The growing emphasis on board certification in medicine in recent years has prompted studies on its impact on medical care. As analyses of the impact of board certification continue, the consequences of board certification status should be examined to evaluate its effect on physician practice characteristics. We studied the effects of board certification on the practice characteristics of general pediatricians, pediatric medical subspecialists, and pediatric surgical specialists and examined the impact of noncertification on Maintenance of Licensure (MOL) and state medical and osteopathic boards. The study utilized the subset of pediatrician respondents to the 2009 Association of American Medical Colleges (AAMC) Survey of Primary Care Physicians. This mail survey was fielded in three rounds in the second half of 2009. The adjusted overall response rate for the survey was 37.6%, but was 49.5% for pediatricians. Data were analyzed using SPSS 18.0. The study found that board certification status is significantly associated with key practice characteristics such as capacity, practice location, and hours worked, and there are differences in the practice characteristics of board certified versus non–board certified general pediatricians, pediatric medical subspecialists, and pediatric surgical specialists. Consequently, advocating for increased levels of board certification may have unanticipated implications for patient access to care. As the majority of pediatricians are board certified, workforce planners should consider and acknowledge these differences when engaging in planning initiatives, particularly in the context of Maintenance of Certification (MOC), MOL, and the expansion of access to care under the Affordable Care Act (ACA).
Board certification is predicted to become ever more crucial for practicing physicians.1 Many hospitals require physicians to become board certified at some point during their employment, and a number of health plans require that a physician be board certified in order to bill for services.2,3,4 Additionally, the American Board of Medical Specialties (ABMS) and its member organizations are strengthening their efforts to expand MOC.5,6,7,8 Furthermore, the Federation of State Medical Boards (FSMB) is placing increased weight on MOC in its recommendations for MOL at the state level.9,10,11
The possible consequences of board certification status, therefore, should be examined to evaluate their effects on physician practice characteristics. Furthermore, the implications of board certification status and resultant physician practice characteristics should be evaluated with respect to MOL and state medical and osteopathic boards, especially within the context of the ACA. A number of researchers have looked at the effects of certification on patient health outcomes,12,13,14,15 but few studies have addressed the effects of certification on physician practice characteristics. While we do not know definitively why some pediatricians choose to pursue board certification and others do not, this study represents an initial attempt to quantify the effects of board certification status, once it is achieved, on the practice characteristics of general pediatricians, pediatric medical subspecialists, and pediatric surgical specialists among a national sample of primary care physicians.
This study utilized the subset of pediatrician respondents to the AAMC 2009 Physician Survey on Primary Care, which was a random, stratified sample of 9,000 U.S. physicians from the American Medical Association (AMA) Physician Masterfile who had a primary specialty designation of pediatrics, family medicine, general practice, internal medicine, and obstetrics and gynecology. A small number of internal medicine subspecialties, pediatric medical subspecialties, and pediatric surgical specialties also were included in the sample. Goals of the original survey included capturing the impact of expanded coverage on primary care services and assessing the capacity (the ability or potential to treat additional patients) of the physician primary care workforce.
This mail survey was fielded in three rounds in the second half of 2009. The adjusted overall response rate was 37.6% for the Survey of Primary Care Physicians and 49.5% for pediatrician respondents. The total sample included 781 general pediatricians and 172 pediatric medical sub-specialists/surgical specialists. The survey was composed of 34 questions in seven sections, and included questions regarding work arrangements, activity levels, the Patient Centered Medical Home (PCMH), and primary care shortages. Questions were mixed and ranged from open-ended to fixed-choice and Likert scale (e.g., asking participants to provide numerical rankings).
Data were analyzed using SPSS 18.0. Statistical significance was tested using chi-square or F-test statistics as appropriate. Respondents were divided into four groups: board certified (BC) general pediatricians, non–board certified (NBC) general pediatricians, BC pediatric medical subspecialists/surgical specialists, and NBC pediatric medical subspecialists/surgical specialists.
Overall, 953 pediatricians completed the survey. Of the respondents, 497 (52.2%) were female (420 general pediatricians and 77 pediatric medical subspecialists/surgical specialists), and 456 (47.8%) were male (361 general pediatricians and 95 pediatric medical subspecialists/surgical specialists). Graduates of U.S. or Canadian medical schools comprised the largest number of respondents (744, or 78.1%), while 209 (21.9%) were international medical school graduates.
According to a Rural–Urban Commuting Areas (RUCAs) match of zip codes, 52 respondents (47 general pediatricians and five pediatric medical subspecialists/surgical specialists) were located in rural areas; 901 respondents (734 general pediatricians and 167 pediatric medical sub-specialists/surgical specialists) were not located in rural areas.
The following analyses were confined to the 884 currently active pediatricians, including 713 general pediatricians and 171 pediatric medical subspecialists/surgical specialists. Respondents were allowed to make more than one selection on the survey for ethnicity. Of the 884 currently active pediatricians, 669 (72.8%) were white, 42 (4.6%) were black/African American, 161 (17.5%) were Asian American, and 58 (6.7%) reported Hispanic, Latino, or Spanish origin. For the board certification analysis, an additional 13 respondents were excluded because they did not complete the board certification question.
There were noteworthy differences between BC and NBC general pediatricians and medical sub-specialists/surgical specialists in the following categories: practice location, working with nurse practitioners (NPs), panel size (the number of individual patients under the care of a specific physician) and patient wait times, time engaged in various activities, and hours worked. These data are provided in Table 1.
The four groups differed significantly in practice setting (x2=159.34, 15 df, p<.001). More BC general pediatricians reported working in a group pediatric practice or a multispecialty practice (49% and 13.6%) than did NBC general pediatricians (29.6% and 9.3%). Also, more BC pediatric medical subspecialists/surgical specialists reported working in a group pediatric practice or a multispecialty practice (12.1% and 11.3%) than did NBC pediatric medical sub-specialists/surgical specialists (4% and 4%).
BC and NBC general pediatricians and pediatric medical subspecialists/surgical specialists also demonstrated statistically significant differences in their working relationships with NPs (x2=17.82, 3 df, p<.001). More BC general pediatricians, for example, reported regularly working with NPs than did NBC general pediatricians (40.5% v. 22.2%). This finding appeared to be reversed for physician assistants (PAs), but the group differences were not statistically significant.
There also were statistically significant differences among the groups in terms of hours worked (F=12.38, 3 df, p<.001). BC general pediatricians reported working fewer hours per week than did their NBC colleagues (50 v. 53.9 mean hours per week), and BC pediatric medical subspecialists/surgical specialists reported working more hours per week than did their NBC colleagues (59.8 v. 43.3 hours). Interesting distinctions also were identified when full-time and part-time employment status was considered (x2=18.69, 3 df, p<.001). Fewer BC general pediatricians (78%) reported working full-time than did NBC general pediatricians (85.7%). However, a greater number of BC medical subspecialists/surgical specialists reported working full-time when compared to their NBC counterparts (91.7% v. 65.4%).
Panel Size and Patient Wait Times
Panel size and patient wait times are generally considered good indicators of physician workforce supply and patient need. Survey findings (see Table 1) showed that NBC general pediatricians reported more interest in significantly increasing their panel size (30.4% NBC v. 12.3% BC) (x2=25.16, 9 df, p<.01 for four groups). Wait times also varied significantly among the groups (x2=101.02, 15 df, p<.001). A larger percentage of NBC general pediatricians could see existing patients the same day the call was made for an appointment (54.5% NBC v. 48.1% BC). Existing patients of NBC general pediatricians were less likely to have to wait 15 or more days for an appointment (3.6% NBC v. 9.9% BC).
The Children's Hospital Association states that for children's hospitals, the benchmark for receiving a specialist appointment should be two weeks or less.16 The data in this study demonstrate that a larger percentage of NBC pediatric medical subs-pecialists/surgical specialists reported being able to see existing patients the same day (18.8% NBC v. 14.4% BC). However, 37.5% of NBC pediatric medical subspecialists/surgical specialists reported that existing patients must wait 15 or more days for an appointment, compared to 30.5% of their BC counterparts.
Percent of Time Engaged in Various Activities
Under the rubric of “various activities,” survey respondents could identify such endeavors as teaching, research, and administration, in addition to patient care. Of BC general pediatricians, 5.4% reported spending any percent of their hours in research, compared to 7.1% of NBC general pediatricians. Of pediatric medical subspecialists/surgical specialists, 41.7% of BC respondents reported spending any percent of their hours worked in research, compared to 28% of their NBC counterparts (x2=151.17, 3 df, p<.001).
The passage and phased implementation of the ACA, with its optional Medicaid expansion component, have prompted a closer examination of this country's ability to provide timely access to care for an increasing number of Americans. As one goal of the AAMC 2009 Survey of Primary Care Physicians was to assess the capacity of primary care physicians, we can identify several interesting trends regarding practice characteristics that may have implications for the future and for the implementation of MOL. Specifically, an increased focus on board certification may have unexpected and unintended effects on patient access to care when viewed in the context of the ACA.
Board certification is an important credential for many practicing physicians and is predicted to become more important in the near future.1,17,18,19 Section 3002 of the ACA modified the Physician Quality Reporting Initiative to include bonus payments for those physicians who report data to the Centers for Medicare and Medicaid Services (CMS) through an MOC program.20 Also, in order to obtain or maintain hospital privileges, many institutions require that a physician be board certified — if not initially, then at some point during his or her employment.21 Additionally, a number of insurers require proof of board certification before a physician may bill for services.22 Furthermore, several large insurers offer bonuses to those physicians enrolled in MOC.23 It is therefore credible to posit that employers, payers, and the federal government are viewing board certification as a proxy for high-quality, safe, and efficacious care.
If the selected plans in the new federal health insurance marketplace and the state health insurance exchanges now, or in the future, are open only to those physicians who are board certified, or if those plans make participation by board certified physicians easier, this may negatively impact patient access to care and reduce physician capacity to treat newly insured individuals. The ABMS has posited and presented preliminary data supporting the claim that the care provided by BC physicians is of higher quality than that provided by NBC physicians.24,25 This may be partially accounted for by the fact that the NBC pediatricians in this study are more likely to report working in solo practices and are therefore less likely to interact with colleagues and absorb new knowledge through this type of contact on a regular basis. If concerns regarding quality of care continue to trend, MOL may be able to offset any identified imbalance.
MOL, an initiative led by the FSMB, “is a system of continuous professional development for physicians that supports, as a condition for license renewal, a physician's commitment to lifelong learning that is relevant to their area of practice and contributes to improved health care.”26 MOL's three core components are reflective self-assessment, assessment of knowledge and skills, and performance in practice. While MOL is not the same as MOC, the certification process managed by member boards of the ABMS, it is expected that participation in MOC will generally lead to compliance with states participating in the MOL initiative.
According to data from the AMA Physician Masterfile for the year 2011, the most recent year for which data is available, 25.1% of all active general pediatricians and 15.6% of active pediatric medical subspecialists/surgical specialists were not board certified.27 In terms of actual numbers, this translates to more than 14,700 active general pediatricians and almost 3,300 active pediatric medical subspecialists/surgical specialists. Interestingly, the data generated by this study suggest that it is this subset of the physician population that has the greater capacity to accommodate the influx of new patients predicted by the implementation of the ACA.
NBC general pediatricians reported more interest in significantly increasing their panel size (30.4% NBC v. 12.3% BC). Also, NBC general pediatricians reported working more hours per week than BC general pediatricians (53.9 mean hours NBC v. 50 mean hours BC). This distinction may become more significant as work-force planners look at pediatricians' capacity to take on more patients and study whether lack of board certification is an impediment to increasing said capacity.
Furthermore, the current administration's focus on enhanced access to primary care through the ACA highlights the importance of examining the amount of time pediatricians report spending directly with patients, providing primary care. Fifty percent of NBC general pediatricians reported spending 100% of their time in primary care, compared to 42.8% of BC general pediatricians.
Using patient wait time as a proxy for access, survey results show that higher percentages of NBC general pediatricians and pediatric medical subspecialists/surgical specialists were able to see existing and new patients the same day an appointment is requested when compared to their BC counterparts (see Table 1). Also, only 7.4% of new patients of NBC general pediatricians must wait 15 or more days for an appointment, compared to 13.7% of new patients of BC general pediatricians. Only 3.6% of existing patients of NBC general pediatricians must wait 15 or more days for an appointment, compared to 9.9% of existing patients of BC general pediatricians.
Studies have found that length of time from initial training may affect clinical competence.28,29 Continuing educational opportunities and professional development, such as that offered by MOC programs, are intended to address such issues and provide transparency to the public regarding the preparedness of the nation's physicians. But MOC programs do not reach all practicing physicians. If the influx of previously uninsured (and often less healthy)30 individuals is disproportionately absorbed by NBC physicians, it will be of paramount importance to ensure that these physicians have the requisite skills, based on current medical knowledge, to treat them. State medical and osteopathic boards can play a pivotal role in maintaining the public trust by guiding NBC physicians toward education, resources, and training opportunities via MOL programs, thereby helping these physicians demonstrate continued clinical competence and ensuring that all populations, especially those deemed vulnerable, receive optimal health care.
The reported findings are specific to pediatrics and may not be translatable to adult medicine. Also, the survey was fielded primarily to general pediatricians and to a relatively small number of pediatric medical subspecialists and surgical specialists; a larger sample size would be desirable despite the statistically significant differences revealed by these analyses.
The study did not attempt to quantify hours worked using a standard definition for “part time” or “full time,” since there is great variability in the use of those terms. The data is not robust enough to clearly allow us to make inferences based on part-time versus full-time status. The study also did not explore the impact of lifestyle factors, such as the decision to reduce working hours based on raising a family or age. Additionally, the findings from this survey do not specifically identify why there is a difference in practice characteristics between BC and NBC pediatricians. Furthermore, a changing economic climate and the partial implementation of health care reform may have affected pediatricians' self-reported intention or ability to increase their workload capacity.
Major workforce shortages have been reported in many of the pediatric medical subspecialties and surgical specialties,16 ,31 ,32 and maldistribution of general pediatricians remains a challenge.33 Patient access to care and the capacity of pediatricians to take on new patients, especially with the Supreme Court decision to uphold key pieces of ACA (and the optional Medicaid expansion plan), are therefore of newly urgent importance to pediatric patients, patient advocates, general pediatricians, pediatric medical subspecialists/surgical specialists, and health workforce planners alike.
Board certification has long been considered a key indicator of physician quality and competency, and individual physician specialty societies have risen to the challenge of providing high-quality, ongoing education to meet the needs of BC physicians and promote patient safety. As not all physicians participate in the board certification process, however, state medical and osteopathic boards are in a unique position to provide opportunities for self-assessment and clinical skills enhancement in order to ensure the delivery of safe, efficacious patient care.
Although the ACA is not the sole driver determining demand for care, this landmark legislation will have a significant impact on the provision of health care, and its implementation raises unanswered questions about access to that care and the workforce that will provide it. To this discussion, our research adds new findings regarding the different practice characteristics between BC and NBC general pediatricians and pediatric medical subspecialists/surgical specialists. If MOL becomes widely accepted, it is possible that NBC physicians would have greater access to additional employment options, health plans, and practice sites. This may, in part, address some of the physician availability concerns raised by the implementation of the ACA. In this scenario, MOL has the potential to become a guiding influence and shape future deliberations about the physician workforce.
About the Authors
Carrie L. Radabaugh, MPP, is Senior Health Policy Analyst in the Division of Workforce & Medical Education Policy, American Academy of Pediatrics.
Holly Ruch-Ross, ScD, is Research Consultant for the Division of Workforce & Medical Education Policy, American Academy of Pediatrics.
Kelly J. Towey, MEd, is Program Consultant for the Division of Work-force & Medical Education Policy, American Academy of Pediatrics.
Holly J. Mulvey, MA, is Director of the Division of Workforce & Medical Education Policy, American Academy of Pediatrics.