Hair restoration surgery is a medical and surgical subspecialty that has matured over the decades since its introduction in the 1960s. By the 1990s, it was evident to leaders in hair restoration surgery that the subspecialty had matured to the point of needing a standards-setting mechanism for assuring the highest level of knowledge and skill in practitioners of hair restoration surgery. The medical profession has such a mechanism in place-the medical specialty board that certifies qualified specialists in their elected specialty or subspecialty. Leaders of hair restoration surgery adopted the medical-board approach to certification, and organized the American Board of Hair Restoration Surgery (ABHRS). In the following article, the principles and purposes of medical boards are described and explained. If you wish to review a description of the ABHRS before reading the rest of the article, see The American Board of Hair Restoration Surgery.
Medical Specialization: The Beginning
The Rise of Medical Specialization
Medical Certifying Boards: The Beginning
The American Board of Medical Specialties
The Purpose of Specialty Certification
Physician Certification: An Example of Self-Regulation in Medicine
What It Means to be Board Certified
What If a Physician Is Not Board Certified?
What About Non-ABMS Boards?
How Is Physician Certification Handled in Other Countries
The American Board of Hair Restoration Surgery
Medical Specialization: The Beginning
The 1930s to 1950s mark a dividing line in American medical education and medical practice. It was during these years that medicine began to specialize, to recognize the value of physicians who chose to become more learned and experienced in one area of medicine rather than to pursue the broad generalism of “medicine” that had been the norm. As burgeoning biological sciences began to generate finer and finer detail about the human body and its ailments, physicians studied the findings and began to adapt them to clinical use in specialties such as ophthalmology, otolaryngology, infectious diseases and dermatology. The increases in knowledge and changes in medical practice mandated changes in medical education, offering additional training in specialty areas.
In 1931, only 17% of U.S. physicians in private practice were full-time specialists. The majority of practicing physicians defined themselves as “general practitioners” or as “physicians and surgeons” who were called upon to treat common infectious diseases such as pneumonia, diphtheria, smallpox and typhoid, common metabolic diseases such as goiter and diabetes, commonly fatal diseases such as cancer and “heart attack”, and to perform various surgical procedures such as tonsillectomy and reduction of bone fractures. In our time, 75 years later, the conditions noted above would involve consultation with an infectious disease specialist, endocrinologist, oncologist, cardiologist, otolaryngologist and orthopedic surgeon.
By 1964, 61% of physicians in private practice were full-time specialists-a significant increase over the 17% in 1931. This was a trend that would continue through successive decades.
The Rise of Medical Specialization
The rise of specialism brought with it a special problem: if a physician is identified as a “specialist”, how can the profession and public be assured that the term “specialist” means a higher quality of medical knowledge and experience? As medical educator Richard Magraw, MD, observed in 1966: “…since the specialist takes the same medical training as everyone else and then takes ‘additional training’…the natural assumption has been that he knows what ordinary doctors know and more besides. It is from this historical fact that the term ‘specialist’ took on…special luster.” [Magraw RM. Ferment in Medicine. Philadelphia” W.B. Saunders Co.; 1966.]
Is the specialist truly a holder of special knowledge and competence, and if so, how could this be demonstrated in an objective manner?
Medical Certifying Boards: The Beginning
Ophthalmology (the specialty of diseases of the eye) was the first “specialty” to recognize the need to objectively demonstrate that a physician who claimed ophthalmology as a specialty had the necessary training, knowledge and experience. The idea for a “specialty board” in ophthalmology was first proposed in 1908; its proposed purpose was to (1) set standards for medical education and training in ophthalmology, (2) prepare a written examination that physicians would have to complete successfully in order to be certified as a specialist in ophthalmology, and (3) set standards for eligibility to sit for the certifying examination, including licensure as a physician by a state medical licensing board.
The American Board of Medical Specialties
After years of experimentation and preparation, the American Board of Ophthalmology was established in 1915 with sponsorship by ophthalmology specialty societies and the Section on Ophthalmology of the American Medical Association.
The American Board of Ophthalmology became the model for formation of additional certifying boards: the American Board of Otolaryngology in 1925, the American Board of Obstetrics and Gynecology in 1930, the American Board of Dermatology and Syphilology in 1932 [the disease of syphilis was usually diagnosed by its skin lesions, and thus fell under dermatology; the term ‘syphilology’ was later dropped from the board’s name].
These four “founding boards” joined other national physician and hospital organizations to organize the Advisory Board of Medical Specialties, the forerunner of the American Board of Medical Specialties (ABMS) that is the “umbrella” for 24 member boards that certify physicians as specialists on the basis of education, training, experience, and successful completion of a certifying examination. (Visit the ABMS Website at www.abms.org).
The 24 member boards under the ABMS umbrella in 2006 represent:
- Allergy & Immunology
- Colon and Rectal Surgery
- Emergency Medicine
- Family Medicine
- Internal Medicine
- Medical Genetics
- Neurological Surgery
- Nuclear Medicine
- Obstetrics and Gynecology
- Orthopaedic Surgery
- Physical Medicine and rehabilitation
- Plastic Surgery
- Preventive Medicine
- Psychiatry & Neurology
- Thoracic Surgery
In the 1970s, a category of “conjoint board” was established to allow newer specialties to come under the ABMS umbrella by association with a primary board. An example: Emergency Medicine became a Conjoint Board of seven Primary Boards in the 1970s, and in 1989 moved to Primary Board status.
The Purpose of Specialty Certification of Physicians
All medical certifying boards state a common mission and purpose-To serve the public interest by promoting excellence in the practice of [a given medical or surgical specialty].
When medical boards were first organized, the certification of a physician by qualifications and examination was not time-limited; certification was valid for the professional lifetime of the physician. As the pace of medical research continued to increase and the volume of medical knowledge accumulate rapidly, it became apparent that lifetime certification was no longer acceptable. In some specialties, medical knowledge doubled or tripled in very few years, and older concepts became invalid.
Medical profession leadership came to believe that physicians should have to show proof that they had kept pace with the rapid growth of medical knowledge. The ABMS member boards began to offer “recertifying” examinations. The physicians in recertification programs were re-examined every 6 to 10 years. In addition, boards added “maintenance of certificate” (MOC) programs, whereby physicians must offer proof of participation in continuing medical education activities related to their specialty. The educational activities qualifying for the MOC were in addition to state licensing board requirements for proof of participation in continuing medical education. The MOC program goes beyond simple proof of participation. It requires certified specialists to demonstrate evidence of professional review of their knowledge and skill.
The overall phrase describing commitment to maintenance of knowledge through continuing medical education is “lifetime learning for physicians”.
Physician Certification: An Example of Self-Regulation in Medicine
Medical education, physician training and physician certification in a specialty are examples of medicine’s self-regulation. The federal government does not intrude upon medicine’s self-regulation of physician education. The reason is one of historical significance.
The profession of medicine in the U.S., embodied in the American Medical Association (AMA), created a Council on Medical Education in 1904. The rationale was the need to promote high standards in medical education, and to drive out of existence any so-called “schools” that did not measure up to those high standards. In 1908, the AMA asked the Carnegie Foundation for the Advancement of Teaching to undertake a survey of medical education in the United States and Canada. The Carnegie Foundation accepted the task and appointed an educator, Abraham Flexner, to head the survey and make recommendations based upon survey findings.
Completed and published in 1910, Flexner’s report, “Medical Education in the United States and Canada” was one of the most important documents in American medicine. Flexner’s recommendation to standardize the quality of all medical schools to the highest level of the best medical schools gave the AMA the leverage it needed to carry out medical education reforms. Flexner also said that state governments-in the form of state medical boards-should properly regulate medical education. Prodded by the AMA, state boards began to implement higher admission standards and curriculum requirements. In 1912, state boards came together in forming the Federation of State Medical Boards (FSMB), which voluntarily agreed to base accreditation policies on academic standards determined by the AMA’s Council on Medical Education.
In this manner, Council on Medical Education decrees regarding undergraduate, graduate and continuing medical education came to have the force of law, without the need for “law” written by state legislatures or federal Congress. Medicine’s self-regulation of medical education is accepted to this day.
The self-regulating mechanisms are apparent in looking at the interlocking relationships of the American Board of Medical Specialties (ABMS):
- American Hospital Association (many training programs are hospital-based)
- American Medical Association (the major national organization of U.S. medicine)
- American Osteopathic Association (a major national organization of U.S. Medicine and certifying entity for D.O.s)
- Association of American Medical Colleges (the national body representing all allopathic U.S. medical schools)
- American Association of Colleges of Osteopathic Medicine (the national body representing all U.S. osteopathic medical schools)
- Council of Medical Specialty Societies and American Osteopathic Association (umbrella organizations of specialty societies)
- Federation of State Medical Boards (the oversight body of state medical boards, the liaison body with related organizations)
- Accreditation Council for Continuing Medical Education and the American Osteopathic Association (the oversight bodies for assuring quality in continuing medical education)
- Accreditation Council for Graduate Medical Education and the American Osteopathic Association (the oversight bodies for assuring quality in postgraduate residency and fellowship training by a process of review and accreditation)
- Educational Commission for Foreign Medical Graduates (the oversight body for assuring that physicians trained in other countries meet U.S. standards before entering practice in the U.S.)
- Liaison Council for Specialty Boards (the body responsible for considering and approving new medical boards)
- National Resident Matching Program (the body that “matches” newly trained physicians with an appropriate residency training program)
What It Means to Be Board Certified
Board certification has both public and professional implications. The primary purpose of board certification of medical specialists is to assure the public of physician knowledge and skill. In organizations where physicians work-hospitals are the prime example-board certification is important in placing physicians in an appropriate professional environment. Among colleagues, board certification has implications of professional quality and standing.
The requirements for board certification are rigorous, and they are applied by all medical boards:
- Holding a M.D. or D.O. (doctor of osteopathic medicine) degree from a recognized school of medicine [M.D./D.O. equivalency-see sidebar below]
- Completion of required training in an accredited residency program designed to train physicians in the given specialty
- Rating of performance by residency training directors or hospital chief-of-service where the specialist practiced his/her specialty
- Holding an unrestricted license from a state licensing board to practice medicine
- Passing the written examination given by the specialty board
Until the 1940s, osteopathic medical schools were considered outside of mainstream (allopathic) medical education. Osteopaths emphasized manipulative treatment of patients by hand/finger pressure applied to specific parts of the body for treatment of specific conditions, and practiced medicine based upon a “whole body” approach to health and disease.
Over a period of decades, osteopathic medicine adopted more and more “allopathic” approaches to diagnosis and treatment. Beginning about 60 years ago, the curriculum of osteopathic medical schools was adjusted to be similar to that of allopathic medical education. The entrance requirements of osteopathic medical schools evolved to parallel those of allopathic schools, and all applicants were required to take the Medical College Admission Test (MCAT). The degree granted by osteopathic medical schools-Doctor of Osteopathic Medicine or D.O.-is recognized by state licensing boards as equivalent to the M.D. degree. Today, most D.O.s still choose primary care, however. D.O.s can pursueany medical or surgical specialty and seek certification in their chosen specialty.
Physicians who meet all of these requirements are certified as specialists and have the status of “Diplomate” in their given specialty. The Diplomate status is meant to assure the public that the physician is indeed a specialist with requisite knowledge and experience.
What If a Physician Is Not Board Certified?
A physician may include specialty medicine in his/her practice, or limit his/her practice to a given specialty, without being board-certified in that specialty. This does not necessarily mean that the physician is any less knowledgeable or experienced than board-certified peers. Some well-recognized and highly competent physicians have chosen not to pursue board certification. These physicians do not have a board-certified plaque to hang on the office wall, but they are always pleased to answer questions regarding their training, knowledge and experience.
What About Non-ABMS or Non-AOA Medical Boards?
The AMBS, in 2006, counted 180 medical boards that functioned outside of the ABMS umbrella. Some of these may eventually move under the ABMS; many never will, and there are a number of reasons why a non-ABMS board will remain outside of the ABMS. Reasons include:
- The specialty or subspecialty represented in the board is multi-specialty-that is, the practitioners of the specialty may come from a number of specialties and even hold certification from a primary ABMS board-but the board does wish to seek Conjoint status
- The specialty or subspecialty is a newly organizing specialty that does not “fit” within a primary ABMS board
- ABMS membership is blocked by a primary ABMS board-for example, on grounds that the physicians who claim new specialty status could be represented within existing ABMS boards
An important hurdle to be overcome by a newly organizing specialty board is to satisfy the Federal Trade Commission that the proposed new board does not represent an attempt to establish a monopoly by means of exclusionary requirements. It is also helpful to have representation in the American Medical Association House of Delegates, usually through a specialty society active in organizing the new board.
The Federal Trade Commission has stated that non-ABMS boards can provide legitimate board certification as an indication of advanced training and skill. American Medical Association guidelines state: “Non-affiliation with ABMS does not indicate that an organization has inadequate review criteria and procedures.” The office of the AMA General Counsel in 1991 described “boards which use the same building blocks of quality as ABMS, but which are not included within the ABMS umbrella. Most of these boards cover a subspecialty of an existing AMBS board or are duplicative of existing boards. A few are new specialties…”
The AMA and state medical boards have agreed that a medical certifying board, ABMS or non-ABMS, must meet three criteria:
1. Require an accredited residency that includes training in the area of medicine for which certification is offered;
2. Require peer review of clinical practice experience; and,
3. Require completion of a rigorous examination of knowledge in the area of medicine for which certification is offered.
How Is Physician Certification Handled in Other Countries?
Undergraduate, graduate and postgraduate medical education and certification of medical specialists are not uniform throughout the world. However, the structure and mechanisms of medical education and specialist certification are based on some common models in many countries.
The most widely emulated medical degree model is that of the United Kingdom (UK). In the UK, an undergraduate medical curriculum leads to the granting of a degree in medicine and surgery. The degree is typically:
- MBBS-Bachelor of Medicine and Surgery, or
- MBChB-Bachelor of Medicine and Surgery with emphasis on surgery (the “Ch” is shorthand for Chiurgery, an older English spelling of surgery).
The MBBS and MBChB are approximately equivalent to the MD degree granted in the United States. It is emulated in many countries, including India, Pakistan, South Africa and a number of countries in the Middle East.
The United Kingdom General Medical Council (GMC) is the body responsible for medical profession oversight. Its purpose is to “deliver and protect the highest standards of medical ethics, education and practice, in the interest of patients, public and the profession”. The GMC sets standards for all levels of medical education and professional development. International Medical Graduates (IMGs)-called Foreign Medical Graduates in the U.S.-must show that they have mandated prerequisites to sit for an examination demonstrating that they have the knowledge and skills necessary to practice in the UK.
The UK lacks a process of specialist certification and regularly scheduled recertification like that of the ABMS Specialty Boards in the U.S. Creation of such a process has been recommended by top medical professionals in the UK, and discussed in a August 2006 issue of the British Medical Journal. The article cites studies showing an association between physician certification and quality of care.
The Royal College of Physicians and Royal College of Surgeons in the UK have one of the oldest models of physician specialist Fellowship, based upon educational and practice prerequisites and the passing of a certification examination. The Royal Colleges set medical standards for Fellows and Members in a broad range of specialties, and offer education and training for professional development.
In Canada, the Medical Council of Canada, established in 1912 after publication of the Flexner Report, has a charge similar to that of the GMC in the United Kingdom. It develops and implements methods for evaluating physician competence, and maintains a national registry of physicians and their qualifications. Among other functions, it also administers qualifying examinations that a physician must pass to become licensed and placed in the national registry. Physician specialty certification in Canada is managed by the Royal College of Physicians and Surgeons of Canada. The Royal College conducts the functions that are conducted in the U.S. by the AMA, various accrediting bodies, and boards of the ABMS. The requirements for certification in Canada are nearly identical to those in the U.S. Canadian and U.S. physicians can move fairly easily between the two countries.
In Australia, the Australian Medical Council has a broad charge for assuring highest quality in medical education and medical practice, including overseeing medical specialist education and training by such functions as:
- Assessing education, training and professional development programs of institutions that train medical specialists,
- Accrediting specialist medical education and training institutions,
- Developing and maintaining standards for accrediting medical specialist education programs, an essential component of self-regulation of medical education by the medical profession.
The comparison of medical specialist training programs is difficult in many parts of the world, where there is no body equivalent to the General Medical Council and Royal Colleges of the UK, the Royal College of Canada, the Australian Medical Council, or the medical education superstructure of the United States.
Responsibility for specialist training in Europe was often located in individual medical schools and universities, and standards of training programs might vary considerably, even within the same country. However, a trend for coordination of specialist training programs has been developing in Europe since formation of the European Union (EU). Medical education and recognition of medical specialties is being coordinated and standardized. The standardization of medical education, improvement in medical specialty continuing medical education, and recognition of medical specialists has been brought under the supervision of a number of EU bodies.
The European Union of Medical Specialists (www.uems.be) has as its purpose the coordination and improvement of the quality of specialist medical care in Europe. Among its activities was the establishment of a European Accreditation Council for Continuing Medical Education (EACCME), modeled in many respects after the U.S. Accreditation Council on Continuing Medical Education. A task of the EACCME is to assure that continuing medical education activities meet common quality standards in all European countries, between specialties, and between systems by which physicians receive credit for participation in continuing medical education.
With formation of the EU, there has been growing awareness in Europe that medical education and medical specialism is increasingly globalized. Physicians move between countries regularly. Less rapid than increasing globalization has been the establishment of standards in medical education, quality assurance in medical care, and standardized recognition of specialty physician knowledge and training. Bodies established within the EU to pursue these goals include the Association for Medical Education in Europe, and the Association of Medical Schools in Europe.
A EU Directive on recognition of professional qualifications was published in 2005, with the objective of facilitating the free movement of physicians and other health professionals between countries, based upon standardized recognition of qualifications. Included in the Directive is a section that states the prerequisites for recognition of medical specialist training.
The World Federation of Medical Education has recognized that some differences in medical education and specialist recognition are difficult to overcome. These include:
- Long established teaching traditions
- Institutional conservatism
- Cultural background
- Socioeconomic conditions in a given country
- Organization of the health care delivery system
- Composition and competence of the health care workforce
- Quality of leadership in the medical profession and health care delivery system
A significant and growing problem worldwide is the number of new medical schools opening their doors-about 100 per year. Many of these schools are in countries where economic and logistic resources are inadequate to support a medical school. A strategy for some of these new schools has been recruitment of foreign students who did not qualify for enrollment in other medical schools, but who will be accepted if they can pay fees and costs. An off-shoot of this trend has been the opening of commercial for-profit medical schools that promise an easy path to a virtually guaranteed medical degree.
In the United States, the Educational Commission for Foreign Medical Graduates (ECFMG) supervises and conducts a rigorous policy of credentialing and examination for foreign medical graduates who wish to practice specialty medicine in the U.S. Foreign medical graduates (FMGs) who successfully pass the ECFMG credentialing process and examination are then able to (1) seek a medical license from a state medical board, and (2) after licensure, seek to meet qualifications to sit for a certifying examination given by the specialty board of the medical specialty they wish to practice.
The basic credential required by the ECFMG is proof that the foreign medical graduate holds a valid medical diploma or degree from a medical school recognized in the country where the school is located. In many countries, the recognition of a medical school would be administered by a central government Ministry of health. The diploma or degree held by the foreign medical graduate must be a certification that the physician has successfully completed a full duration of training in subjects applicable to the practice of medicine. Although four years of undergraduate medical education is typical for a U.S. medical school that grants a Degree of Medicine (MD), the duration of training varies from country to country. The title bestowed by a degree acceptable to the ECFMG also varies among countries. For example:
- Argentina-Medico diploma
- Bulgaria-Magister’s (Master’s)/Physician diploma
- France-Docteur en Medecine diploma
The MBBS degree is common among many countries as discussed above.
The American Board of Hair Restoration Surgery (ABHRS)
Hair restoration surgery is a surgical subspecialty practiced by physicians who have training and experience also in a primary specialty. Primary specialties of hair restoration physicians include dermatology, plastic surgery and general surgery among others. Hair restoration surgery is not currently a subspecialty of any ABMS primary specialty.
Origins of the ABHRS
As hair restoration surgery matured as a discipline, with distinct knowledge and skills, it became apparent to leadership organizations that there was a growing need for a certifying board and certification process. Impetus for development of a certifying process came from the public in the form of many inquiries, asking the American Hair Loss Council (AHLC) and other hair restoration organizations how to assess the knowledge and skill of a hair restoration surgeon.Hair restoration leaders identified an independent certification process as a “self-regulation” mechanism that would bring hair restoration surgery fully into the mainstream of the self-regulating philosophy of American medicine.
Discussions of the need for a certification process led the AHLC to organize, in 1996, an initial meeting of all physician specialty societies whose members performed hair restoration surgery. Presidents of the American Academy of Cosmetic Surgery, the International Society of Hair Restoration Surgery, the American Academy of Facial Plastic and Reconstructive Surgery, and the American Society of Dermatologic Surgery were each invited to send three representatives to a meeting to discuss the development of a certification process.
In two successive meetings, the representatives of these organizations recommended the organization of an independent body that would develop a credentialing and examination process meeting all the requirements of specialty board certification of physicians. The American Board of Hair Restoration Surgery (ABHRS) was organized later in 1996; each of the societies represented in the organization of the board agreed to recognize in the ABHRS the only board certification unique to hair restoration surgery.
As one of its first actions, the ABHRS mandated (1) the development of a certifying examination with written and oral components that would be (2) statistically and psychometrically validated to identify candidates whose knowledge and skill and practice habits are consistent with safe, aesthetically sensitive hair restoration surgery.
Physicians who wish to sit for the ABHRS examination must present proof of required credentials. Candidates must meet the criteria for one of the three routes to certification:
- Experience Route, based upon three years in private practice and proof of a required number of hair restoration cases;
- Fellowship Route, based upon fellowship training and proof of at least a year in private practice with proof of a required number of hair restoration cases; and,
- Lifetime Achievement Route, based upon a minimum of 400 case logs as primary surgeon and 50 documented operative reports.
Copies of the ABHRS Examination Application with full details of requirements are available from the ABHRS Website at www.ABHRS.org
At the request of the European Society of Hair Restoration Surgery, the ABHRS was recognized internationally in 2000. International candidates who meet credentialing prerequisites and pass the certifying examination now have the option of receiving certification from the “International Board of Hair Restoration Surgery”.
Mission, Goals and Objectives of the ABHRS
The Mission of the ABHRS is to act for the benefit of the public to establish specialty standards and to examine surgeons’ skill, knowledge and aesthetic judgment in the field of hair restoration.
The Goals and Objectives of the ABHRS are to grant certification to candidates who meet the highest standards of the medical profession in the field of hair restoration surgery with the express provision that the ABHRS will not act as a business, vocational or post-secondary school.
The ABHRS Certification Examination
The ABHRS certification examination consists of written and oral components. Candidates who wish to sit for the examination may learn about prerequisites and process by visiting the ABHRS Website www.ABHRS.org.
The written portion of the certifying examination consists of 200 multiple-choice items selected and written by subject matter experts, and reviewed by an independent psychometric consultant. All items are subjected to subject matter review at least twice before they are used in the examination. Test results are subjected to statistical evaluation at the end of each examination.
The oral component of the certifying examination consists of cases presented in the presence of two examiners who grade the candidate on the basis of Case Management criteria and Critical Interventions. As with the written portion, all items are reviewed by subject matter experts and an independent psychometric consultant. The psychometric consultant calculates results of the findings of the two examiners.
ABHRS Recognition as a Specialty Board
The ABHRS does not currently come under the American Board of Medical Specialties (ABMS) “umbrella”. (Click on What About Non-ABMS Boards?)
Future developments for the ABHRS include (1) seeking ABHRS sub-specialty board status, with the sponsorship of an ABMS primary board, and (2) more distantly, seeking ABMS recognition of hair restoration surgery as a distinct entity and the ABHRS as a primary board.