We consistently advise consumers to select physicians who are “board certified,” and we report on board certification status in our ratings of doctors here at Checkbook.org. What does board certification mean, and why is it important?

In the U.S., there are 24 medical specialty boards, among them the American Board of Thoracic Surgery and the American Board of Internal Medicine (ABIM). These boards certify physicians in various specialties and subspecialties. For instance, the ABIM certifies physicians in the specialty of internal medicine plus 20 subspecialties and areas of special qualifications (for example, cardiovascular disease, gastroenterology, geriatrics, and hematology). There are also separate medical specialty boards for osteopathic physicians.

To become certified, a physician must spend several years after medical school—in some cases more than six years—receiving supervised in-practice training.

In addition, all specialty boards require passage of a written exam, completed without assistance and administered in a secure testing facility; some specialties also require an oral exam. These exams are intended to assess medical knowledge and clinical judgment.

The specialty boards used to issue non-expiring certifications, which meant that a doctor who earned a certification kept it for life. In 1970 the American Board of Family Medicine began issuing time-limited certifications; since then the other boards also began issuing time-limited certifications, which typically must be renewed every 10 years.

Doctors whose certificates are time-limited must successfully complete recertification requirements or they can’t continue to call themselves board-certified. The requirements for recertification, like the requirements for initial certification, include passing an exam intended to measure clinical knowledge and judgment.

Since the individual specialty boards develop their own exams for certification and recertification, the validity of the exams as measures of physician competence varies by board. On the exam for recertification in general internal medicine, the largest specialty, the pass rate for first-time test takers for the last few years was more than 90 percent; the rates for other specialties may be higher or lower.

Good exams confront test-takers with real-life situations where knowledge of current medical guidelines, along with good judgment, can be expected to lead to correct answers. For example, a typical exam question might ask about: A 22-year-old male college student visits 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 had been diagnosed with a heart murmur. After receiving the results of several in-office examinations, the test-taker must make a diagnosis.

In 1999 the specialty boards all agreed to move beyond recertification based on simply passing tests 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 implements this policy in its own way, but all are committed to a program that requires that the physician—

• Maintain a license in good standing with state licensing boards. If a physician has had his or her license revoked, the physician cannot participate in maintenance of certification. Having a license suspended—or being put on probation or otherwise restricted—could also disqualify a physician from participation.
• Periodically show evidence of knowledge and judgment, typically by passing the types of exams we’ve already discussed.
• Show evidence of a commitment to lifelong learning and involvement in a periodic self-assessment process, targeted in particular on new developments in the physician’s specialty field. Physicians can complete appropriate continuing education courses, and some boards have identified or created learning materials and computer-based tools that physicians can use to learn about the newest developments in their field. Most boards require physicians to self-administer tests to identify knowledge gaps, and to periodically complete patient safety self-assessment programs.
• Periodically participate in programs aimed at improving patient outcomes or demonstrating use of best practices. For example, a physician might pull data from case records for patients with a specific condition such as diabetes or asthma and submit the data to the board for evaluation. The board would issue a report comparing the physician’s practice patterns to national guidelines, developing a plan for improvements, and then measuring whether the improvements have worked. Another example of a target for self-evaluation might be physician-patient communication; a physician could conduct surveys of patients, use the results to guide quality improvement, and then re-survey to assess the extent of improvement.

Except for the exams testing knowledge and judgment for time-limited certifications, maintenance of certification typically is not dependent on the results—the scores—of assessment activities. It is enough that the physician performs the self-assessments, develops plans for improvement, and assesses the extent of improvement—regardless of how bad or good the physician appears in the assessments.

You can check whether any physician you are considering is board certified by accessing the Certification Matters website of the American Board of Medical Specialties, the umbrella organization for the 24 individual specialty boards. Physicians who are not board certified are not listed. For many specialty boards, the site also indicates whether physicians participate in maintenance of certification programs.

What useful information does the board certification system and ongoing maintenance of certification program provide to patients?

Unless you have a compelling reason to do otherwise, you may as well choose physicians who are board certified. But be aware that board certification is not a very discriminating measure. About 85 percent of physicians in the U.S. are certified.

Knowing how recently a physician has been certified or recertified is important, since there is substantial evidence that physician performance declines over time. Some of the specialty boards report initial and recertification dates on ABMS’ lookup website.

Although the diminishing number of physicians who were certified for life can, if they wish, seek voluntary recertification, not many have done so. Those who don’t recertify point to the cost, time required, risk of failure, and other factors. For the relatively few physicians with lifelong certification who have voluntarily become recertified, that diligence and self-scrutiny may be a meaningful indicator of quality.

Can specialty boards provide consumers with additional types of comparative information on individual physicians? Possibly.

First, boards could publicize physicians’ scores on the written exams of knowledge and judgment—or at least information such as “top 10 percent,” “top 25 percent,” or “top half.” While boards can’t report data that they have promised physicians would be kept permanently confidential, changes in confidentiality policies are possible in the future. And even in the near term, the boards could consider releasing scores for physicians who give permission for such release. Disclosure of test scores would certainly put physicians out ahead of most professions, few of which disclose personal test scores. And the advantage of releasing these scores is that they would reflect aspects of quality that other measures of physician performance may miss.

Second, the boards could work more with patient advocates and physician leaders to change the self-assessment process into one that would combine self-assessment and public assessment. Various efforts are already underway—led by government agencies, health insurance plans, employers, and consumer organizations—to increase public reporting of physician quality measures. For instance, claims data from Medicare, Medicaid, and private insurance plans are used to show whether a physician consistently administers all appropriate tests and treatments to diabetes patients. Large-scale national surveys of patients could be conducted to report how well doctors communicate. And specialty boards could measure and report on patient outcomes. Some of the specialty boards are involved in developing these types of measurement efforts, but few publicly report results for individual doctors. Overall, the boards should do far more to explore how data and analyses can improve public reporting of physician self-improvement progress.

If measures are to be useful for public reporting, they will have to be standardized and independently collected. To meet their maintenance of certification requirements, some boards allow physicians to self-select the cases they abstract for the specialty board to review—which they can cherry-pick to look good or include only patients likely to give good reports. There is not much harm in that when the data are being used only for self-assessment; worst case, a physician who gets a performance report back from the board might simply say, “Wow, I did that badly even though I was cheating.”

For public reporting, the system has to be free of potential manipulation or bias. For clinical measures, the specialty boards would have to work with health insurance plans, Medicare, and others to develop systems to collect data from medical records or claims records, for example. And for patient- and peer-survey measures, boards should use a nationwide standardized patient survey and standardized audited process for selecting patients to survey—so that the resulting measures can be used both for physician practice improvement and public reporting. Having forward-thinking specialty boards involved in the development of these measures could move the measurement process forward and ensure that measures are well-designed.

If the boards don’t get actively involved in public reporting efforts, however, remembering what is being done—and the progress that has been made toward continuing maintenance of certification—is still 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.

Because commitment to professionalism and the desire to help others—not public scrutiny—have traditionally been the most powerful forces for quality in healthcare, fostering these motivations would be a very good thing.