INTRODUCTION

The use of physician specialization to measure the quality of care provided by individual physicians represents a structural approach to measuring quality. Like other structural indicators, physician specialization is often used to assess quality on the assumption that certain characteristics of physicians may lead to better performance, which in turn may bring about better patient outcomes.

A person who wants to practice medicine and surgery legally in a State must obtain a license or certification of qualification from the State Board of Medical Examiners or other designated agency (70 Corpus Juris Sec. 12). Although the requirements for medical licensure vary among States, in general, a person must be a graduate of a medical school accredited by the Liaison Committee on Medical Education,1 have completed 1 year of residency training in a program approved by the Accreditation Council for Graduate Medical Education,2 and have passed the Federation Licensing Examination sponsored by the Federation of State Medical Boards (470).3 With a medical license from a given State, a physician can practice medicine in that State, in whatever specialty area he or she chooses.

Some physicians, in addition to having general medical training, may have received training in

'The Liaison Committee on Medical Education is the official accrediting body for educational programs leading to the M.D. degree and is listed for this purpose by the U.S. Secretary of Education and recognized by the Council of Postsecondary Accreditation. The committee consists primarily of members from the Council on Medical Education of the American Medical Association and the Association of American Medical Colleges (157).

'The Accreditation Council for Graduate Medical Education is composed primarily of members from the American Board of Medical Specialties, the American Hospital Association, the American Medical Association, the Association of American Medical Colleges, and the Council of Medical Specialty Societies. Louisiana, Missouri, Ohio, and Tennessee do not require any residency training for licensure. Connecticut, Guam, Maine, New Hampshire, and Washington require completion of 2 years of residency training, and Nevada requires 3 years (470).

'Most States also recognize certifying examinations of the National Board of Medical Examiners to license physicians (513).

a particular specialty area. Such training is not required for medical licensure, but physicians who have specialty training may be eligible to become certified by a specialty board. Even if they have not received specialty training or been boardcertified, however, physicians may designate themselves specialists.

Two major operational definitions of physician specialization have been used:

• certification by a specialty board, and ⚫ the fact that a physician is practicing in his or her area of specialty training.

Many organizations certify physicians. The American Board of Medical Specialties and the American Medical Association (AMA) officially recognize the 23 specialty boards shown in table 10-1. These boards certify 63.5 percent of the physicians practicing in the United States (365). The Advisory Board for Osteopathic Specialists recognizes the 17 osteopathic specialty boards shown in table 10-2. All of the 40 specialty boards recognized either by the American Board of Medical Specialties or by the Advisory Board for Osteopathic Specialists require physicians to complete a specified amount of training and a certain set of requirements and to pass an examination. In addition to these boards, there exist at least 69 specialty boards not recognized by the American Board of Medical Specialties or the Advisory Board for Osteopathic Specialists (see table 10-3).

'Depending on the specialty, a physician may complete 1 to 5 years of additional training in a specialty area. The American Board of Orthopaedic Surgery requires 5 years of additional specialty training for a physician to become board certified, while the American Board of Colon and Rectal Surgery requires only 1 year of additional training. The term "board eligible" is sometimes used to describe a physician who has completed the necessary training and other predetermined requirements to become board certified, but has not taken the formal examination offered by the board. Because of continuing confusion about the term board eligible, however, the American Board of Medical Specialties' policy has disavowed the use of the term. The American Board of Medical Specialties has declared that the term has been given "such diverse meanings by different agencies that it has lost its usefulness as an indicator of a physician's progress toward certification by a specialty board" (18).

Hand surgery

Surgical critical care

General vascular surgery