Sustaining Care in Crisis: COVID-19’s Impact on US Physician Board Certification

COVID-19 has collided with all sectors of American society, disproportionately affecting access to care for historically marginalized groups.^1,2  From the frontline, US physicians have had the unenviable responsibility of maintaining care standards across diverse communities and determining appropriate treatment strategies despite a paucity of information.³  Publicly and conflictingly described as both essential heroes and venal profiteers, physicians have held on through volatile trust while at the same time coping with canceled elective procedures and uncertain job markets.^4,5 

The COVID-19 pandemic tested the process by which newly trained physicians are certified into their respective specialties, a fundamental pillar of American medical care ever since the Flexner report of 1910 first argued the need for both defining and verifying increasingly specialized physician qualifications.⁶  Standardized core competencies are of particular importance to underserved populations. Discrepancies in physician board certification have been previously noted between rural and urban as well as African and European ancestry communities and may well be exacerbated by obstacles facing the certification process today.^7,8 

Annual board certification of physicians across a range of specialties is broadly recognized as “a mark of the ability to provide high-quality medical care,”⁹  with the ABMS serving as a national umbrella organization for 24 specialty boards. Although an overall shortage of US physicians is an established issue with proportionally greater need among minority populations,^10,11  there have until now only been anecdotal reports of the extent to which COVID-19 has changed the traditional certification process. Because of the real consequences these challenges may have on a healthcare system already under strain, it is necessary to shed light on the state of US physician board certification at the height of the pandemic.

The 24 board certification organizations listed under ABMS as participating US medical specialties were initially included in this study. Two of these, the American Board of Allergy & Immunology (ABAI) and the American Board of Colon and Rectal Surgery (ABCRS), were excluded given their strict prerequisite of completed training in internal medicine or pediatrics and general surgery, respectively. Data not readily available through ABMS or specialty board websites were acquired through a brief electronic survey conducted through the REDCap data capture platform.^12,13 

Survey participants were key administrators identified through each medical specialty board website and contacted via email by 1 of 2 physician investigators using a predetermined, standardized template. Those specialty boards not reached on first attempt were contacted up to 3 additional times. Deidentified data were aggregated to obfuscate specialty-specific variability and to assuage any professional concerns related to participation. Descriptive statistics were performed using Excel (Microsoft Corp, Redmond, WA). The study was determined to be exempt from human subjects’ research through the Beth Israel Deaconess Medical Center Institutional Review Board in Boston, MA.

Available ABMS data, shown in Figure 1, revealed that US annual first-time physician certifications fell from a total of 31723 physicians in 2019 to 23598 in 2020, before rising again to 38557 in 2021. The median number of first-time certifications across all specialty boards saw a steep decline from 550 (IQR, 249-1,853) to 332 (IQR, 86-615) between 2019 and 2020, or a decrease of 39.6%. Among the 22 specialty boards contacted by email and phone, 7 (31.8%) adequately completed the survey conducted from June through July 2021. The requirements, timeline, and costs associated with board certification vary substantially by specialty, with some requiring oral examination or case logs. Participating specialty boards required a median 4 years (IQR, 3.5-4.5 years) of postgraduate clinical training and 2900 USD (IQR, 2273-3600 USD) in overall certification fees (Table 1).

The survey group saw a total of 7825 new first-time certifications in 2020 compared with 7925 in 2019 (a decrease of 1.3%). Median first-time certifications, however, fell by 58 (11.0%) over the same period. Of the 11722 applicants originally scheduled for testing in 2020, 5426 (46.3%) had a component canceled or rescheduled due to the pandemic (Table 2). This finding was largely specialty dependent, with 1 specialty board suggesting that it had not canceled or rescheduled anyone because of COVID-19, while another reported doing so for 80.5% of its 2020 applicants.

Looking specifically at test dates rather than candidates, 132 dates were rescheduled while only 87 had been originally planned. This implies that some specialties introduced more testing dates than initially intended, presumably as a strategy to prevent COVID-19 transmission. Based on the applicant and test date counts provided in the survey, a median of 90 (IQR, 46-217) candidates were initially scheduled for each test date. Two of the responding specialty boards reported neither canceling nor rescheduling any certification exam dates, and, at the other end of the spectrum, 1 specialty board ultimately scheduled 2.9 times the number of exam dates originally intended.

In addition to exploring how COVID-19 influenced the scheduling of certification exam applicants and dates, survey data also provided a glimpse into the role new technologies played in the 2020 certification process. Four specialty boards endorsed newly incorporating a virtual format, affecting 2274 (19.4%) of all applicants. These specialty boards specifically saw a median 92.2% of 2020 candidates take part (IQR, 79.6-95.6%). One board indicated 100.0% of its 2020 candidates engaged in virtual assessments, of whom just 0.40% had an exam canceled or rescheduled. Only the smallest participating specialty, both by currently valid active certifications and annual new certifications, reported no cancelation, rescheduling, or virtual format for any of its applicants.

As the country ages and grows more diverse, a continued commitment to physician quality and accessibility is paramount. Available data suggest 2020 experienced a unique and profound decrease in overall first-time specialty certifications, yet each specialty board’s experience was unique.

One specialty board did not need to reschedule or cancel any testing, while another did so for 80.5% of its applicants. And, while 3 boards did not choose to incorporate a virtual component in 2020, 1 did so for all its candidates. In total, nearly half of the applicants had a testing date altered in 2020, yet the decrease in number of first-time certifications was ultimately modest. Certain specialties, either out of necessity or flexibility, were able to adapt quickly to meet their certification timeline. Further research is needed to understand why other specialties did not make such changes and what effect that had, if any, on the certification process.

Notable in the ABMS data, 4 specialty boards had no new certifications for the entire 2020 year: the American Board of Emergency Medicine (ABEM), the American Board of Medical Genetics and Genomics (ABMGG), the American Board of Otolaryngology -Head and Neck Surgery (ABOHNS), and the American Board of Thoracic Surgery (ABTS). ABMGG issues certifications every other year and had never intended to do so in 2020. It is striking that all 3 of the remaining boards were among the 11 requiring oral examination to achieve certification. Transitioning from traditionally in-person evaluation to a secure, remote format requires significant adaptation and resource utilization, all while maintaining process integrity. ABEM had far more 2019 certifications than ABTS and ABOHNS combined (2129 versus 117 and 313), which likely exacerbated its challenge in coordinating first-time certifications for this key specialty at the frontline of the pandemic.¹⁸  Tellingly, all 3 boards have since incorporated a virtual component. In contrast, the 3 participating specialty boards that were able to do so in 2020 for more than 90% of their candidates saw only a 3.50% rate of cancellation or rescheduling due to COVID-19.

It is notable that there was an increase in certifications in 2021. This rebound may have occurred as compensation for past delays or through process improvements as an adaptation to the restraints of testing during the pandemic. The emergence of a global pandemic in early 2020 posed an abrupt shock to existing certification mechanisms for which specialty boards were not immediately prepared. The American Board of Obstetrics & Gynecology (ABOG), for example, announced that, specifically due to the ongoing pandemic, candidates would be allowed to use an 18-month case list so as to meet volume minimums that were simultaneously lowered for the 2021 case collection year.¹⁴  Such relaxations in requirements were commonly seen across specialties, including forgiven fees, eligibility extensions, and rotation waivers.^15,16  These swift changes, while laudable attempts at mitigating adverse effects of the pandemic on professional careers and healthcare access, nonetheless raise significant questions on the ability to adequately adapt to the crisis at-hand without sacrificing physician competency. The concept of “crisis standards” in this way re-emerges as critical to how these specialty governing bodies can and should move to maintain the certification process for physicians, while recognizing the ethical implications doing so may have on patient care.¹⁷  While board certification in general has been linked to improved patient care and reduced disciplinary action,^19-21  the relevance to patient outcomes of in-person oral examination, let alone its virtual equivalent, remains to be shown. Merely meeting a predetermined annual certification quota should not alone be held as a kind of litmus test of the COVID-19 strategy employed, and these findings importantly do not address how changes in the certification process affected clinical outcomes, scoring, or even COVID-19 positivity among applicants. They were further limited by the number of specialty boards that were willing and able to partake, introducing a potential bias. Three boards were unable to provide sufficient data, 7 declined to do so, and 5 did not respond definitively within the study period. Notably, while public ABMS data show 5 boards were unable to issue any certifications in 2020, not 1 board that agreed to participate in this study was unable to do so. Furthermore, several boards required data request review processes, and 1 board’s participation would have been contingent on its own ability to review the conclusions drawn. Although incomplete and potentially biased participation precludes generalization to the broader physician certification system, this limited participation may itself suggest an ongoing influence of these logistical issues on board transparency and hesitancy within the pandemic context.

Steps must be taken to make the certification process more resilient. For the individual physician, board certification confers clinical validation, financial stability, and importantly the ability to contribute to and help advance their respective field. That these opportunities have been at risk for a substantial number of the country’s frontline workers is surely of moral importance. But from the broader perspective of a nation already facing dramatic, systematic barriers to health equity during an unprecedented healthcare crisis, alterations in the normal certification process likely exacerbate existing workforce gaps and risks. And, insofar as some physicians inevitably practice uncertified or certified under altered requirements, a potential decrease in care standards could become unsafe for the most at-risk patients. Future research directions must explore this question further, specifically looking at how various adaptations to the certification process might reduce existing access-to-care barriers that compound inequities in health across specialties and geographies.

2020 saw unprecedented change in the way physicians were newly welcomed into US clinical specialties. Data are insufficient to conclude causality, but the ability of boards to adapt to the COVID-19 pandemic with new testing modalities such as a virtual format may serve applicants in the future. Board certification exams are often only offered on an annual or semi-annual basis in pre-designated locations. Virtual testing offers an alternative approach to board certification by increasing accessibility for healthcare workers. In preparing for the future, medical governing boards must continue to develop innovative strategies able to sustain physician certification while safeguarding the quality of patient care, thereby conferring greater resilience to the healthcare system as a whole. Public health crises often require extraordinary measures to maintain the best possible care for patients despite limited resources, yet there is no resource more essential than qualified medical practitioners able to respond to an increase in need.

The authors comprise the College Student Committee of the Group for the Advancement of Psychiatry.