What Is a Pediatrician and Who Is Asking?
Article Outline
Abbreviations: ABP, American Board of Pediatrics
The question “What is a pediatrician?” seems rather straightforward. A medical dictionary defines a pediatrician as “an expert in the field of pediatrics”.1 Pediatrics is defined as the “branch of medicine which treats of the child, its development and care, and of the diseases and their treatment”.1 For whom is this question important? Parents, patients, insurers, corporate self-insurers, state licensing boards, hospitals, professional societies, and accreditation boards all have an interest in the answer to this question.
See related article, p 645
In this issue of The Journal, Freed et al2 examine a group of state licensing applications to evaluate the qualifications of those physician applicants who describe a practice in pediatrics. Although their results suggest a lack of validation of the qualifications of these physicians who practice pediatrics, this article raises a larger, more pervasive issue: How does one determine the quality of a physician who cares for children?
On the surface, the finding by Freed et al that 11% of applicants to 8 state licensing boards stated that they practice pediatrics but are not board-certified is surprising, if not distressing. More alarming are the results of their survey of these physicians, which found that 12% of a sample of the physicians had no specific postgraduate training in pediatrics. A number of explanations exist for why these physicians might not be board-certified. Certification by the American Board of Pediatrics (ABP) requires that a physician be trained in a residency program approved by the Accreditation Council of Graduate Medical Education. Physicians who are trained in the United Kingdom, Europe, Australia, India, and elsewhere are not eligible to take the ABP examination. No current method exists for assessing the competency of such physicians (pediatricians) aside from peer evaluations. Similarly, osteopaths and family physicians might practice “pediatrics” but not be ABP certified. A small number of respondents were eligible to take the examination but not yet had the opportunity to do so.
An inference from the article by Freed et al is that the physician respondents were disingenuous about their qualifications. I am not comfortable with such an interpretation for 2 reasons. Many of the state licensing applications asked the respondent to describe a scope of practice rather than to define himself or herself as a “pediatrician.” Understandably, a physician would declare a practice of pediatrics if he or she planned to care for children. Thus, family physicians, surgeons, allergists, and osteopaths might describe a practice in pediatrics and yet not be certified by the ABP. The state licensing applications that I reviewed did not ask for board certification, did not define “pediatrics” for the respondents, and in fact did not ask whether the respondent was a “pediatrician.” In addition, more than 50% of the non–ABP-certified physicians declaring a practice of pediatrics for the state licensing requirements were certified by another licensing board. This suggests that these respondents were conscientious physicians who were participating in programs to maintain competency in their scope of practice. My assessment is that state licensing applications should be more explicit in defining the scope of practice, as well as the qualifications of the applicants if that is an objective of the medical license application.
The important question raised by the study of Freed et al is how to define and evaluate the quality of a pediatrician. Certainly, certification by the ABP is one measure of competency.3 Historically, board certification has been determined by performance on an examination of medical knowledge. For many years, a single examination following training ensured board certification throughout one’s career. More recently, pediatricians have been required to pass an examination of medical knowledge every 7 years to “recertify.” However, the demand for evaluation of practice performance has emerged from many fronts. There is no assurance that a vast fund of medical knowledge translates to the quality of medical care.
The ABP, along with other specialty-accrediting boards, has moved toward the concept of “maintaining” certification by combining requirements for continuing medical education, knowledge assessment with an examination and practice assessment, and quality improvement.4 This program is still evolving, and the impact of these requirements has not yet been assessed. In fact, the ability to measure improvements based on these requirements will be elusive at best. The challenge of evaluating outcomes of patient care within individual pediatric offices, and with a vast array of unrelated and unconnected medical records, is immense. Even in the more visible and accessible hospital practice environment, assessing an individual physician, who often practices as part of a team of child health providers, is daunting if not impossible.
In today’s world, few people have no access to sources of electronic information. This transparent world offers the medical profession and the public an opportunity to assess physicians’ qualifications and, possibly someday, the outcomes of their practices. As the public comes to better understand the meaning and value of ABP certification and its maintenance, I expect that the relatively small number of “pediatricians” who are not now certified will pursue certification more aggressively. Consideration should be given to methods of validating the competencies of those individuals trained in pediatrics outside the United States and Canada who would like to satisfy the requirements of the ABP but cannot do so under the current eligibility criteria.
References
PII: S0022-3476(07)00257-0
doi:10.1016/j.jpeds.2007.03.037
© 2007 Mosby, Inc. All rights reserved.
Refers to article:
- Who Claims to Be a Pediatrician?