Board certification/recertification/maintenance of certification: a malignant growth.
Subject: Physicians (Practice)
Health care industry (Laws, regulations and rules)
Author: Dubravec, Martin
Pub Date: 06/22/2011
Publication: Name: Journal of American Physicians and Surgeons Publisher: Association of American Physicians and Surgeons, Inc. Audience: Academic Format: Magazine/Journal Subject: Health care industry Copyright: COPYRIGHT 2011 Association of American Physicians and Surgeons, Inc. ISSN: 1543-4826
Issue: Date: Summer, 2011 Source Volume: 16 Source Issue: 2
Topic: Event Code: 200 Management dynamics; 930 Government regulation; 940 Government regulation (cont); 980 Legal issues & crime Advertising Code: 94 Legal/Government Regulation Computer Subject: Health care industry; Government regulation
Product: Product Code: 8011000 Physicians & Surgeons NAICS Code: 621111 Offices of Physicians (except Mental Health Specialists)
Organization: Organization: American Medical Association
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 267810798
Full Text: Introduction

Board certification is an extra step that physicians choose to take, which shows that they have reviewed a set of information deemed important by a certifying board.

Although board certification has been considered voluntary, the process is becoming increasingly necessary for hospital privilege status, insurance company network participation, and membership in certain organizations. The process has become expensive, time-consuming, and to many physicians clinically irrelevant. The majority of physicians object to the current system. (1,2)

Although the American Medical Association has passed resolutions stating that board certification should not be mandatory for such things as hospital privileges and participation in managed-care networks, many hospitals and insurance companies now mandate board certification, or its attainment within a certain number of years, in order to maintain these privileges.

Board certification organizations have no authority under federal or state law. However, in states such as California, a physician is not allowed to advertise as a specialist in a certain field unless that physician has attained board certification recognized by the American Board of Medical Specialties (ABMS) and its subsidiary boards. Although ABMS is not the only board-certifying authority for all physicians, it has, because of its size and scope, a virtual monopoly.

A Multimillion-Dollar Industry

Currently, ABMS is set up as a parent board with 24 specialty boards that certify and re-certify members. ABMS recently began maintenance of certification (MOC) for its members. This is a multimillion-dollar industry. A few examples, from publicly available IRS forms 990 for the year 2009, are illustrative. In that year, the chairman of ABMS received $492,517 in salary and benefits. An adviser to the chairman received $249,859 in salary and benefits. The chairman of the American Board of Internal Medicine (ABIM) received a salary of more than $800,000. Total assets of the American Board of Internal Medicine at that time were $57,586,843. The chairman of the American Board of Allergy and Immunology, working two hours a week, earned more than $98,000. Total assets of the American Board of Pediatrics were reportedly $41,759,971.

The board certification process includes written and/or oral tests. The process for board certification/recertification/MOC costs thousands of dollars. As an example, recertification for an allergist in 2011 costs $2,700. Maintenance of certification for an allergist costs $2,850. This does not include time away from patients in order to study for the exams, nor does this cost reflect board review courses that are often offered and that some physicians feel are necessary in order to pass the exam. These add thousands of dollars in costs, for course fees, hotel bills, and transportation.

The board certification process originally involved one exam, usually taken shortly after completion of residency or fellowship training. This was then modified to be time-limited, i.e., board certification will expire after a period of 7 to 10 years. Now, MOC has crept in, adding tasks that doctors must fulfill to retain their board certification. Furthermore, there is active discussion to have continuous MOC programs in all specialties, which would involve recurrent test taking on a yearly or biannual basis.

Arguments for Certification/Recertification/MOC

Proponents of these processes claim there is evidence that doctors who are board-certified offer better quality care. Overwhelmingly, these studies were either produced by individuals tied to ABMS, or sponsored by ABMS itself. Furthermore, the studies in question showed no significant difference between board-certified and non-board-certified physicians. In other words, the ABMS's own studies do not show that board-certified doctors are better doctors. (3)

Proponents also state that there is a public demand for board certification/recertification/MOC. However, ABMS itself conducted a survey that revealed that about two-thirds of those surveyed did not know what board certification meant. When challenged to provide evidence for the public demand, no information from the ABMS has been forthcoming.

Supporters of ABMS and its vast bureaucracy tout the "transparency" of the process. However, sources of material for the board certification tests are not available. Furthermore, participants in the process are not allowed to discuss the content of the tests after they are taken. In fact, ABIM sanctioned a group of physicians who attempted to discuss test question material after the exam.

Some physicians have asked about possibly bringing a lawsuit to stop recertification or MOC. But board certification is not legally necessary to practice medicine. Therefore, the legal profession is hesitant to take on a lawsuit, even though non-certified physicians might claim restraint of trade.

Proponents of board certification/recertification/MOC have argued that other professions such as the airline industry require more frequent competency assessment of workers such as airline pilots. (4) However, the qualities necessary to be a good doctor are far less well-defined than the skills necessary to fly an aircraft. Few airline pilots (fewer than five percent, according to one study) fail their competency testing, which is managed by the individual airline companies. Different airline companies have different modes of testing, but one does not hear arguments that the tests are irrelevant to the required tasks. Airline pilots are compensated during periods when they are taking the tests, which are not considered time away from their clientele. In contrast, the current board certification/recertification/MOC process clearly takes time away from patients, is very costly and uncompensated, and its clinical relevance is questionable.

The best way to ensure we have high-quality individuals as physicians is to carefully select them during medical school admission as well as residency and fellowship placement. No test or series of tests can ensure or guarantee the quality of a physician.

Solutions

Doctors now have to make important decisions about recertification and maintenance of certification.

One option is to ignore these processes. The ABIM has noted that 23 percent of general internists and 40 percent of subspecialists are not renewing their internal medicine certification, and 14 percent of subspecialists are not recertifying in their subspecialty. This number will most likely increase as these processes become more expensive and more time consuming, and continue not to reflect clinical practice. Other physicians simply follow ABMS directives and continue the recertification process, regardless of its cost and the time away from patients or family. Some doctors have approached the ABMS or its subsidiary boards to request review and modification of the process, but without results. Some physicians are also contemplating or are actually in process of developing alternative organizations for certification/recertification/MOC.

A major concern for all doctors should be the discussion ABMS is having with the Federation of State Medical Boards (FSMB). Their goal is to change medical licensure from simple renewal and meeting some continuing medical education requirements to a more active and demanding process called maintenance of licensure. Physicians involved with ABMS are working to mandate MOC as a part of maintenance of licensure. It will be up to each state to decide whether to adopt such measures. Doctors should actively engage their state licensing authorities to prevent this from happening.

At a minimum, maintenance of one's licensure should not be dependent on MOC. Doctors should be able to choose options that best suit their clinical practices to assure the best possible patient care.

Doctors interested in this issue are invited to visit www.changeboardrecert.com for more information.

REFERENCES

(1) Change Board Recertification. Website poll. Available at: http://www. changeboardrecert.com/vote.html. Accessed Apr 20, 2011.

(2) Orient JM. AAPS survey: physicians skeptical of recertification. J Am Phys Surg 2009;14:17-18.

(3) Norcini JJ, et al. Evaluating the quality of care provided by graduates of international medical schools. Health Affairs 2010;29(8):1-8.

(4) Perspective: the American Board of Allergy and Immunology maintenance of certification program: to door not to do? That is the question. Ann Allergy Asthma Immunol 2010;105(6):485-488.

Martin Dubravec, M.D., is an allergist/immunologist. Contact: 200 East Mason St., Cadillac, MI 49601. Tel.: (231) 779-4444.
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