The Bogleheads On Board Certification

Dr BobbleheadMy wife saved this article on board certification for physicians by the Vanguard Bogleheads for me. I started writing a reply to post and was intending to register to get a login username and password and the whole nine yards. But I’m sure my reply was just too long. No moderator would have stood still for it. So I made it a blog post instead.

The original question asks if board certification would be best applied to a specific specialty rather than to doctors practicing general medicine.

There are many specialties and all align with their own specialty certification boards. I happen to be a board certified general psychiatrist and also hold a subspecialty certification in Psychosomatic Medicine, which means I also subspecialize in the field of providing consultation to my colleagues in medicine and surgery when they need help caring for patients with complex and comorbid psychiatric and medical illness.

There also seems to be a question here about how consumers should go about deciding whether a doctor who is board certified is superior to one who is not. That is further complicated by considering whether participation in Maintenance of Certification (MOC) makes a doctor even more competent.

If the main question is whether initial board certification and participation in MOC are markers for better doctors in order to find a good doctor, my opinion is that board certification might be a place to start. However, it’s far from clear whether board certification or MOC by themselves suffice to help a consumer find the best family doctor, psychiatrist, or surgeon.

When you’re in the process of deciding for yourselves what “good doctor” means to you and your family by examining who is listed in your insurance panel, checking with the state medical board to see who has a valid license to practice medicine, deciding what kind of health care you need the most, what qualities are most important (e.g., decent bedside manner, technical expertise), etc., where would board certification stand in the priority list?

As others have noted in the forum, lack of initial board certification is not necessarily a sign of incompetence. And there has been and continues to be a great deal of conflict between rank and file physicians and the American Board of Medical Specialties (ABMS) and the specialty certification boards regarding the utility of MOC. The ABMS sets the standard format of what MOC should include to theoretically ensure that physicians maintain their competence in their specialties.

But there is no high level evidence that MOC improves medical outcomes. Many physicians say that the requirements of Continuing Medical Education (CME) credits, Self-Assessments, Performance in Practice Clinical Modules and Feedback, and periodic secure Recertification Examinations are not better than CME alone and large organizations including the American Psychiatric Association (APA) call for major reforms (essentially returning to CME only) to which the boards are not agreeable.

Older physicians are “Grandfathered” meaning they are not required to participate in MOC, which makes no sense to many younger physicians because if anyone needs regular updating of their medical knowledge and patient care skills in a rapidly changing healthcare environment, it would be aging doctors.

So what should consumers do to check out their doctors? Ask them what they are doing to engage in the process of lifelong learning. If I were trying to choose my own doctor I would expect them to come up with more than just the pat reply, “Oh, I’m board certified.” Few of them would volunteer that they’re participating in MOC because many would feel less sure that patients would understand it—and may not feel confident they could explain it because it’s unnecessarily complicated.

See if they mumble, sweat, clear their throats a lot, or try to change the subject. Their ability to communicate clearly, calmly, and honestly without defensiveness about what they do specifically to stay current in their specialty not just to stay competent but to achieve excellence should arouse confidence. They may not participate in MOC or even be board certified.

But they may be checking the medical literature every day and tailoring the results of recent reviews and controlled studies to the special needs of their patients. True, many con artists can elicit confidence and the world of medicine is no different from society at large—crooks are everywhere.  Let the buyer beware. Many people spend more time shopping for a car than shopping for a family physician.

Obtaining objective information about doctors is difficult. At minimum you can check with the state medical board to see if there are any outstanding complaints about them. Often this information might be available on line. Talk with friends, neighbors, and coworkers about doctors they trust.

I would not put any faith in online rating sites, such as HealthGrades or Vitals which may publish hearsay complaints from persons who may or may not have a legitimate gripe.

Don’t let board certification be your only guide to a trustworthy and competent doctor. Shop around.

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Comments

  1. It’s noteworthy but not surprising that the Boglehead moderator killed the discussion thread that started this blog post with this comment:

    “I removed a number of posts, continuity is lost.

    As noted by the previous post, the discussion devolved into an all-out smack down on the uselessness of board certifications, qualification criteria, and challenges on the quality of peer reviewed articles.

    This thread has run its course and is locked.”

    It was not clear what the original question was and I assumed it was about how consumers should go about choosing a doctor based on board certification status. The reason it “devolved into an all-out smack down” on, among other items, board certification (read MOC here), is the overwhelming evidence against it as a reliable indicator by itself of physician competence.

    The moderator failed to see that what emerges from the thread is the inescapable sense that MOC is an inadequate embodiment of the principle of lifelong learning, which is a vital core competency for doctors.

    The point is that consumers need to find other criteria for choosing a physician. Furthermore, board executives need to acknowledge that practice-based learning and improvement can be, at best, encouraged and cultivated–not enforced.

    That is because the drive for excellence is an individualized “inside-out” pursuit.

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