During a recent presentation to a group of managed care professionals about next year's introduction in the United States of the proctored GALEN Certification Examination (a developing world-specific version of which the International Association of Physicians in AIDS Care [IAPAC] has administered in southern Africa for the past two years), I was asked to explain "GALEN" as an acronym. As regular readers of the IAPAC Monthly know well, the acronym stands for Global AIDS Learning & Evaluation Network. But beyond that literal description, there is a more profound connection behind our branding: its direct association to Claudius Galenus of Pergamum, better known in English as Galen.

Galen was an ancient Greek physician whose views dominated European medicine for over 1,000 years. His On the Elements According to Hippocrates describes the philosopher's system of four bodily humors -- blood, yellow bile, black bile, and phlegm -- which were identified with the four classical elements, and in turn with the seasons. Galen created his own theories from those principles, and much of his work can be seen as building on the Hippocratic theories of the body.

It is difficult to overstate the importance of Galen for European medical thought in the centuries between the fall of Rome and modern times. His collected works total 22 volumes. In his prolific writing, he absorbed all preceding medical thought and shaped the categories within which his successors thought about not only the history of medicine, but its practice as well.

Galen's importance in the history of medicine makes him a particularly appropriate point of reference for IAPAC's GALEN. As the historical Galen collected and codified existing knowledge and developed new theories, methods, and classifications, the IAPAC physician-members who created GALEN have identified the most essential and cutting-edge knowledge for HIV/AIDS-treating physicians and presented that information as a proctored examination. As Galen was emblematic of the movement to systematize the practice of medicine for the good of physicians and their patients, GALEN will systematize the training in and practice of HIV medicine, and create a global standard for defining what it means to become and remain an HIV specialist. It is not an overstatement to assert that the proctored GALEN Certification Examination and its accompanying continuing education offerings will positively impact the field of HIV medicine in developed and developing world countries alike.

In the past few months, IAPAC has fine-tuned GALEN to better meet its objectives. In the developing world, emphasis has been placed upon the benefit to physicians and patients of rigorously enforced standards of care. As agreed upon during a June 2004 World Health Organization (WHO) consultation on the topic of HIV service delivery,¹ training and certification of health workers can perform several important functions, including:

• Quality assurance. Transparent and controlled certification procedures help to establish and demonstrate that individual health workers are equipped to perform their tasks. The presence of certified staff is often a standard used in assessing the quality of a service delivery point.

• Benchmarking. Clearly defined certification standards help to establish what competencies are expected from health workers, and can give training providers guidance in developing their courses with clear aims and standards in mind.

• Incentive. Being rewarded with certification provides an incentive for health workers to attain these standard levels of competence -- particularly if such certification is linked to professional progression and/or advantages.

• Driving change. The definition of certification standards can in itself be used as an instrument for policy change -- for example, in driving the acceptance by professionals (and paraprofessionals) of task shifting between various types of health workers.

In the developed world, GALEN Certification Committee Co-Chair, John G. Bartlett (Johns Hopkins University, Baltimore), has identified several vital benefits to being recognized as an HIV specialist through the GALEN Certification Examination:

• The secured examination will verify clinical competence and certify HIV care expertise based on a standard process.

• The examination will target the body of information that a clinician caring for HIV-positive patients can reasonably be expected to know, with categories weighted by their importance in real-world care (e.g., 50% of questions are devoted to overall antiretroviral therapy delivery).

• The examination will be psychometrically analyzed to ensure questions adequately measure knowledge and its application (50% of questions are knowledge-based, and the remaining 50% are case study-based). Authorities in the field of HIV medicine will review the examination to determine the overall quality and clinical relevance of each question.

• Study guides will be written to aid participants in preparing for the examination. The act of preparing for the examination through concentrated study is of immediate benefit to both physicians and patients.

• The examination process will follow established testing standards set by certification boards such as the ABIM, and will be jointly sponsored with equitable contributions by like-minded professional and specialty medical societies. In recognition of the potential ethical problems inherent in associations certifying their own members, IAPAC will establish an independent HIV medicine-specific certification board comprised of relevant professional and specialty medical societies to administer the GALEN Certification Examination and to evaluate its results.

It should be noted that IAPAC has for several years publicly supported efforts by national medical societies in various developed world countries to recognize HIV medicine as a specialized field of study and practice. For example, in the United States, IAPAC endorsed attempts by the HIV Medicine Association (HIVMA) to convince the ABIM and other boards that comprise the American Board of Medical Specialties (ABMS) to approve a "Certificate of Added Qualification (CAQ) in HIV Medicine." This would have allowed primary care physicians to be certified in HIV medicine by taking one year of clinical training and passing a proctored certification examination. However, in July 2006 the ABIM effectively shut down this effort by voting to discontinue the granting of CAQs.²

IAPAC continues to support HIVMA as it attempts to push for the creation of an HIV subspecialty through means that would "provide a pathway for future internists and others to receive training and become certified in HIV medicine."³ But in the meantime, it is our belief that the issue of ensuring quality HIV/AIDS care is too important to allow ABIM's refusal to stand as the last word. We can not indefinitely mark time while there remains a critical need to "acknowledge and to validate the expertise that scores of internists currently practicing on the frontline[s] of HIV medicine now possess."³

We have known for some time that providing quality care requires quality training. According to a 1999 study by the Society of General Internal Medicine's AIDS Task Force, "optimal care of HIV infection requires a combination of disease-specific expertise and primary care skills and organization."⁴ The study's abstract goes on to note that the "management of HIV has become sufficiently complex that primary care physicians cannot be routinely expected to have extensive specialized knowledge in this area." If such an observation was true seven years ago, how much more urgent is specialized training today? And if training is in fact the answer to the question of how we improve care, then a corollary is that certification is essential to ensure that training is hitting its mark.

Finally, the benefits of effective training and certification resonate beyond the improved capabilities of the individual physician and the improved outcomes for the individual patient. The concept of "disease management" emphasizes the use of integrative care to control or prevent chronic disease and reduce health care costs. Certification can be a cornerstone in the disease management process by assuring that physicians are adequately trained in providing timely and appropriate evidence-based treatment. In a time of scarce human and financial resources, it is imperative that we wisely budget a small portion of our precious time and energy to creating and administering a program that will benefit both patient care and the financial efficiency of our health care systems.

José M. Zuniga is President/CEO of the International Association of Physicians in AIDS Care, and Editor-in-Chief of the IAPAC Monthly.

References/Notes

1. Treat, Train, Retain: Report on the Consultation on AIDS and Human Resources for Health. May 11-12, 2006. World Health Organization. Geneva.

2. ABIM Says No New CAQ Areas. HIVMA e-News. July 13, 2006. Issue No. 74. HIV Medicine Association. www.idsociety.org/HIVMA. (Accessed October 9, 2006.)

3. HIV Medicine Association correspondence to Harry R. Kimball, President of the American Board of Internal Medicine, and Marjorie A. Bowman, President of the American Board of Family Practice, in support of the development of a Certificate of Added Qualification in HIV Medicine. April 19, 2002. www.idsociety.org/HIVMA. (Accessed October 9, 2006.)

4. Hecht FM, Wilson IB, Wu AW, Cook RL, Turner BJ. Optimizing care for persons with HIV infection. Society of General Internal Medicine AIDS Task Force. Ann Intern Med. 1999;131(2):136-143.