With pediatric otolaryngology continuing to evolve, the American Society of Pediatric Otolaryngology (ASPO) is exploring subcertification in the field, saying it is specialized enough that it deserves recognition. The society has approached the American Board of Otolaryngology (ABOto) about the possibility and is working on defining the knowledge base that would be required for a physician to become subcertified as a pediatric otolaryngologist.
But previous subcertification processes have shown that it can be a sensitive topic, and the ABOto is emphasizing the importance of keeping the lines of communication open as the process goes forward.
ASPO President-Elect Richard Rosenfeld, MD, MPH, who is chairing the effort for pediatric subcertification, said the purpose is to give proper recognition for advanced knowledge and isn’t meant to erode general otolaryngologists’ share of pediatric cases.
“It recognizes it as a distinct body of knowledge and experience within the broader discipline of otolaryngology—many pediatric otolaryngologists have advanced training and experience beyond what you get in residency,” Dr. Rosenfeld said. “We absolutely want to avoid at all cost any suggestion of making this a surgical qualification where you have to do XYZ number of tonsillectomies.”
Subcertification, in general, can be case-based, determined by a physician’s performance of certain types of procedures or by a physician’s mastery of a certain body of knowledge. Subcertification for pediatric otolaryngology would fall into the latter category, Dr. Rosenfeld said. And it would most likely be a written exam, with or without an oral component. He anticipates the completion of the subcertification process some time in the next two to five years but said there is no rush.
“It’s resurfaced that people want this designation— the question is why.”—Gerard Healy, MD
The Process
To become subcertified, a doctor would have to complete an accredited fellowship in pediatric otolaryngology and pass an exam. Dr. Rosenfeld said the exam would include areas of additional knowledge beyond basic knowledge learned in regular residency, such as clinical genetics, developmental anatomy, child development and growth, advanced reconstructive surgery of the pediatric airway, management of foreign bodies and foreign material ingestion in infants and children, neoplasms of the head and neck in children and other areas.
But there would be an alternate pathway for about seven or eight years, during which physicians who hold a primary otolaryngology certificate could qualify for pediatric subcertification without an accredited fellowship.
Dr. Rosenfeld said the society is trying to avoid creating division within the field of otolaryngology.
“The goal is not to be exclusionary,” he said. “We’re really bending over backward to emphasize that our purpose is not to steal tonsillectomies” and other procedures commonly performed in children by general otolaryngologists. He added, however, that the increasing number of accredited fellowships for pediatric otolaryngology makes this a logical time to move forward.
Lessons from the Past
Robert Miller, MD, executive director of the ABOto, noted that the neurotology subcertification process had its share of controversy. When subcertification in otology/neurotology was explored, otolaryngologists who practice otology as part of their overall practice expressed concern that the name of the subspecialty would negatively affect them. Based on these comments, the term “otology” was dropped. After the subcertification process was officially announced and after discussions for many years with the leadership of the affected societies, some doctors were still not happy, he said.
“There was a very small but vocal opposition that fought it a bit,” said Dr. Miller, who is also editor of ENT Today. “The leadership was very genuine in their interest, but I don’t know to what extent their membership knew what was going on,” he said. “Part of the opposition had to do with some physicians just not wanting to take the exam.”
Based on this experience, the ABOto learned the importance of communicating directly with everyone affected, not just the society leaders, he added.
The ABOto went about the process for subcertification in sleep medicine differently, Dr. Miller said. “…We did e-mails, we did editorials, we did questionnaires, basically saying, ‘Here’s what we’re thinking about doing. What are the pros and cons?’” he said. “It’s just true with anything in life, communication is just critical.”
Dr. Miller said pediatric otolaryngology is “a logical subcertification. It is clearly an identified subspecialty with ACGME-accredited fellowships.”
Defining “the Dura”
The main hurdle, Dr. Miller said, is defining the subspecialty of pediatric otolaryngology. For neurotology, the line was drawn fairly simply: For the most part, procedures inside the dura belong to neurotology, and those that don’t belong to otology.
“How do you define the dura for pediatric otolaryngology?” Dr. Miller said. “That is the challenge for otolaryngology.”
Dr. Miller said it’s important to protect the value of the primary otolaryngology certificate. “The otolaryngology world is somewhat sensitized, because some people have gone out and advertised that they’re a pediatric otolaryngologist and marketed themselves as … the only ones who can operate on children,” he said.
Ron Kuppersmith, MD, president of the American Academy of Otolaryngology-Head and Neck Surgery, said pediatric otolaryngology subcertification could be a good thing if done correctly.
The range of pediatric cases varies widely among otolaryngologists, but for many, a third to half of their cases, or even more, could be pediatric, Dr. Kuppersmith estimated.
“I think the important thing is to continue the conversation and to hopefully come up with something everybody can agree to,” Dr. Kuppersmith said. “I commend ASPO and Rich Rosenfeld and others who have tried to engage the entire specialty on what is the right way to do this.”
Gerald Healy, MD, professor of otology and laryngology at Harvard Medical School and former president of the American College of Surgeons, said he is in favor of subcertification, as long as it is narrowly defined. As an example, he pointed out that Charles Bluestone, MD, came up with a good general definition of pediatric otolaryngology more than 30 years ago when he said it should be training individuals to care for “common things in unusual children and uncommon things in healthy children.”
Dr. Healy wondered about the motivation for the interest in subcertification at this point in time. “It’s resurfaced that people want this designation—the question is why?” he said. “Is it truly that a group of people want to improve care and make sure that physicians who claim to be pediatric specialists have the credentials and knowledge to do this, or is there another economic agenda?”
Dr. Healy said subcertification should be reserved for those “who have a very specific type of practice that the board would carefully outline and define. That way,” he said, “you avoid giving a specific designation to fellowship-trained physicians who then go to a community and do routine pediatric care.”
“As with any process, there may be some who seek certification for personal gain or a competitive advantage, but I am sure the vast majority will not.”—Richard Rosenfeld, MD, MPH
The Business of Subcertification
Harold Pillsbury, MD, chair of the otolaryngology-head and neck surgery department at the University of North Carolina Medical School and former president of the American Board of Otolaryngology, said a board-recognized subcertification in pediatric otolaryngology would be a reasonable step.
He dismissed concerns about those with more expertise in pediatrics siphoning business from other otolaryngologists, because it’s happening already. “That horse already left the barn,” he said.
Dr. Rosenfeld acknowledged he could not predict whether some otolaryngologists would use the subcertification as a way to attract more basic pediatric cases but said it should not be a problem for other otolaryngologists. There are only several hundred otolaryngologists who might be eligible for pediatric subcertification, compared with over 10,000 who have a primary certificate, he said. Only about 25 additional fellowship-trained pediatric otolaryngologists emerge each year, a number too small to impact the caseload of general otolaryngologists, he added.
“As with any process, there may be some who seek subcertification for personal gain or a competitive advantage, but I am sure the vast majority will not,” Dr. Rosenfeld said. Overall, subcertification should benefit patients, clinicians and the specialty by acknowledging the richness of the discipline and by appropriately recognizing individuals with advanced training, he said.
Dr. Rosenfeld expects the subcertification to move forward eventually; he just isn’t sure when.
“It’s basically inevitable, in the nature of a subspecialty, to move from accreditation to subcertification,” he said. “It’s the natural evolution of defining a body of knowledge in a subspecialty area. And the only thing that slows it down is politics, generally, which can be substantial at times.”
The Maturation of Pediatric Otolaryngology
1919
Surgeon Herbert Coe, MD, dedicates his practice solely to the care of children. D. Crosby Greene reports that the Department of Diseases of the Throat at Children’s Hospital Boston has performed 2,028 operations.
1930s
Dr. Coe petitions the American College of Surgeons (ACS) for a separate pediatric surgery section. The ACS denies his petition out of fear that it would splinter an already fragmenting field.
1940
Dr. Coe approaches the American Academy of Pediatrics (AAP) with his idea of establishing a special section for pediatric surgery. The request is denied.
1948
Resistance to Dr. Coe’s idea is softened and he is asked to serve as first chairman of the Surgical Section of the AAP.
1950s
Three prominent full-time pediatric otolaryngologists come to the forefront in North America: Seymour Cohen in Los Angeles, Blair Fearon in Toronto and Charles Ferguson in Boston.
1965
Stephen Gans and C. Everett Koop establish the Journal of Pediatric Surgery.
1966
H. William Clatworthy organizes the Committee on Postgraduate Education and Residency Training with the Surgical Section of the AAP to define and standardize training in pediatric surgery.
1968
Sylvan Stool and Marvin Culbertson, Jr., post a notice for an informal gathering of those interested in pediatric otolaryngology, to be held at the AAP meeting. About 20 otolaryngologists and audiologists attend.
1969
The ACS forms an advisory council for pediatric surgery.
1970
The American Pediatric Surgical Association (APSA) is formed.
1972
After two prior rejections, the American Board of Surgery (ABS) accepts a petition from C. Everett Koop to approve a written exam that would grant a Certificate of Competence in Pediatric Surgery.
1973
The AAP pediatric otolaryngology group formalizes as the Society for Ear, Nose, and Throat Advances in Children (SENTAC).
1975
Charles Bluestone and Sylvan Stool create the first formal pediatric otolaryngology fellowship at the Children’s Hospital of Pittsburgh.
1985
Fifty-six otolaryngologists from the U.S. and Canada meet in Bermuda and decide to form the American Society of Pediatric Otolaryngology (ASPO).
1992
The American Board of Otolaryngology (ABOto) receives approval from the American Board of Medical Specialties to create a Certificate of Added Qualification (CAQ) in Pediatric Otolaryngology. The ABOto has not, to date, offered such specialty certification, however.
1995
The otolaryngology residency review committee of the Accreditation Council for Graduate Medical Education (ACGME) develops criteria for accrediting pediatric fellowships.
2001
The ABS creates a Pediatric Surgery Board.
Source: Adapted from Cunningham MJ, Lin AC. Pediatric otolaryngology: The maturation of a pediatric surgical subspecialty [published online ahead of print June 18, 2010]. Laryngoscope.