Should Board Certification Organizations Have to Meet Particular Standards?

Should organizations that bestow board certifications be required to meet particular standards? That was one of the questions debated by members of the American Medical Association's (AMA) House of Delegates at its meeting this week.

The delegates discussed on Tuesday a resolution that would amend AMA policy to say that board certification programs "must first meet industry standards for certification that include both a process for defining specialty-specific standards for knowledge and skills, and [that] offer an independent, external assessment of knowledge and skills for both initial certification and recertification in the medical specialty."

The resolution, brought by the Congress of Neurological Surgeons and the American Association of Neurological Surgeons (AANS), largely passed, although one part was referred for further study.

Growing anger over the expense and difficulty of the maintenance of certification (MOC) process instituted by the American Board of Medical Specialties (ABMS) -- the dominant certification board -- sparked lawsuits and led to physicians pursuing alternative paths to MOC, like one from the National Board of Physicians and Surgeons (NBPAS), for example.

Many certifying boards beyond ABMS do set standards and grant physician certification based on independent assessment of knowledge and skills, but not all boards do this, "which diminishes the value of board certificates," argued Laura Stone McGuire, MD, alternate delegate for the AANS who spoke for the delegation.

"We believe this resolution is timely and prudent," she said. "Organized neurosurgery believes this improves existing AMA policy by clarifying the basic standards and principles embodied in specialty-specific board certification."

Not so fast, some delegates said. "We need to have a lot more study before we say that the NBPAS system is worthy of being killed," argued Ken Certa, MD, a delegate for the American Psychiatric Association (APA). "I think it needs more study than this [resolution] allows."

He moved to have the entire resolution referred to the AMA Board of Trustees for study and a report back.

Lee Tynes, MD, an alternate delegate for the APA who spoke for the Psychiatry Section Council, also argued for referral. "A fair number of my peers in the APA elected to go with NBPAS in response to maintenance of certification [requirements from ABMS]," he said. "It seems like this is indeed quite a complicated matter, and we support referral for study."

Frank Dowling, MD, who spoke for the New York delegation in favor of referral, added that, although that day's discussion revolved around the NBPAS, other alternative boards may also crop up. "Do these criteria fit fairly or are they helping to support the monopolies and excessive fees and all the other challenges we've worked hard in this AMA to fight back against?" he said.

In the end, the delegates voted narrowly -- 242-253 -- not to refer the entire resolution for study.

However, Certa then asked for the delegates to refer for study just the portion of the resolution that called for the AMA to "advocate for federal and state legislatures, federal and state regulators, physician credentialing organizations, hospitals, and other health care stakeholders ... to define physician board certification as establishing specialty-specific standards for knowledge and skills, using an independent assessment process to determine the acquisition of knowledge and skills for initial certification and recertification."

That amendment would mean that the AMA would lobby against what many psychiatrists have as their continuing certification, he said, suggesting it could further thin the ranks in an already small specialty. "This is not a trivial matter ... A lot of people who are currently board-certified in this way are not going to be able to practice," he said. "I'm sorry; I can't let this go without trying hard to get this referred so we can have a study of what the effects would be on my specialty and many other specialties."

Gregory Pinto, MD, speaking for the New York delegation, also argued in favor of referral of the one amendment. "The expensive and arduous process of ABMS maintenance of certification is a major source of the moral injury that causes physician burnout," he said. "We need to study this issue to get it right; we need to see the report back."

Anthony Geroulis, MD, a delegate from the American Academy of Cosmetic Surgery speaking on his own behalf, disagreed. "This is not a policy to pick on psychiatric friends of ours. This doesn't change anything for them," he said. "What it does is, it expands the opportunity for all the people here that [are] members in smaller organizations but qualified [via alternate] boards -- qualified with exams. This is not a question of paying $20 and getting a board certification; this is only respectable boards that qualify with all the things you have to do to become board-certified ... It does not change these other boards at all. I feel we should not be referring this and we should bring this to a vote."

Michael Carius, MD, a member of the Connecticut delegation who is also the current chair of the ABMS board of directors, too argued against referral. "Board certification in a given specialty is important in establishing a physician's competence to practice medicine in that specialty following the successful completion of a legitimate professional training program. Continuing certification is important in demonstrating continued competence in that specialty. Ultimately, both initial certification and continuing certification are equally important in enhancing the safety of medical care for patients and the public in general."

After the discussion, the delegates voted 340-145 in favor of referring that portion of the resolution, and passed the rest of it. The delegates will meet again in June 2023 in Chicago.

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