With more doctors failing re-certification tests, questions arise over the use of board exams as a measure of physician quality.
By Jay Greene, AMNews staff. July 31, 2000.
An increase in the failure rate for board recertification in family practice and in some internal medicine subspecialties has elevated concern among physicians who have seen colleagues without certification lose managed care contracts and the prestige associated with the higher professional recognition.
In 1999, failure rates for recertification in family practice increased to 8% from 4% in 1998. Failure rates for general internists and obstetrician-gynecologists have remained steady at about 10% and 4%, respectively. But when 11 internal medicine subspecialties are added, overall internal medicine failure rates for recertification — including those physicians who failed and then retested — increased to 11% this year from 7% in 1999.
Price of failing can be high
Although there are numerous reasons why physicians fail boards, one disturbing truth remains: Board certification means a lot more now than originally intended.
Physicians who are board certified have greater access to managed care contracts and hospital privileges in competitive markets. Large clinics sometimes demand board certification as a condition of employment. And board-certified physicians also can more effectively present themselves to the public through marketing and advertising vehicles, including online physician “report cards.”
The bottom line is: Physicians can earn more money if they have board certifications.
“[Losing certification] could devastate a practice, bankrupt an individual and create havoc in underserved areas,” said J. James Rohack, MD, a cardiologist in Temple, Texas, and a member of the AMA’s Council on Medical Education. “Every one of my colleagues sweats bullets before recertification tests.”
In small towns, managed care organizations that require board certification can destroy relationships between patients and physicians.
“I know one doctor who is retiring after 32 years because he can’t pass the boards,” said John Van Etta, MD, an internist and president of the Minnesota Medical Assn. “Managed care payers used to allow doctors on their panels if they were board eligible. Now they are requiring doctors to be board certified. It is eliminating a lot of very qualified doctors. I get calls all the time from doctors who can’t pass boards.”
So does Robert Avant, MD, executive director of the American Board of Family Practice.
“Doctors call me and say, ‘You are to blame for me losing my job.’ I say, ‘I am not, it is managed care,’ ” Dr. Avant said. “Every day I deal with doctors who are distressed because they failed the test or couldn’t take it.”
Physician groups are opposed to the use of board certification as the sole criterion in credentialing.
But the Assn. of American Health Plans acknowledges that some HMOs require board certification as a marketing tool. AAHP officials, however, say exceptions are made sometimes if patient access to physicians is jeopardized.
“With time-limited certificates, every day doctors lose their right to practice because they are not board certified. But we can’t lower our standards,” Dr. Avant said.
The test is offered once a year. To guard against failure, sickness or a freak event like a missed plane, 50% of family physicians take boards a year before their seven-year certification expires, Dr. Avant said.
Still, about 275 family physicians lost their certification in 1999. During the past 10 years, the range of recertification failure has been 3% to 5%, making the 8% failure rate in 1999 all the more perplexing, Dr. Avant said. “We haven’t made it harder,” he said.
But Dr. Avant added that test scores decline as family physicians become more specialized. “As a practice gets narrowed, physicians become weaker in certain areas,” he said.
For example, a family physician who has specialized in pediatrics might not be as current in gynecology or geriatrics, Dr. Avant said.
Meanwhile, overall failure rates for general internists have ranged between 10% in 1996 and 13% in 2000. When such subspecialties as endocrinology, infectious disease, nephrology and rheumatology, which all scored 100% pass rates, are included, overall failure rates improved to 7% in 1999. But only endocrinology and rheumatology scored 100% in 2000, leading to an increase in overall failure rates to 11%.
“We don’t believe the changes in pass rates are significant,” said Daniel Duffy, MD, executive director of the American Board of Internal Medicine.
Norman Gant, MD, executive director of the American Board of Obstetrics and Gynecology, said few diplomates lose certification because the basic exam is offered three times a year. Physicians also have the option of renewing every year by reading materials and taking home tests.
“If they do not do well on the written exam, it is because of stress or problems at home,” Dr. Gant said. “Some others haven’t prepared and applied themselves.”
But an estimated 15% to 20% of licensed physicians are ineligible to take boards either because they were trained in another country or they didn’t complete their residency.
Income-cutting problem
Michael DeBevec, MD, a family practice-trained physician in rural Minnesota, has been practicing medicine for 23 years, specializing in sports medicine for the past seven.
Business was booming until UnitedHealthcare, a Minneapolis-based HMO, required Dr. DeBevec to be board certified in sports medicine to be reimbursed at the higher specialty rate.
But Dr. DeBevec is ineligible to become board certified because he did not complete his three-year family practice residency. “I had two little kids and I needed to start my practice,” he said. “I knew this was going to happen one day.”
Dr. DeBevec’s income dropped “dramatically overnight,” he said. “Dollars are determining medical practice nowadays,” said the 49-year-old physician. “Certification does indicate some degree of quality, but it has made it impossible for me to be paid for my expertise in sports medicine. My patients don’t understand it.”
Neither do physicians.
“The business of medicine has decided that board certification is necessary for payment,” Dr. Van Etta said. “There are many other factors to consider when considering the competence of a physician: professionalism, clinical judgment, ethical behavior and compassion. Passing a test does not make a good physician.”