tific section of the American Medical Association (AMA). All the boards are evaluated for recognition according to the ABMS “Essentials for Approval of Examining Boards in Medical Specialties.” Each board thus requires similar levels of training and experience.

The residency program must be approved by the Accreditation Council for Graduate Medical Education (ACGME), an organization composed of members of the ABMS, the AMA, and other concerned organizations. Together with appropriate specialty boards, the ACGME develops accreditation standards for each specialty residency program. These are regularly modified in conjunction with changing specialty board requirements and must be approved by the AMA’s Council on Medical Education (Havighurst and King, 1983). Ultimately, candidates must also pass comprehensive examinations administered by the specialty board.

Candidates for certification must receive and complete specialty training in an approved graduate medical program, the length and extent of which vary somewhat among the specialties. A majority of physicians in the United States identify themselves as specialists, but only about one-half are actually certified by an ABMS board. The number seeking certification has grown and continues to grow rapidly. Almost all physicians newly entering practice now seek some sort of certification. Of those who designate themselves as specialists, an increasing number are actually board certified.

Strengths. Certification in a medical specialty is widely accepted as an indication that certified physicians possess a superior level of training and skill in their area of specialization. Information on certification is readily available from such sources as county medical societies, the ABMS, AMA, American Medical Directory, and the AMA Physician Masterfile. Certification has been endorsed by the Joint Commission as an “excellent benchmark for the delineation of clinical privileges” (Joint Commission, 1989, p. 106).

Limitations. Ramsey and his co-workers (1989) compared the performance of board-certified and noncertified practitioners in internal medicine using measures of knowledge, judgment, communications skills, and humanistic qualities. Scores of board-certified internists on a written examination were significantly higher than those of noncertified internists, but ratings by professional associates, patient satisfaction scores, and performance in the care of common illnesses (as measured by medical record review) showed few differences. There were modest differences in preventive care and patient outcomes that favored the certified physicians.

The Office of Technology Assessment (OTA, 1988) reviewed 13 studies on the adequacy of physician specialization as a measure of quality and found little evidence that board certification accurately predicts high-qual-



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