Academic Psychiatry 28:12-17, March 2004
© 2004 Academic Psychiatry
Subspecialty Certification by the American Board of Psychiatry and Neurology
Dorthea Juul, Ph.D.,
Stephen C. Scheiber, M.D. and
Thomas A. M. Kramer, M.D.
Dr. Juul is Vice President for Research and Development at the American Board of Psychiatry and Neurology (ABPN), Inc., Deerfield, IL. Dr. Scheiber is Executive Vice President for Research and Development at ABPN. Dr. Kramer is Associate Professor of Psychiatry at the University of Chicago, Chicago, Illinois. Address correspondence to Dr. Juul, American Board of Psychiatry and Neurology, Inc., 500 Lake Cook Rd., Deerfield, IL 60015-5249. djuul{at}abpn.com (E-mail).
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ABSTRACT
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Objective: The authors describe the approval processes for subspecialties and the mechanisms for certification and recertification and review the status of training programs and numbers of diplomates with subspecialty certification. Methods: Published information and relevant data bases were reviewed. To date, 5,327 child and adolescent psychiatry, 2,595 geriatric psychiatry, 1,854 addiction psychiatry, and 1,384 forensic psychiatry certificates have been awarded. In clinical neurophysiology and pain medicine, specialties that are primarily for neurologists and child neurologists, 21 and 28 psychiatrists, respectively, have been certified. There are 113 residency programs in child and adolescent psychiatry, 62 in geriatric psychiatry, 43 in addiction psychiatry, and 40 in forensic psychiatry. There are no psychiatry-based training programs in clinical neurophysiology and pain medicine. While this may not be of concern for clinical neurophysiology, it may lessen psychiatry’s contribution to pain medicine. Results: The ABPN took a conservative approach to establishing subspecialty certification in psychiatry. Conclusion: It is expected that subspecialists will enhance patient care through their clinical activities as well as through teaching and research.
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INTRODUCTION
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Spurred by the growth in medical knowledge and technical complexity, twentieth century American medicine was characterized by the continuous and, at times, extremely rapid growth of specialties and subspecialties (1,2). As training programs proliferated, residency supplanted internship as the route to practice as well as to an academic career, and additional training was associated with financial advantage and enhanced prestige.
A related development was the creation of boards to certify physician specialists, the first being the American Board of Ophthalmology, organized in 1917. In 1933 an umbrella organization, the Advisory Board for Medical Specialties, was formed for the boards and other related organizations. It was reorganized as the American Board of Medical Specialties (ABMS) in 1970.
The American Board of Psychiatry and Neurology (ABPN) was founded in 1934. In 1991 the American Board of Medical Genetics was approved as the 24th ABMS board. These 24 boards currently grant 37 general certificates and 88 subspecialty certificates (3). In their mission statements, both the ABPN and the ABMS emphasize that the goal of certification is to enhance medical care through the voluntary certification.
The purpose of this paper is to describe the approval processes of the ABPN and the ABMS for subspecialties and the ABPN’s mechanisms for certification and recertification. The number of certificates that have been awarded, recertification rates, and training program data are also presented.
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Subspecialty Approval
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In 1959, the ABPN issued its first subspecialty certificate, which was in child and adolescent psychiatry. This was the only ABPN subspecialty until 1991, when the first examination in geriatric psychiatry was administered. This was followed by the first examination in clinical neurophysiology in 1992, addiction psychiatry in 1993, forensic psychiatry in 1994, and pain medicine in 2000. In March 2003, the ABMS approved a proposal for subspecialty certification in psychosomatic medicine, with the first test to be administered in 2005. (The ABPN also issues subspecialty certificates in neurodevelopmental disabilities for child neurologists and has received ABMS approval for subspecialty certification in vascular neurology.)
As this history suggests, the ABPN was "conservative" in developing new subspecialty certificates, with the board following the field rather than leading it (4). The process generally began with representatives of subspecialty organizations approaching the board. Scheiber noted that some of these exchanges extended over many years and did not always lead to new certificates, as was the case with administrative psychiatry, adolescent psychiatry, psychoanalysis, and consultation-liaison psychiatry (5).
The reasons these areas did not become subspecialties recognized by the ABPN were varied. Administrative psychiatry was principally turned down on the grounds that it was not a clinical subspecialty of psychiatry. Adolescent psychiatry overlapped with the subspecialty certificate in child psychiatry that was already being issued and addressed adolescence, and the name of the certificate was eventually changed to child and adolescent psychiatry. Subspecialization in psychoanalysis was not seriously pursued because psychoanalytic training programs and organizations did not wish to yield the necessary prerogatives to the ACGME or the ABPN.
Consideration of consultation-liaison psychiatry led to the conclusion that consultation psychiatry was an integral part of psychiatric practice, and thus not a subspecialty. In contrast, the more recent proposal for psychosomatic medicine revealed that training programs in this area dealt with the most severe medical and surgical problems. Hence, there was a knowledge base distinct from that of general psychiatry.
The ABPN’s subspecialty requirements, the current version of which appear in Table 1, reflected the board’s responsive stance to a field and emphasized the need for documentation of the professional and scientific status of the subspecialty. If a subspecialty met these criteria, the ABPN submitted a proposal to the ABMS, where it was reviewed by the Committee on Certification, Subcertification and Recertification, and the Executive Committee, each of which prepared recommendations. The proposal and recommendations were then submitted to the ABMS’ voting representatives for a final decision. Among other requirements, the ABMS’ guidelines specify a minimum of 1 year of residency training accredited by the Accreditation Council for Graduate Medical Education (ACGME) that incorporates a specific and identifiable body of knowledge and is not limited to a technical skill (3).
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Residency Program Requirements
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Typically following ABMS approval, the ABPN requested the Psychiatry Residency Review Committee (RRC) to develop the criteria for training in a subspecialty, which had to be approved by the ACGME. At times, ACGME accreditation preceded ABMS approval, as was the case with vascular neurology. Following approval of the program requirements, individual residency programs were reviewed by the Psychiatry RRC.
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Number of Training Programs/Residents
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The number of training programs in the four primary psychiatry subspecialties, the number of approved/offered resident positions, and the number of filled positions as of June 30, 2003 appear in Table 2 (6). Geriatric psychiatry had 62 programs with 104/163 (64%) filled positions. There were 43 programs with 59/108 (55%) filled positions in addiction psychiatry and 40 programs with 66/97 (68%) filled positions in forensic psychiatry. For child and adolescent psychiatry, the oldest subspecialty, there were 113 programs with 681/861 (79%) filled positions.
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TABLE 2. Number of Residency Training Programs, Number of Approved/Offered Resident Positions, and Number of Filled Positions for the Academic Year Ending June 30, 2003
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There were 87 clinical neurophysiology programs, all of which were associated with neurology residencies, with 169 filled positions. There were also 103 pain medicine programs, 97 of which were associated with anesthesiology residencies and six with physical medicine and rehabilitation residencies, with 235 filled positions. A small number of programs have also been submitted to the Neurology Residency Review Committee for consideration. Psychiatry departments can sponsor residency training in these areas if no programs exist at their institutions.
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Subspecialty Certification Requirements
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To qualify for examination for certification in a subspecialty, an applicant must be certified by the ABPN in psychiatry, hold an unrestricted license to practice medicine in a state, commonwealth, territory, or possession of the United States or province of Canada, and have satisfactorily completed ACGME-accredited training in the subspecialty for which he or she is applying. During the first 5 years in which a given subspecialty certificate was offered, applicants also had the options of meeting the latter requirement through practice time in the subspecialty or successful completion of non-ACGME-accredited residency training in the subspecialty. (This is commonly referred to as the "grandfathering" period.)
Additionally, candidates must also successfully complete an evaluation procedure. Although oral examinations were part of certification processes in general psychiatry and in child and adolescent psychiatry (CAP), the board directors decided not to use this format for the new subspecialties because of the significant logistic and cost considerations. Multiple-choice tests were used instead. In addition to the relative ease of administration and scoring, multiple-choice questions (MCQs) allow for the assessment of a broad range of cognitive objectives in an efficient manner. Clinical material can be readily incorporated into MCQs, either verbally as case vignettes or in graphics such as neuroimaging studies.
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Examination Development And Administration
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Shortly after ABMS approval, an eight- to 12-member test committee of experts in the subspecialty was appointed. Under the leadership of an ABPN director, the first committee task was to develop a "blueprint" for the examination, specifying the content areas to be covered and assigning relative weights (percentages) to each topic. This content outline, provided to examinees, was used to guide item-writing. The subspecialty examinations consisted of 200 MCQs, except for clinical neurophysiology, which had 250 items.
In addition to item writing and reviewing, another test committee task was establishing the pass/fail standard for the examination. For all of its examinations, the ABPN uses a criterion-referenced approach to standard setting. Individual committee members were asked to determine how a minimally competent examinee should perform on all the items on the examination, and the results were combined to arrive at the final standard. In contrast to a norm-referenced approach in which one examinee is judged relative to other examinees, regardless of their actual scores, all candidates can meet the standard and pass the test.
The subspecialty examinations were administered under closed-book, proctored conditions. Recently, they have been administered at the ABPN’s computer test center in Deerfield, Illinois and, when warranted by an excessive number of examinees, they are given at the test centers of the American Boards of Pathology (Tampa, FL) and of Radiology (Tucson, AZ). Computer testing met with very positive responses from examinees, even from those who had little experience in manipulating a mouse.
After the tests were administered, the initial results were reviewed by ABPN staff, who flagged any items with aberrant performance for further review by the chair and co-chair. Typically, an item was reviewed if less than 30% of the examinees selected the correct answer and/or if there was a negative correlation between performance on that item and the total test score. Faulty items (e.g., too difficult, more than one correct answer) were deleted from the second scoring; the chair and co-chair met again to ratify the final pass/fail standard for the examination; and grade letters were sent to the examinees.
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Examination Results
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The cumulative examination results for the newer subspecialties through 2002 appear in Table 3. The numbers of certificates awarded were 2,595 in geriatric psychiatry, 1,854 in addiction psychiatry, and 1,384 in forensic psychiatry. Examinations for clinical neurophysiology and pain medicine were primarily taken by neurologists and child neurologists. Twenty one psychiatrists were certified in clinical neurophysiology, and 28 were certified in pain medicine. In child and adolescent psychiatry, 5,327 certificates were issued between 1959 and 2002.
As expected, the number of examinees dropped sharply after the 5-year "grandfathering" period, during which applicants could qualify via practice time or non-ACGME-accredited training, ended (which it has for all of these subspecialties except for pain medicine, which will end after the 2006 examination). Pass rates on the examinations have gone up as all candidates have completed ACGME-accredited training programs. For example, the pass rate for both the 2000 and 2002 addiction psychiatry examinations (78 examinees total) was 100%.
The rate at which graduates of ACGME-accredited training programs applied for certification could not be directly determined since no centralized records of trainees existed. However, estimates were made based on data derived from the American Medical Association’s annual surveys of the number of residents who were on duty on August 1. It was assumed that all of those residents finished training in June of the following year. Based on the requirement that subspecialty candidates had to be certified in general psychiatry and the subspecialty examinations were administered every other year, it was assumed that the most likely candidates for the 2002 examinations, for example, were those who finished training in 1999 (7) and 2000 (8). Those numbers were 80 (34 + 46) for addiction psychiatry and 189 (91 + 98) for geriatric psychiatry. There were 37 candidates for the 2002 addiction examination, and 103 for the geriatric psychiatry examination. There were 83 candidates for the 2003 forensic psychiatry examination, compared to 89 (44 + 45) graduates in 2000 (8) and 2001 (9).
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Recertification
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All of the certificates issued in the newer subspecialties were 10-year, time-limited certificates, while time-limited certificates in child and adolescent psychiatry were first issued in 1995. Hence, diplomates who wish to retain their status will need to be recertified. Those who have time-limited certificates in general psychiatry will also have to maintain their general certificates, except for child and adolescent psychiatrists who have the option of only maintaining their subspecialty certification.
Like the initial certification examinations, the recertification examinations consisted of MCQs and were proctored tests administered via computer. The first recertification examination in geriatric psychiatry was administered in 2000, clinical neurophysiology in 2001, addiction psychiatry in 2002, and forensic psychiatry in 2003. The first recertification examination for child and adolescent psychiatry was scheduled for 2004. The same test development procedures used for the initial certification examinations were used for these tests, but the recertification tests had their own content outlines and emphasized clinical practice and significant new knowledge in the field. As expected, pass rates were high (>95%).
Because it is early in the process, it is not yet known how many diplomates will opt to maintain their certification status. Three recertification examinations have been administered for geriatric psychiatry, and about 65% of the diplomates who needed to recertify have done so (10).
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Conclusion
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The ABPN was relatively conservative in developing subspecialty certification in psychiatry, with only one such certificate available until the 1990s. It can be argued that the emergence of the subspecialties in geriatric psychiatry, addiction psychiatry, and forensic psychiatry represented advances in the knowledge base of the field. A significant number of practitioners have been certified in these subspecialties, and a number of residency programs are in place, although funding for training beyond the number of years needed for primary certification is an ongoing issue. Very few psychiatrists have been certified in clinical neurophysiology and pain medicine, and no residency programs are currently offered by psychiatry departments in these areas.
Of the three newer subspecialties, geriatric psychiatry has the most programs and positions, followed by forensic psychiatry and addiction psychiatry. For the academic year ending in June 2003, addiction psychiatry was somewhat less successful in filling its slots (55% compared to 64% for geriatric psychiatry and 68% for forensic psychiatry). Addiction psychiatry, geriatric psychiatry, and forensic psychiatry all remain much smaller than child and adolescent psychiatry where there are 113 programs with 681 filled positions for 2002–2003, nor have they been as successful as child and adolescent psychiatry in filling positions.
As mentioned above, there are no psychiatry-based training programs in clinical neurophysiology or pain medicine. For clinical neurophysiology, this is not surprising because it is unlikely that many psychiatrists will be attracted to this subspecialty, which addresses both EEG (which has relevance to psychiatry) and EMG (which does not have relevance to psychiatry). This equal emphasis on EMG is also likely to discourage psychiatry departments from sponsoring residency training in clinical neurophysiology.
Pain medicine was conceived as a multidisciplinary subspecialty, and representatives of three boards (the American Boards of Anesthesiology and Physical Medicine and Rehabilitation as well as the ABPN) and four disciplines (anesthesiology, physical medicine and rehabilitation, psychiatry, and neurology) all participate on the test writing committee. Failure of psychiatry departments to develop residency training programs may diminish the importance of psychiatry’s role in this multidisciplinary arrangement, as there are many programs in anesthesiology and physical medicine and rehabilitation and neurology have also started to develop programs.
One indication of the value of certification to the individual practitioner will be the rates at which training programs’ graduates seek certification and recertification. A clear picture does not emerge from the available preliminary data on rates of certification, although it was anticipated that most graduates would seek and obtain ABPN certification. There may be more of a delay in applying than was assumed here, or graduates may, indeed, choose not to become certified. For recertification, the only subspecialty that has an ample history is geriatric psychiatry, for which the recertification rate is 65%. Because of the "grandfathering" period, many of those certified in the early years are older and toward the end of their careers or retired. It is also possible that diplomates are no longer practicing in the subspecialty or may not need the credential for their practices.
As mentioned in the introduction, the aim of certification is to enhance medical care, and it is anticipated that, in addition to patient care activities, board-certified subspecialists will play leading roles in the education of practitioners at all levels of training and in conducting research in the subspecialty.
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REFERENCES
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- Ludmerer KM: Time to Heal: American Medical Education from the Turn of the Century to the Era of Managed Care. New York, Oxford University Press, 1999
- Stevens R: American Medicine and the Public Interest: A History of Specialization. Berkeley, University of California Press, 1998
- American Board of Medical Specialties:2002 Annual Report and Reference Handbook. Evanston, IL, American Board of Medical Specialties, 2002
- Langsley DG: Certification in psychiatry and neurology: past, present, and future, in Certification, Recertification, and Lifetime Learning in Psychiatry. Edited by Shore JH, Scheiber SC. Washington, DC, American Psychiatric Press, 1994, p 22
- Scheiber SC: Graduate psychiatric education, in Comprehensive Textbook of Psychiatry, 7th edition. Edited by Sadock BJ, Sadock VA. Philadelphia, Lippincott, Williams and Wilkins, 2000, p 3254
- Accreditation Council for Graduate Medical Education Web Site. Available at http://www.acgme.org (accessed March 31, 2003)
- Appendix II: graduate medical education. JAMA 1999; 282:893–906[Free Full Text]
- Appendix II: graduate medical education. JAMA 2000; 284:1159–1172[Free Full Text]
- Appendix II: graduate medical education. JAMA 2001; 286:1095–1107[Free Full Text]
- Juul D, Scheiber SC: Subspecialty certification in geriatric psychiatry. Am J Geriatr Psychiatry 2003; 11:351–355[Abstract/Free Full Text]
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ABSTRACT
INTRODUCTION
