Certification and Recertification in Medicine: Self-Improvement, Self-Delusion, or Self-Strangulation?

CERTIFICATION AND RECERTIFICATION IN MEDICINE: SELF-IMPROVEMENT, SELF-DELUSION, OR SELF-STRANGULATION? ALLEN B. WEISSE* Although I never had the pleasure of meeting him personally, Dr. Herrman L. Blumgart (1895-1977) was well known to me and to all other internists back in the early 60s when I began my medical career as an internist-cardiologist. Harvard-trained, Dr. Blumgart had left the Thorndyke Memorial Laboratory at the Boston City Hospital in 1928 to head up the research program at Beth Israel Hospital in the same city. There he developed and maintained an outstanding clinical research program until his retirement 34 years later in 1962. Like many great figures in medicine, Blumgart was the subject of numerous anecdotes, including one I was particularly fond ofduring the years that I witnessed the growth of certification and then recertification throughout organized American medicine. This story relates to the question of his standing for an examination for certification either in internal medicine or the subspecialty of cardiovascular disease after these boards were established . It was reported that when the question of certification was put to him, Dr. Blumgart, in the frostiest of tones, replied, "And who, may I ask, is going to examine me?" I later learned that a similar remark had been ascribed to other senior physicians of the time who had been approached in this way after having already demonstrated their skills to the medical world and achieved nain addition to those individuals and institutions specifically mentioned in either the text or the reference section, the author would like to express appreciation to Lisa R. Colwell and Muriel Horne of the American Board of Internal Medicine; to Tracey Beardon and Susan Lucius of the American Heart Association; and to Dr. Oglesby Paul, Professor of Medicine Emeritus of Harvard, for providing important data critical to the successful completion of this project. The opinions contained herein are expressly those of the author and do not necessarily reflect those of any institution or society with which he is affiliated, nor those of any correspondents whose input was critical to the completion of this paper. *164 Hillside Avenue, Springfield, NJ 07091.© 1998 by The University of Chicago. All rights reserved. 0031-5982/98/4104-1065$01.00 Perspectives in Biology and Medicine, 41, 4 ¦ Summer 1998 | 579 donai and sometimes international recognition for their accomplishments. So perhaps the story as it relates to Blumgart is apocryphal; the point of it, nevertheless, is a telling one. The plan to recognize medical expertise and encourage higher standards by board certification began in the United States back in 1917, with the first of the specialty boards set up by the ophthalmologists. In 1936 Internal Medicine became the 12th specialty to so define itself, with the surgeons following suit in 1937. Currently there are over 20 specialty and subspecialty boards that have been established in this country, with the American Board of Family Practice being the latest major one to have come into being (1969). Recent developments along the lines of certification and recertification prompted this review, although the major emphasis will be on Internal Medicine and Cardiovascular Disease, with which I am most familiar and which might serve as paradigms for the subject in general. An early recruitment problem for the American Board of Internal Medicine (ABIM) was the attitude of many practicing experts such as Blumgart. In order to succeed in the certification effort, for which the support of the existing medical hierarchy was vital, the founders of the board recognized the necessity for "grandfathering in" individuals who had airead}' demonstrated their proficiency in the field. Three categories of physician were recognized as eligible for certification upon application during the early years of the ABIM: professors and associate professors of approved U.S. and Canadian medical schools; internists who had practiced in the field for at least 10 years and were members or fellows of certain select societies; and internists in practice for 15 years or more who were recommended by the executive committee of the Section on the Practice of Medicine of the American Medical Association [I]. AU other applicants were required to undergo testing, with the first written examination (thesis type) administered in 1936. Success...