Becoming board certified is a rite of passage. It has become a de-facto must-have document in addition to licensing. For many jobs, you need to be board certified or board eligible. Many hospitals require it to become part of its active medical staff. If you want privileges at many healthcare institutions, you must be board eligible or board certified.
Many insurance plans require the same thing.
While you don’t have to be board certified to participate in Medicare, some Medicare Advantage Organizations do require its network providers be board certified.
You do not need to be board certified to obtain a medical license.
But if you want to apply to participate in the Interstate Medical Licensure Compact (IMLC), you must “Hold a current specialty certification or time-unlimited certification by an ABMS or AOABOS board.” IMLC is a streamlined process to obtain medical licensure in multiple states. Interestingly, once you are in the IMLC ecosystem, you do not need to stay board certified.
“The Compact does not require a physician to participate in Maintenance of Certification (MOC) at any stage, nor does it require or make mention of the need to participate in MOC as a licensure renewal requirement in any state. Board certification is only an eligibility factor at the initial entry point of participation in the Compact process.”
Becoming board certified is a high-stakes exam.
When I became board certified, the oral examination process was three one-hour sessions. There was a senior and a junior examiner.
The white-haired (or no-haired) senior examiner viewed his/her role as narrow. Make sure I wasn’t going to kill or maim patients. And make sure I didn’t bring shame to the profession.
The youthful junior examiner’s role was to show off to the senior examiner how much he/she knew. And how dumb I was.
The youthful junior examiner had much to learn about what being board certified was for.
Not everyone takes tests well. They may be talented in the exam room. Proficient in the operating room. Have the respect of their peers. And still struggle with passing.
What I’ve learned over time is that some very smart candidates struggle with a cryptic “disability.” Meaning a disability as defined by the Americans with Disabilities Act.
The law is clear.
Federal law mandates that candidates be provided equal access to obtaining certification. But it does not guarantee certification.
If a candidate has a disability, they must be provided reasonable accommodations, as long as those accommodation does not pose an undue hardship on the entity making the provision.
Under the Americans with Disabilities Act (ADA), “undue hardship” refers to a situation where providing a reasonable accommodation to a qualified individual with a disability would cause the employer (or in this case, the testing entity) significant difficulty or expense. This is determined on a case-by-case basis, considering the specific circumstances of the employer and the nature of the accommodation requested.
In addition, any accommodation cannot fundamentally alter the examination’s ability to assess the skills and knowledge it is designed to measure.
As an example, the American Board of Surgery (ABS) notes:
Further, no candidate will be granted an accommodation that would compromise either examination’s ability to accurately assess the skills and knowledge it is designed to measure. Similarly, no auxiliary aid or service will be provided that would fundamentally alter either examination or would result in an undue burden to the ABS.
The ABS allows appropriate accommodations in order to best ensure that the results of the examination reflect each individual’s proficiency in the content areas, rather than reflecting an individual’s impaired sensory, manual, cognitive, or psychological skills (except where those skills are the factors that the examination purports to measure). While the intent of the use of an examination accommodation is to enable an individual to demonstrate their proficiency in the knowledge being assessed, granted, or approved accommodations are not a guarantee of improved performance, test completion, a passing score, or ABS certification.
What about giving a candidate extra time, if that is the reasonable accommodation required to address a disability, such as Attention Deficit Hyperactivity Disorder (ADHD)?
The American Board of Anesthesiology does allow select accommodations for specific individuals with ADHD.
Requests for Extended Examination Time. Any requests or recommendations for extended examination time must be justified by documentation that includes a rationale supported by objective data and explicit data-based arguments that demonstrate why additional time is necessary. During evaluations, we encourage both standard and extended time administration, which could provide objective evidence of the benefit of additional time.
The American Board of Emergency Medicine is less flexible.
By and large, ADA accommodations are not available for the Oral Exam. By policy, accommodations can not change the construct of the exam or the knowledge, skills, or info intended to be tested. As the Oral Exam, in part, tests a candidate’s ability to function under time constraints, etc., any and all of the common ADA accommodations are not available for the Oral Exam.
Medical courtesy requests may still be applicable and most do not require approval.
Arguably, both anesthesiologists and emergency physicians care for patients where time is of the essence. Still, most physicians do not experience a constant staccato of crises (multiple cases over three hours) requiring immediate answers. While “The Pitt” makes for excellent television, it does not mirror the real world. And even if there were exceptional situations, such as managing a mass casualty, that should not be the metric for passing or failing your boards.
Does the American Board of Emergency Medicine (ABEM) allow for extra examination time or more frequent breaks for breastfeeding candidates?
If you need an accommodation for the Qualifying Exam, please submit your written request immediately by filling out this form or emailing qualify@abem.org. There is limited seating for candidates testing under special circumstances.
If you request accommodations under the Policy on Americans with Disabilities Act or the Guidelines on Courtesy Modifications Requests (e.g., for temporary conditions, such as pregnancy, breastfeeding, crutches, or medical equipment), ABEM must schedule your exam appointment for you. Pearson VUE cannot work directly with you to schedule or change appointments if you are testing under special circumstances.
ABEM distinguishes between a temporary condition and a disability covered by the ADA.
Pregnancy is not considered a disability under ADA.
Case law arising from the Americans with Disabilities Act (ADA) suggests that medical conditions related to pregnancy are protected, according to labor and HR experts. That means that courts are starting to recognize that morning sickness, placenta previa, a high risk of miscarriage, gestational diabetes and other pregnancy-related ailments are conditions employers must accommodate, said Jon Hyman, a partner in the labor and employment practice at Ohio-based Kohrman Jackson & Krantz PLL.
There are also federal laws (outside of ADA) that afford workplace protections and employment rights for workers who are pregnant or nursing.
Back to other specialty boards, such as the American Board of Surgery.
It can get complicated.
Pregnant Candidates
Pregnant candidates may request a “frequent break accommodation” (taken during an exam session) and/or an “access to medication accommodation.”
Additional Break Time Accommodations for Lactating Candidates
- The General Surgery Qualifying Examination (GSQE) and the Vascular Surgery Qualifying Examination (VSQE) will start with a bank of 70 minutes of break time.
- To express breast milk during the GSQE or the VSQE, lactating candidates will receive an additional 60 minutes of break time added to the break bank, for a total of 130 minutes of break time.
- The Pediatric Surgery Qualifying Examination (PSQE), the Complex General Surgical Oncology Qualifying Examination (CGSO QE), and Surgical Critical Care Certifying Examination (SCC CE) will start with a bank of 20 minutes of break time.
- To express breast milk during the PSQE, the CGSO QE, or the SCC CE, lactating candidates will receive an additional 30 minutes of break time added to the break bank, for a total of 50 minutes of break time.
- With break banking, the candidate has the flexibility to choose how much break time (if any) to use at scheduled breaks between exam sections during the examination. To add further flexibility and more break time, any unused exam time from the previous exam section will be added to the break bank. An examinee’s break bank balance will appear in the dialog box when their exam is placed in scheduled break mode. Examinees may wish to make note of this balance. Examinees are responsible for managing their own break time. Pearson VUE staff will not monitor break time and will not provide examinees with reminders.
- Note: If an examinee exceeds the break time allotted in their bank, that time will be deducted from their next exam section.
Different specialty boards have different policies on whether they’ll allow extra time to complete the examination and/or extra time for breaks. To me, this is not unreasonable. In my estimation, the specialty board examinations are a floor. Not an aspirational ceiling.
Yes, I believe there are some basic skills that must be mastered, and demonstrated for some specialties, where time is of the essence. For example, intubation—for anesthesiologists and emergency medicine physicians. And central line placement. And running a code. But that list is short.
If a specialty board allows extra time for a woman candidate who is breast feeding, what about a male who has galactorrhea?
Yes, they do exist. They may have a prolactinoma. Sometimes it’s caused by hypothyroidism. Or even some SSRIs.
What if a candidate has a colostomy, and it should be timely emptied?
I can give other examples.
My point is this. I’m not convinced rigidly enforcing time limits on a board examination actually tests a candidate’s knowledge and skills in most domains. And given how high the stakes are in becoming board certified, I hate to see otherwise qualified individuals make it through 4 years of medical school, 7 years of residency, receive the support of peers and mentors, obtain a medical license, and then freeze on an exam because they can’t ignore a ticking clock. And then their employment opportunities contract. A lot.
I sometimes wish we can go back to the days when the senior examiners just tested to make sure the candidates wouldn’t kill or maim patients, nor bring shame to the profession.
What do you think?
Jeff,
In reading this, I recall a client who had a real problem with her disability who was facing a Board exam. It was a difficult battle convincing the Board to give her significant “reasonable accommodation”, but you were ultimately successful. Just because, in theory, a regulation permits something, does not mean that it becomes reality. And, the disability can not be interpreted as something that can affect a doctor’s ability to do the job. It’s often a battle, a careful battle. Good job, Jeff.
Richard B Willner
The Center for Peer Review Justice
New Orleans, Louisiana
Decades ago, I have seen and heard of instances where the inability to respond in a clinical situation was the difference between being able to save a patient or practice competently.
Have there been studies proving that fully trained physicians who are board certified perform better than those that were not certified who were also fully trained. I’ve seen board certified physicians that were arrogant and complacent, and disasters that were just waiting to happen.
How about scrapping this entire board certification system and starting over with a simulator based clinical exam, with many different situations that might be commonly encountered. Then have a session for rarely encountered scenarios.
The debated continues to rage about board certification.
Is it for basic competence?
Is it to demonstrate mastery of a subject?
Do the board examiners think that someone that has gone through medical school and then spent years in residency training was asleep during all of that time?
What about the MOC (maintenance of certification), every 10 years, where physicians who specialize no longer spend time doing the mainsteam things that MOC tests for?
Some of the best advice was given to me by my chief decades ago.
He said that if you panic during an emergency then the patient is lost.
He said if you keep your composure, you will be able to think through a problem.
That was always good advice.
Do boards train for that? No. Should they? Yes.
Central line placement is a perishable skill. When I was doing my cardiac anesthesia fellowship long before the advent of ultrasound, we were placing 4 central lines per day. It would take us less than 10 minutes per line. Even decades later in practice, I still was able to do that. Could I do that today?
Perhaps, but I’ve been retired a long time. The muscle memory may still be there.
Does MOC train for that? No.
We want competent physicians, that can rise to emergencies and perform well.
We don’t want good test takers.
A physician I knew decades ago, graduated with honors from medical school, attending the best residency in his specialty at the time, was board certified, and yet could not perform.
Whatever was in his head, did not translate into his hands.
Board certification does not prevent that from happening.
Therefore, what good is it?
It’s SO hard to get into med school now, with an emphasis on high MCAT scores > 510, all future docs will be professional test takers, and will not need accommodations – except for the PG or those with a prolactinoma. Thanks!
I still remember the good old days when men were men….
And women were…?
When it comes to surgery boards, most boards require a “successful” exposure to a wide range of individual types and classifications of surgery. In most cases, after completion of your residency, you get most of those procedures, but by no means ALL. And there is no guarantee that the attending physicians you work with will actually allow you to start, process and complete the procedure by yourself. Some attendings will. Others not.
When I was a resident, the chief of surgery would proctor surgery residents from a place in the room where he was not necessarily visible to the student surgeon. When I started the process, I was not “informed” of his ghostly visitation. I had no idea it occurred until well after my training. Since my training was at a VA hospital, multiple surgeons observed me anyway. If there were any problems, I’m sure that data would have been presented to my chief.
Surgery Boards, despite their attempts to be open handed and fair, are still a political organization, not in the sense of being Left or Right, but rather whom they will allow to pass. Personality, by definition enters the fray. Professional orchestras deal with this by putting up a blind so the conductor and first chair judges cannot identify the applicant. Every violinist knows the cadenza to the Brahms Concerto. But they probably do not know the cadenza to the Hindemith Concerto.
As pointed out by Dr. Segal, some special privileges are granted to board members that can affect income and opportunities. There is not much about access to a medical license that is “fair.” By definition, it separates people who are not able to master deeply difficult science, and have superior test taking abilities. This further separates us.
Some superior test takers do not have the manual dexterity or tissue handling confidence to actually learn how to do podiatric surgery, which is actually very complex. I have seen this myself as a residency director. My point is that this is and never will be a “fair” process. But that does not mean we should stop trying.
Michael M. Rosenblatt, DPM
This was an interesting column, Jeff, that required a LOT of research, for which thanks! I took the very first ABEM Oral Board Exam in 1981. NONE of the examiners were trained in EM, as I was. I was also 2 months pregnant. One of the examiners (who later became a notorious expert witness against EPs) was smoking cigars in the hall in which we were required to wait to enter exam rooms. Another examiner (a surgeon of course) performed his role as it had been performed upon him: In the most devious patient scenario, he stood up and yelled at me that I did not deserve to be an Emergency Physician, which completed the discombobulation that the smoking-aggravated morning sickness had initiated. I have never forgotten this experience, though clearly the intentionally abusive one did: he continues to consider me a friend, after some of the professional work I later did helped him to solve a family problem. Anyway, the result was that I established one of the longest running board preparation courses in the country, to spare younger colleagues the pain I felt at having failed my first exam attempt in the face of these abuses.
It was quite interesting for me to learn that only INITIAL Interstate Licensing compact application requires current board certification. I never applied for that program, because at the time you also had to maintain maintenance of certification, which to me was little more than a cash cow for ABIM and other ABMS boards. (I recall correctly, when ABIM started raking in a fortune which they spent on a condo and a limousine in Philadelphia, the Anesthesiologists erected an entire building designed to REtest recertifying candidates in, for example their intuabion skills…how could they have remained in practice had they not mastered this basic skill????). Fortunately, I have IM certification that does not expire; but I also maintain ABPS certification, which is recognized in some states and in Canada.
I was disappointed to read the ABEM ADA policies, which do not seem to me to be in complete compliance with ADA, but it may be that in actual practice, they DO make reasonable testing accommodations as is required by the law. Calling a temporary disability NOT a disability is just as meretricious as is claiming these accommodations to be “courtesy”. And these “break time” stipulations seem ridiculous. Do they clock you with a stopwatch, as you perform whatever medical function you must? After all, you could be studying behind that closed bathroom door! And although time IS of the essence in EM on occasion, for the most part if a patient (or you) require more time to accomplish something, there is a team in place to support you and the patient in the interim. I would hope that training programs are not graduating residents until they demonstrate that they can perform lifesaving procedures. Some amazing accommodations (e.g. performing CPR with feet) have been developed by trainees with disabilities. I know of several severely mobility impaired physicians whose clinical skills are exceptional. I am working with the AMA on improving access to medicine, and to leadership in organized medicine, by trainees and physicians with disabilities. (the October issue of Academic Medicine is open access and dedicated to this subject, and will be reviewed at AMA Interim meeting coming up Nov 16 https://bit.ly/DisabAcademicMed)
Overall, I agree with your conclusions: that the principal role of board examiners is to assure that they are not certifying those who are likely to harm patients, or bring disgrace to the profession. And specifically, NOT to assure that all who wish to enter the profession are perfect(ly healthy) specimens, who are also able to perform under very artificial and unnecessarily stressful situations.