The data presented here indicate that most recent graduates of the ABPN primary specialties of neurology, child neurology, and psychiatry recognize the value of certification and attempt to achieve and maintain that status. While the main reasons for seeking certification are undoubtedly different among these specialists, they almost certainly include a desire to demonstrate competence to provide state-of-the-art quality care, obtain personal and professional recognition, become eligible for academic advancement, and fulfill credentialing requirements of service delivery systems and insurance panels.
Unlike their child neurology and psychiatry colleagues, most neurology graduates evidently see the value of fellowship training. Many neurologists who do pursue fellowship training in clinical neurophysiology do not perceive the added value of obtaining certification in that subspecialty to be worth the effort and expense to obtain it. (For 2010, the fees for specialty certification are $3,000, and for the subspecialties they are $1,900.) The ABPN requires all candidates for certification in a neurologic subspecialty to be certified first in neurology. Many fellowship-trained clinical neurophysiologists evidently consider their certification in neurology to be adequate to meet their practice and reimbursement requirements.
The original enthusiasm expressed in most of the neurologic subspecialty applications about the opportunities to increase the future numbers of accredited fellowship programs seems not to have been completely realized. While the numbers of clinical neurophysiology programs and fellows have steadily increased from the date of application, the numbers of neurodevelopmental disabilities, vascular neurology, and neuromuscular medicine programs and fellows initially decreased substantially. In recent years, the numbers of programs and fellows have increased substantially in vascular neurology and neuromuscular medicine and minimally in neurodevelopmental disabilities.
Large numbers of practicing subspecialists desiring certification do not necessarily translate into an adequate number of fellowship programs or sufficient numbers of trainees recruited into those programs to ensure the long-term survival of the subspecialty. The numbers of “grandfathers” seeking certification have been greater than the numbers of fellowship graduates doing so for all of the neurologic subspecialties. Under the current ABPN examination development process, fees from about 150 candidates are required to cover examination costs. Given the current number of fellowship graduates, it is unlikely that that number of candidates will be achieved in any subspecialty other than clinical neurophysiology even by administering the subspecialty examinations every other year.
The equivalent average performance of clinical neurophysiology graduates compared to “grandfathers” on the certification examination raises questions about the added value of fellowship training in that subspecialty. It appears that the experiences available to the “grandfathers” prepared them adequately for the breadth of content covered on the ABPN certification examination. Of course, it is also probable that additional competencies are gained through fellowship training that are not assessed on the ABPN certification examination.
The part I examinations in the ABPN specialties appear to have been barriers to certification for many candidates. While residents, residency programs, and residency graduates historically have expended considerable effort in preparation for the ABPN oral part II examinations, these results suggest that perhaps greater attention should have been paid to preparing for the content covered in these basic cognitive examinations. Since subspecialty certification is not possible without specialty certification, the part I examinations have also served as a barrier to subspecialty certification. While the performance of candidates on the initial administration of the new neurology and child neurology certification examination appears to be superior to the performance of candidates on the part I examinations, it is well to remember that only new candidates who have just finished their residencies took the new certification examination while the part I examinations included both new and repeat candidates. When only new part I candidates are considered, their pass rate is only about 5% less than that of the new certification examination candidates.
Once fellowship graduates achieve ABPN specialty certification, their success on the subspecialty examinations has been very good. This is undoubtedly due in part to their clinical experiences and participation in fellowship training. It also seems likely, however, that some individuals are very adept at taking standardized examinations, and their success on the part I examination predicts a high likelihood of success on subsequent subspecialty examinations.
Just as clinical neurophysiology graduates seek certification in smaller percentages than specialty graduates, to date they have also maintained their certification in smaller percentages than specialty diplomates. Like their colleagues who never sought certification in the first place, these subspecialty diplomates have evidently concluded that the value of subspecialty certification is not currently worth the effort and expense to maintain it.
Most specialty and clinical neurophysiology diplomates who seek to maintain their ABPN certification have little trouble passing the MOC examinations. (In 2010, the fees for these examinations are $1,500.) These results should not be surprising, since all of these diplomates have already passed the relatively difficult part I and part II specialty certification examinations, most are only about 10 years into their careers, and the MOC examinations focus on practical, clinically oriented content. Whether or not these same diplomates will be able to maintain these levels of performance over time remains to be seen.
While the current status of some ABPN neurologic subspecialties (clinical neurophysiology and vascular neurology) seems fairly secure, others (neurodevelopmental disabilities and neuromuscular medicine) remain in doubt. The long-term viability of any neurologic subspecialty will most likely depend on the answers to at least some of the following interrelated social, economic, and political questions, which are not presented in any particular order of priority. Each of these questions could be the subject of an extensive analysis in its own right, and space limitations permit only brief comments here.
First, will there be a change in emphasis on subspecialty care in the new health care era? Political decisions about the relative need for different types of physicians in the coming years could have a major impact on the types of students recruited into medical schools and the interest of those students in subspecialty medicine.
Second, will the public have ready access to subspecialty services or will there be renewed efforts by the payers for clinical services to encourage gatekeeping by primary care physicians and specialists? Economic or administrative barriers to subspecialty physician access could have a negative impact on the interest of physicians in pursuing additional training and certification in those areas.
Third, will there be increased public and political pressure on physicians to objectively demonstrate that they are competent to provide quality clinical care? If so, then additional subspecialty training and certification credentials could well be of value to physicians.
Fourth, will public and private institutions that credential physicians or pay for clinical services increase their requirements for subspecialty training and certification? If those institutions continue to credential and reimburse non-subspecialty-trained or non-subspecialty-certified physicians, there will be little incentive to pursue subspecialty training or certification.
Fifth, will adequate numbers of stipends be available to support fellowship training? Closely related to the first question above, government and private support of fellowship education will be a major determinant of whether or not subspecialties thrive in the future.
Sixth, will future research findings support the continued existence of specific subspecialties? Biomedical and genetic research developments are producing dramatic changes in our basic understanding of health and disease processes. No subspecialty can exist for long without an academic basis of support, and it may well be that some current subspecialties will be replaced with entirely new conceptual models for education, research, and clinical services.
Seventh, will states adopt maintenance of licensure requirements mandating that physicians document objectively their competence to provide quality medical care to specific types of patients in order to remain licensed to practice medicine? If so, then it is likely that those states will accept ABPN certification and MOC participation as sufficient to meet their requirements, and this could promote added interest in subspecialty training and certification.
Eighth, will the ABPN develop new methods for subspecialty certification that reduce costs? The ABPN is currently exploring new and less expensive methods for the development of subspecialty examinations that might reduce the certification fees for existing subspecialties and also make it more feasible to recognize new ones. Anything that improves the cost-benefit ratio for subspecialty certification will likely result in increased numbers of physicians seeking that status.
While the ABPN was relatively slow to embrace the subspecialty movement, in recent years it has recognized increasing numbers of subspecialties. The interest of physicians in training and certification in some of the subspecialties, however, has not lived up to expectations. Whether or not any of the ABPN subspecialties will thrive in the future will depend upon a complicated series of questions whose answers will be decided in the social, political, and economic arenas of the new health care era.