PEDIATRICS Vol. 121 No. 4 April 2008, pp. 711-717 (doi:10.1542/peds.2007-1956)
ARTICLE |
Characteristics of General and Subspecialty Pediatricians Who Choose Not to Recertify
a Child Health Evaluation and Research Unit
b Division of General Pediatrics, University of Michigan, Ann Arbor, Michigan
c American Board of Pediatrics, Chapel Hill, North Carolina
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ABSTRACT |
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OBJECTIVE. The goal was to determine the reasons given for nonparticipation in maintenance of certification by general pediatricians and pediatric subspecialists whose board certification had expired.
METHODS. All United States-based pediatricians whose board certification had expired and who had not recertified as a generalist or subspecialist in 2004 or 2005 were surveyed. The total sample included 1001 pediatric generalists and 1237 subspecialists. We conducted a mail survey study, with a total of 3 mailings to nonrespondents. Analyses initially were conducted separately for generalists with expired certificates, subspecialists with active subspecialty but expired general pediatrics certificates, and subspecialists with expired subspecialty certificates (regardless of their general pediatrics certification status).
RESULTS. The overall response rates were 68% for generalists and 76% for subspecialists. Of pediatricians who had allowed their certificates to expire, the majority still intended to recertify (65% of the generalists and 86% of the subspecialists, in their primary subspecialty). The most common reasons cited by the 35% of generalists with expired certificates who were not planning to participate in maintenance of certification were the expense, the time required to complete maintenance of certification, and the perceived lack of relevance to their current practice. The 14% of subspecialists who were not planning to recertify in their primary subspecialty most commonly cited the expense, a change in career path making recertification unnecessary, and the time required.
CONCLUSIONS. Although the physicians in this study had allowed their certificates to expire, they still overwhelmingly believed that physicians who provide direct patient care should maintain their certification. There was general consensus among our respondents regarding the professional value to patients and peers of participation in the maintenance of certification program.
Key Words: professional attitudes • certification • participation • credentials • physician practice patterns
Abbreviations: ABP—American Board of Pediatrics • MOC—maintenance of certification • ActSS—active subspecialty • ExpGP—expired general pediatrics • ExpSS—expired subspecialty • ActGP—active general pediatrics
The American Board of Pediatrics (ABP) was founded in 1933 to establish standards and to certify the competence of physicians who provide care for children. For 54 years, certificates granted by the ABP were valid for the entire professional life of a pediatrician (permanent certificates). In 1988, the ABP joined several other specialty boards and began issuing time-limited certificates. These certificates require renewal every 7 years to maintain the status of a board-certified pediatrician. Pediatricians certified before 1988 are not required to recertify to maintain their certification status.
The process through which recertification takes place has undergone changes since the first recertification examinations in 1994. Most recently, the ABP has joined the other 23 approved medical specialty boards in adopting a maintenance of certification (MOC) program. The pediatrics MOC program includes a proctored (secure) examination, clinical performance assessments, demonstration of lifelong learning and self-assessment activities, and assessments of professionalism. Such activities have been put in place to conform to the 6 competencies that define quality medical care, as promulgated by the American Board of Medical Specialties, that is, (1) medical knowledge, (2) patient care, (3) interpersonal and communication skills, (4) professionalism, (5) practice-based learning, and (6) systems-based practice.1
Some physicians have chosen not to enroll in the MOC program. Of general pediatricians whose certification expired in 2004, 86% participated in recertification. For subspecialists, 88% participated. Although this represents a significant majority, a small but meaningful proportion of both generalists and subspecialists are not participating in MOC, despite data demonstrating patient preferences for board-certified physicians.2,3 Furthermore, with increased attention being placed on patient safety issues, it is likely that hospitals and health plans will increasingly require that their credentialed physicians participate in MOC.
Although one previous study sought to investigate the issues surrounding the decision not to participate in MOC, it was limited to general internists and internal medicine subspecialists.4 It is not known whether those findings are generalizable to other specialties. Therefore, we sought to determine the reasons given for nonparticipation in MOC by general pediatricians and pediatric subspecialists whose board certification had expired.
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METHODS |
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Sample
The ABP maintains a database of all physicians who are certified as generalists or subspecialists within the field of pediatrics. The list includes all those who have ever been board-certified and notes whether their certification is current or has expired. To examine the factors associated with nonparticipation in MOC, we selected the complete list of United States-based pediatricians whose certification had expired and who had not recertified as a generalist or subspecialist in 2004 or 2005. The total sample included 1001 pediatric generalists and 1237 subspecialists. These subspecialists might have had either an expired general pediatrics (ExpGP) certificate or an expired subspecialty (ExpSS) certificate. The ABP does not require subspecialists to maintain certification in general pediatrics to maintain their subspecialty certificate.
Survey Instrument
We developed 2 structured questionnaires, 1 for generalists (9 items) and 1 for subspecialists (11 items). Both were designed to be completed in 
5 minutes. The surveys focused on reasons for participation or nonparticipation in the MOC program, exploring board certification and MOC requirements by employers and attitudes regarding MOC. Questionnaires were composed of a mixture of fixed-choice, Likert-scale, and open-ended questions. The subspecialist questionnaire was identical to the generalist questionnaire with the exception of 2 additional questions regarding subspecialty recertification.
Questionnaire Administration
The first mailing of questionnaires was sent via Priority Mail in August 2006. The survey packet contained a personalized, signed, cover letter, the instrument, a business mail reply envelope, and a $5 bill as an incentive. Two additional mailings were sent to nonrespondents, in October and November 2006.
Data Analyses
Initially, analyses were conducted separately for generalists with ExpGP certificates, subspecialists with active subspecialty (ActSS) but ExpGP certificates, and subspecialists with ExpSS certificates (regardless of their general pediatrics certification status). First, frequency distributions were calculated for all survey items. Next, comparisons were made between generalist respondents who were working in the field of pediatrics and those who were not working in the field but indicated that they might return in the future. Similar comparisons were not calculated for subspecialists because there were too few respondents who reported not currently working in the field of pediatrics. The 
2 statistics were used to determine the level of association between the outcome variables and the predictor variables within the generalist population and, subsequently, the items common to both the generalist and subspecialist surveys.
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RESULTS |
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Response Rates
Generalists
Of the initial 1001 surveys mailed to physicians with ExpGP certificates, 234 were returned as undeliverable, 248 physicians did not respond, and 519 physicians responded. This yielded an overall response rate of 68%. Of the 519 respondents, 90 physicians were ineligible because of retirement or because they were not currently working in pediatrics and did not plan to in the future. Therefore, the final sample for analysis was 429. Not all respondents answered every question.
Subspecialists
Of the initial 1237 surveys mailed to subspecialists, 172 were returned as undeliverable, 261 physicians did not respond, and 804 physicians responded. This yielded an overall response rate of 76%. Of the 804 respondents, 43 physicians were ineligible because of retirement or because they were not currently working in pediatrics and did not plan to in the future. Therefore, the final sample for analysis was 761; of those, 586 had ActSS/ExpGP certificates and 175 had ExpSS certificates with either active general pediatrics (ActGP) or ExpGP certificates. Not all respondents answered every question.
Physician Employment Characteristics
Employment characteristics of the respondents are presented in Table 1. Among respondents with ExpGP certificates, 56% were either self-employed or employed by a private group, whereas 20% were employed by an academic health center. Respondents with ActSS/ExpGP certificates were employed primarily by academic health centers (54%). Respondents with ExpSS certificates were employed most commonly by private groups (36%) or academic health centers (36%). Most general pediatrician (85%) and subspecialist (81%) respondents reported that they spent the majority of their professional time in clinical practice.
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Institutional Certification Requirements
Among the surveyed physicians with ExpGP certificates, fewer than one third reported general pediatrics MOC requirements from academic health centers, health maintenance organizations, insurance plans, medical groups, or any hospitals. Among pediatric subspecialists, significant differences were seen among those who had ExpSS versus ActSS certification. Respondents with ExpSS certificates were more likely to be required by institutions to maintain their general pediatrics certification (Table 2). In contrast, respondents with ActSS/ExpGP certificates were more likely to report institutions, insurance plans, and hospitals requiring subspecialty MOC (Table 3).
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MOC Participation
Planned General Pediatrics Certification
The majority of general pediatrician respondents (65%) planned to participate in general pediatrics MOC at some point in the future. However, only 46% of respondents with ExpSS certification and 29% of those with ActSS/ExpGP certification (P < .0001) planned to participate in general pediatrics MOC (Table 4).
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Respondents who planned to recertify were asked to select
1 reason why they had participated or planned to participate in general pediatrics MOC. As shown in Table 4, some factors associated with participation were similar among generalists and subspecialists. Generalists who planned to recertify cited maintaining or improving professional image (63%), updating knowledge (58%), MOC requirements for privileging (48%), and personal preference (48%) as the top factors influencing their decisions. Respondents with ActSS/ExpGP certificates cited personal preference (60%), updating knowledge (53%), and maintaining or improving professional image (50%) as the most common factors for wanting to participate in general pediatrics MOC. In contrast, respondents with ExpSS certificates more frequently stated that general pediatrics certification was required for their privileging or credentialing (43% vs 22%; P < .0001). Less than 10% of all groups reported maintenance of referrals or monetary benefits as reasons for participation. Generalist and subspecialist respondents who did not plan to participate in general pediatrics MOC were asked to identify the reasons for that decision. There were significant differences between generalists and subspecialists and between subspecialists with ActSS and ExpSS certificates. Generalists who did not plan to recertify cited the expense (53%), the belief that certification was irrelevant to their current practice (50%), and the belief that there was too much time involved (45%) as the top factors influencing nonparticipation. Slightly more than one third (35%) of generalists who did not plan to participate stated that they did not want to take a proctored examination. Respondents with ActSS/ExpGP certificates were more likely than those with ExpSS certificates to state that general pediatrics recertification was too expensive (59% vs 23%; P < .0001), not relevant to current practice (62% vs 31%; P < .0001), and not required for privileging (63% vs 18%; P < .0001).
Pediatric Subspecialty Certification
Overall, 86% of subspecialists who did not recertify planned to participate in MOC in their primary subspecialty at some time in the future. A significantly greater proportion of respondents with ActSS/ExpGP certificates, compared with those with ExpSS certificates, reported that they planned to participate in MOC for their primary pediatric subspecialty (95% vs 56%; P < .0001). Pediatric subspecialists who planned to recertify in their primary subspecialty were asked to select 1 reason why they had participated or planned to participate in the subspecialty MOC. Respondents with ActSS/ExpGP certificates were more likely than those with ExpSS certificates to cite privileging requirements (74% vs 47%; P < .0001) and employment requirements (64% vs 35%; P < .0001). Only 
10% of subspecialists overall reported monetary incentives to be a factor influencing their decision to participate in MOC (Table 5).
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Less than one half of respondents with ExpSS certificates with no plans to participate in subspecialty MOC reported that MOC was too expensive (44%) or took too much time (38%). Many reported that they had changed their career path (45%) or that subspecialty MOC was not relevant to their current practice (38%). Just less than one third (29%) stated that they did not want to take a proctored examination, approximately one fourth reported that MOC was not required for privileging (23%), and 19% reported that they were not clinically active.
Attitudes About MOC
Generalist and subspecialist respondents were asked to indicate the extent to which they agreed or disagreed with a series of 9 statements regarding MOC, using a 5-point Likert scale. Subspecialists also responded to 1 additional statement regarding pediatric subspecialty certification.
A large majority of pediatric generalists and subspecialists believed that general pediatricians working in direct patient care should be board-certified. Approximately three fourths of respondents from all groups believed that patients and peers perceive certified physicians to be more competent than noncertified physicians (Table 6). Approximately one fourth (28%) of respondents with ExpGP certificates thought that an expired certificate would have an adverse impact on their career. The majority (89%) of respondents with ActSS/ExpGP certificates thought that a lapse in subspecialty certification would have an adverse impact on their career, compared with only 39% of those with ExpSS certificates (P < .0001). More than two thirds of respondents from all groups thought that MOC takes too much time and >80% of generalists and subspecialists thought that MOC is too expensive. Less than one fifth of generalists and subspecialists agreed that a proctored examination is important for assessment of whether a pediatrician is up to date.
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Results According to Work Status
MOC Participation According to Work Status
Plans for participation in the general pediatrics recertification program differed significantly between those who were currently active in pediatrics and those who were not but planned to return to the field in the future. Respondents who reported currently working in the field of pediatrics were more likely to take part in the general pediatrics recertification program (71% vs 44%; P = .0001). There were no significant differences in reasons for participation in MOC between these 2 groups. However, the reasons for not participating did differ for many variables. Those who were currently working in pediatrics were more likely than those who were not to state that they were not participating in MOC because it is not relevant to their current position (57% vs 39%; P = .03) and it takes too much time (52% vs 33%; P = .03).
Attitudes About MOC According to Work Status
Responses to 2 of the Likert-scale questions were significantly different between those currently working in pediatrics and those not (Table 7). Respondents who were not currently active in pediatrics were more likely to believe that patients and peers perceive certified physicians to be more competent than uncertified physicians.
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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The most important finding from this study is that, of this population of pediatricians who allowed their certification to expire, the vast majority still intended to recertify (65% of the generalists and 86% of the subspecialists, in their primary subspecialty). More than one half of both generalists and subspecialists indicated that the ability to update their knowledge was one of the reasons they planned to participate in MOC at some point in the future. This suggests that many physicians are aware of the rapidly changing nature of medicine within their own disciplines and think that the structured format of MOC components provides a framework in which they can maintain their competency and currency.
The reasons cited most commonly by the 35% of generalists with expired certificates who were not planning to participate in MOC were the expense, the time required to complete MOC, and the perceived lack of relevance to their current practice. Although the cost of recertification is significant, it is important to note that the fee is incurred every 7 years and the annualized cost is less than $250, comparable to or less than most state licensure fees or professional society membership fees. It is unlikely that the public, if aware of the costs to recertify, would view this expense as a legitimate financial barrier to a physician maintaining certification. Previous studies demonstrated that patients prefer board-certified physicians.2 Recent public attention focused on patient safety issues will likely increase the number of hospitals and health plans that require MOC participation among the physicians with whom they have relationships. The more aware the public becomes regarding MOC, the more likely it is that demands will be placed on organized medicine to embrace these increased standards for physician competence.
The 14% of subspecialists who were not planning to recertify in their primary subspecialty most commonly cited the expense, a change in career path making MOC recertification unnecessary, and the time required. The majority of subspecialists who chose not to participate in MOC in their primary subspecialty were those who had ExpSS certificates and had moved away from active practice of their subspecialty. Those subspecialists were more likely to maintain their general pediatrics certification, rather than participate in MOC for their primary subspecialty. It is apparent that some subspecialists shift to a general, rather than subspecialty, clinical practice. The magnitude of this shift deserves additional study and may have implications for the relative shortages in some pediatric subspecialties.
A recent change in the recertification process in pediatrics has been the institution of a secured (proctored) examination. Approximately one third of both generalists and subspecialists who were not planning to recertify identified not wanting to take a secure examination as a reason for not participating in the recertification program, and <20% believed that the proctored examination is important for assessment of whether a pediatrician keeps up to date in clinical pediatrics. Interestingly, the ABP states that the proctored examination was implemented to provide the public (eg, families, state licensing boards, and hospitals) with greater certainty that the person completing the examination is the person undergoing the recertification procedure.5 This was not possible with the previous "take-home," open-book, version of the examination in earlier recertification programs. An additional benefit of the secure examination has been that some states have waived the requirement for a state-administered examination for physicians relocating to that state if applicants have been recertified by a board that requires a secure examination.6
Hospital privileging requirements were noted frequently by both generalists (48%) and subspecialists (70%) as a reason why they planned to recertify. This is of interest because these physicians had already allowed their certificates to expire. It is possible that they were experiencing some type of pressure from a hospital to enroll in the recertification program to maintain their privileges. However, a recent study documented that almost one half of all hospitals did not ever require certification for privileging.7 Similar results were found regarding health plan credentialing, with only 41% ever requiring board certification of their pediatricians.8 It is possible that increased attention to standards of care in hospitals and health plans will result in more such entities requiring board certification in the future.
Interestingly, although the physicians in this study had allowed their certificates to expire, they still overwhelmingly believed that physicians who provide direct patient care should maintain their certification. More than three fourths of all physicians in the study believed that general pediatricians conducting patient care should maintain their certification. Furthermore, 89% of subspecialists with ActSS/ExpGP certificates, compared with only 39% of those with ExpSS certificates, believed that a lapse in subspecialty certification would have an adverse impact on their career, and most believed that patients and their physician peers perceive certified physicians to be more competent than noncertified physicians. These findings are consistent with those found by Lipner et al4 in their study of internists. They also support the findings of Kinchen et al,9 who reported that physicians consider board certification an issue of major importance when choosing a specialist for referral.
Because of our sample size and the paucity of physicians in some subspecialties, we were unable to determine differences among such groups. However, our high response rate suggests that our results are likely generalizable. Comparison of the demographic characteristics of respondents and nonrespondents demonstrated only that international medical graduates were more likely to be nonrespondents.
Our findings have some important implications. Among this group of generalists and subspecialists with expired certificates, there was general consensus regarding the professional value to patients and peers of participation in the MOC program. However, there is a growing need for studies to assess the impact of new MOC requirements in improving the quality of care provided by both generalists and subspecialists. It is incumbent on boards to evaluate the potential value provided by MOC participation to both the public and members of the profession. The field of pediatrics should respond to growing public demand regarding patient safety concerns, and a more-comprehensive process of recertification is a step in that direction. However, we must ensure that these standards are meaningful and effective and are embraced by the hospitals and health plans entrusted with the organization and delivery of health care to our nation's children.
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ACKNOWLEDGMENTS |
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This work was funded by the American Board of Pediatrics Foundation.
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FOOTNOTES |
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Accepted Aug 23, 2007.
Address correspondence to Gary L. Freed, MD, MPH, University of Michigan, 300 North Ingalls, Building 6E08, Ann Arbor, MI 48109-0456. E-mail: gfreed{at}med.umich.edu
The authors have indicated they have no financial relationships relevant to this article to disclose.
| What's Known on This Subject Physicians overwhelmingly believe that physicians who provide direct patient care should maintain their certification. There is professional value to patients and peers of participation in the maintenance of certification program.
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| What This Study Adds Studies are needed to assess the impact of new requirements in improving the quality of care provided by generalist and subspecialist pediatricians. It is incumbent on boards to evaluate the potential value provided by participation in maintenance of certification.
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REFERENCES |
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- American Board of Medical Specialties. Maintenance of certification. Available at www.abms.org/About_Board_Certification/MOC.aspx. Accessed June 21, 2007
- Brennan TA, Horwitz RI, Duffy FD, Cassel CK, Goode LD, Lipner RS. The role of physician specialty board certification status in the quality movement.
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[Abstract/Free Full Text] - American Board of Pediatrics. Pediatric diplomats, 2003. Available at: www.abp.org/. Accessed June 21, 2007
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- Freed GL, Uren RL, Hudson EJ, Lakhani I, Wheeler JRC, Stockman JA. Policies and practices related to the role of board certification and recertification of pediatricians in hospital privileging.
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[Abstract/Free Full Text] - Freed GL, Singer D, Lakhani I, Wheeler JRC, Stockman JA. Use of board certification and recertification of pediatricians in health plan credentialing policies.
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[Abstract/Free Full Text] - Kinchen KS, Cooper LA, Levine D, Wand NY, Powe NR. Referral of patients to specialists: factors affecting choice of specialist by primary care physicians.
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PEDIATRICS (ISSN 1098-4275). ©2008 by the American Academy of Pediatrics
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