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Medical Board of California: ABCS is not equivalent to ABMS board

It took less than 30 seconds for years of deliberation and debate to come to an end in California, as the Medical Board of California (MBC) denied – by unanimous vote – the American Board of Cosmetic Surgeons' (ABCS) request to advertise as "board-certified" cosmetic surgeons.

The swiftness of the decision at the Dec. 18 hearing stood in stark contrast to the exhaustive process that preceded it. That process was an examination of the core question: Is ABCS certification and the training provided in its required American Academy of Cosmetic Surgery (AACS) fellowships equivalent to ABMS certification and the ACGME training that buttresses it? The answer – through extensive analysis by an independent medical reviewer hired by the MBC – was a resounding "no."

"What I'm most pleased about is the thoroughness and conclusiveness of this process," says ASPS President Alan Matarasso, MD. "After the depth of review that was done and discussion that was heard, you cannot doubt the medical board's assessment."

California Society of Plastic Surgeons (CSPS) President Michael Wong, MD, also lauded the exhaustive investigative work by the MBC, and added that its decision clearly was the right one. "I'm very pleased," he tells PSN.

A tall stack of paper

The MBC performed a thorough review of ABCS's petition in both structure and substance. It involved two hearings and the opportunity for ABCS to submit what MBC Vice President Ronald H. Lewis, MD, described during the first hearing as "reams" of materials. ABCS also was provided extended time to testify, rebut the conclusions of the independent medical reviewer and answer questions about its training.

Critically, though, the MBC's review involved substantial public input from concerned individuals, physicians and organizations. Leading this input was a widespread effort throughout the plastic surgery specialty to study AACS training and articulate the numerous ways in which it falls short of ACGME-accredited training. That effort produced comprehensive analyses demonstrating the quantitative and qualitative case against approval of the petition from ASPS, CSPS and the American Board of Plastic Surgery.

"I think that was instrumental," says Dr. Wong, who joined Debra Johnson, MD, past president of both ASPS and CSPS, current CSPS Legislative chair and current ABPS Board of Directors member, to testify against approval at the initial hearing.

"If you were to look only at the ABCS submission and listen to their testimony – well, they know exactly what to say," Dr. Wong says. "It's only when you dig into what they aren't saying and start to look at what they are actually doing that the differences between their training and the ACGME training that supports ABMS certification become stark."

That deep-dive approach ultimately produced a body of information that Dr. Lewis described as a "stack of paper that's taller than I am," and which explained and substantiated the varying concerns with ABCS.

Unexpected opportunity

By the end of the first hearing, not all MBC members were certain they'd fully wrapped their arms around such a large a body of information. Although that depth of analysis was central to the ultimate decisiveness of the MBC's decision, it also compelled several members to abstain from a vote on the petition and ask for additional materials. The first hearing ended with the MBC voting to develop a list of outstanding questions and areas of concern with both the ABCS certification and AACS General Cosmetic Surgery fellowships.

Concerns included how AACS fellowships are monitored to ensure that programs (all of which are based in individual private practices) adhere to the AACS's written program requirements. This was a core concern for both ASPS and CSPS in their analyses of AACS training, sparked by the appearance in publicly available information of widespread instances of those program requirements being violated.

"When it comes to having consistency in the quality of training programs and certainty that any quality issues are identified and addressed, you have to go beyond just a series of written requirements," says ASPS Board Vice President of Health Policy and Advocacy Gregory Greco, DO, FACS. "To really do that right, you have to have systems in place – backed by human and institutional resources – to actively monitor, intervene and remediate. The AACS essentially copied a number of ACGME requirements in large swaths. But you don't have to read past the second sentence in the second requirement (2.1: Program Director, Personnel, and Resources – Program Director) to find a clear example where most current AACS programs are in violation. That was the first thing that popped out in our research and analysis, and it was troubling."

Near the conclusion of the first hearing, MBC member Janet Levine, MD, in describing why she wanted additional documentation of how ABCS and AACS monitor and ensure adherence to requirements at the individual program level, said: "The absence of evidence is not the same thing as evidence of absence," and asked about the extent to which ABCS/AACS could provide evidence that the 27 individual fellowships abide by the criteria laid out in the AACS guidelines.

With a second hearing set, the Board requested the independent medical reviewer again assess ABCS's answers to the outstanding concerns. Although a lack of resolution in the first hearing was disappointing, the second hearing produced a more-thorough documentation and articulation of the critical distinctions between ABCS and ABMS certifications.

Evidence of absence

To review the quality of ABCS's medical education programs and whether they meet the requirements for equivalency of ABMS member boards, the MBC hired Neil Fleming, MD, PhD, a professor of clinical anesthesiology at the University of California-Davis, and a former core program director for an ACGME anesthesiology residency program.

In his first report, Dr. Fleming found several areas in which ABCS's educational requirements proved to be lacking, noting in particular that clinical case-volume is a greater focus than comprehensive medical education. As a result, he concluded "it is not apparent that the (AACS) training programs as described can consistently provide the broad-based exposure to all aspects of cosmetic surgery as encompassed by the single certification."

"That's a far less rigorous program than what's required for ABPS certification," notes CSPS past President Steven Teitelbaum, MD, who's been deeply involved in this issue.

Dr. Fleming's report goes on to add, "of greater concern is the assessment (by ABCS and the AACS) of approved fellowship training programs and their adherence to the training guidelines." He argued that it appeared that current training programs do not consistently meet the spirit or content of the recommended guidelines in multiple arenas, and as such, do not provide consistently adequate preparation.

Dr. Fleming came to his recommendation against approving the application based on the materials provided by ABCS and publicly-available information. In structuring his second review, the MBC placed a premium on acquiring documentation from ABCS related to specific concerns, with 11 of the 14 requests asking for specific evidence.

In six of those 11 responses, ABCS failed to provide specific items requested. These gaps ranged from the very basic (a summary of their members' current state licensure); to key pieces of evidence refuting the apparent rampant violation of program requirements by current program directors (a summary of their academic appointments and recent scholarly activity, which both appear lacking and are requirements). Where documentation was provided, Dr. Fleming often found it neither addressed the MBC's request or alleviated the MBC's concern – even in the case of foundational components of medical training, such as the presence and use of a formally structured curriculum in every program.

In light of these shortcomings, Dr. Fleming confirmed his initial recommendation, emphasizing in his conclusion that "the supplemental documentation provided upon request has not supported the contention that the current AACS fellowship training programs consistently adhere to the program training guidelines as provided by the ABCS."

A specialty-wide effort

Dr. Teitelbaum proved integral in organizing and articulating the case against ABCS equivalency. He says Dr. Fleming's conclusions follow the findings of the different groups that examined the question.

"Obviously, one year of training is not equivalent to the ABPS," Dr. Teitelbaum says. "The more you read about ABCS and AACS fellowships, the more what you find continues to shock. With one year of training, they certify ENT's to operate for the first time anywhere below the neck; OB-GYN's to operate anywhere outside of the pelvis; and general surgeons to operate anywhere throughout the head and neck. It's really startling to see."

"Anything that compromises patient safety serves as a galvanizing and mobilizing force in our specialty and across medicine," Dr. Matarasso says. "I was heartened to see so many organizations and members concerned enough about this issue to engage."

Dr. Teitelbaum says preserving the public's association of board certification with quality as uniquely important to plastic surgeons.

"I truly believe the sweat equity of people from all across our specialty helped unearth some very serious problems with the ABCS and with AACS training programs, and it helped explain those problems to MBC."

Dr. Matarasso says the specialty was bolstered by the work of ASPS staff.

"This result could not have been achieved without their hard work," he says. "They were well prepared, preempted several issues that arose or could have come up, and their institutional knowledge proved to be an invaluable resource."

However, Dr. Teitelbaum notes that unless enforcement efforts change, the MBC decision won't have an immediate, profound impact.

"The ABCS has been breaking the law with its advertising, and unless the law's enforced, not much will change," he says.

Next steps

In 2017, California changed its law so that only ABMS member boards and previously-approved non-ABMS boards could be advertised by physicians in the state. Although this means that ABCS cannot apply for equivalency again, Dr. Matarasso expects the specialty will have to keep an eye on the issue.

"When Dr. Johnson was doing her analysis, she found a substantial number of ABCS diplomates in California already illegally advertising as 'board certified,'" he says. "I think it's possible that some of those individuals will not respect this decision. I think everyone in California who's committed to patient safety and, frankly, the rule of law needs to keep an eye out for that and do what Dr. Johnson did when she saw the violations – file a complaint with the MBC."

In the meantime, patients should laud the MBC decision, Dr. Wong says.

"Patients should know that this is protection for them," he says. "The MBC has done something that's to their benefit and can help protect them."