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Pay-for-Performance and Accountability

Christine K. Cassel, MD
[+] Article and Author Information

From the American Board of Internal Medicine, Philadelphia, PA 19106.


Potential Financial Conflicts of Interest: None disclosed.


Ann Intern Med. 2007;146(11):822-823. doi:10.7326/0003-4819-146-11-200706050-00018
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Use of Board Certification as Single Criterion of Competence or Quality is Wrong
Posted on June 6, 2007
Edward J. Volpintesta
No Affiliation
Conflict of Interest: None Declared

The author's opinions merit two comments. First, she seems to have forgotten that the determination of quality is solely the responsibility of the medical profession-- not of health insurers whose primary function is to make profits for shareholders. Thus, any initiatives by insurers in the realm of physician education or quality should be suspect. The pay for performance programs being touted by some insurers serve to fragment our profession. Clearly, they do not unite us. This should worry all doctors.

Second, board certification, at best can only determine a small part of a physician's competence and his or her total capacity and worth. The boards cannot measure how well a physician forms a therapeutic bond with his patients or how well he connects with them. Neither can they determine if a doctor is a good team player on the health team, how well he works to advocate for his patients, or how hard he tries to fit them in to a busy schedule. Furthermore they say nothing about how well he runs his office or if he participates in the affairs of his state and county medical societies, or in the medical affairs of his local hospital. The boards have serious limitations that should be obvious to all.

Yet for no good reason, the ABMS has amassed inordinate power amassed too much power, almost equaling that of state licensing boards since, not having them may keep a physician off of an hmo panel. Or stigmatize him. Clearly, not being boarded is rapidly becoming seen as a professional impropriety.

Besides, the board exams are costly and time- consuming. Some doctors either in preparation for the boards or because they have failed them, take board review exams. These too are costly and time-consuming. And assimilating information only to regurgitate it on an exam seems meaningless. Sort of like steroids before the Superbowl. And one wonders if those who don't take them are disadvantaged, making the whole testing process ineffective.

Board certification was intended to be a voluntary exam intended to demonstrate a level of academic knowledge above the minimum needed to practice competently. Usually those in academic and teaching positions had them for obvious reasons. They were never intended to infringe on a doctor's ability to make a living.

Doubtless, it is important for doctors to stay knowledgeable and competent. And the great majority do. But the boards are seen by many as out of sync with reality. Doctors will soon be more concerned with passing their tests than on actually being a good doctor.

To make things worse, the ABMS is offering further certifications in areas like palliative care and hypertension. Board exams seem to have become an end in themselves.

Perhaps the biggest flaw of the boards is their pass/fail approach. Ideally the boards should help physicians identify areas of weakness and offer remedial studying. Failing them serves no good purpose.

The AMA's AMAP test (which was defeated for political reasons not clearly explained in the medical literature), had a more comprehensive approach to a physician's competence because it took into account several important personal qualities that good physicians should have but which were overlooked in the ABMS exams. Physicians should have a choice of accrediting exams to sit for. Having only one is dangerous and harmful and places many doctors at risk of being ostracized or suspected of incompetence.

One wonders if the use of board certification as an indictor of competence is an over-reaction to the Institute of Medicine's 1999 report on patient safety, which has caused unnecessary public fear and mistrust of the medical profession in general.

The use of the boards by health insurers as measurers of competence and quality has several limitations and merits investigation. Not doing so is a mistake because in their current use they have great potential to harm physicians' livelihoods and reputations.

Conflict of Interest:

None declared

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