Point/Counterpoint— Physician Certification: A Positive or Negative? Part 2

Credentialing surgical expertise is an admirable goal, except when it fails to measure any real qualification. Consider the American Board of Eye Surgery (ABES), which in my opinion does not seek, approximate, or attain valid surgical credentialing. I was “certified” by the ABES in 1998 at the encouragement of one of the surgeons who was instrumental in its foundation. That experience gave me firsthand knowledge about the philosophy behind the organization's origin and of the validity of its testing methods. I believe the ABES has a misbegotten birth, no altruistic purpose in existence, no valid criteria for certification, and a dishonorable “pay-your-money-get-your-diploma” track record.

AN IGNOMINIOUS BIRTH
The ABES was created as a marketing tool, and its certification was intended as a stigma to differentiate between the small-incision/phacoemulsification and large-incision/ECCE surgeons. The founders sought to use this seal of approval as a device to capture local cataract markets.

During the expected expansion of managed care in the 1990s, these high-volume surgeons hoped to secure the profitable cataract niche. They would use ABES certification to justify their selection as preferred surgical providers by HMOs. Unfortunately, they failed to recognize that managed care organizations aren't interested in patients who require surgery or in surgeons who frequently perform it. From a managed-care viewpoint, these high-utilization, high-cost physicians and patients merely drain profits. They are the exact clients HMOs don't want. Moreover, HMOs recognized that the sole purpose of the mega-surgeon practices was to attract and screen thousands of patients in order to generate surgical procedures and fees.

An ophthalmic practice was nothing more than a specialized profit factory, and any actual patient benefit was merely a pleasant byproduct. Dazzled by their 50-cases-a-day surgical volumes, these self-imagined “efficient” practices were and continue to be financial disasters, maintaining at least 70% overhead on average. Practices such as these proved to be the last providers of choice for managed care.

The founding effort of the ABES failed. Its certification effort affords surgeons no professional prestige and little market advantage. Phacoemulsification has developed into cataract surgeons' primary technique, and it features no definable skill or technical differences between credentialed and noncredentialed surgeons. The ABES organization is left with no mission, no direction, and no purpose for existence.

AN INCAPABLE EXISTENCE
The two-step methodology of surgical credentialing by the ABES is without value and does not identify superior surgeons. By design, failure to achieve this certification is basically impossible. First, the surgeon-applicant collects and submits data from any 50 consecutive cases he has performed. Naturally, he selects a series of cases with the most favorable outcomes. If the American Board of Ophthalmology followed an equivalent certification method, it would allow applicants to select and answer 50 questions of their choice! Who could fail such a test?

Second, ABES certification requires a $2,000 payment in travel, lodging, and meal expenses for an ABES official. Take him out to dinner! Buy him lunch! Pick up the bar tab! What purpose could the required videotape serve? Could the ABES reject an applicant if he lost vitreous, made a poor wound, or induced an expulsive hemorrhage? Short of blatant and staggering malpractice, is there anything on a videotape of three cases that could be used to objectively and unequivocally reject an applicant? Statistically, reviewing and evaluating an applicant based upon three nonrandom cases is absurd. The sample size and method of selection (the surgeon's choice) precludes any validity.

The ABES credentialing process is subjective and therefore invalid. No objective standards for cataract surgery techniques, outcomes, and complication rates exist. Could a surgeon performing ECCE be certified as an expert? Yes. Could a surgeon submitting 10-minute clear-cornea cases be approved? Yes. Twenty-minute cases? Yes. How about a 1% rate of vitreous loss? How about a 50% rate of vitreous loss? What is the “expert” choice in anesthesia: retrobulbar, peribulbar, topical, intracameral, none? What is the “expert” incision: scleral, near clear, or clear corneal? Does he use metal or diamond keratomes? ECCE? Phacoemulsification? Sutures? Do the experts crack, flip, divide and conquer, chop, choo-choo chop, or stop and chop? Which lenses do the experts use: acrylic, silicone, plate, PMMA, hydrogel? Insertion by forceps or by shooter? There is no consensus in ophthalmic surgery defining which techniques are superior in a given surgeon's hands. How can one judge an applicant-surgeon without any recognized standards of surgery to apply?

The ABES refuses to release the percentages of applicants who are passed and failed for certification. I suspect the rate approaches zero. Financially, the Board cannot afford a reputation for turning an applicant down after he spends thousands of dollars; no one would apply. More importantly, the ABES could not afford to face lawsuits by angry, rejected applicants. In the absence of rigorous and objective standards for failure, the rejections would be indefensible in court.

SEEKING MEANINGFUL CREDENTIALING
ABES certification is in no way a measure of expertise. If 100% of applicants pass, certification is either meaningless or unnecessary. If more than 50% of applying eye surgeons pass, the organization does no more than certify mediocrity. In effect, the Board is essentially awarding a degree to anyone who sends in enough cereal-box tops. We already have a system to certify surgical competence: a recognized ophthalmic residency with 3 years of intimate training, observation, supervision, and evaluation by prestigious ophthalmic professors with decades of experience.

Someday, perhaps, a meaningful form of surgical credentialing will be developed.
Mark Johnson MD, FACS, is in private practice in Venice, Florida. He may be reached at (941) 408-1700; onebluetree@netscape.net.