Re: Future of Board Certification in a New Era of Public Accountability
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* Martin Donohoe

*To the Editor:* Dr Weiss’1 article wisely calls for continuous modification of the board certification process to meet the needs of physicians and the general public. I believe that obtaining and maintaining certification should be required for licensure of all physicians.

In my field of internal medicine, those physicians who became board certified after 1992 (myself included) are required to recertify every 10 years at significant cost (currently $1,570).2 Ironically, those who created this policy do not have to recertify, unless required to do so by their employers. Given the costs associated with recertification (recertification fee plus time lost from work or vacation to take the examination), this amounts to a regressive tax, since it falls more heavily on younger physicians who have spent fewer years in practice and may have lower incomes and higher educational debts.

In addition to being fair, requiring recertification for all practicing physicians may improve quality of care. One study found some evidence that physicians who had graduated from medical school more than 20 years ago were more likely to score in the lowest quartile on the Maintenance of Certification examination for internal medicine and do worse on some performance measures for Medicare patients.3 In a systematic review of data relating experience and age to physician performance, 70% of studies demonstrated a negative association between length of time in practice and several measures of good physician performance.4 It would be interesting to know how many academic medical centers require their more senior faculty to maintain board certification, given that these institutions function as leaders in education and policy.

Furthermore, consideration should be given to creating a national medical license. Having obtained a number of state licenses over the years myself (consequent to brief locum tenens stints between residency and fellowship), the process of licensing by state boards places a financial burden on physicians (separate fees for each state) and creates a large administrative burden. Having separate state licensing boards may not efficiently root out bad physicians who leave one state under a cloud of suspicion only to have their trails of malfeasance rooted out later because state reports regarding physicians who have been disciplined for unethical and/or illegal activity are not always readily available to other states or to the general public,5 even since the establishment of the National Practitioner Data Bank.

## Notes

*   The above letter was referred to the authors of the article in question, who offer the following reply.

## References

1.  Weiss KB. Future of board certification in a new era of public accountability. J Am Board Fam Med 2010; 23(Suppl 1): S32–9.
    
    [Abstract/FREE Full Text](http://www.jabfm.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NToiamFiZnAiO3M6NToicmVzaWQiO3M6MTc6IjIzL1N1cHBsZW1lbnQvUzMyIjtzOjQ6ImF0b20iO3M6MjI6Ii9qYWJmcC8yMy81LzY4Ny4xLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

2.  American Board of Internal Medicine. ABIM Maintenance of Certification exam schedule. Available at [http://www.abim.org/exam/schedule-moc.aspx](http://www.abim.org/exam/schedule-moc.aspx). Accessed 30 October 2009.
    
    

3.  Holmboe ES, Wang Y, Meehan TP, et al. Association between maintenance of certification examination scores and quality of care for Medicare beneficiaries. Arch Intern Med 2008; 168: 1396–403.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.1001/archinte.168.13.1396&link_type=DOI) 
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=18625919&link_type=MED&atom=%2Fjabfp%2F23%2F5%2F687.1.atom) 

4.  Choudhry NK, Fletcher RH, Soumerai SB. Systematic review: the relationship between clinical experience and quality of health care. Ann Intern Med 2005; 142: 260–73.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.7326/0003-4819-142-4-200502150-00008&link_type=DOI) 
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=15710959&link_type=MED&atom=%2Fjabfp%2F23%2F5%2F687.1.atom) 
    
    [Web of Science](http://www.jabfm.org/lookup/external-ref?access_num=000227239500004&link_type=ISI) 

5.  Larson M, Lurie P, Marcus B, Wolfe S. Survey of state medical and osteopathy board disciplinary web sites in 2006. Health Matrix Clevel 2009 Winter; 19: 121–36.