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Board certification and why it matters


As any doctor, and I guarantee they will say two things about board certification:

  1. Maintaining their certification is a hassle and doesn’t add or mean much

  2. They would not let their family members see a physician who’s not board certified


At first glance, these are two contradictory statements. To be a mid-career, board-certified physician requires maintaining certification. The requirements for maintaining certification vary by specialty, but most involve submitting proof of continuing medical education courses, a quality project, and some kind of testing component (anything from quizzes every three months to a big test every 10 years). I think most physicians feel like they would keep up in their field without the pressure of having to then submit that paperwork for certification just so they can fulfill their original intent of being a good doctor. The submission process is often cumbersome and takes effort to keep track of.


The testing component may have questions that, for many very specialized physicians, are completely inapplicable since the tests tend to be for specialities (like internal medicine) rather than subspecialties (like cardiology). So you have a cardiologist who hasn’t treated a patient with a urinary tract infection in over thirty years trying to answer a question about which antibiotic to choose.


The quality component is a relatively recent addition to the Maintenance of Certification programs that tries to encourage physicians to pursue a quality improvement program in their practices. These vary widely in rigor depending on the specialty. Some specialties’ requirements require a the physician to lead a project, submit it for approval, and then demonstrate results over a year or more, and others simply require the physician to attest that s/he has been part of a committee that worked on a quality project.


There has been a notable physician backlash to these MOC programs in the past several years, involving several lawsuits related to anti-trust law, as well as a general sense that maintaining certification (a practice only in place for about the past 30 years) is an expensive hassle. Several specialty boards have changed their approaches during that time. For example, the American Board of Anesthesiology changed from a proctored test every 10 years to a quiz every 3 months, in part to help push out new information (like information on COVID) to their members. Several studies have shown that the MOC portion does not improve patient outcomes. The boards that administer the MOC programs, though, continue to defend the program, saying that they have a responsibility to ensure their members’ knowledge remains current.


If many physicians don’t feel that MOC programs are that important, why would they insist on a board-certified physician for their family members?


That’s because initial certification is an entirely different process from ongoing certification.


This process often is seen as “weeding out” weak physicians. There are certainly good arguments that the initial board certification process is not the best one as it misses many of the crucial “soft” skills needed to be a good physician, but it remains a yardstick for ensuring a minimum level of medical knowledge in a specialty.


Initial certification processes vary by specialty, but all of them involve a long, detailed exam, often called the “written board”. Many of them require oral boards as well. This means candidates have to fly to a different city, go into a hotel room, and discuss patient management with experts in the field. Often there are case scenarios presented to the candidate, and s/he has to talk through the concerns, possible diagnoses, next steps, mechanisms of drugs, and anything else the interviewer wants to ask. The interviewer is trying to understand the candidate’s thought process and knowledge base for the field. The candidate is trying to survive an extremely high-stakes and stressful situation. In surgical specialities, the process often involves the interviewers asking about specific surgeries the candidate has performed over the first year or two of practice, with questions about why a certain approach was chosen or what the cause of a complication was.


It’s very difficult to get hospital privileges if you’re not board-certified, since the board-certification acts as kind of a screening process. However, it’s not required for state licensure. So you can start your own clinic if you aren’t board-certified and that is completely legal, and you also won’t have the oversight of complications that you would have in a hospital situation. Many “doc in a box” or urgent care clinics also don’t require board certification.


In summary, the medical community believes that initial certification is valuable, while the ongoing certification requirements are more debatable. But at least for now, you have to do the MOC to demonstrate that you passed the initial certification, so it remains a valuable benchmark.


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