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In CHECKBOOK magazine, we try to give you as much information as possible
to help you in selecting and working with the most important type of service
provider in the health care field: physicians.
We tell you which physicians are most recommended by their peers and how
physicians are rated by patients. We advise that you check for hospital
affiliations, medical school teaching responsibilities, use of electronic
medical records, and other indicators of quality.
In addition, we consistently recommend that you select physicians who are
“board certified.” What does board certification mean, and why is it important?
In the U.S., there are 24 medical specialty boards, such as, the American
Board of Thoracic Surgery and the American Board of Internal Medicine.
These boards certify physicians in various specialties and subspecialties.
For instance, the American Board of Internal Medicine certifies physicians
in the specialty of internal medicine and in 17 subspecialties and areas
of special qualifications—including cardiovascular disease, gastroenterology,
geriatrics, and hematology.
To become certified, a physician must spend several years (in some cases,
more than six years) after medical school getting supervised, in-practice
training.
In addition, all specialty boards require passage of a written exam, completed
without assistance, usually administered interactively by computer in a
secure testing facility. Some specialties also require an oral exam. The
exams are intended to assess medical knowledge and clinical judgment.
Until 1970, all specialty boards issued non-expiring certifications. At
that time, the family practice board began issuing time-limited certifications.
Over the following 30-plus years, other boards began issuing time-limited
certifications, and now all boards issue only time-limited certifications.
The certifications generally last for 10 years, but a few boards’ certificates
are for just six or seven years.
Doctors whose certificates are time-limited must successfully complete
re-certification requirements or they can’t call themselves board-certified.
The requirements for re-certification, like the requirements for initial
certification, include an unassisted written (computer-administered) exam,
intended to measure clinical knowledge and judgment.
Since the individual specialty boards develop their own exams for certification
and re-certification, the validity of the exams as measures of physician
competence varies by board. On the exam for re-certification in general
internal medicine, the largest specialty, the pass rate has been in the
85 to 92 percent range in recent years, but the rates in other specialties
may be higher or lower.
In the good exams, a test-taker is confronted with real-life situations
where knowledge of current medical guidelines, along with good judgment,
can be expected to lead to correct answers. Here is the type of case you
might find on an exam: a 22-year-old male college student came to the doctor’s
office after fainting for less than a minute during wrestling practice;
the patient had suffered previous episodes of lightheadedness and at age
10 was diagnosed with a heart murmur. The test-taker is given the results
of several in-office examinations. Then the test-taker is expected to make
a diagnosis.
In 1999, all of the specialty boards agreed to move beyond re-certification
based on passing a test of knowledge and judgment to a program of “maintenance
of certification.” The policy is that “maintenance of competence should
be demonstrated throughout the physician’s career by evidence of lifelong
learning and ongoing improvement of practice.” Each board is implementing
this policy in its own way, but all are committed to a program that requires
that the physician—
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Show evidence of knowledge and judgment—typically by passing the same types
of unassisted, written (computer-administered) exams that have been the
basis for certification for many years.
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Show evidence of a commitment to lifelong learning and involvement in a
periodic self-assessment process. Boards have identified or created learning
materials and computer-based interactive tools that a physician can use
to learn about the newest developments in his or her field. The physician
is expected to self-administer tests to identify knowledge gaps.
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Show evidence of self-evaluation of performance in practice. For example,
the American Board of Internal Medicine (ABIM) asks that a physician periodically
pull data from case records for patients with a specific condition like
diabetes or asthma, submit the data to the board for evaluation, get back
from the board a report comparing the physician’s practice patterns to
national guidelines, develop a plan for improvements, and then measure
whether the improvements have worked. Through this process, a physician
might discover, for instance, that he or she has information on LDL cholesterol
results for too few diabetes patients and this awareness might prompt the
physician to take steps to do better. Physicians are also encouraged to
do surveys of patients and to use the results to guide quality improvement.
Except for the written tests of knowledge and judgment, re-certification
is not dependent on the results—the scores—from the assessment activities.
It is enough that the physician does the self-assessments and develops
plans for improvements—regardless of how bad or good the physician looks
in the assessments.
So, what useful information does the board certification system provide
you?
You can check whether any physician you are considering is board certified
by checking the website of the American Board of Medical Specialties, the
umbrella organization for the 24 individual specialty boards, at www.abms.org.
If the physician you are considering is not board certified, he or she
will not be listed.
Unless you have a compelling reason to do otherwise, it is hard to see
why you would choose a physician who is not board certified. But be aware
that board certification is not a very discriminating measure. About 87
percent of physicians in the U.S. are certified.
Also, be aware that for many physicians being certified does not assure
you that he or she has kept up-to-date: there are still many physicians
in practice who were certified for life, before the change to time-limited
certification and periodic re-certification took effect. All of the specialty
boards allow physicians who were certified before time-limited certification
began to call themselves “board certified.”
Knowing how recently a physician has been certified or re-certified is
important, since there is substantial evidence that physician performance
gets worse over time. A 2005 article published in the Annals of Internal
Medicine reviewed 62 studies that had examined the relationship between
age or time in practice and various measures of quality—physician knowledge,
adherence to recognized care guidelines, and medical outcomes. Of these
studies, 45 reported decreasing performance on some or all quality measures
over time, and only two reported improved performance.
Physicians who were certified for life can if they wish seek voluntary
re-certification, but not many have done so. Those who don’t point to the
cost, the time required, the risk of failure, and other factors. For the
relatively few physicians who have voluntarily become re-certified despite
having a life-long certification, that diligence and self-scrutiny may
be a meaningful indicator of quality.
It would be desirable for the specialty boards to create and advertise
a concept like “recently certified” or “certification updated” so consumers
could easily distinguish physicians whose certification status is based
only on having been certified for life from those who are actively engaged
in self-assessment and practice improvement. Unfortunately, the www.abms.org
website, which reports on all specialties’ certifications, doesn’t provide
information on when a physician was certified or whether the physician
has voluntarily become re-certified. Some of the individual specialty boards
do provide that information on their websites, but some provide virtually
no consumer information. The ABMS and all of the individual boards should
have the information on their websites.
Are there additional types of comparative information specialty boards
could provide consumers on individual physicians? Possibly.
First, it might be possible in the future for the boards to release to
the public physicians’ scores on the written exams of knowledge and judgment—at
least information like “top 10 percent,” “top 25 percent,” or “top half.”
The boards can’t unilaterally begin to report data that they have historically
promised physicians would be kept confidential. But changes in confidentiality
policies might be possible in the future. And even in the near term, the
boards might consider releasing scores for physicians who give permission
for such release. Disclosure of test scores would certainly put physicians
out ahead of most professionals; it is not common to have one’s personal
test scores made public. But the advantage of releasing these scores is
that they can be expected to reflect on aspects of quality that other measures
of physician performance may miss.
Second, the boards might consider, for the future, working with physician
leaders to change the self-assessment process into a process that has the
combined purpose of self-assessment and public assessment. There are already
various efforts underway—led by government agencies, health plans, employers,
and consumer organizations—to increase public reporting of physician quality
measures—for instance, measures from medical records showing whether a
physician consistently gives all the appropriate tests and treatments to
diabetes patients, or measures from patient surveys of how well the physician
communicates. Some of the specialty boards are involved in these public
measurement efforts, but more might be done to use the same data and analyses
for public reporting and physician self-improvement purposes.
If measures are to be useful for public reporting, they will have to be
standardized and independently collected. Currently a physician can self-select
the diabetes cases he or she abstracts for the specialty board and can
even cherry-pick to look good, or can decide to survey only patients who
are likely to give good reports. There is not much harm in that when the
data are being used only for self-assessment; worst case, when the physician
gets a performance report back from the board, he or she might simply say,
“Wow, I did that badly even though I was cheating.”
For public reporting, the system would have to change. The specialty boards
would have to work with health plans, Medicare, and others to develop systems
to collect data from medical records or claims records, for example, and
to develop a nationwide standardized patient survey—so that the resulting
measures could be used not only for physician practice improvement but
also for public reporting. Having forward-thinking specialty boards involved
in the development of measures might help to move the measurement process
forward and to assure that measures are well designed.
Public reporting of standardized measures would not only help you choose
good physicians, but would also enable health plans to reward high-rated
physicians and would facilitate public and peer recognition of top performers.
All that might reinforce incentives for the kind of physician quality that
is the mission of the specialty boards.
If the boards don’t get actively involved in public reporting efforts,
however, it is still important to remember that what is being done, and
the progress that has been made toward continual maintenance of certification,
is important. Even without more public reporting, board certification provides
tools for quality improvement, channels through which well-motivated physicians
can fulfill a desire for professional improvement, and a way for each physician
to demonstrate to patients and the public that he or she is committed to
professional development.
It is important to realize that the commitment to professionalism and the
desire to help others—not public scrutiny—have probably been the most important
forces for quality in health care over the years. So fostering these motivations
is a good thing.
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