PRESIDENT'S COLUMN
I~~~~~~~
PHYSICIAN CERTIFICATION Alma R. George, MD President, National Medical Association Detroit, Michigan
INTRODUCTION Public concern about the quality and lack of standards for medical specialty practices during the 1900s led to the establishment of medical specialty boards. Medical specialty boards are responsible for the examination and certification of candidates who have met the prerequisite training and education beyond the MD degree, and who wish to be recognized as experts in a chosen field of medicine. Medical specialty boards are incorporated as independent organizations and are not associated with state medical licensing boards. Today, there are 23 specialty boards operating under the American Board of Medical Specialties (ABMS). These specialty boards certify physicians in more than 70 specialties and subspecialties. The ABMS describes its goals and purposes as "The improvement of medical care through the setting of professional standards and surveillance of medical competence." I Each ABMS member board functions independently in setting its requirements for certification. Each candidate must complete a training requirement. The total number of required training years varies from 3 to 8 years depending on the chosen specialty area. All specialty board members hold written examinations for certification. In addition to the written examination, 16 specialty boards require oral examinations as well. Upon completion of all prerequisites, a candidate is issued a "general certificate" by the specialty board. As subspecialties began to emerge within the 23 general specialty areas, the primary boards began to issue "special certificates" to designate special competence in a subspecialty field represented by that board. At its March 1985 meeting, ABMS approved a third type of Dr George is Director, Primary Care Initiative, Surgical Services, St Joseph's Clinic, Samaritan Health Center, Detroit, Michigan. Requests for reprints should be addressed to Dr Alma R. George, National Medical Association, 1012 Tenth St, NW, Washington, DC 20001. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 10
certificate-"added qualification"-to address an area of special competence within a particular subspecialty. The special certificate and the added qualification certificate diminished the value of the general certificate. In an attempt to eradicate any deficiencies in the value of the general certificate, the ABMS issued a policy stating that under no circumstances should a diplomat be considered unqualified to practice within an area of subspecialty solely because of the lack of the additional certificates.2 The reasoning behind this policy was that the evaluation examinations on which general certificates are based assign appropriate emphasis to each of the subspecialties or areas of special competence to deem a physician holding the general certificate competent to effectively perform the same tasks as physicians holding a special certificate or added qualification certificate. Certification by a medical specialty board is not valid for the lifetime of a physician. In order to assure maintenance of a certain level of competency, each board requires its diplomats to be evaluated periodically for recertification. In essence, each board currently issues time-limited certificates that are valid only for a certain number of years. In order to assess the impact that physician certification has had on Afro-American physicians and the delivery of health care to the Afro-American population, the statistics must be reviewed. The statistics on physician certification will reveal the trends in the total physician population and in the Afro-American physician population in particular.
STATISTICS ON PHYSICIAN CERTIFICATION As the number of physicians receiving licenses increased at a slower rate in the 1980s compared to the 1970s, the number of physicians becoming board certified has continued to grow from 1971 to 1987.3 At 857
PRESIDENrS COLUMN
the end of the 19th century, 90% of physicians were general practitioners. By 1981, 53.2% of physicians were board certified. As of 1986, approximately 74% to 79% of all practitioners were board certified. A recent study suggests that if the annual growth rate of 7.2% of physicians obtaining board certification continues, at the end of the 20th century, nearly 100% of physicians will be board certified specialists.4 Approximately 50% of American medical school graduates have obtained certification in one of the three primary care fields of internal medicine, family practice, or pediatrics. Physicians in these fields are responsible for direct and continuous care of patients in private offices, clinics, and hospitals. However, a 1982 study revealed a change in young doctors' interest away from primary care specialties to high technology specialties in orthopedics, ophthalmology, anesthesiology, radiology, and the surgical subspecialties.5 For instance, since 1982, many of the prestigious training programs in internal medicine failed to fill all of their positions. While the preceding statistics provided certification data on the overall physician population, there was no breakdown by race, nor were there any exclusive data concerning Afro-American physician certification. However, in reviewing the number of Afro-American residents on duty from 1985 to 1987, some light may be shed on the goals for certification in the Afro-American physician population. In 1987, there were 80 908 residents on duty in the United States. Of that number, only 3897 (4.8%) were Afro-Americans.6 Although the number of Afro-American residents has increased from 1985 to 1987, that increase was relatively smallmerely 0.4%. Of the total number of Afro-American residents in specialty area programs, approximately 50% were in the primary care specialty fields of internal medicine, family practice, and pediatrics. Approximately 22% were specializing in the high technology specialties of orthopedics, ophthalmology, anesthesiology, radiology, and surgery as of 1987.6 Although these statistics do not give evidence to the number of Afro-American physicians that are currently board certified, it does shed a dim light on the small number of Afro-American physicians represented in the total resident population striving for certification. It also states that the number of Afro-American physicians that are board certified represents a small percentage of the total number of certified physicians in this country. Certification in a chosen field of practice has evolved as the litmus test in determining a physician's compe858
tency. As specialization has become a permanent fixture in the practice of medicine in this country, it is imperative that every Afro-American physician become certified in a chosen field of medicine recognized by one of the 23 medical specialty boards. In so doing, it is crucial that Afro-American physicians are aware of the effects board certification will have on their careers and the delivery of health care to their patients, as well as the legal ramifications certification has had on the medical profession in its ability to regulate itself
EFFECTS OF CERTIFICATION ON A PHYSICIAN'S CAREER Although physician certification is voluntary and is not associated to state licensing, whether a physician is certified in a specialty area or not may have a great impact on the development of his or her career. In the United States, almost all hospitals have adopted procedures governing medical staff membership privileges. These procedures often require a physician to be certified in a specialty area as the basis for granting new privileges or in renewing existing hospital privileges. In the primary care specialty areas, medical staff privileges allow a physician to admit patients, to supervise their treatment, and to discharge them. It also gives that physician an opportunity to participate in policy making and administrative decisions concerning the hospital. This allows the physician a voice in making recommendations about who should receive privileges and decisions about bylaws and regulations defining the scope of practice for nonphysician healthcare providers. Physicians in the high technology areas generally do not admit patients, but provide specialized diagnostic or therapeutic services to the patients admitted by primary care physicians. These physicians rely on technology and equipment that may only be available in a hospital. Hospitals usually contract with these physicians for their services, and certification has become a prerequisite for such transactions to occur. Therefore, as with primary care physicians, it is imperative to these physicians that they become certified in order to deliver their services. In addition to the granting of hospital privileges, certification provides several other advantages to the medical practitioner. It places practitioners in a position of constant contact with other certified practitioners for networking, which can lead to referrals for new patients. Certified physicians are diplomats of their particular medical specialty boards, which place the physicians on the front line to receive information disseminated on JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 10
PRESIDENT'S COLUMN
educational programs. These continuing medical education programs are essential in maintaining professional skills and knowledge. Certification places the physician on a higher level of prestige in the medical profession. Department chairmen are seldom generalists. Certification may also determine whether a physician receives research grants or other types of professional awards in recognition of exceptional service in a particular field of medicine. The area of specialization a physician chooses will also make a difference in fee schedules and income, and will directly impact the physician's lifestyle. For example, primary care specialists have direct contact with patients. Their "on-call" scheduling is grueling, and their pay is generally less than that offered to physicians training in the procedural or technical areas of medicine. Their status in hospitals may be lower, which leads to less amenities. If the primary care specialist decides to open his or her own office, the overhead rate usually consumes a very high percentage of the profits.5 On the other hand, the high technology specialists have little contact with patients. Compensation per unit of time is relatively high. Their hours are usually regular and predictable. Their status in the hospital is usually higher than the primary care practitioner, and they usually are provided with new and expensive equipment by hospital administrators because such machines contribute heavily to the "bottom line." The one disadvantage to these specialists may be their high malpractice insurance premiums.5 A license to practice medicine allows a physician to work in his or her chosen profession; however, certification can broaden the scope of that practice. Failure to obtain certification in a particular specialty area not only suggests a lower level of competence, but also may result in a physician being denied hospital privileges and the other amenities enjoyed by certified physicians. For Afro-American physicians, the consequences of noncertification may be twofold. First, not being certified will limit the scope of the physician's practice and the development of his or her career. Second, it will affect the delivery of health care to those in the Afro-American population being serviced by Afro-American physicians.
CERTIFICATION AND THE DELIVERY OF HEALTH CARE Certification has affected the delivery of health-care services through public access and the quality and cost of health care. Patients generally have had direct access to specialists in this country. However, with more people joining prepaid health-care plans, this direct JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 10
access to specialists may be altered. Many health maintenance organizations (HMOs) and competitive medical plans (CMPs) are now requiring their patients to see a primary care practitioner before being referred to a specialist. The primary care practitioner will determine whether a patient requires the services of a specialist, and the primary care practitioner will have the opportunity to refer that patient to a specialist of his or her choice if needed. This requirement will break the direct access line patients have had to specialists and subsequently will result in physicians of different specialty areas competing with each other. It is also a concern that with a higher percentage of doctors practicing solely in their areas of certification, primary care will be less accessible to patients because of the availability of fewer primary care physicians.4 The consensus within the medical profession is that certification has led to an improvement in the quality of care. By specializing, physicians are able to keep knowledge and skills in their specialty areas at peak performance. This results in patients receiving the benefits of the latest advances and technology in treatment. The down side of specialty care is that the demand for such services may be less than the supply of physicians trained to provide such services. This can lead to specialists performing unnecessary services or losing their skills from lack of constant usage. Some in the medical profession are also concerned with the lack of comprehensive care for the entire body since specialists provide fragmented care.4 The cost of health-care services is sometimes the determining factor in deciding whether to seek a physician's services. Certification has contributed to the increased cost of health care. Specialists charge more than generalists, and the fee increases even more with subspecialists. As HMOs and CMPs attempt to cut their costs, one must wonder whether primary care physicians will become reluctant to refer patients to specialists or subspecialists. Certification has led to some in-depth changes in the delivery of health care. As more Afro-American physicians become certified, their concerns over access to health care, the quality of health care, and the cost of health-care services will escalate. Because of the overall health-care deficit in the Afro-American population, these concerns will be compounded for Afro-American physicians servicing those communities, where cost is usually the determining factor in health-care decisions.
LEGAL ASPECTS OF CERTIFICATION The antitrust acts are federal statutes that protect 859
PRESIDENTS COLUMN
trade and commerce from unlawful restraints, price discriminations, price fixing, and monopolies. Most states also have their own antitrust acts patterned after the federal acts. The antitrust statutes promote open and free competition in the US free market economy. Violators of antitrust laws may be enjoined from continuing activities deemed unlawful and assessed treble damages for any harm resulting from such activities. The violator also must pay the plaintiffs attorney's fees and may be subjected to criminal charges, punishable by up to 5 years in prison and/or a stiff fine. Complaints against antitrust violators may be filed by the US Justice Department, the Federal Trade Commission, consumers, or competitors.7 Until 1975, the "learned professions" of medicine, law, engineering, and teaching were not considered commercial services and were thus exempted from the antitrust laws. The Supreme Court rejected the "learned profession" exemption in Goldfarb v Virginia State Bar (421 US 773). The case involved a price-fixing scheme devised by lawyers that established a minimum charge for tide searches in real estate deals. The Court found that the lawyers' activity was sufficiently commercial to warrant antitrust regulation. However, the Court stated that it would be unrealistic to view the practice of the professions as interchangeable with other business activities and to automatically apply the antitrust concepts that originated in other areas to the professions. The special aspects of the professions, such as public service, require that activities, which could be viewed as an antitrust violation in another context, be treated differently when carried out by the professions.7 After the Goldfarb decision, the medical profession is no longer exempt from the antitrust laws. The application of the antitrust laws in the area of physician certification raises concern because this activity is self-regulated. Medical professionals may restrict competition through the granting of hospital privileges or through certification boards directly. When physicians control the decision-making process that determines whether a practitioner is granted privileges or not, they may use certification requirements to fence out licensed but noncertified practitioners. If the physician's rights are simply limited, as opposed to totally excluded, and there are other facilities available to carry out his or her practice, the impact on the denial of privileges is lessened. However, when certain classes of physicians are excluded altogether and when the facilities are unique and essential to those physicians' practices, the denial of hospital privileges will more than likely be subject to strict antitrust scrutiny. 860
Medical specialty boards can restrict certification to protect certified physicians from competition by noncertified physicians. Generally, specialty boards are viewed as procompetitive when operating in a reasonable and fair manner. Certification programs are likely to be legal provided they are: * based on reasonable and objective criteria, * directly related to the legitimate aims of the profession, * administered with fairness and due process, and * not abused to simply exclude competition from the market or coerce third parties.8 Medical specialty boards also must apply the standards of reasonableness and fairness when setting the requirements for recertification. This is to make sure that the new entrants and existing practitioners meet the same standards in skills and knowledge. If new entrants are required to meet higher standards, the competition between new entrants and existing practitioners may be undermined, unless existing practitioners have satisfied the higher standards through experience or length of practice. Thus, if a particular medical specialty board raises its standards, it should do so universally. As more physicians become certified in a particular area of medicine, competition within the profession will increase. Self-regulatory professional boards not only have the power to set their own competency requirements, but also can use these requirements to control the number of practitioners holding credentials issued by the boards. The result is less competition for existing practitioners. All medical specialty boards, as well as hospital boards setting privileges criteria, must continue to operate in a reasonable and fair manner to escape the antitrust laws. Afro-American physicians must familiarize themselves with the legal limits of these boards for it was not long ago that they were denied privileges because of their race.
CONCLUSION Health conditions in the Afro-American community are at an alarming state in 1991. From one of the highest percentages of infant mortality rates in the Western world, to a shorter life expectancy than other ethnic groups in this country, the dismal health conditions in the Afro-American community span from the young to the elderly. As a consequence, more pressure is placed on Afro-American physicians serving these communities. It is essential that they deliver optimum health care to their patients. Certification in a chosen field of medicine is evidence of a physician's competence and that his or JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 10
PRESIDENT'S COLUMN
her skills and education allow him or her to deliver optimum health care. Certification has evolved as a trend for the future in the medical profession. Whether a practitioner is certified may be the determining factor in the granting of hospital privileges and will greatly impact the practitioner's career development and lifestyle. The consequences of noncertification also may affect the manner in which practitioners deliver health-care services to their patients. Finally, it may be an important factor in a legal dispute between a practitioner and a hospital or medical specialty board. The percentage of doctors certified in the total physician population has continued to increase since the 1970s. The goal for the end of the 20th century is to have 100% of the total physician population certified in a special field of medicine. In order to be deemed competent, to benefit from all of the amenities of the profession, to deliver optimum health care to the Afro-American community, and to remain competitive with their professional peers, it is imperative for the goals of Afro-American physicians to concur with the goals of the total physician population. Individually and collectively, Afro-American physicians must set certifi-
_
cation as a professional and personal goal for the good of health care in the Afro-American community. Literature Cited 1. Lloyd JS, Langsley DG, eds. Evaluating the Skills of Medical Specialists. Chicago, III: American Board of Medical Specialties; 1983:1. 2. Langsley DG, Darragh JH, eds. Trends in Specialization: Tomorrow's Medicine. Evanston, III: American Board of Medical Specialties; 1985:8-9. 3. Moore FD, Priebe C. Board-certified physicians in the United States, 1971-1986. N Engl J Med. 1991;324:536. 4. Spivey BE. Today's health care system: the role of specialization in the U.S. In: Langsley DG, Darragh JH, eds. Trends in Specialization: Tomorrow's Medicine. Evanston, III: American Board of Medical Specialties; 1985:27-32. 5. McCarthy DJ. Why are today's medical students choosing high-technology specialties over internal medicine? N EngI J Med. 1987;317:567-569. 6. Crowley AE, Etzel SJ. Graduate medical education in the United States. JAMA. 1988;260:1093-1 101. 7. Langsley DG. Legal Aspects of Certification and Accreditation. Chicago, III: American Board of Medical Specialties; 1983:17-20. 8. Pollard MR, Leibenloft RF Antitrust and the Health Profession. Washington, DC: Federal Trade Commission; 1981:88.
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JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 10
861
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PHYSICIAN CERTIFICATION Alma R. George, MD President, National Medical Association Detroit, Michigan
INTRODUCTION Public concern about the quality and lack of standards for medical specialty practices during the 1900s led to the establishment of medical specialty boards. Medical specialty boards are responsible for the examination and certification of candidates who have met the prerequisite training and education beyond the MD degree, and who wish to be recognized as experts in a chosen field of medicine. Medical specialty boards are incorporated as independent organizations and are not associated with state medical licensing boards. Today, there are 23 specialty boards operating under the American Board of Medical Specialties (ABMS). These specialty boards certify physicians in more than 70 specialties and subspecialties. The ABMS describes its goals and purposes as "The improvement of medical care through the setting of professional standards and surveillance of medical competence." I Each ABMS member board functions independently in setting its requirements for certification. Each candidate must complete a training requirement. The total number of required training years varies from 3 to 8 years depending on the chosen specialty area. All specialty board members hold written examinations for certification. In addition to the written examination, 16 specialty boards require oral examinations as well. Upon completion of all prerequisites, a candidate is issued a "general certificate" by the specialty board. As subspecialties began to emerge within the 23 general specialty areas, the primary boards began to issue "special certificates" to designate special competence in a subspecialty field represented by that board. At its March 1985 meeting, ABMS approved a third type of Dr George is Director, Primary Care Initiative, Surgical Services, St Joseph's Clinic, Samaritan Health Center, Detroit, Michigan. Requests for reprints should be addressed to Dr Alma R. George, National Medical Association, 1012 Tenth St, NW, Washington, DC 20001. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 10
certificate-"added qualification"-to address an area of special competence within a particular subspecialty. The special certificate and the added qualification certificate diminished the value of the general certificate. In an attempt to eradicate any deficiencies in the value of the general certificate, the ABMS issued a policy stating that under no circumstances should a diplomat be considered unqualified to practice within an area of subspecialty solely because of the lack of the additional certificates.2 The reasoning behind this policy was that the evaluation examinations on which general certificates are based assign appropriate emphasis to each of the subspecialties or areas of special competence to deem a physician holding the general certificate competent to effectively perform the same tasks as physicians holding a special certificate or added qualification certificate. Certification by a medical specialty board is not valid for the lifetime of a physician. In order to assure maintenance of a certain level of competency, each board requires its diplomats to be evaluated periodically for recertification. In essence, each board currently issues time-limited certificates that are valid only for a certain number of years. In order to assess the impact that physician certification has had on Afro-American physicians and the delivery of health care to the Afro-American population, the statistics must be reviewed. The statistics on physician certification will reveal the trends in the total physician population and in the Afro-American physician population in particular.
STATISTICS ON PHYSICIAN CERTIFICATION As the number of physicians receiving licenses increased at a slower rate in the 1980s compared to the 1970s, the number of physicians becoming board certified has continued to grow from 1971 to 1987.3 At 857
PRESIDENrS COLUMN
the end of the 19th century, 90% of physicians were general practitioners. By 1981, 53.2% of physicians were board certified. As of 1986, approximately 74% to 79% of all practitioners were board certified. A recent study suggests that if the annual growth rate of 7.2% of physicians obtaining board certification continues, at the end of the 20th century, nearly 100% of physicians will be board certified specialists.4 Approximately 50% of American medical school graduates have obtained certification in one of the three primary care fields of internal medicine, family practice, or pediatrics. Physicians in these fields are responsible for direct and continuous care of patients in private offices, clinics, and hospitals. However, a 1982 study revealed a change in young doctors' interest away from primary care specialties to high technology specialties in orthopedics, ophthalmology, anesthesiology, radiology, and the surgical subspecialties.5 For instance, since 1982, many of the prestigious training programs in internal medicine failed to fill all of their positions. While the preceding statistics provided certification data on the overall physician population, there was no breakdown by race, nor were there any exclusive data concerning Afro-American physician certification. However, in reviewing the number of Afro-American residents on duty from 1985 to 1987, some light may be shed on the goals for certification in the Afro-American physician population. In 1987, there were 80 908 residents on duty in the United States. Of that number, only 3897 (4.8%) were Afro-Americans.6 Although the number of Afro-American residents has increased from 1985 to 1987, that increase was relatively smallmerely 0.4%. Of the total number of Afro-American residents in specialty area programs, approximately 50% were in the primary care specialty fields of internal medicine, family practice, and pediatrics. Approximately 22% were specializing in the high technology specialties of orthopedics, ophthalmology, anesthesiology, radiology, and surgery as of 1987.6 Although these statistics do not give evidence to the number of Afro-American physicians that are currently board certified, it does shed a dim light on the small number of Afro-American physicians represented in the total resident population striving for certification. It also states that the number of Afro-American physicians that are board certified represents a small percentage of the total number of certified physicians in this country. Certification in a chosen field of practice has evolved as the litmus test in determining a physician's compe858
tency. As specialization has become a permanent fixture in the practice of medicine in this country, it is imperative that every Afro-American physician become certified in a chosen field of medicine recognized by one of the 23 medical specialty boards. In so doing, it is crucial that Afro-American physicians are aware of the effects board certification will have on their careers and the delivery of health care to their patients, as well as the legal ramifications certification has had on the medical profession in its ability to regulate itself
EFFECTS OF CERTIFICATION ON A PHYSICIAN'S CAREER Although physician certification is voluntary and is not associated to state licensing, whether a physician is certified in a specialty area or not may have a great impact on the development of his or her career. In the United States, almost all hospitals have adopted procedures governing medical staff membership privileges. These procedures often require a physician to be certified in a specialty area as the basis for granting new privileges or in renewing existing hospital privileges. In the primary care specialty areas, medical staff privileges allow a physician to admit patients, to supervise their treatment, and to discharge them. It also gives that physician an opportunity to participate in policy making and administrative decisions concerning the hospital. This allows the physician a voice in making recommendations about who should receive privileges and decisions about bylaws and regulations defining the scope of practice for nonphysician healthcare providers. Physicians in the high technology areas generally do not admit patients, but provide specialized diagnostic or therapeutic services to the patients admitted by primary care physicians. These physicians rely on technology and equipment that may only be available in a hospital. Hospitals usually contract with these physicians for their services, and certification has become a prerequisite for such transactions to occur. Therefore, as with primary care physicians, it is imperative to these physicians that they become certified in order to deliver their services. In addition to the granting of hospital privileges, certification provides several other advantages to the medical practitioner. It places practitioners in a position of constant contact with other certified practitioners for networking, which can lead to referrals for new patients. Certified physicians are diplomats of their particular medical specialty boards, which place the physicians on the front line to receive information disseminated on JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 10
PRESIDENT'S COLUMN
educational programs. These continuing medical education programs are essential in maintaining professional skills and knowledge. Certification places the physician on a higher level of prestige in the medical profession. Department chairmen are seldom generalists. Certification may also determine whether a physician receives research grants or other types of professional awards in recognition of exceptional service in a particular field of medicine. The area of specialization a physician chooses will also make a difference in fee schedules and income, and will directly impact the physician's lifestyle. For example, primary care specialists have direct contact with patients. Their "on-call" scheduling is grueling, and their pay is generally less than that offered to physicians training in the procedural or technical areas of medicine. Their status in hospitals may be lower, which leads to less amenities. If the primary care specialist decides to open his or her own office, the overhead rate usually consumes a very high percentage of the profits.5 On the other hand, the high technology specialists have little contact with patients. Compensation per unit of time is relatively high. Their hours are usually regular and predictable. Their status in the hospital is usually higher than the primary care practitioner, and they usually are provided with new and expensive equipment by hospital administrators because such machines contribute heavily to the "bottom line." The one disadvantage to these specialists may be their high malpractice insurance premiums.5 A license to practice medicine allows a physician to work in his or her chosen profession; however, certification can broaden the scope of that practice. Failure to obtain certification in a particular specialty area not only suggests a lower level of competence, but also may result in a physician being denied hospital privileges and the other amenities enjoyed by certified physicians. For Afro-American physicians, the consequences of noncertification may be twofold. First, not being certified will limit the scope of the physician's practice and the development of his or her career. Second, it will affect the delivery of health care to those in the Afro-American population being serviced by Afro-American physicians.
CERTIFICATION AND THE DELIVERY OF HEALTH CARE Certification has affected the delivery of health-care services through public access and the quality and cost of health care. Patients generally have had direct access to specialists in this country. However, with more people joining prepaid health-care plans, this direct JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 10
access to specialists may be altered. Many health maintenance organizations (HMOs) and competitive medical plans (CMPs) are now requiring their patients to see a primary care practitioner before being referred to a specialist. The primary care practitioner will determine whether a patient requires the services of a specialist, and the primary care practitioner will have the opportunity to refer that patient to a specialist of his or her choice if needed. This requirement will break the direct access line patients have had to specialists and subsequently will result in physicians of different specialty areas competing with each other. It is also a concern that with a higher percentage of doctors practicing solely in their areas of certification, primary care will be less accessible to patients because of the availability of fewer primary care physicians.4 The consensus within the medical profession is that certification has led to an improvement in the quality of care. By specializing, physicians are able to keep knowledge and skills in their specialty areas at peak performance. This results in patients receiving the benefits of the latest advances and technology in treatment. The down side of specialty care is that the demand for such services may be less than the supply of physicians trained to provide such services. This can lead to specialists performing unnecessary services or losing their skills from lack of constant usage. Some in the medical profession are also concerned with the lack of comprehensive care for the entire body since specialists provide fragmented care.4 The cost of health-care services is sometimes the determining factor in deciding whether to seek a physician's services. Certification has contributed to the increased cost of health care. Specialists charge more than generalists, and the fee increases even more with subspecialists. As HMOs and CMPs attempt to cut their costs, one must wonder whether primary care physicians will become reluctant to refer patients to specialists or subspecialists. Certification has led to some in-depth changes in the delivery of health care. As more Afro-American physicians become certified, their concerns over access to health care, the quality of health care, and the cost of health-care services will escalate. Because of the overall health-care deficit in the Afro-American population, these concerns will be compounded for Afro-American physicians servicing those communities, where cost is usually the determining factor in health-care decisions.
LEGAL ASPECTS OF CERTIFICATION The antitrust acts are federal statutes that protect 859
PRESIDENTS COLUMN
trade and commerce from unlawful restraints, price discriminations, price fixing, and monopolies. Most states also have their own antitrust acts patterned after the federal acts. The antitrust statutes promote open and free competition in the US free market economy. Violators of antitrust laws may be enjoined from continuing activities deemed unlawful and assessed treble damages for any harm resulting from such activities. The violator also must pay the plaintiffs attorney's fees and may be subjected to criminal charges, punishable by up to 5 years in prison and/or a stiff fine. Complaints against antitrust violators may be filed by the US Justice Department, the Federal Trade Commission, consumers, or competitors.7 Until 1975, the "learned professions" of medicine, law, engineering, and teaching were not considered commercial services and were thus exempted from the antitrust laws. The Supreme Court rejected the "learned profession" exemption in Goldfarb v Virginia State Bar (421 US 773). The case involved a price-fixing scheme devised by lawyers that established a minimum charge for tide searches in real estate deals. The Court found that the lawyers' activity was sufficiently commercial to warrant antitrust regulation. However, the Court stated that it would be unrealistic to view the practice of the professions as interchangeable with other business activities and to automatically apply the antitrust concepts that originated in other areas to the professions. The special aspects of the professions, such as public service, require that activities, which could be viewed as an antitrust violation in another context, be treated differently when carried out by the professions.7 After the Goldfarb decision, the medical profession is no longer exempt from the antitrust laws. The application of the antitrust laws in the area of physician certification raises concern because this activity is self-regulated. Medical professionals may restrict competition through the granting of hospital privileges or through certification boards directly. When physicians control the decision-making process that determines whether a practitioner is granted privileges or not, they may use certification requirements to fence out licensed but noncertified practitioners. If the physician's rights are simply limited, as opposed to totally excluded, and there are other facilities available to carry out his or her practice, the impact on the denial of privileges is lessened. However, when certain classes of physicians are excluded altogether and when the facilities are unique and essential to those physicians' practices, the denial of hospital privileges will more than likely be subject to strict antitrust scrutiny. 860
Medical specialty boards can restrict certification to protect certified physicians from competition by noncertified physicians. Generally, specialty boards are viewed as procompetitive when operating in a reasonable and fair manner. Certification programs are likely to be legal provided they are: * based on reasonable and objective criteria, * directly related to the legitimate aims of the profession, * administered with fairness and due process, and * not abused to simply exclude competition from the market or coerce third parties.8 Medical specialty boards also must apply the standards of reasonableness and fairness when setting the requirements for recertification. This is to make sure that the new entrants and existing practitioners meet the same standards in skills and knowledge. If new entrants are required to meet higher standards, the competition between new entrants and existing practitioners may be undermined, unless existing practitioners have satisfied the higher standards through experience or length of practice. Thus, if a particular medical specialty board raises its standards, it should do so universally. As more physicians become certified in a particular area of medicine, competition within the profession will increase. Self-regulatory professional boards not only have the power to set their own competency requirements, but also can use these requirements to control the number of practitioners holding credentials issued by the boards. The result is less competition for existing practitioners. All medical specialty boards, as well as hospital boards setting privileges criteria, must continue to operate in a reasonable and fair manner to escape the antitrust laws. Afro-American physicians must familiarize themselves with the legal limits of these boards for it was not long ago that they were denied privileges because of their race.
CONCLUSION Health conditions in the Afro-American community are at an alarming state in 1991. From one of the highest percentages of infant mortality rates in the Western world, to a shorter life expectancy than other ethnic groups in this country, the dismal health conditions in the Afro-American community span from the young to the elderly. As a consequence, more pressure is placed on Afro-American physicians serving these communities. It is essential that they deliver optimum health care to their patients. Certification in a chosen field of medicine is evidence of a physician's competence and that his or JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 10
PRESIDENT'S COLUMN
her skills and education allow him or her to deliver optimum health care. Certification has evolved as a trend for the future in the medical profession. Whether a practitioner is certified may be the determining factor in the granting of hospital privileges and will greatly impact the practitioner's career development and lifestyle. The consequences of noncertification also may affect the manner in which practitioners deliver health-care services to their patients. Finally, it may be an important factor in a legal dispute between a practitioner and a hospital or medical specialty board. The percentage of doctors certified in the total physician population has continued to increase since the 1970s. The goal for the end of the 20th century is to have 100% of the total physician population certified in a special field of medicine. In order to be deemed competent, to benefit from all of the amenities of the profession, to deliver optimum health care to the Afro-American community, and to remain competitive with their professional peers, it is imperative for the goals of Afro-American physicians to concur with the goals of the total physician population. Individually and collectively, Afro-American physicians must set certifi-
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cation as a professional and personal goal for the good of health care in the Afro-American community. Literature Cited 1. Lloyd JS, Langsley DG, eds. Evaluating the Skills of Medical Specialists. Chicago, III: American Board of Medical Specialties; 1983:1. 2. Langsley DG, Darragh JH, eds. Trends in Specialization: Tomorrow's Medicine. Evanston, III: American Board of Medical Specialties; 1985:8-9. 3. Moore FD, Priebe C. Board-certified physicians in the United States, 1971-1986. N Engl J Med. 1991;324:536. 4. Spivey BE. Today's health care system: the role of specialization in the U.S. In: Langsley DG, Darragh JH, eds. Trends in Specialization: Tomorrow's Medicine. Evanston, III: American Board of Medical Specialties; 1985:27-32. 5. McCarthy DJ. Why are today's medical students choosing high-technology specialties over internal medicine? N EngI J Med. 1987;317:567-569. 6. Crowley AE, Etzel SJ. Graduate medical education in the United States. JAMA. 1988;260:1093-1 101. 7. Langsley DG. Legal Aspects of Certification and Accreditation. Chicago, III: American Board of Medical Specialties; 1983:17-20. 8. Pollard MR, Leibenloft RF Antitrust and the Health Profession. Washington, DC: Federal Trade Commission; 1981:88.
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