Is Board Certification Overrated?

There’s less evidence of its value it than you might think.

Board certification: it’s expensive and time-consuming. And it’s almost as much a necessity for practicing medicine today as a medical degree. Certification is a prerequisite for privileges at most hospitals and for credentialing by most insurers. Few practices will hire physicians who aren’t board-certified.

But there’s no doubt that the certification process improves the quality of physicians — and, in turn, patient outcomes.

Or is there?

Although a number of studies have demonstrated a correlation between board certification and improved patient outcomes, there’s actually little if anything in the literature that firmly establishes causation, largely because of the difficulty of controlling for factors other than board-certification that might affect patient outcomes. The sheer domination of board-certification in the medical community, meanwhile, has also made it hard to find cases involving noncertified docs to compare against.

Still, board certification is taken for granted in American healthcare today, less than a century since it took root in the physician establishment. And given that 91 percent of the public considers board certification “important” or “very important” in choosing a doctor; that the Joint Commission lists board certification as a reasonable way for hospitals to meet its requirement to vet doctors; and that some 85 percent of doctors are board certified in at least one specialty, one would think that the medical literature would be heavy with studies quantifying certification’s value to patients.

But it’s not.

So it’s time to ask: Is board certification overrated?

The origins of certification

Board certification has its origins in the beginning of the 20th century, when nearly half of all physicians in the country were general practitioners. Most patients who visited a doctor never saw a specialist, and many GPs were accustomed to providing all manner of care to their patients, regardless of specialized need.

That situation irked specialists like Derrick T. Vail.

In 1908, Vail, president of the American Academy of Ophthalmology and Otolaryngology, proposed a board that would license ophthalmologists. He hoped it would protect patients against what he called the “six-week specialist,” those physicians with little training in the specialty — and, no doubt, he was also hoping to protect genuine specialists’ turf against overstepping generalists. As Alvin A. Hubbell, chair of the AMA’s ophthalmology section at the time, noted, the idea would protect the interests of the ophthalmologist “who has qualified at much sacrifice of time, energy, and money.”

In 1917, the American Board of Ophthalmic Examinations, now the American Board of Ophthalmology, was formed. Other specialties soon followed the board-certification model, and in 1933 the Advisory Board of Medical Specialties, later renamed the American Board of Medical Specialties, was formed. Currently, the ABMS comprises 24 certifying medical boards.

Over time, the concept of board certification has been transformed. Conceived as a one-time certification granted for life, periodic recertification has lately become standard. Certification now represents more of a barometer of the physician’s ongoing knowledge than just a demonstration of academic study.

The process continues to evolve today. While a knowledge exam is still a core feature, many boards now incorporate peer review, practice performance indicators, and even patient assessments as required components of certification. The idea of comparing physician performance to evidence-based best practices and national quality benchmarks is already a key feature of certification for the American Board of Internal Medicine and the American Board of Pediatrics, and it’s a concept that is spreading rapidly to other ABMS member boards.

“Board certification has served as the gold standard for close to 75 years now in assuring the public that those that bear the imprimatur of each of the 24 boards that comprise the [ABMS] have the necessary training, experience, and knowledge to provide high quality care to their patients,” says James C. Puffer, MD, president and chief executive officer of the American Board of Family Medicine.

Numbers don’t lie . . . do they?

Maybe so, but what does that gold standard mean in the real world? Are board-certified doctors better doctors?

A 2002 review article written by Lisa Sharp and four others that appeared in Academic Medicine, a peer-reviewed journal published by the Association of American Medical Colleges, examined relevant studies published between 1966 and 1999 that attempted to correlate board certification to better outcomes. Sharp and her colleagues identified 13 studies (of some 200 that they looked at) that positively correlate certification and clinical outcomes. But they also noted gaping limitations on the quality of available research. Only 5 percent of the papers they looked at used appropriate research methods, they said. And while they cite various studies that associate certification with “increased medical knowledge, superior training, and certain aspects of patient care,” they note that none of these studies were direct measures of clinical care.

Of the studies Sharp and her researchers examined, no two measure the same variable of outcome within the same specialty. And none of the studies measured physicians’ time since board certification — an important factor, since some physicians practicing today were certified for life before boards began requiring periodic recertification. “Many factors unrelated to the physician affect clinical outcomes, such as the type of clinical setting, size of support staff, and systems of clinical care, to name a few,” they write.

Still, Sharp and her colleagues supported the continued use of certification as a means of evaluating doctors: “Despite the lack of unequivocal evidence documenting the value of board certification, we do not advocate removing it as a measure of expertise. Intuition, expert opinion, surrogate markers, and the findings reported here support the ABMS position that board certification is but one of several important considerations in evaluating a physician’s knowledge, skill, and ability to provide good clinical care.”

Eric N. Grosch, a physician who formerly practiced internal medicine and is now attending law school, read the Sharp review at the time, and found her team’s position uninspiring. He wrote his own review article in response, publishing “Does Specialty Board Certification Influence Clinical Outcomes?” in the Journal of Evaluation in Clinical Practice in 2004.

“They came to the conclusion that there was no good evidence, no strong evidence, no conclusive evidence that showed board certification was any advantage,” Grosch says in an interview. “But they said they still recommend it as an index of expertise. That’s known as ignoring the evidence.” Grosch noted that two members of Sharp’s team were ABMS executives at the time of their article’s publication.

One coauthor, Sheldon Horowitz, a pediatrician who in 2002 was an associate vice president at ABMS and is today a special adviser to its president, says, “There are a number of papers that show that initial certification by an ABMS board is associated with improved preventive care, including prenatal care, improved myocardial infarction care, better anesthesia outcomes, better perinatal outcomes, and better surgical outcomes.”

Some of these papers have been published since the 2002 Sharp review. In particular, a 2008 paper in the Journal of the American Medical Association, “Assessing Quality of Care: Knowledge Matters,” shows that good performance on the certification exams correlates with better quality of care.

But these later studies have the same flaw that plagued the earlier research Sharp’s team reviewed: correlation doesn’t prove causation, and because they fail to isolate for variables other than board certification that might affect patient outcomes, they’re ripe for attack by critics. “These are hard studies to do because of the relatively small percentage of noncertified doctors,” argues Horowitz.

But Grosch sees a conspiracy: “[Board certifications] are a cash cow, and somebody has a vested interest in the financial benefits to themselves of maintaining it. To be sure, the ABMS and all of the 24 boards under it consider board certification to be a major cash cow for the owners of the boards.”

Common sense?

Yet even if quantifying the value of specialty certification is a difficult thing to do, aren’t the correlation studies, however imperfect, plus simple common sense enough? In a society that places such a premium on physicians’ abilities, do we really need an exhaustive study to prove that periodic testing of knowledge is good for patients?

“I suspect that if you talked to many of these people who feel that it’s not necessary to regularly assess physicians and if you asked them whether they would be willing to get on a transcontinental airline and travel across country with a pilot who had not been assessed at regular intervals, they would probably be reluctant to do so,” asserts Puffer. “Even on an intuitive level, I think frequent and regular assessment makes sense to most people, even ignoring the significant body of literature that exists that would support the notion of maintenance of certification.”

Horowitz agrees. “No matter how good the care you provide, there are always ways to improve your care. In my mind, that’s the most important reason for things like certification and maintenance of certification. It’s to try to ensure that physicians are up-to-date and deliver high-quality care as an ongoing process, because there’s always new stuff.”

Yet the critics are asking interesting questions even if one accepts the basic logic of ongoing assessment as an obvious good. Who’s to say, for example, that the best way of judging a physician’s knowledge is through a multiple-choice exam, the backbone of most certification programs? Who’s assessing the assessors? And what about the time away from patients needed to study for such exams, and the expense of certification itself? Healthcare is fraught with access and cost problems. Doesn’t it also make common sense to ask whether the certification is worth the added expense and the reduced physician time with patients?

Grosch bemoans the amount of red tape that practicing medicine in the U.S. involves. He points out that, in addition to specialty certification boards, there are 69 separate bureaucracies handling medical and osteopathic licensure today. Having to qualify in each state for a medical license is onerous enough without having to additionally pass a specialty certification that has little evidence to back up its efficacy.

“If it’s not a helpful thing, it’s an awful lot of trouble to prepare for. I’ve known guys who quit their practices for a year to study for it. It is a great disruption in their professional lives to have to study for it,” says Grosch. “The expense of it is exorbitant . . . and for what? No benefit in patient outcome.”

The future of certification

A 2004 Gallup poll and an ABMS consumer survey in 2008 both showed that the public rated board certification as an important consideration when choosing a physician. The ABMS poll showed that 91 percent considered board certification “important” or “very important.” Gallup’s number was 70 percent. There is no doubt that board certification, as a concept, has been well marketed and is accepted by the general public.

“The survey basically said that if their doctors stopped being certified, they would look for another doctor,” says Horowitz. “That was more important to them than their friends’ recommendations about doctors.”

Any changes made to the boards’ certification requirements will increase their importance, frequency, and stringency. Most of the ABMS boards either have or soon will introduce new steps that will incorporate patient registries, peer and patient review, and comparison of clinical outcomes and physician performance to national benchmarks.

If the future of healthcare includes incentive payments for improved quality of care, that future belongs to board-certified physicians. The recently passed healthcare reform legislation specifically identifies improvements to the Physician Quality Reporting Initiative, Medicare’s pay-for-performance program. Starting in 2011, physicians can qualify for additional payments if they submit data measures through a maintenance-of-board-certification (MOC) program that meets the criteria for a patient registry. Similarly, recognition by the National Committee for Quality Assurance (NCQA) is at least partially predicated on board certification. NCQA recognition qualifies physicians for many national and regional pay-for-performance efforts.

And just to make physicians’ lives a little easier, there is currently a referendum before the Federation of State Medical Boards that will allow participation in a maintenance-of-certification program to serve as a surrogate for maintenance of licensure. Board certification and licensure — already confused in the public mind — will likely move one step closer to each other.

The true value of board certification to patient outcomes remains difficult to quantify. But whatever it’s worth to patients, certification will soon become something physicians simply cannot practice without, if they ever could.

By Robert Anthony

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