The Journal of
ALLERGY and
CLINICAL
IMMUNOLOGY
VOLUME 56
NUMBER 3
Presidential address Quality Sheldon
assurance C. Siegel,
M.D. Los Angeles, Calif.
At this time each year it has been the duty and the privilege of the retiring president to present an overview of his stewardship and some commentary on the events of the Academy in the year just past. In addition, it has been customary for many of my predecessors to offer some philosophical suggestions as to the future policies, goals, and priorities for the Academy. This afternoon I, too, will touch on the Academy’s past activities and discuss future action that I feel should be considered seriously by the Academy’s leadership. Shortly after I was born, the Association for the Study of Asthma and Allied Conditions and the American Association for the Study of Allergy were formed to promote better understanding of the causes of allergy and to improve patient care. Twenty-one years later these two societies combined to become the American Academy of Allergy. Although I have not been a member of the Academy for the entire 31 years of its existence, I have been privileged, as a pediatrician might say, to observe its growth and maturation into the strong specialty organization it is today, one that has more than fulfilled the object of its formation as stated in our constitution. First I would like to focus this afternoon on one of the primary purposes of the Academy as stated in our constitution, namely, “to encourage union and cooperation among those engaged in this field.” During the past several years of my service on the Executive Committee of the Academy, I have heard the leadership express on numerous occasions the desirability of the major national allergy societies merging into one National Allergy Society. The three immediate Presented at the Thirty-first Annual Meeting of the American Academy of Diego, Calif., Feb. 15-19, 1975. Reprint requests to: Dr. Sheldon C. Siegel, 8540 S. Sepulveda Blvd., Los Angeles, Vol.
Allergy, Calif.
San 90045.
56, No. 3, pp. 161-167
162
Siegel
J. ALLERGY CLIN. IMMUNOL. SEPTEMBER 1975
Past-Presidents alluded to the merits of this move in their presidental addresses. In addition, the Delphi Survey which my predecessor, Dr. Charles Reed, had the wisdom and foresight to implement as a means of learning our membership’s desires and needs, as well as a recent survey by the American Association for Clinical Allergy and Immunology, clearly indicated that the majority of t,hose surveyed favored an amalgamation of the national societies. I might add that during my term of office I received several letters from local, state, and regional allergy societies also urging merger. As your President I have participated in some of the recent merger meetings. I am pleased to report that considerable progress has been made in our joint efforts to achieve this goal. As many of you already know, a combined meeting of the Academy with the College, the Association, and the American Association of Certified Allergists is scheduled for 1976 in New York. More importantly, it, has been agreed by the leadership of all four societies that we begin to draft a Constitution and Bylaws for an amalgamated society. The cooperative spirit and working rapport of the Medical Services Committee’s and Conjoint Socioeconomic Council’s members have been a heartening indication that we can work together. Nevertheless, some minor roadblocks are evident, such as concern expressed regarding adequate representation of the clinician versus the academician, the pediatrician versus the internist, and certified versus noncertified allergists. I feel that those charged with resolving the details entailed by a merger can resolve these problems, and I urge that we move forward to eliminate overlapping membership and activities so that allergy can speak with one clear, strong, and harmonious voice. I will now turn to the major theme of my address, the subject of the quality aS.surance of medical care to our patients, i.e., our accountability to the public. This subject includes the so-called controversial techniques in allergy, recertification, self-assessment, and manpower distribution. The medical profession in the past has traditionally enjoyed the confidence of the public and independence from regulation because it professed an ability to promote and guarantee the quality of its members’ performance. Indeed, a number of mechanisms by which the profession attempted to fulfill this responsibility were developed over the years. These include the Hippocratic oath; state licensure; national board and specialty examinations; accreditation of training programs and hospitals ; research on effectiveness and control of the use of drugs, surgery, and other forms of therapy; continuing education through meetings and publications of medical journals; hospital committees such as those concerned with review of the pathology of tissues, infections, etc.; rounds in hospitals; and public mechanisms of grievances in courts of law through malpractice suits. More recently, utilization committees to monitor length of hospital stays and peer review have been developed to help control costs as well as to improve quality of care. Despite these measures, the public has become dissatisfied and has sought through legislation other means of regulating the quality of health care delivery. Several factors undoubtedly have contributed to the public’s demand for greater accountability of the medical profession. These include: (1) the rising cost of
Quality
VOLUME 56 NUMBER 3
assurance
163
medical care (though the physicians’ fees have contributed little to these rising costs) ; (2) third party payment of these costs by public and private insurance carriers, thereby giving them visibility and the payers leverage to control costs; (3) decreased ease of access to medical care with a perceived loss of personal or humanistic aspect of quality care; (4) increased specialization and fewer primary care physicians ; and (5) increased education of the public generating a greater concern for quality by the patient as well as the physician. The Constitutions of both the Academy and the College, and I am certain also the Association’s and Certified Allergists’ Constitutions, clearly indicate that one of the objects of these societies should be to advance and maintain the highest possible standards among those engaged in the practice of allergy, and, furthermore, to foster the education of the public. I would interpret these objectives stated in our Constitutions that we as allergists have an obvious obligation in safeguarding the quality of care administered to our patients. Recognizing that the Academy and the other national allergy societies have done much in the past to improve and assure quality care of the public, I believe we must now take an even greater leadership role in this endeavor. With the rapidly changing social and complex medical environment and because we are entering a new era of government control and direction of medical care, I urge that our membership wholeheartedly support the Conjoint Socioeconomic Council, which has as one of its primary goals the assurance of optimal care for our patients. I agree with my predecessor Dr. Charles Reed that we can no longer be a purely education-oriented society, but must become involved in the practical socioeconomic issues of the day as they relate to improving quality care and controlling utilization and costs of health services. Our national societies need to take positions on national health issues, particularly as they relate to standards of care to our patients and to the preservation of the quality and integrity of the education, research, and service programs of our academic medical institutions. We can no longer sit by and be reactive when the changes come, but should have early input and continuing impact on these new challenges to our profession. CONTROVERSIAL
TECHNIQUES
The national societies can be more responsive to public needs related to a matter confronting our specialty that has greatly concerned me and, in general, the leadership of our national societies. The matter I am referring to is the so-called “controversial techniques.” These include such diagnostic and treatment methods as end point titration, provocative testing, sublingual desensitization, and leukocytotoxic testing. As most of you know, these methods have in some sections of our country, and I might add even in some academic settings, been embraced by allergists and otolaryngologists as the primary methodology for diagnosis and treatment of allergic disorders. Local peer review and Professional Standard Review Organizations have set normative standards of medical care, such as was derived from the data laboriously collected by the members of our Medical Services Committee. Third Party payment is increasing and passage of a National Health Insurance plan
164
Siegel
J. ALLERGY CLIN. IMMUNOL. SEPTEMBER 1975
this coming year seems assured. Who is to decide whether certain diagnostic and therapeutic techniques are unproved and controversial4 If we are to protect the public, should we condone compensation for these procedures? Who will be responsible for protecting the patient wherever unproved methodologies are in the “mainstream” or considered “normal community practices.” The present laws applying to malpractice suits suggest that we can no longer abide by the “locality rule.” I believe that we have only to gain by moving away from the criterion of “the average locally qualified allergist,” with its varying standards in different geographic and social situations, to a broad and intelligent specialists’ consensus that is truly responsible to the public. Unfortunately, defining what constitutes quality care for allergic patients is often difficult, as is the case for most chronic diseases with comparable variable etiologic and disease patterns. Furthermore, we must admit that many acceptable forms of clinical therapy have been dcrivcd empirically, without support by adequate controlled investigations. It has been only in the last two decades that advances in our knowledge of the underlying pathophysiologic and immunologic mechanisms involved in allergic reactions have permitted a better understanding and a more rational basis for our present standard diagnostic and treatment modalities. Yet many uncertainties and questions remain, and much more work must be done to elucidate and verify certain allergic practices. Accordingly, though I believe we may be justified in being critical of others for using techniques that have little or no scientific evidence of validity, we must always be open in defining standards for quality care, and never resistant, to changes based on sound scientific investigations. Thus, I believe the time is now ripe for the national societies to assume a more vigorous stance in what we consider optimal treatment for our patients. With this goal in mind, and in keeping with the resolution proposed a number of years ago by Past-President Dr. Francis Lowell that the Academy adopt a policy of providing statements on new or controversial techniques, the Executive Committee has recently authorized an editorial in the JOURXAL concerning the “controversial techniques.” Its major thrust will point out the lack of scientific evidence to support the use of these procedures and the need for the proponents to come forth with appropriate evaluations of their efficacy. RECERTIFICATION
I would now like to turn to another aspect of quality assurance, namely, recertification. A commitment to the maintenance of professional competence by a continuing educational process is not new to medicine. As a matter of fact, it was one of the primary motivating forces that led to the formation of the Academy and to most other professional societies. Your attendance at this meeting, as well as other continuing education courses and refresher seminars, indicates the interest of most allergists in being informed on new developments in medicine. The sponsoring and formation of the American Board of Allergy and Immunology, A Conjoint Board of the American Board of Internal Medicine and the American Board of Pediatrics, which I will henceforth refer to as the
VOLUME 56 NUMBER 3
Quality
assurance
165
ABAI, by all of the national allergy societies to improve the quality of allergy and immunological care to the public and to establish and improve standards for the teaching and practice of allergy and immunology is further evidence of allergists’ concern for education and the maintenance of medical competence. The current impetus for the medical profession to develop methods of recertification stems from the Millis Commission rep0rt.l The preface of the Millis report states the case succinctly : “For any learned profession there are but two alternatives for establishing standards of practice and education. Responsibility can be assumed by society as a whole; operating through government; or can be assumed by the organized profession through voluntary self-discipline. There are no alternatives, for, if the profession does not take the responsibility, society will surely demand that the vacuum be filled and the government assumethe responsibility.” Subsequently, in March of 1973, the membership of the American Board of Medical Specialties (ABMS) adopted in principle “the policy that voluntary periodic recertification of medical specialists will have become a standard policy of all Member Boards.” The ABA1 as well as the Executive Committee of the Academy have also approved this concept. Although all Boards, with the exception of one, agree that recertification is desirable, opinions differ widely as to how their respective recertification programs will be implemented. For example, the American Board of Family Practice recertification is mandatory every six years and can lead to decertification. The American Board of Internal Medicine program is based on an assessment of the candidates’ knowledge of advances in internal medicine over the past few years, Participation in the program is entirely voluntary and failure to perform adequately will not result in decertification. The exact method all Boards will use has not been finalized, but will probably include peer review, participation in continuing educational programs, and an examination. Although our Board has approved the concept of recertification, what form it should take has not been settled. Guidelines from the ABMS have been recommended that for the most part have been adopted by the Board. The essential points of these guidelines are that recertification (1) should be voluntary, (2) should be periodically done at approximately 6-year intervals, and (3) should provide for variable methodologies of recertification. Although it is clear that the primary responsibility for recertification will be the Board’s, it would seem to me appropriate for the Academy, and hopefully in concert the other national societies, to develop an Ad Hoc Committee on Recertification to work with a similar committee already appointed by the Board. This Joint Committee would be directed to study in depth the complex issues involved in recertification and to recommend specific plans and guidelines for implementation of recertification. The experiences gained by other Boards and Specialty Societies should also be evaluated. So that our efforts may be in step with other specialty groups, I would urge that we move forward this year in this endeavor.
166
J. ALLERGY CLIN. IMMUNOL. SEPTEMBER 1975
Siegel
SELF-ASSESSMENT
A related matter to certification, recertification, and maintenance of medical competency is the matter of self-assessment examinations. As most of you know, although the previous self-assessment examination given the American Foundation for Allergic Diseases was good, it had a different format, content outline, and topic emphasis from the Board examination. Thus, examinees were lulled into complacency and did not get a true gauge of t.heir preparedness for taking the Board examination. Consequently, much dissatisfaction concerning the selfassessment examination was expressed in many quarters. In an attempt to make future self-assessment examinations a more realistic evaluation of the examinee’s own strengths and weaknesses and a better appraisal of his competency in those areas considered important by those responsible for certification and recertification, the Board has formed a liaison committee to work with the present Self-Assessment Committee appointed by the presidents of the four national allergy societies. In addition, a comprehensive reference list for the subject matter covered in the forthcoming Board examination to be given next October will be available shortly. We might also profit from the experience of the ABIM and the American College of Physicians’ selfassessment program. A syllabus of important advances in Internal Medicine in the past five years with appropriate references thereto was sent in time for study to those who wished to subscribe to the recertification examination. All questions in the examination pertained to the material included in the syllabus. It is my understanding that this program was highly successful, and I would urge that the Ad Hoc Committee that will be assigned to study the matter of recertification give serious consideration to this educational approach for increasing physician competency and thereby quality assurance to the public. MANPOWER
DISTRIBUTION
Lastly, I would like to mention the health manpower distribution that also concerns quality assurance for the care of the public and therefore must involve the national allergy societies. Although the need for the production of numbers of physicians in relationship to the general population growth is being met, there is also a need for effective geographic and specialty distribution, Ideally, physicians should be evenly accessible to the population in all geographic settings, Primarily because of economic and social conditions, as well as accessiblity to teaching institutions, this has obviously not been the case. The right kind of physician in the right place at the right time is the basis of quality assurance and public accountability in modern medicine. Numerous recommendations have been made to correct maldistribution of general physicians and specialists. The development of increased numbers of primary care physicians-family practitioners, internists, and pediatricianshas been suggested as one solution. A number of pending and recommended Congressional legislative measures are also likely to have an impact on our field of allergy. To name but a few, they include the upgrading and strengthening of the National Health Service Corps by increasing scholarships, by modifying
VOLUME 56 NUMBER 3
Quality
assurance
167
and improving its delivery of services, increasing financial support for primary care residencies, and granting authority to the Secretary and either a specially named advisory commission or the Coordinating Council on Medical Education to correct maldistribution among specialties. Two years ago Past-President Elliott Middleton in his presidential address anticipated health manpower needs as they relate to the field of allergy. One of his thoughtful suggestions was to establish a task force to determine availability of allergy services in different parts of the country and to devise a plan to provide allergy services in deprived areas. The Academy has appointed an ad hoc committee with Dr. Robert Reisman as chairman to delve into this problem and to make recommendations for its resolution. The objectives of this committee will be to provide general background data for discussion with various groups, including legislators, health officers, medical schools, and others concerned with allergic diseases. More specific objectives will concern: (1) establishing the current prevalence of allergic diseases in the United States; (2) estimating their current economic impact; (3) developing a profile of currently available manpower in the United States concerned with allergic diseases; (4) assessingthe gap between care currently available and the trained manpower needed for adequate care; and (5) lastly, estimating the magnitude of funds required to close the gap between needs and available manpower. These objectives are of a large order and probably outside management consultants will be required to fulfill them adequately. Since this is a matter that concerns all allergists, I would suggest that this committee be expanded to include representation from the other national allergy societies. In closing, I would like to say that I have touched on just a few of the urgent and complex social and medical issues the allergist now faces, But it seems essential that allergists, joining in one strong harmonious voice to meet these new challenges, not lose sight of our primary goal, “to better the public welfare.” With the support of its membership and in concert with the other national societies, I feel confident that the Academy will in a conscientious and expeditious manner fulfill this responsibility. REFERENCE 1 Millis, J. S.: The Graduate Education of Physicians, The Report of the Citizens Commission on Graduate Medical Education. Commissioned by the American Medical Association, 1966.
ALLERGY and
CLINICAL
IMMUNOLOGY
VOLUME 56
NUMBER 3
Presidential address Quality Sheldon
assurance C. Siegel,
M.D. Los Angeles, Calif.
At this time each year it has been the duty and the privilege of the retiring president to present an overview of his stewardship and some commentary on the events of the Academy in the year just past. In addition, it has been customary for many of my predecessors to offer some philosophical suggestions as to the future policies, goals, and priorities for the Academy. This afternoon I, too, will touch on the Academy’s past activities and discuss future action that I feel should be considered seriously by the Academy’s leadership. Shortly after I was born, the Association for the Study of Asthma and Allied Conditions and the American Association for the Study of Allergy were formed to promote better understanding of the causes of allergy and to improve patient care. Twenty-one years later these two societies combined to become the American Academy of Allergy. Although I have not been a member of the Academy for the entire 31 years of its existence, I have been privileged, as a pediatrician might say, to observe its growth and maturation into the strong specialty organization it is today, one that has more than fulfilled the object of its formation as stated in our constitution. First I would like to focus this afternoon on one of the primary purposes of the Academy as stated in our constitution, namely, “to encourage union and cooperation among those engaged in this field.” During the past several years of my service on the Executive Committee of the Academy, I have heard the leadership express on numerous occasions the desirability of the major national allergy societies merging into one National Allergy Society. The three immediate Presented at the Thirty-first Annual Meeting of the American Academy of Diego, Calif., Feb. 15-19, 1975. Reprint requests to: Dr. Sheldon C. Siegel, 8540 S. Sepulveda Blvd., Los Angeles, Vol.
Allergy, Calif.
San 90045.
56, No. 3, pp. 161-167
162
Siegel
J. ALLERGY CLIN. IMMUNOL. SEPTEMBER 1975
Past-Presidents alluded to the merits of this move in their presidental addresses. In addition, the Delphi Survey which my predecessor, Dr. Charles Reed, had the wisdom and foresight to implement as a means of learning our membership’s desires and needs, as well as a recent survey by the American Association for Clinical Allergy and Immunology, clearly indicated that the majority of t,hose surveyed favored an amalgamation of the national societies. I might add that during my term of office I received several letters from local, state, and regional allergy societies also urging merger. As your President I have participated in some of the recent merger meetings. I am pleased to report that considerable progress has been made in our joint efforts to achieve this goal. As many of you already know, a combined meeting of the Academy with the College, the Association, and the American Association of Certified Allergists is scheduled for 1976 in New York. More importantly, it, has been agreed by the leadership of all four societies that we begin to draft a Constitution and Bylaws for an amalgamated society. The cooperative spirit and working rapport of the Medical Services Committee’s and Conjoint Socioeconomic Council’s members have been a heartening indication that we can work together. Nevertheless, some minor roadblocks are evident, such as concern expressed regarding adequate representation of the clinician versus the academician, the pediatrician versus the internist, and certified versus noncertified allergists. I feel that those charged with resolving the details entailed by a merger can resolve these problems, and I urge that we move forward to eliminate overlapping membership and activities so that allergy can speak with one clear, strong, and harmonious voice. I will now turn to the major theme of my address, the subject of the quality aS.surance of medical care to our patients, i.e., our accountability to the public. This subject includes the so-called controversial techniques in allergy, recertification, self-assessment, and manpower distribution. The medical profession in the past has traditionally enjoyed the confidence of the public and independence from regulation because it professed an ability to promote and guarantee the quality of its members’ performance. Indeed, a number of mechanisms by which the profession attempted to fulfill this responsibility were developed over the years. These include the Hippocratic oath; state licensure; national board and specialty examinations; accreditation of training programs and hospitals ; research on effectiveness and control of the use of drugs, surgery, and other forms of therapy; continuing education through meetings and publications of medical journals; hospital committees such as those concerned with review of the pathology of tissues, infections, etc.; rounds in hospitals; and public mechanisms of grievances in courts of law through malpractice suits. More recently, utilization committees to monitor length of hospital stays and peer review have been developed to help control costs as well as to improve quality of care. Despite these measures, the public has become dissatisfied and has sought through legislation other means of regulating the quality of health care delivery. Several factors undoubtedly have contributed to the public’s demand for greater accountability of the medical profession. These include: (1) the rising cost of
Quality
VOLUME 56 NUMBER 3
assurance
163
medical care (though the physicians’ fees have contributed little to these rising costs) ; (2) third party payment of these costs by public and private insurance carriers, thereby giving them visibility and the payers leverage to control costs; (3) decreased ease of access to medical care with a perceived loss of personal or humanistic aspect of quality care; (4) increased specialization and fewer primary care physicians ; and (5) increased education of the public generating a greater concern for quality by the patient as well as the physician. The Constitutions of both the Academy and the College, and I am certain also the Association’s and Certified Allergists’ Constitutions, clearly indicate that one of the objects of these societies should be to advance and maintain the highest possible standards among those engaged in the practice of allergy, and, furthermore, to foster the education of the public. I would interpret these objectives stated in our Constitutions that we as allergists have an obvious obligation in safeguarding the quality of care administered to our patients. Recognizing that the Academy and the other national allergy societies have done much in the past to improve and assure quality care of the public, I believe we must now take an even greater leadership role in this endeavor. With the rapidly changing social and complex medical environment and because we are entering a new era of government control and direction of medical care, I urge that our membership wholeheartedly support the Conjoint Socioeconomic Council, which has as one of its primary goals the assurance of optimal care for our patients. I agree with my predecessor Dr. Charles Reed that we can no longer be a purely education-oriented society, but must become involved in the practical socioeconomic issues of the day as they relate to improving quality care and controlling utilization and costs of health services. Our national societies need to take positions on national health issues, particularly as they relate to standards of care to our patients and to the preservation of the quality and integrity of the education, research, and service programs of our academic medical institutions. We can no longer sit by and be reactive when the changes come, but should have early input and continuing impact on these new challenges to our profession. CONTROVERSIAL
TECHNIQUES
The national societies can be more responsive to public needs related to a matter confronting our specialty that has greatly concerned me and, in general, the leadership of our national societies. The matter I am referring to is the so-called “controversial techniques.” These include such diagnostic and treatment methods as end point titration, provocative testing, sublingual desensitization, and leukocytotoxic testing. As most of you know, these methods have in some sections of our country, and I might add even in some academic settings, been embraced by allergists and otolaryngologists as the primary methodology for diagnosis and treatment of allergic disorders. Local peer review and Professional Standard Review Organizations have set normative standards of medical care, such as was derived from the data laboriously collected by the members of our Medical Services Committee. Third Party payment is increasing and passage of a National Health Insurance plan
164
Siegel
J. ALLERGY CLIN. IMMUNOL. SEPTEMBER 1975
this coming year seems assured. Who is to decide whether certain diagnostic and therapeutic techniques are unproved and controversial4 If we are to protect the public, should we condone compensation for these procedures? Who will be responsible for protecting the patient wherever unproved methodologies are in the “mainstream” or considered “normal community practices.” The present laws applying to malpractice suits suggest that we can no longer abide by the “locality rule.” I believe that we have only to gain by moving away from the criterion of “the average locally qualified allergist,” with its varying standards in different geographic and social situations, to a broad and intelligent specialists’ consensus that is truly responsible to the public. Unfortunately, defining what constitutes quality care for allergic patients is often difficult, as is the case for most chronic diseases with comparable variable etiologic and disease patterns. Furthermore, we must admit that many acceptable forms of clinical therapy have been dcrivcd empirically, without support by adequate controlled investigations. It has been only in the last two decades that advances in our knowledge of the underlying pathophysiologic and immunologic mechanisms involved in allergic reactions have permitted a better understanding and a more rational basis for our present standard diagnostic and treatment modalities. Yet many uncertainties and questions remain, and much more work must be done to elucidate and verify certain allergic practices. Accordingly, though I believe we may be justified in being critical of others for using techniques that have little or no scientific evidence of validity, we must always be open in defining standards for quality care, and never resistant, to changes based on sound scientific investigations. Thus, I believe the time is now ripe for the national societies to assume a more vigorous stance in what we consider optimal treatment for our patients. With this goal in mind, and in keeping with the resolution proposed a number of years ago by Past-President Dr. Francis Lowell that the Academy adopt a policy of providing statements on new or controversial techniques, the Executive Committee has recently authorized an editorial in the JOURXAL concerning the “controversial techniques.” Its major thrust will point out the lack of scientific evidence to support the use of these procedures and the need for the proponents to come forth with appropriate evaluations of their efficacy. RECERTIFICATION
I would now like to turn to another aspect of quality assurance, namely, recertification. A commitment to the maintenance of professional competence by a continuing educational process is not new to medicine. As a matter of fact, it was one of the primary motivating forces that led to the formation of the Academy and to most other professional societies. Your attendance at this meeting, as well as other continuing education courses and refresher seminars, indicates the interest of most allergists in being informed on new developments in medicine. The sponsoring and formation of the American Board of Allergy and Immunology, A Conjoint Board of the American Board of Internal Medicine and the American Board of Pediatrics, which I will henceforth refer to as the
VOLUME 56 NUMBER 3
Quality
assurance
165
ABAI, by all of the national allergy societies to improve the quality of allergy and immunological care to the public and to establish and improve standards for the teaching and practice of allergy and immunology is further evidence of allergists’ concern for education and the maintenance of medical competence. The current impetus for the medical profession to develop methods of recertification stems from the Millis Commission rep0rt.l The preface of the Millis report states the case succinctly : “For any learned profession there are but two alternatives for establishing standards of practice and education. Responsibility can be assumed by society as a whole; operating through government; or can be assumed by the organized profession through voluntary self-discipline. There are no alternatives, for, if the profession does not take the responsibility, society will surely demand that the vacuum be filled and the government assumethe responsibility.” Subsequently, in March of 1973, the membership of the American Board of Medical Specialties (ABMS) adopted in principle “the policy that voluntary periodic recertification of medical specialists will have become a standard policy of all Member Boards.” The ABA1 as well as the Executive Committee of the Academy have also approved this concept. Although all Boards, with the exception of one, agree that recertification is desirable, opinions differ widely as to how their respective recertification programs will be implemented. For example, the American Board of Family Practice recertification is mandatory every six years and can lead to decertification. The American Board of Internal Medicine program is based on an assessment of the candidates’ knowledge of advances in internal medicine over the past few years, Participation in the program is entirely voluntary and failure to perform adequately will not result in decertification. The exact method all Boards will use has not been finalized, but will probably include peer review, participation in continuing educational programs, and an examination. Although our Board has approved the concept of recertification, what form it should take has not been settled. Guidelines from the ABMS have been recommended that for the most part have been adopted by the Board. The essential points of these guidelines are that recertification (1) should be voluntary, (2) should be periodically done at approximately 6-year intervals, and (3) should provide for variable methodologies of recertification. Although it is clear that the primary responsibility for recertification will be the Board’s, it would seem to me appropriate for the Academy, and hopefully in concert the other national societies, to develop an Ad Hoc Committee on Recertification to work with a similar committee already appointed by the Board. This Joint Committee would be directed to study in depth the complex issues involved in recertification and to recommend specific plans and guidelines for implementation of recertification. The experiences gained by other Boards and Specialty Societies should also be evaluated. So that our efforts may be in step with other specialty groups, I would urge that we move forward this year in this endeavor.
166
J. ALLERGY CLIN. IMMUNOL. SEPTEMBER 1975
Siegel
SELF-ASSESSMENT
A related matter to certification, recertification, and maintenance of medical competency is the matter of self-assessment examinations. As most of you know, although the previous self-assessment examination given the American Foundation for Allergic Diseases was good, it had a different format, content outline, and topic emphasis from the Board examination. Thus, examinees were lulled into complacency and did not get a true gauge of t.heir preparedness for taking the Board examination. Consequently, much dissatisfaction concerning the selfassessment examination was expressed in many quarters. In an attempt to make future self-assessment examinations a more realistic evaluation of the examinee’s own strengths and weaknesses and a better appraisal of his competency in those areas considered important by those responsible for certification and recertification, the Board has formed a liaison committee to work with the present Self-Assessment Committee appointed by the presidents of the four national allergy societies. In addition, a comprehensive reference list for the subject matter covered in the forthcoming Board examination to be given next October will be available shortly. We might also profit from the experience of the ABIM and the American College of Physicians’ selfassessment program. A syllabus of important advances in Internal Medicine in the past five years with appropriate references thereto was sent in time for study to those who wished to subscribe to the recertification examination. All questions in the examination pertained to the material included in the syllabus. It is my understanding that this program was highly successful, and I would urge that the Ad Hoc Committee that will be assigned to study the matter of recertification give serious consideration to this educational approach for increasing physician competency and thereby quality assurance to the public. MANPOWER
DISTRIBUTION
Lastly, I would like to mention the health manpower distribution that also concerns quality assurance for the care of the public and therefore must involve the national allergy societies. Although the need for the production of numbers of physicians in relationship to the general population growth is being met, there is also a need for effective geographic and specialty distribution, Ideally, physicians should be evenly accessible to the population in all geographic settings, Primarily because of economic and social conditions, as well as accessiblity to teaching institutions, this has obviously not been the case. The right kind of physician in the right place at the right time is the basis of quality assurance and public accountability in modern medicine. Numerous recommendations have been made to correct maldistribution of general physicians and specialists. The development of increased numbers of primary care physicians-family practitioners, internists, and pediatricianshas been suggested as one solution. A number of pending and recommended Congressional legislative measures are also likely to have an impact on our field of allergy. To name but a few, they include the upgrading and strengthening of the National Health Service Corps by increasing scholarships, by modifying
VOLUME 56 NUMBER 3
Quality
assurance
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and improving its delivery of services, increasing financial support for primary care residencies, and granting authority to the Secretary and either a specially named advisory commission or the Coordinating Council on Medical Education to correct maldistribution among specialties. Two years ago Past-President Elliott Middleton in his presidential address anticipated health manpower needs as they relate to the field of allergy. One of his thoughtful suggestions was to establish a task force to determine availability of allergy services in different parts of the country and to devise a plan to provide allergy services in deprived areas. The Academy has appointed an ad hoc committee with Dr. Robert Reisman as chairman to delve into this problem and to make recommendations for its resolution. The objectives of this committee will be to provide general background data for discussion with various groups, including legislators, health officers, medical schools, and others concerned with allergic diseases. More specific objectives will concern: (1) establishing the current prevalence of allergic diseases in the United States; (2) estimating their current economic impact; (3) developing a profile of currently available manpower in the United States concerned with allergic diseases; (4) assessingthe gap between care currently available and the trained manpower needed for adequate care; and (5) lastly, estimating the magnitude of funds required to close the gap between needs and available manpower. These objectives are of a large order and probably outside management consultants will be required to fulfill them adequately. Since this is a matter that concerns all allergists, I would suggest that this committee be expanded to include representation from the other national allergy societies. In closing, I would like to say that I have touched on just a few of the urgent and complex social and medical issues the allergist now faces, But it seems essential that allergists, joining in one strong harmonious voice to meet these new challenges, not lose sight of our primary goal, “to better the public welfare.” With the support of its membership and in concert with the other national societies, I feel confident that the Academy will in a conscientious and expeditious manner fulfill this responsibility. REFERENCE 1 Millis, J. S.: The Graduate Education of Physicians, The Report of the Citizens Commission on Graduate Medical Education. Commissioned by the American Medical Association, 1966.
