To Be Certified or Not to Be
Is That the Question?
Interventional cardiology, more than any other discipline in medicine, sprang forth like Athena, if not as fully armed, at the specific time when Andreas Gruentzig performed the first coronary angioplasty in 1977. As this procedure became the principle raison d’etre for a subspecialty of cardiology, a movement for establishing accredited training and testing was mounted by the Society for Cardiac Angiography and Interventions and the American College of Cardiology. The purpose of establishing formalized, recognized training and testing certification was the same as it was for internal medicine practitioners 80 years before, that is, to recognize “to their peers and the public that these physicians have the clinical judgment, skills and attributes essential for the delivery of excellent patient care.”1 Conversely, it is to identify those who do not possess these qualifications so that they might consider a different line of work. How did it work before boards? In the late 1970s and 1980s, many physicians desiring to perform percutaneous interventions (present author included) attended 1-week courses observing percutaneous coronary angioplasty (percutaneous coronary intervention) and then attempting it on their own. Others, after participating in such a short course, would bring patients with their angiograms and scrub in with those of us who had more experience. Training programs of various durations were established by individual institutions. We began a 1-year clinical fellowship in 1981, headed of course by Andreas Gruentzig. Throughout the 1980s and most of the 1990s, fellowship programs proliferated, and by the mid-1990s there was a growing interest in defining the requirements for adequate training. The establishment of training standards, largely developed by the American College of Cardiology activity and eventually approved by the American Board of Medical Specialists, was a parallel effort to the application for a testing component, the Certificate of Added Qualification of the Cardiovascular Boards. Later, this was redesignated as its own certifying examination.2 The era of see one, do one, teach one had fortunately evolved so that most cardiologists entering the field had trained in a clinical program of some type.
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When we received approval for a Certificate of Added Qualification in 1999, the candidates eligible to take the examination were those who had been practicing interventional cardiology and had performed a reasonable volume (500 in their total experience or 150 over the previous 2 years). We proposed these volume measures as a surrogate for active engagement in the field. This grandfather provision remained in effect for 5 years. After 1999, when the Residency Review Commission had approved training programs, their graduates also became eligible to take the certifying examination. The purpose of establishing a recognized subspecialty, which requires some kind of testing, was started to ensure that these individuals who achieved recognition had mastered a level of knowledge, judgment, and skills. Currently, almost all entering interventional cardiologists have completed the prescribed training and are eligible for board certification. Has this effort been worth it? Has the quality of performance in this field been enhanced?
In this issue of Circulation, in an effort to measure the value of certification in interventional cardiology, Fiorilli et al3 have performed a study examining the association of physician certification in interventional cardiology with in-hospital outcomes of percutaneous coronary interventions. This major effort matches physicians who perform coronary interventions with their certification status and then examines some clinical outcomes according to whether they are board certified or not. There are significant differences in many characteristics of the patients, so a multivariable adjustment was performed to look for variability in primary and secondary outcomes of all-cause mortality, emergency surgery, bleeding, and vascular injury, all during the index hospitalization. There was excess mortality and emergency surgery in the group of patients treated by physicians without board certification, and there was no difference in bleeding or vascular complications. The authors are to be congratulated for their heroic effort to answer the question of whether there is an association between board certification and clinical outcomes. However, the question remains unanswered. The reasons that this is hard to measure are more interesting than the question itself.
The Patients and the Outcomes
As I indicated, there are many differences in the patient populations, and even though multivariable adjustments are made, there is no accounting for the most discriminating features of coronary intervention – the coronary anatomy and the degree and distribution of disease. Unfortunately, we have no data as to how many arteries are involved or how many lesions are treated. We do not know if bifurcation lesions or chronic total occlusions are treated. Different physicians treat different coronary conditions based on their training and experience. Among the clinical outcomes, myocardial infarction is missing, and the hospital mortality does not take into account future mortality or disability or recurrent intervention. A residual SYNTAX score would be an interesting acute comparator that does have prognostic significance, but these data and long-term follow-up are not available. Using hospital mortality as the primary quality measure for percutaneous coronary interventions has always been problematic. Even if early mortality is not a significant measure of quality, the findings here of 1 excess death per 1250 patients treated by physicians without boards would translate to ≈10 excess deaths per year in my city, not an insignificant clinical outcome. However, quality of coronary interventions cannot be ensured by a low mortality rate. An attempt was made to evaluate judgment in the selection of therapy. Although the appropriate use criteria were retrospectively applied, the fact that almost half of the patients could not be classified gives little confidence that the wise selection of patients for percutaneous coronary intervention could be adequately evaluated.
Of even greater interest are the physician groups that were compared. There were 5 groups of physicians according to certification status in 2010. The percentage of procedures performed by those with boards were 47.5% by those trained before 1999, 30.7% by those trained in or after 1999, plus 5.3% who had passed the board examinations earlier but who had not been recertified. Therefore, 83.5% of all procedures were performed by physicians who had passed the boards at some time. Procedures performed by physicians without boards were 16.5%. Of these, 2.3% of the total was performed by physicians who trained during or after 1999. Although the number of physicians in this group is small (149 of 5175), the multivariable outcomes of death and emergency surgery were highest in this group. Are these physicians who completed their training after board certification was established without boards because they did not take the examination or because they failed to pass the examination? The authors of the current study point out that they were only examining the certification status at the 2010 sampling time and were not looking toward the value of recertification or maintenance of competence. These 2 issues are, in fact, the ones that have generated the most questions, not the initial certification. Whether taking an entry examination again or participating in maintenance of competence activities enhances the goal of maintaining competence for the continuously engaged practitioner is under scrutiny and is not addressed in the current study.
I agree and disagree with the conclusions of the article. The assertion that, “Certification status alone is not a strong predictor of outcomes,” (at least these acute outcomes) is clearly correct, and many other measures of quality are germane. But that these findings “indicate a need to enhance subspecialty certifications” is not supported by this evidence. It may be true, but for different reasons I will come to. It was suggested that improved technology has enhanced the ability to obtain good results from percutaneous coronary intervention. Surely this is true, but it does not belie the value of training and documentation of the mastery of that training. As technology advances, so does the opportunity to address more complex and challenging situations. I differ somewhat with the assertion that the examination cannot test “the ability to make good decisions…and to quickly recognize and effectively treat procedural complications.” During my tenure as chairman of the interventional cardiology examination, many of the most discriminating questions were about the recognition of angiographic anatomy and anticipation of best approaches to performance and solutions to complications. This is practical knowledge that comes from extensive experience. Certainly other methods of evaluation, such as the use of simulators, may augment the evaluation. However, our attempt to devise a simulator-based test was only mildly discriminating between experts, trainees, and interventional-naïve cardiologists.4,5 With adequate resources, it is likely that better simulation tests can be developed. Direct observation of the candidate by expert observers is attractive to those of us who survived the oral medicine and cardiology examinations, but we must remember that these were abandoned because they were subject to examiner bias.
I return to my original question – Certification or No Certification? Because all physicians now entering the field have been through an American Board of Medical Specialist training program approved by the Residency Review Commission, they should be capable of successfully sitting for the examination. The Interventional Cardiovascular Board was established to set a bar (which is not too high, because the vast majority pass) to define those who have mastered an adequate level of knowledge, judgment, and skills. There will be trainees who are better suited for other endeavors, and, through training program evaluations or the examination itself, they may be encouraged to move in other directions.
Because the training itself and the assessment of satisfactory mastering of the subjects of that training are really inseparable, the more important question currently is a different one. Interventional cardiology itself has become a discipline of sub-subspecialties. Some physicians have mastered very complex coronary interventions, to include chronic total occlusion recanalization, whereas others have mastered approaches to structural heart disease, and still others have mastered approaches to peripheral vascular interventions. How will interventional cardiologists assure their peers and the public that they have “the clinical judgment, skills and attributes essential for the delivery of excellent patient care” in these specialized areas? This will require active engagement of the professional societies, academic training programs, and testing organizations.
Certification or no certification? For those physicians who trained >16 years ago and have been performing percutaneous intervention for decades, there is no option to become board certified. They have been ineligible to take the examination for >10 years. For physicians trained within the past 16 years, approved training programs and certifying examinations have been the entry point for obtaining board certification. One other value of certification has not been studied. Although the methodology of this study does not allow it, one would like to know how many physicians failed to successfully complete their training or failed to pass the qualifying examination and choose other areas more suited to their talents. This may be an important result of the certification process. Interventional cardiology has evolved, and training and certification of competence must evolve as well. See one, do one, teach one is for the history books.
The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.
- © 2015 American Heart Association, Inc.
- 1.↵American Board of Internal Medicine. About ABIM. http://www.abim.org/about/default.aspx. Accessed May 22, 2014.
- 2.↵American Board of Internal Medicine. Certification in Interventional Cardiology (Brochure). Philadelphia, PA: American Board of Internal Medicine; 1999.
- Fiorilli PN,
- Minges KE,
- Herrin J,
- Messenger JC,
- Ting HH,
- Nallamothu BK,
- Lipner RS,
- Hess BJ,
- Holmboe ES,
- Brennan JJ,
- Curtis JP