Pediatric Neurology 51 (2014) 598e599
Contents lists available at ScienceDirect
Pediatric Neurology journal homepage: www.elsevier.com/locate/pnu
Perspectives in Pediatric Neurology
American Board of Psychiatry and Neurology Certification in Epilepsy: Just What the Doctor Ordered, Another Board Examination M. Scott Perry MD a, *, Anup D. Patel MD b a b
Comprehensive Epilepsy Program, Jane and John Justin Neuroscience Center, Cook Children’s Medical Center, Fort Worth, Texas Division of Pediatric Neurology, Nationwide Children’s Hospital and The Ohio State College of Medicine, Columbus, Ohio
In 2010, the American Board of Psychiatry and Neurology (ABPN) approved the creation of the subspecialty board in epilepsy, and the first examination was administered in October of 2013. The primary purpose of this certification was to “establish the field of epilepsy as a definite area of subspecialization in neurology and child neurology and to provide a means of identifying physicians properly trained and experienced in treating epilepsy.”1 To qualify for the examination, candidates must be certified by the ABPN in neurology or neurology with special qualification in child neurology and have completed a 1-year fellowship in an Accreditation Council for Graduate Medical Educationaccredited epilepsy fellowship program. During the grandfathering period, which ends in 2017, candidates can qualify if they document a 1-year fellowship in epilepsy at a nonaccredited program affiliated with an accredited neurology program or if they attest to 25% of their practice time devoted to epilepsy for at least 2 years after residency training. Although creation of the epilepsy subspecialty board was viewed favorably by many, allowing nonfellowship trained physicians to qualify for certification left some candidates feeling that their unique expertise and additional training were being discounted. Many questioned the need for such certification given the many years of providing epilepsy care as is commonly practiced among child neurologists. A similar argument can be made in discussing whether certification is required in neurophysiology to interpret routine electroencephalography (EEG) recordings. One can ponder whether it is necessary to offer
Article History: Received July 23, 2014; Accepted in final form July 26, 2014 * Communications should be addressed to: Dr. Perry; Comprehensive Epilepsy Program; Jane and John Justin Neuroscience Center; Cook Children’s Medical Center; 1500 Cooper Street; 4th Floor; Fort Worth, Texas 76104. E-mail address: [email protected] 0887-8994/$ - see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.pediatrneurol.2014.07.035
an epilepsy subspecialty board certification and whether holding certification will serve the intended purpose to “identify properly trained and experienced” physicians in the long run. As to whether offering an epilepsy board is worthwhile, look no further than today’s trainees and previous options to certify their fellowship. Although some centers offered epilepsy fellowships, these were not recognized by ACGME and thus not acceptable for subsequent board certification. Most trainees looking to subspecialize in epilepsy entered a clinical neurophysiology fellowship after residency. The purpose of clinical neurophysiology training is to offer broad-based instruction in not only EEG but also in electromyography (EMG), nerve conduction studies (NCS), intraoperative monitoring, and sleep studies. Although this being the intent, most programs focus clinical training on a specific area often dichotomized between epilepsy and neuromuscular medicine. Among child neurologists, training often favors epilepsy. In addition, if a trainee is interested in sleep or neuromuscular medicine, they already have the option to pursue fellowship training and board certification in those subspecialties. Thus, many fellows complete neurophysiology training feeling confident in their EEG interpretation skills but much less prepared for other areas of neurophysiology. Candidates would then pursue the ABPN Clinical Neurophysiology Board, which evenly examines EMG and/or NCS knowledge to that of EEG. An alternative track for certification is available through the American Board of Clinical Neurophysiology, which also covers all aspects of neurophysiology testing. As a result, many fellows chose not to take any examination and simply remain board eligible. Many that certify choose to focus their clinical practice on the portion that they are the most comfortable and not perform other skills that are the part of neurophysiology certification. Further, many current neurophysiology fellowships may not provide specialized information in the field of epilepsy care and management,
M.S. Perry, A.D. Patel / Pediatric Neurology 51 (2014) 598e599
instead focusing on test performance and interpretation. For these reasons, a subspecialty board which recognized the specialization in epilepsy was applauded. The new board mirrored the path the Board established in 2005 when it created the subspecialty examination in neuromuscular medicine. Since the establishment of the epilepsy subspecialty board, the ABPN and ACGME have also created accredited epilepsy fellowships. During the transition, the epilepsy board should more accurately test and represent the expertise of trainees in this field; many question whether the grandfathering criteria allowing attestation of greater than 25% clinical practice in epilepsy will dilute the end value. For most practicing general neurologists, epilepsy will easily eclipse 25% of their patient care. In pediatric neurology, this essentially allows all child neurologists to become certified in epilepsy. Pediatric epilepsy specialists worry that a lack of differentiation in training will exist. For example, a fellowship-trained epileptologist will be fairly comfortable with epilepsy surgery evaluations and invasive EEG monitoring, whereas a general neurologist who spends time seeing patients with epilepsy may be only comfortable with the medical management of the patient, in spite of having the same board certification. How is the consumer to differentiate the expertise of these providers? Further, there is some risk for misrepresentation of skills from the provider, which can lead to poor patient outcomes and a decrease in the quality of care received. These concerns are probably not warranted. The subspecialty epilepsy board covers a broad array of topics related to diagnosis, evaluation, and management of epilepsy (both surgical and medical) and should adequately differentiate those providers with expertise in epilepsy regardless of their training. It is unlikely that a general neurologist who does not have a great deal of expertise in epilepsy would take the examination. The end of the grandfathering period will decrease the training discrepancy. However, it does not eliminate it because there will remain differences between training programs with regard to educational emphasis, especially between medical and surgical management strategies, which exist in the current system. Board certification in epilepsy recognizes knowledge of all aspects of epilepsy care, beyond that of a general neurologist. Even if a certified provider is not comfortable with every aspect of management, they have demonstrated understanding the appropriate approach to treatment and can refer to other providers if needed.
599
The creation of the epilepsy subspecialty board will help identify providers with proper experience treating epilepsy. It provides an examination that is more in line with the training most fellows receive during their neurophysiology fellowships and will also reflect the education provided in dedicated epilepsy training programs. The board will not completely recognize the expertise of providers trained in neurophysiology, as intraoperative monitoring, NCS, EMG, and sleep are not included, but this was never the intent of the examination. For trainees who desire certification in neurophysiology beyond EEG, they will continue to need clinical neurophysiology board certification. This dual board requirement will likely disappear in the future because trainees interested in epilepsy will be able to pursue dedicated fellowships avoiding clinical neurophysiology fellowship. In fact, one has to wonder whether clinical neurophysiology will survive with available tracts in epilepsy, neuromuscular, and sleep medicine essentially cannibalizing potential fellows. As originally conceived, the epilepsy fellowship requirements did not to include EEG review requirements, but this has since changed. This fact is concerning to neurophysiology programs as EEG review is a major portion of the training in many current fellowships. In addition, it remains unclear whether epilepsy board certification will be viewed as an alternative method to demonstrate qualification for EEG reading and interpretation as well as patient management. Generally speaking, most clinical neurophysiology fellows have expressed their desire to take only the epilepsy board examination, which would decrease the number of people who are board certified in clinical neurophysiology. In the end, the epilepsy board should delineate experts in epilepsy care and will be beneficial to the profession and our patients by focusing training and evaluation on this specialized field. Perhaps certification should be reserved for those interested in providing care for complicated epilepsy patients. However, credentialing requirements of hospitals and academic institutions, which sometimes mandate board certification, will remain unclear. Reference 1. Epilepsy: History and statement of principles. American Board of Psychiatry and Neurology. Available at: www.abpn.org/sub_epilepsy. html. Updated July 8, 2014. Accessed July 8, 2014.
Contents lists available at ScienceDirect
Pediatric Neurology journal homepage: www.elsevier.com/locate/pnu
Perspectives in Pediatric Neurology
American Board of Psychiatry and Neurology Certification in Epilepsy: Just What the Doctor Ordered, Another Board Examination M. Scott Perry MD a, *, Anup D. Patel MD b a b
Comprehensive Epilepsy Program, Jane and John Justin Neuroscience Center, Cook Children’s Medical Center, Fort Worth, Texas Division of Pediatric Neurology, Nationwide Children’s Hospital and The Ohio State College of Medicine, Columbus, Ohio
In 2010, the American Board of Psychiatry and Neurology (ABPN) approved the creation of the subspecialty board in epilepsy, and the first examination was administered in October of 2013. The primary purpose of this certification was to “establish the field of epilepsy as a definite area of subspecialization in neurology and child neurology and to provide a means of identifying physicians properly trained and experienced in treating epilepsy.”1 To qualify for the examination, candidates must be certified by the ABPN in neurology or neurology with special qualification in child neurology and have completed a 1-year fellowship in an Accreditation Council for Graduate Medical Educationaccredited epilepsy fellowship program. During the grandfathering period, which ends in 2017, candidates can qualify if they document a 1-year fellowship in epilepsy at a nonaccredited program affiliated with an accredited neurology program or if they attest to 25% of their practice time devoted to epilepsy for at least 2 years after residency training. Although creation of the epilepsy subspecialty board was viewed favorably by many, allowing nonfellowship trained physicians to qualify for certification left some candidates feeling that their unique expertise and additional training were being discounted. Many questioned the need for such certification given the many years of providing epilepsy care as is commonly practiced among child neurologists. A similar argument can be made in discussing whether certification is required in neurophysiology to interpret routine electroencephalography (EEG) recordings. One can ponder whether it is necessary to offer
Article History: Received July 23, 2014; Accepted in final form July 26, 2014 * Communications should be addressed to: Dr. Perry; Comprehensive Epilepsy Program; Jane and John Justin Neuroscience Center; Cook Children’s Medical Center; 1500 Cooper Street; 4th Floor; Fort Worth, Texas 76104. E-mail address: [email protected] 0887-8994/$ - see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.pediatrneurol.2014.07.035
an epilepsy subspecialty board certification and whether holding certification will serve the intended purpose to “identify properly trained and experienced” physicians in the long run. As to whether offering an epilepsy board is worthwhile, look no further than today’s trainees and previous options to certify their fellowship. Although some centers offered epilepsy fellowships, these were not recognized by ACGME and thus not acceptable for subsequent board certification. Most trainees looking to subspecialize in epilepsy entered a clinical neurophysiology fellowship after residency. The purpose of clinical neurophysiology training is to offer broad-based instruction in not only EEG but also in electromyography (EMG), nerve conduction studies (NCS), intraoperative monitoring, and sleep studies. Although this being the intent, most programs focus clinical training on a specific area often dichotomized between epilepsy and neuromuscular medicine. Among child neurologists, training often favors epilepsy. In addition, if a trainee is interested in sleep or neuromuscular medicine, they already have the option to pursue fellowship training and board certification in those subspecialties. Thus, many fellows complete neurophysiology training feeling confident in their EEG interpretation skills but much less prepared for other areas of neurophysiology. Candidates would then pursue the ABPN Clinical Neurophysiology Board, which evenly examines EMG and/or NCS knowledge to that of EEG. An alternative track for certification is available through the American Board of Clinical Neurophysiology, which also covers all aspects of neurophysiology testing. As a result, many fellows chose not to take any examination and simply remain board eligible. Many that certify choose to focus their clinical practice on the portion that they are the most comfortable and not perform other skills that are the part of neurophysiology certification. Further, many current neurophysiology fellowships may not provide specialized information in the field of epilepsy care and management,
M.S. Perry, A.D. Patel / Pediatric Neurology 51 (2014) 598e599
instead focusing on test performance and interpretation. For these reasons, a subspecialty board which recognized the specialization in epilepsy was applauded. The new board mirrored the path the Board established in 2005 when it created the subspecialty examination in neuromuscular medicine. Since the establishment of the epilepsy subspecialty board, the ABPN and ACGME have also created accredited epilepsy fellowships. During the transition, the epilepsy board should more accurately test and represent the expertise of trainees in this field; many question whether the grandfathering criteria allowing attestation of greater than 25% clinical practice in epilepsy will dilute the end value. For most practicing general neurologists, epilepsy will easily eclipse 25% of their patient care. In pediatric neurology, this essentially allows all child neurologists to become certified in epilepsy. Pediatric epilepsy specialists worry that a lack of differentiation in training will exist. For example, a fellowship-trained epileptologist will be fairly comfortable with epilepsy surgery evaluations and invasive EEG monitoring, whereas a general neurologist who spends time seeing patients with epilepsy may be only comfortable with the medical management of the patient, in spite of having the same board certification. How is the consumer to differentiate the expertise of these providers? Further, there is some risk for misrepresentation of skills from the provider, which can lead to poor patient outcomes and a decrease in the quality of care received. These concerns are probably not warranted. The subspecialty epilepsy board covers a broad array of topics related to diagnosis, evaluation, and management of epilepsy (both surgical and medical) and should adequately differentiate those providers with expertise in epilepsy regardless of their training. It is unlikely that a general neurologist who does not have a great deal of expertise in epilepsy would take the examination. The end of the grandfathering period will decrease the training discrepancy. However, it does not eliminate it because there will remain differences between training programs with regard to educational emphasis, especially between medical and surgical management strategies, which exist in the current system. Board certification in epilepsy recognizes knowledge of all aspects of epilepsy care, beyond that of a general neurologist. Even if a certified provider is not comfortable with every aspect of management, they have demonstrated understanding the appropriate approach to treatment and can refer to other providers if needed.
599
The creation of the epilepsy subspecialty board will help identify providers with proper experience treating epilepsy. It provides an examination that is more in line with the training most fellows receive during their neurophysiology fellowships and will also reflect the education provided in dedicated epilepsy training programs. The board will not completely recognize the expertise of providers trained in neurophysiology, as intraoperative monitoring, NCS, EMG, and sleep are not included, but this was never the intent of the examination. For trainees who desire certification in neurophysiology beyond EEG, they will continue to need clinical neurophysiology board certification. This dual board requirement will likely disappear in the future because trainees interested in epilepsy will be able to pursue dedicated fellowships avoiding clinical neurophysiology fellowship. In fact, one has to wonder whether clinical neurophysiology will survive with available tracts in epilepsy, neuromuscular, and sleep medicine essentially cannibalizing potential fellows. As originally conceived, the epilepsy fellowship requirements did not to include EEG review requirements, but this has since changed. This fact is concerning to neurophysiology programs as EEG review is a major portion of the training in many current fellowships. In addition, it remains unclear whether epilepsy board certification will be viewed as an alternative method to demonstrate qualification for EEG reading and interpretation as well as patient management. Generally speaking, most clinical neurophysiology fellows have expressed their desire to take only the epilepsy board examination, which would decrease the number of people who are board certified in clinical neurophysiology. In the end, the epilepsy board should delineate experts in epilepsy care and will be beneficial to the profession and our patients by focusing training and evaluation on this specialized field. Perhaps certification should be reserved for those interested in providing care for complicated epilepsy patients. However, credentialing requirements of hospitals and academic institutions, which sometimes mandate board certification, will remain unclear. Reference 1. Epilepsy: History and statement of principles. American Board of Psychiatry and Neurology. Available at: www.abpn.org/sub_epilepsy. html. Updated July 8, 2014. Accessed July 8, 2014.
