Board Certification Varies With Demographics, Education

September 6, 2011 — Specific demographic and educational factors are associated with board certification of physicians. These include race and education debt, according to a study published in the September 7 issue of JAMA.

Certification by an American Board of Medical Specialties member board is an important credential, and it is becoming increasingly common. Previous studies have shown better outcomes in patients who are in the care of board-certified physicians, and health maintenance organizations, hospitals, and insurance plans use board certification as an evaluation tool for physicians.

Donna B. Jeffe, PhD, and Dorothy A. Andriole, MD, both from Washington University School of Medicine, St Louis, Missouri, investigated how demographic, medical school, and graduate medical education were associated with American Board of Medical Specialties board certification. They conducted a retrospective study of a national cohort of 42,440 medical students who graduated from US medical schools between 1997 and 2000. Participants were followed up through March 2, 2009.

Of the participants, 37,054 (87.3%) were board certified. The researchers found that board certification was associated with first-attempt passing scores in the highest tertile (compared with those who failed on the first attempt) on US Medical Licensing Examination Step 2 Clinical Knowledge. This trend held true in all physician categories. The lowest adjusted odds ratio (AOR) was found in emergency medicine (87.4% vs 73.6%; AOR, 1.82; 95% confidence interval [CI], 1.03 - 3.20). The highest was found for radiology (98.1% vs 74.9%; AOR, 13.19; 95% CI, 5.55 - 31.32).

Participants who self-identified as underrepresented racial/ethnic minorities had a lower likelihood of being board-certified — a trend that held for every physician category except family medicine. The percentage in pediatrics was 83.5% (vs 95.6% of whites; AOR, 0.44; 95% CI, 0.33 - 0.58). In other nongeneralist specialties, the percentage was 71.5% (vs 83.7% in whites; AOR, 0.79; 95% CI, 0.64 - 0.96).

Increased debt also had an effect. Among obstetrics/gynecology specialists, every $50,000 stepped increase in debt was associated with a lower likelihood of board certification (AOR, 0.89; 95% CI, 0.83 - 0.96) compared with those who had no debt. The reverse was true among family medicine specialists (ie, family practitioners with higher educational debt were more likely to be board certified; AOR, 1.13; 95% CI, 1.01 - 1.26).

The authors noted that the observational nature of the study makes it impossible to assign causal associations, and longer follow-up times may increase the rates of board certification. The results also cannot be applied to osteopathic physicians or students at international medical schools.

"Nevertheless, our findings can inform an understanding of factors contributing to US medical school graduates' advancement along the medical education continuum to board certification, an outcome of interest for medical school graduates, their patients, and the relevant professional organizations involved in undergraduate medical education, [graduate medical education], and board certification," the authors write.

The study was supported by the National Institutes of Health National Institute of General Medical Sciences. The authors received travel funds from the National Institutes of Health for meeting attendance. One author received an honorarium and travel reimbursement from the University of Cincinnati supporting a lecture on MD-PhD programs and their graduates.

JAMA. 2011;306:961-970.