An Alternative Mechanism for Clinical Medical Subspecialties' Accreditation and Recognition in Iraq and Other Developing Countries

In many nations around the world there has been increasing demand for scientific research and high-quality graduate medical education in subspecialty areas of medicine, surgery, and hospital-based specialties to provide a high standard of patient care. In North America, subspecialties have been evolving since the beginning of the 20th century.1 This evolution has been due in part to the introduction of new technologies and treatment modalities and growing awareness of the needs of patients with chronic disorders. Common health problems and diseases with known therapies continue to be managed by generalists, but for patients with complex diseases access to subspecialty care is critically important. In addition, having trained subspecialists contributes to discovery and the scholarly application of knowledge to patient care, with subspecialists functioning as scholarly leaders and educators in their field. In North America, subspecialists have made major and unique contributions to health care by advancing medical knowledge and technology and promoting excellence in the management of complex illnesses.2 

In present-day Iraq, the infrastructure for various subspecialties has not yet been established, a “modern” subspecialty physician workforce does not exist,3 and the requirement for subspecialty training as in North America and Europe currently cannot be met. The delay in the introduction of modern technologies and advances in medicine and surgery has been largely attributed to a lack of qualified faculty, educators, and leaders in various subspecialty fields. This has resulted in delay in building subspecialty centers. Particularly, training and recognition of surgical subspecialties and subspecialists in Iraq is not possible without the presence of qualified faculty to teach in these fields. The purpose of this letter is to propose an alternative mechanism for recognizing subspecialty clinicians in Iraq and other nations in similar circumstances.

Historical accounts of the establishment of subspecialties in North America and Europe have identified the following steps4,5:

1. Definition of the subspecialist and the work he/she undertakes.

2. Setting requirements for the general recognition as a subspecialist: number of years of training in the general specialty and the subspecialty, research in the subspecialty field, and a high training standard.

3. Setting a requirement for the recognition of the subspecialty training venue.

4. Setting a mechanism for recognition of the subspecialist.

Given the absence of these components in Iraq, a research-based subspecialty program concluding with a doctorate in the given subspecialty field rather than formal subspecialty training and board certificate may be more applicable:

1. Holding a professional certificate in the general specialty, for example, pediatrics, internal medicine.

2. Two years of subspecialty practice in a subspecialty consultation clinic that receives referral of the difficult cases.

3. Publication of 2 or more research reports in the field of subspecialty in indexed peer-reviewed medical journals possibly international.

This approach bases subspecialty recognition on the valid criteria accessible in Iraq. Recognition granted by unqualified boards and councils cannot be substantiated and may not be valid or useful for the community.

Advantages to this approach for developing subspecialty recognition in Iraq include (1) subspecialists recognized via this approach will have better knowledge, research skills, and likely clinical skills in the subspecialty field than the cohort of general specialists; (2) the process of recognizing the subspecialists will stimulate research in the subspecialty fields that may contribute to addressing health problems specific to the geographic region; and (3) the approach will provide the seed for the formation of future academic subspecialty boards. The largest potential drawback of this approach is that it lacks formal training programs for the subspecialty, and it is thus not possible to guarantee that it will create significant improvements in the clinical practice of the subspecialty, particularly in surgical subspecialties. Due to this shortcoming, the proposed approach is more appropriate for medical rather than surgical subspecialties. The aim of this proposal is to promote better research and accumulation of knowledge in the subspecialty areas, leading to enhancements in patient care.