of knowledge of a dermatologist or cardiologist without some evidence of supervised training. This is contradictory to the whole system of medical specialization which has come about because of the need to manage a vast expl6'sion of knowledge in medical science. The credibility of trained specialists is weakened by the large number of practitioners who offer services in occupational medicine despite having no formal training in the field. Equally important is the issue of quality assurance and quality control. In an era in which practice parameters are becoming the standard of care, providers must apply uniform diagnostic and therapeutic principles and have a thorough academic knowledge of the area in which they purport to provide services. This allows industry and individual consumers to receive higher quality services and to make more informed decisions regarding their care. Additionally, from its inception, occupational medicine has had a somewhat different focus than most specialties. Since it is actually a specialty of preventive medicine, its main thrust has always been to avoid illness and injury, whereas most specialties must deal with the results of the failure or neglect of preventive modalities. This view of prevention, developed through knowledge of risk factors and identification of disease clusters, is most thoroughly developed in the atmosphere of supervised training. As our society becomes more aware of issues such as cost containment and quality of life, it is mandatory that we develop and encourage preventive sciences and support their credibility in order to truly bring about changes in lifestyles and policies. The response of the American College of Occupational Medicine and its membership regarding the incorporation of environmental medicine into the specialty demonstrates a similar lack of understanding and short-sightedness surrounding the importance of this credibility. Although there are many good reasons for this
ROLE OF BOARD CERTIFICATION
137
merger of disciplines, the largely uncredentialed group of self-identified occupational specialists has not yet even dealt with the issue of board certification. "Gaining turf" may represent an important motivation for this name change in a very competitive provider atmosphere. However, the College should first be pursuing its stated goals of excellence by encouraging board certification among its members, seeking to eliminate open-ended alternative pathways to such certification, and at the same time defining the realm of environmental medicine while establishing training protocols. Territorial battles are most likely to be won on the basis of credibility as other specialties have recognized. The proposal of a certificate of special competence • for internists, uniform pathways of board certification, as well as time-limited certification support this argument. At the political level, the College should insist that regulatory standards require that board-certified occupational medicine physicians perform medical surveillance and address health issues in the work environment. This would not only ensure quality of care, but also establish territorial boundaries for providers. CONCLUSION The foregoing discussion reviews a manpower shortage in occupational medicine for which a number of solutions have been proposed. Most have agreed that the increasing complexity of occupational medicine is best addressed in the longterm through formalized training and board certification. Short-term needs may require training and special certification for primary caregivers. Occupational medicine currently suffers an identity crisis, in part because of this lack of board-certified specialists. A move to change the name of the American College of Occupational Medicine to include the study and treatment of environmental illness is both reasonable and timely and can enhance the specialty's identity. However, occupational medicine and the College, as its major educational and political organization, must emphasize credibility to preserve its identity among the other medical specialties. Uniform minimum training requirements and encouragement toward board certification are two necessary aspects of creating this credibility. It is fitting in this issue of Environmental Research honoring the achievements of Dr. Selikoff and his contribution to the field of occupational medicine to insist upon this level of excellence. REFERENCES American Board of Preventive Medicine Incorporated (1987). "Booklet of Information," revised ed. American Board of Preventive Medicine, Dayton, OH. American College of Occupational Medicine (1991). "Membership Directory: 1991-1992." American College of Occupational Medicine, Arlington Heights, IL. Castorina, J. S., and Rosenstock, L. (1990). Physician shortage in occupational and environmental medicine. Ann. Intern. Med. 113, 983-986. Cullen, M. R., and Figueroa, S. T. (1990). Incorporating environmental medicine into training programs in occupational medicine. J. Occup. Med. 32, 1104-1107. DeHart, R. L. (1990). An opportunity lost, an opportunity regained: The challenge for an evolving specialty. J. Occup. Med. 32, 1110. Ducatman, A. M., Chase, K. H., Farid, I., LaDou, J., Logan, D. C., McCunney, R. J., Milroy,
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W. C., Mitchell, F., Monosson, I., and Sunderman, F. W. (1990). What is environmental medicine? J. Oecup. Med. 32, 1130-1132. Glassock, R. J., Benson, J. A., Copeland, R. B., Godwin, H. A., Johanson, W. G., Point, W., Popp, R. L., Scherr, L., Stein, J. H., and Taunton, O. D. (1991). Timeqimited certification and recertification: The program of the American Board of Internal Medicine. Ann. Intern. Med. 114, 59-62. Gochfeld, M., and Becker, C. E. (1990). What's in a name? Taking poetic license with occupational and environmental medicine. J. Oecup. Med. 32, 1108-1109. Jonas, S. (1986). Health manpower. In "Health Care Delivery in the United States," 3rd ed., pp. 54-89. Springer, New York. Kilbourne, E. M., and Weiner, J. (1990). Occupational and environmental medicine: The internist's role. Position paper of the American College of Physicians. Ann. Intern. Med. 113, 974-982. Kipen, H. (1991). Occupational medicine: Too much expected (letter)? Ann. Intern. Med. 114, 915. Lifshitz, E. (1991). Timeqimited certification (letter). Ann. Intern. Med. 114, 432. McCunney, R. J., and Greaves, W. (1990). Addressing the shortage of occupational physicians (letter). J. Occup. Med. 32, 1247-1248. McDiarmid, M. A. (1990). Occupational medicine board certification (letter). J. Occup. Med. 32, 949. McDonagh, T. J., DeHart, R. L., Gorkun, L. J., Harber, P. I., Peterson, K. W., and Shaptini, E. A. (1990). To change or not to change. J. Oceup. Med. 32, 1160A-1160B. Pearson, R. J., Kane, W. M., and Keimowitz, H. K. (1988). The preventive medicine physician: A national study. Am. J. Prey. Med. 4, 28%297. Pransky, G. (1990). Occupational medicine specialists in the United States: A survey. J. Occup. Med. 32, 985-988. Teichman, R. F., and Goldstein, M. D. (1990). Filling the void of well-trained occupational medicine physicians: A challenge for the 1990s. J. Occup. Med. 32, 124-126. Tepper, L. B. (1990). Environment and the American Board of Preventive Medicine. J. Occup. Med. 32, 1111. Vernon, S. W., Cooper, S. P., Morris, R. D., Buffier, P. A., Key, M. M., and Bradley, B. L. (1991). Physicians' management of health effects related to industrial exposures: Two case reports. Texas Med. 87, 83-87. Warshaw, L. J. (1990). Toward the year 2000: Challenges to the occupational physician. J. Occup. Med. 32, 524-528.
