Beyond specialization: ACVS developing certification program for sub-specialties that could begin in 2010

San Diego — The Age of Specialization in veterinary medicine was still in its infancy when the American College of Veterinary Surgeons (ACVS) was founded in 1970.

Thirty-eight years later, interest in surgery specialization is stronger than ever, but there's no mistaking that a new age is dawning.

Call it the Age of Sub-specialization.

It means that soon many ACVS diplomates will move beyond specializing as large-animal or small-animal surgeons to become board-certified in areas of veterinary surgery of particular interest to them.

"It's clear that what has served us well for the last quarter-century or more is no longer enough to accommodate the interests of our members and the growing demand of clients," says Larry R. Bramlage, DVM, MS, Dipl. ACVS, last year's ACVS president who on Oct. 23 was installed as Chairman of the Board of Regents at the diplomates' annual business meeting, concluding the ACVS Symposium in San Diego.

The ACVS is responding to that interest and demand by developing a sub-specialization certification program that it hopes to introduce around October of 2009, and that could be implemented as early as the spring of 2010. It's been working on the program for a year.

It will begin with three sub-specialties, after which the number will increase gradually over succeeding years. "I doubt that it will exceed 10 (sub-specialties), but we'll see," Bramlage says.

In the beginning, the ACVS will certify small-animal diplomates in the sub-specialties of neurosurgery and oncological surgery, while large-animal diplomates could sub-specialize in sports medicine/lameness.

"Younger DVMs want this training; many are currently doing work in these areas and improving their skills. Those who already have the skills want more interaction among themselves," Bramlage says. "For some time, the interest has been higher than could be accommodated. The (public) demand is strong enough to gobble up all the specialists we can produce."

Currently, a veterinarian becomes ACVS board-certified after a one-year internship, followed by a three-year residency that includes a specific number and types of surgical cases. Then he or she must publish a paper and take the three-part board exam the following year. That's a 3.5-year commitment.

Now tack on one additional year to become certified in one of the ACVS sub-specialties.

While that may seem daunting, it's a challenge many diplomates are ready to accept.

The ACVS began 2008 with about 1,400 members, and just added 65 more diplomates who passed this year's exam. That's about the average number of new ACVS diplomates per year for the past several years.

For years, only universities could offer residencies, for which competition is high. Now some larger, modern hospitals can offer specialized training, too. With the addition of these new training programs and plans for sub-specialties, the potential exists for a moderate increase in ACVS diplomates in coming years.

The shift toward sub-specialization in veterinary medicine "is not a novel concept," Bramlage likes to point out. "As everyone knows, human medicine went in that direction long ago; ear-nose-throat specialists are one of the earliest and best examples. In veterinary medicine, the other colleges are moving this way, and some perhaps are further along," says Bramlage.

The American College of Veterinary Internal Medicine (ACVIM) certifies specialists in large-animal internal medicine, small-animal internal medicine, neurology, oncology and cardiology. It doesn't call them sub-specialists, although acknowledging that some of its diplomates do have areas of interest within their specialties, such as urology and nephrology. Dermatology was an ACVIM specialty until 1982, when the separate American College of Veterinary Dermatology was established.

The ACVIM currently has 1,929 diplomates, 97 of whom are double-boarded. This year, 87 new diplomates were added, which has been roughly the average over the last six years.

As a partner in Lexington's Rood and Riddle Equine Hospital, Bramlage is personally aware of the rising demand for high-quality equine lameness examinations using MRI. "A (basic) lameness exam, using radiology and ultrasound, gives us much useful information, but MRI expands our capability so much, pinpointing exactly where the lameness is," he says. "Clients value and want a higher quality exam."

The coming ACVS certified sub-specialty in sports medicine/lameness will help meet that demand.

Limited licensure?

A discussion of sub-specialization and the concept behind it shifts easily to the subject of limited licensure, the argument for which is fairly clear, Bramlage says: As the science of veterinary medicine expands, it becomes ever more difficult for most practitioners to stay current in all areas.

"I have to admit that I may not practice small-animal medicine anymore, even though I'm licensed to do it. As you get deeper into one area, naturally you are shallower in others."

But he adds this caveat: Limited licensure makes sense only in situations where one has enough business to stay busy.

In rural areas, where serious DVM shortages are reported, there will be a continuing need for generalists, Bramlage believes.

"In those areas, you can't say that we should stop licensing GPs. That would only make it (the rural shorage) worse. We will still need people there who are broad (in knowledge and skills) but not necessarily deep in the specialties. In that sense, you can still be a James Herriott."

But, aside from that, "I really believe we must admit that we can no longer train veterinary students in everything. They will have to declare where they want to concentrate, and then the easiest and most practical thing would be internships, on-the-job training," Bramlage says.

Looking ahead

What challenges does Bramlage see for DVMs in the next decade?

Rising demand for specialists and sub-specialists, for one.

Another is public interest in animal welfare, which he believes will keep growing exponentially.

"One of our big challenges will be to educate a more urbanized society about what animals need for good health, to help people understand that society is much better served by entrusting the important decisions on animal welfare to those who are educated and trained for it."