The development of new medical specialties

The development of new medical specialties has been an essential feature of the growth of modern scientific medicine. The time has long since passed when any individual could master the entire field of medical knowledge and practice. Perhaps Hermann Boerhaave of Leyden was the last of the great medical polymaths, but the course of medical education and practice since the early part of the eighteenth century has been one of progressive and inexorable specialization. For the most part, the medical specialties have developed in concert with scientific advances in a special area, although the history of specialization dates all the way back to ancient Egyptian practices, in which “one physician is confined to the study and management of one disease.” Sir William Osler recognized the necessity of specialization, but expressed his concern about the dangers of excessive fragmentation of the specialties themselves. “The incessant concentration of thought upon one subject, however interesting, tethers a man’s mind in a narrow field.” In the early part of the twentieth century, medical specialization was proceeding rapidly, but the educational systems were not in place to provide proper education and training. Organizations such as the American College of Surgeons and other specialty societies were formed in part to provide the educational basis for the development of special knowledge and skills. Nevertheless, physicians were able to practice in medical specialties without adequate training, and there was no assurance to the public that a physician had the requisite knowledge, training, and skills to practice safely in a specialty area. In his Presidential Address to the American Academy of Ophthalmology and Otolaryngology in 1908, Derrick T. Vail proposed the concept of the organization of a specialty board to set the standards for training in ophthalmology and to certify to the public that a physician had been found competent to practice in that specialty. “After a sufficiently long time of service in an ophthalmic institution in America or abroad, he should be permitted to appear before a proper examining board, similar to any State Board of Examination and Registration, for examination, and if he is found competent let him then be permitted and licensed to practice ophthalmology.” The American Board for Ophthalmic Examinations was created in 1917 to “arrange, control, and supervise examinations to test the preparation of those who design to enter on the special or exclusive practice of ophthalmology.” The second specialty Board, in Otolaryngology, was founded in 1924. The American Board of Surgery was a relative latecomer to the Board system, being organized in 1937. There are now 24 recognized specialty Boards, all of which are separately incorporated and financially independent organizations. The function of the Boards is to “provide assurance to the public that a physician specialist certified by a member Board of the American Board of Medical Specialties (ABMS) has successfully completed an educational program and an evaluation process which includes an examination designed to assess the knowledge, skills, and experience required to provide quality patient care in that specialty.” The American Board of Medical Specialties grew out of the Advisory Board for Medical Specialties, which was formed in 1933 for the purpose of providing coordination and advice to the member Boards, and to assume jurisdiction over those common processes expressly delegated to it by the participating Boards. The Advisory Council agreed not to interfere with the autonomy of any of the represented examining Boards. The Advisory Board became the American Board of Medical Specialties (ABMS) in 1970. One of the functions of the ABMS is to determine when a new or developing specialty can be recognized as such, and have its own examining Board. This function is delegated to the Liaison Committee for Specialty Boards (LCSB), which is a committee jointly formed by the ABMS and the Council on Medical Education (CME) of the American Medical Association (AMA). The ABMS and the AMA each appoint 4 voting members, under the chairmanship of the Chairman of the CME. The LCSB receives and evaluates applications for the formation of a new board, and it holds hearings. If the LCSB approves the application for a new Board, that recommendation is forwarded to the ABMS and the CME of the AMA. Each of these latter organizations must then act by a 2/3 majority in order to approve a new Board. If an application is not approved, it may be resubmitted after 12 months. Alternatively, the applicant may appeal the decision to an appeals committee, which makes a recommendation back to the LCSB. The LCSB then takes a final action. Correspondence: Inquiries to Paul Friedmann, MD, Department of Surgery, W3, Baystate Medical Center, Springfield, MA 01199; fax: (413) 794-0300; e-mail: paul.friedmann@bhs.org