by Steven E. Zimmet, MD, RVT, FACPh

We all know that many patients with venous disease are being treated by physicians whose primary training was in a nonvascular field. We know that many of these physicians have been delivering vein care for a long time. We know that some of these physicians have served an important role in advancing the field and in educating others, even those from vascular specialties. Few thoughtful and objective physicians would disagree that the venous curriculum in vascular specialties needs to bestandardized and strengthened considerably.

Given that there are many people from various medical backgrounds delivering vein care, surely it is reasonable and important to have some way for those people have at least a foundation of knowledge as well as experience.

Some leaders have dismissed certification as a useful determinant of cognitive knowledge and its correlation with quality of care. Although it is true that the literature is mixed and that it’s not easy to study, there is literature to support the value of certification.

Here is a brief summary of a few of these publications:

• “When all other variables were held constant, certification was associated with a 15% reduction in acute myocardial infarction (AMI) patients’ mortality.” This study looked at data on all hospitalizations for AMI in Pennsylvania in 1993. Thirty-day mortality was significantly lower by certified physicians across all specialties (FP, IM and cardiology). Based on the data, the authors estimated there would have been almost 500 fewer inhospital deaths if treatment had been delivered only by certified physicians.
• Certification was the major variable affecting performance on measures of clinical competence.

This was a prospective measurement of the knowledge, skills, and attitudes of certified vs. noncertified internists who had completed training five to 10 years previously, by written examination, evaluation by professional associates, a patient questionnaire assessing satisfaction with care, preventive care and review of records of patients with common illnesses. Examination scores correlated highly with the ABIM certification exam. Ratings of clinical skills by professors were higher for certified physicians and correlated highly with ABIM certification scores. Head nurses rated each physician, and they were significantly more reluctant to refer family members to physicians who were not certified.

• Risk for death and failure to rescue were greater with noncertified vs. certified anesthesiologists.

Medicare records for 144 ,883 patients who underwent general surgical or orthopedic surgery were used to determine provider-specific outcome rates adjusted to account for patient severity, case mix and hospital characteristics.

• Physician cognitive skills, as measured by MOC examination scores, are associated with higher levels of patient care.

Physicians were grouped into quartiles based on their performance on the ABIM MOC examination. Physicians scoring in the top quartile were more likely to perform processes of care for diabetes and mammography screening than physicians in the lowest quartile, even after adjustment for multiple factors.

• The title of a recent editorial in JAMA ,“Assessing Quality of Care: Knowledge Matters,” speaks for itself.

The relevance and intent of the ABPh certification process are also being challenged and criticized by some leaders in vascular specialties.

Boards are obligated to ensure their examinations are a relevant and meaningful measure of cognitive competence. It is obvious that adequate knowledge is essential to the development of medical expertise and effective clinical decision making. One should take a careful look at the content outlines across the vascular specialties landscape to see which certification exams best evaluate knowledge of venous disease. The ABPh certification process involves an extensive assessment of cognitive knowledge across the key areas in venous disease.

The ABPh exam consists of approximately 200 items in the following content areas, including superficial, deep, acute and chronic venous disease and lymphatic disease. The content categories and percent weighting on the exam are:

• Basic Science (8%)
• Venous Disease/Syndromes (20%)
• Diagnostic Tools/Screening (10%)
• Duplex Ultrasound/Other Imaging (25%)
• Treatment (35%)
• Professional Standards (2%)

Some have further criticized the ABPh certification process, arguing that anyone can take the exam. However, physicians who go through the ABPh certification process have provided evidence of significant experience in the field, including the performance of many procedures and ultrasound exams.

Having a comprehensive qualifying exam is an incentive for people to develop their knowledge base and learn about the whole spectrum of venous disease and treatment modalities, in spite of the fact that some peoples’ practices only include a portion of the field. The exam content lets people know what they need to learn and holding an exam sets the standard. As we know, many people who have trained, even in vascular fields, do not have the knowledge base that they really should when treating patients with venous disease. It is hard to imagine that anyone would doubt that preparation for an exam helps build the examinees’ knowledge base.

The ABPh pass rate is 85%, which is in line with ABMS boards. The ABPh retake failure rate is >70%. Does anyone really think there is no real difference in knowledge between those who pass and those who fail the exam?

Some physicians have suggested that the ABPh is misleading the public by condoning advertising of board certification by its diplomates. In fact, the ABPh advertising policy prohibits the following:

• Advertise as “board certified in phlebology
• Make claims of regional exclusivity
• Use ABPh logo on documents, websites, or other “marketing” material
• Claim expertise/special skills not possessed by other clinicians

The purpose of the ABPh is to raise physician standards and improve patient care. A physician increases his fund of knowledge by preparing for the certification exam. Setting standards and thresholds to qualify for the certification process raises the bar. We are currently developing program requirements that could help strengthen and standardize the venous curricula in training programs across the vascular specialty landscape. Patient care is better when physicians have more knowledge and training. These goals are supported by the ABPh credentialing and MOC processes.

“Professionalism is the basis of medicine’s contract with society. It demands placing the interests of patients above those of the physician, setting and maintaining standards of competence and integrity and providing expert advice to society on matters of health. The principles and responsibilities of medical professionalism must be clearly understood by both the profession and society.” The willingness of a physician to demonstrate competence in knowledge through an examination can be viewed as an important act of professionalism.