Robert Anthony

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Board certification: it’s expensive and time-consuming. And it’s almost as much a necessity for practicing medicine today as a medical degree. Certification is a prerequisite for privileges at most hospitals and for credentialing by most insurers. Few practices will hire physicians who aren’t board-certified.

But there’s no doubt that the certification process improves the quality of physicians - and, in turn, patient outcomes.

Although a number of studies have demonstrated a correlation between board certification and improved patient outcomes, there’s actually little if anything in the literature that firmly establishes causation, largely because of the difficulty of controlling for factors other than board-certification that might affect patient outcomes. The sheer domination of board-certification in the medical community, meanwhile, has also made it hard to find cases involving noncertified docs to compare against.

Still, board certification is taken for granted in American healthcare today, less than a century since it took root in the physician establishment. And given that 91 percent of the public considers board certification “important” or “very important” in choosing a doctor; that the Joint Commission lists board certification as a reasonable way for hospitals to meet its requirement to vet doctors; and that some 85 percent of doctors are board certified in at least one specialty, one would think that the medical literature would be heavy with studies quantifying certification’s value to patients.

So it’s time to ask: Is board certification overrated?


Board certification has its origins in the beginning of the 20th century, when nearly half of all physicians in the country were general practitioners. Most patients who visited a doctor never saw a specialist, and many GPs were accustomed to providing all manner of care to their patients, regardless of specialized need.

That situation irked specialists like Derrick T. Vail.

In 1908, Vail, president of the American Academy of Ophthalmology and Otolaryngology, proposed a board that would license ophthalmologists. He hoped it would protect patients against what he called the “six-week specialist,” those physicians with little training in the specialty - and, no doubt, he was also hoping to protect genuine specialists’ turf against overstepping generalists. As Alvin A. Hubbell, chair of the AMA’s ophthalmology section at the time, noted, the idea would protect the interests of the ophthalmologist “who has qualified at much sacrifice of time, energy, and money.”

In 1917, the American Board of Ophthalmic Examinations, now the American Board of Ophthalmology, was formed. Other specialties soon followed the board-certification model, and in 1933 the Advisory Board of Medical Specialties, later renamed the American Board of Medical Specialties, was formed. Currently, the ABMS comprises 24 certifying medical boards.

Over time, the concept of board certification has been transformed. Conceived as a one-time certification granted for life, periodic recertification has lately become standard. Certification now represents more of a barometer of the physician’s ongoing knowledge than just a demonstration of academic study.

The process continues to evolve today. While a knowledge exam is still a core feature, many boards now incorporate peer review, practice performance indicators, and even patient assessments as required components of certification. The idea of comparing physician performance to evidence-based best practices and national quality benchmarks is already a key feature of certification for the American Board of Internal Medicine and the American Board of Pediatrics, and it’s a concept that is spreading rapidly to other ABMS member boards.

“Board certification has served as the gold standard for close to 75 years now in assuring the public that those that bear the imprimatur of each of the 24 boards that comprise the [ABMS] have the necessary training, experience, and knowledge to provide high quality care to their patients,” says James C. Puffer, MD, president and chief executive officer of the American Board of Family Medicine.


Maybe so, but what does that gold standard mean in the real world? Are board-certified doctors better doctors?

A 2002 review article written by Lisa Sharp and four others that appeared in 

, a peer-reviewed journal published by the Association of American Medical Colleges, examined relevant studies published between 1966 and 1999 that attempted to correlate board certification to better outcomes. Sharp and her colleagues identified 13 studies (of some 200 that they looked at) that positively correlate certification and clinical outcomes. But they also noted gaping limitations on the quality of available research. Only 5 percent of the papers they looked at used appropriate research methods, they said. And while they cite various studies that associate certification with “increased medical knowledge, superior training, and certain aspects of patient care,” they note that none of these studies were direct measures of clinical care.

Of the studies Sharp and her researchers examined, no two measure the same variable of outcome within the same specialty. And none of the studies measured physicians’ time since board certification - an important factor, since some physicians practicing today were certified for life before boards began requiring periodic recertification. “Many factors unrelated to the physician affect clinical outcomes, such as the type of clinical setting, size of support staff, and systems of clinical care, to name a few,” they write.

Still, Sharp and her colleagues supported the continued use of certification as a means of evaluating doctors: “Despite the lack of unequivocal evidence documenting the value of board certification, we do not advocate removing it as a measure of expertise. Intuition, expert opinion, surrogate markers, and the findings reported here support the ABMS position that board certification is but one of several important considerations in evaluating a physician’s knowledge, skill, and ability to provide good clinical care.”

Eric N. Grosch, a physician who formerly practiced internal medicine and is now attending law school, read the Sharp review at the time, and found her team’s position uninspiring. He wrote his own review article in response, publishing “Does Specialty Board Certification Influence Clinical Outcomes?” in the 

Journal of Evaluation in Clinical Practice

“They came to the conclusion that there was no good evidence, no strong evidence, no conclusive evidence that showed board certification was any advantage,” Grosch says in an interview. “But they said they still recommend it as an index of expertise. That’s known as ignoring the evidence.” Grosch noted that two members of Sharp’s team were ABMS executives at the time of their article’s publication.


One coauthor, Sheldon Horowitz, a pediatrician who in 2002 was an associate vice president at ABMS and is today a special adviser to its president, says, “There are a number of papers that show that initial certification by an ABMS board is associated with improved preventive care, including prenatal care, improved myocardial infarction care, better anesthesia outcomes, better perinatal outcomes, and better surgical outcomes.”

Some of these papers have been published since the 2002 Sharp review. In particular, a 2008 paper in the 

Journal of the American Medical Association

, “Assessing Quality of Care: Knowledge Matters,” shows that good performance on the certification exams correlates with better quality of care.

But these later studies have the same flaw that plagued the earlier research Sharp’s team reviewed: correlation doesn’t prove causation, and because they fail to isolate for variables other than board certification that might affect patient outcomes, they’re ripe for attack by critics. “These are hard studies to do because of the relatively small percentage of noncertified doctors,” argues Horowitz.

But Grosch sees a conspiracy: “[Board certifications] are a cash cow, and somebody has a vested interest in the financial benefits to themselves of maintaining it. To be sure, the ABMS and all of the 24 boards under it consider board certification to be a major cash cow for the owners of the boards.”


Yet even if quantifying the value of specialty certification is a difficult thing to do, aren’t the correlation studies, however imperfect, plus simple common sense enough? In a society that places such a premium on physicians’ abilities, do we really need an exhaustive study to prove that periodic testing of knowledge is good for patients?

“I suspect that if you talked to many of these people who feel that it’s not necessary to regularly assess physicians and if you asked them whether they would be willing to get on a transcontinental airline and travel across country with a pilot who had not been assessed at regular intervals, they would probably be reluctant to do so,” asserts Puffer. “Even on an intuitive level, I think frequent and regular assessment makes sense to most people, even ignoring the significant body of literature that exists that would support the notion of maintenance of certification.”

Horowitz agrees. “No matter how good the care you provide, there are always ways to improve your care. In my mind, that’s the most important reason for things like certification and maintenance of certification. It’s to try to ensure that physicians are up-to-date and deliver high-quality care as an ongoing process, because there’s always new stuff.”

Yet the critics are asking interesting questions even if one accepts the basic logic of ongoing assessment as an obvious good. Who’s to say, for example, that the best way of judging a physician’s knowledge is through a multiple-choice exam, the backbone of most certification programs? Who’s assessing the assessors? And what about the time away from patients needed to study for such exams, and the expense of certification itself? Healthcare is fraught with access and cost problems. Doesn’t it also make common sense to ask whether the certification is worth the added expense and the reduced physician time with patients?

Grosch bemoans the amount of red tape that practicing medicine in the U.S. involves. He points out that, in addition to specialty certification boards, there are 69 separate bureaucracies handling medical and osteopathic licensure today. Having to qualify in each state for a medical license is onerous enough without having to additionally pass a specialty certification that has little evidence to back up its efficacy.

“If it’s not a helpful thing, it’s an awful lot of trouble to prepare for. I’ve known guys who quit their practices for a year to study for it. It is a great disruption in their professional lives to have to study for it,” says Grosch. “The expense of it is exorbitant . . . and for what? No benefit in patient outcome.”


A 2004 Gallup poll and an ABMS consumer survey in 2008 both showed that the public rated board certification as an important consideration when choosing a physician. The ABMS poll showed that 91 percent considered board certification “important” or “very important.” Gallup’s number was 70 percent. There is no doubt that board certification, as a concept, has been well marketed and is accepted by the general public.

“The survey basically said that if their doctors stopped being certified, they would look for another doctor,” says Horowitz. “That was more important to them than their friends’ recommendations about doctors.”

Any changes made to the boards’ certification requirements will increase their importance, frequency, and stringency. Most of the ABMS boards either have or soon will introduce new steps that will incorporate patient registries, peer and patient review, and comparison of clinical outcomes and physician performance to national benchmarks.

If the future of healthcare includes incentive payments for improved quality of care, that future belongs to board-certified physicians. The recently passed healthcare reform legislation specifically identifies improvements to the Physician Quality Reporting Initiative, Medicare’s pay-for-performance program. Starting in 2011, physicians can qualify for additional payments if they submit data measures through a maintenance-of-board-certification (MOC) program that meets the criteria for a patient registry. Similarly, recognition by the National Committee for Quality Assurance (NCQA) is at least partially predicated on board certification. NCQA recognition qualifies physicians for many national and regional pay-for-performance efforts.

And just to make physicians’ lives a little easier, there is currently a referendum before the Federation of State Medical Boards that will allow participation in a maintenance-of-certification program to serve as a surrogate for maintenance of licensure. Board certification and licensure - already confused in the public mind - will likely move one step closer to each other.

The true value of board certification to patient outcomes remains difficult to quantify. But whatever it’s worth to patients, certification will soon become something physicians simply cannot practice without, if they ever could.

has written for the healthcare and practice management industries for seven years. His work has appeared in

 Physicians Practice, edge, Humana’s Your Practice, 

 He is based in Baltimore, and can be reached via 

This article originally appeared in the July/August 2010 issue of

Articles

It’s expensive, time-consuming, and practically a prerequisite for practicing medicine today. But does board certification make you a better physician? You might be surprised by the answer.

Is Board Certification Overrated?


Most of us have come to accept that an electronic health records system can make life a little easier. You can recycle all of those paper charts, save a fortune on filing cabinets, and free up all that office space you’ve been using to store paper records. Practices with multiple offices can even access patient information from every location.

But in the words of the old Peggy Lee song, “Is that all there is?”

A number of practices are starting to ask themselves that very question. With the high price tag of many EHR systems, practices want more than just a 

 and instant access. They want to see a genuine 


Southeast Texas Medical Associates is a multispecialty practice founded in 1995. Headquartered in Beaumont, Texas, and with three offices, SETMA was an early adopter of EHR technology. They implemented their first EHR in January of 1999, and by May of that year a light bulb went off.

“I suddenly realized that we had spent a lot of money and gone to a lot of effort and were still 

 to accomplish something that had little value,” says CEO and founding partner James L. Holly, MD.

What the practice needed was not electronic patient records but electronic patient management.

“Our EHR was merely an electronic means of doing what we used to do by paper or by Dictaphone,” explains Holly. “We suddenly realized that the complexities of 21st-century medicine could not be done with 19th-century methodologies, like pen and paper, or 20th-century methodologies, like Dictaphone and transcription. In the 21st century we needed to have electronic methodologies to accomplish the many different things that we needed to do.”

Over the next few years, the practice customized their EHR to create 

. Their “digital dashboards” address areas such as diabetes, hypertension, and dyslipidemia, and allow them to review quality of care benchmarks for patients with these diseases. Not only can the practice physicians and staff compare the clinical values of individual patients to 

 and standards of care, they can compare the progress of individual patients to other patients within the practice. And they can look within groups of patients (e.g., all patients with diabetes) to gauge the overall quality of care for a specific population.

It’s been a fundamental shift in the way the practice delivers care, allowing them to look at the health of patients on a very high level and target specific ways the practice can improve outcomes. Over time SETMA has been able to use their EHR to not only track their own progress but see what initiatives have had the most impact. By tracking the average levels of HbA1c in their diabetic population, for example, they saw significant drops during the year when they implemented a diabetes self-management education program, and again when they recruited an endocrinologist for the practice.

That kind of data collection allowed SETMA to reallocate their practice’s resources to maximize their return on investment. And it revealed a measurable improvement in patient care that would otherwise have been invisible or impossible to track.

“You can’t do that without data,” says Holly. “An 

 begins to expand and deepen, focus and sharpen, and strengthen the quality of care that’s being given.”


Nearly every practice interviewed cited this data-driven approach to care as critical in improving patient outcomes. Like SETMA, Village Health Partners, a 10-provider family practice in Plano, Texas, has made significant investments in technology - and reaped significant quality-of-care rewards.

To cite just one example, Village Health incorporated mammogram tracking into its EHR and now has 63 percent of the eligible population getting tested regularly. Some physicians in the practice have even achieved an 85 percent level of compliance.

“If you consider the fact that we don’t provide mammograms in our office, that’s an absolutely amazing figure,” says president and family physician Christopher Crow.

Other practices have been equally successful: incorporating colonoscopy measurements, cholesterol testing, blood pressure monitoring, and any number of tests and indicators that are important contributors to future positive outcomes.

The secret? Not having to remember everything.

“We can address the clinical care and wellness and disease management gaps, because the EHR is a database that has information, and it will cue you when things are missing,” says Crow.


Does the patient need an updated lipid test? The EHR will let the provider know it’s time to schedule it. Has the patient been counseled to quit smoking? The EHR keeps track. Is the patient’s HbA1c within normal target range? The EHR will let you know.

Holly cites the advantages of this last point for a practice with many providers. Every year the American Diabetes Association updates its Clinical Practice Recommendations, but not a single provider at SETMA needs to read this 100-page document. Holly updates the practice’s EHR, and providers only have to check the EHR to see how an individual patient measures against the latest guidelines.

“We can instantly infuse into our practice that standard of care,” says Holly.

Jonathan Bertman, a board-certified family physician and a clinical assistant professor of family medicine at Warren Alpert School of Medicine at Brown University, built a similar functionality into Amazing Charts, the custom EHR software that he developed and now sells to other practices. “The benefit of EHRs is that at the moment of care physicians are going to be gently reminded about some things they don’t know or that they might forget. For example, I saw a patient who had gout. I forgot what the current recommended treatment for this acute case of gout was. In my EHR we have a 5-Minute Clinical Consult right at the point of care, so I clicked the button and it popped up and told me what to do.”

 to do. Take the patient who comes in for a cold and is commonly prescribed an antibiotic, despite the lack of benefits. “It doesn’t shorten the duration of the illness, it just adds expense for the medicine, plus there are risks for the patients, and resistance issues. But the way it works right now, physicians just do it,” says Bertman. “They understand it’s not necessarily good care, but they are trying to get through their 25 patients a day, so they might essentially do what is obviously an incorrect choice.”

An EHR can provide a reminder at the moment of care that makes a provider think twice about a less-than-excellent treatment decision. It also can be used later to see how often those less-than-excellent decisions are made - and then help change behavior.

“It means that you can do a superb job every time, whether you’re tired or alert, whether you’re focused or you’re thinking about this or not, because we’ve already sat down and gone through the algorithms,” says Holly.


If your EHR is the elephant that never forgets, it can also be the pack animal that does all your heavy lifting.

“There’s actually no way without an amazing amount of time, resources, and dollars that you could ever pull off this type of information about yourself in the paper world,” says Crow. “In 10 seconds I can tell you the number of Pap smears we’ve done in the last year. Imagine doing that in a practice with a bunch of [paper] charts. It would take you most of the weekend with a bunch of people pulling charts the whole time to make little check marks.”

Family physician Robert Brenner, chief medical officer of Summit Medical Group in Berkeley Heights, N.J., saw the immediate implications of this versatility right away. “What if I want to find all the patients that are on a particular medicine because I need to recall that medicine? I could query the database and find all the patients that are on a particular medicine, such as Vioxx, and then send out an automated e-mail. In terms of patient safety, that’s an immediate response.”

Summit uses its EHR to identify high-risk patients, and then sends a list to its call center to schedule patient follow-ups and callbacks. It has been using Allscripts’ Clinical Quality Solutions module to track quality-of-care indicators for its Medicare population and is now working on a fully implemented solution that will cover all of its patients.

“Things have gotten so complicated being a physician,” says Brenner. “Here there is a consistent method that the group, managing 55,000 encounters a month, is able to control and chip away at, managing each disease entity the best that we can.”

Not only has Summit seen marked improvement in the management of diabetes, hypertension, and mammograms, they’ve managed to make those improvements pay. Says Brenner, “We did get quite a return on our ability to capture Medicare dollars back from it.”


If data collection and population trends don’t motivate you, maybe you should consider the more immediate applications of EHR technology. Barbara Morris is a pediatrician with an eight-provider practice in Saratoga Springs, N.Y., and chief medical officer of Community Care Physicians, a 180-provider multispecialty group practice. She and other providers in her office have been using a mobile app to access their EHR on their iPhones and Blackberries that is helping them to provide more complete care for their young patients.

Take the case of the 6 year old who had been complaining of knee stiffness and joint pain. Located in Upstate New York, Morris immediately thought of Lyme disease. She sent out blood work to start the evaluation process and prescribed antibiotics to be safe. In the meantime, the patient’s symptoms worsened. Concerned that it might be secondary stage Lyme disease with encephalitis, Morris sent the child and parents to the emergency room.


Even though she was not at the office, Morris was able to access the patient’s electronic records through her iPhone and send this data and a summary of what had been happening ahead to the ER specialist. The information arrived at the hospital before the patient.

“They were able to track down the labs and determined that, in fact, this was just a viral illness and not Lyme disease, avoiding this little girl having to have a spinal tap,” explains Morris. “Of course I could have picked up the phone, but they never would have had all of the information. And I would have been relying on my memory to say there are these tests that are out, this is the lab they went to, this is what her exam was two days ago - I think.”

Morris notes an additional advantage to using EHR and smartphone technology together. “Most physicians, I think, if you talk to them about their experiences on call, especially as they get those phone calls in the middle of the night, do a less than ideal job of documenting their contacts and what they actually told the patient. And if you talk to people who talk about medical liability, they will say that phone conversations and inadequately documenting are probably one of the worst things to encounter when you’re involved in any kind of medical liability litigation.”


With the cost of some EHR solutions reaching as high as $25,000, many practices, especially smaller ones, are asking themselves whether an EHR is worth the money. Nearly all of the practices interviewed said yes, with both Holly of SETMA and Crow of Village Health pointing to the EHR as a tool that actually has helped their practices grow.

 are considerable. If you’re a smaller practice with a limited budget that still wants to reap the outcome and treatment benefits of an EHR, smaller vendors might be the way to go. Consider, too, that a number of large vendors are developing smaller, less expensive EHR software that will be on the market soon. Your practice may not realize all of the advantages of the large and expensive enterprise solutions, but it will certainly be easier on your bottom line.

Keep in mind, too, that money is not the only investment your practice will make. Physicians who think that implementing an EHR is like flipping a switch are in for a surprise. Not only will there be a significant initial training period for physicians and other staff, but ongoing training and development is essential to maximize the effectiveness of the EHR and create more efficient work processes.

“I will tell you that the vast majority of practices just implement and then they get stuck. They don’t ever continuously improve,” says Crow. “One of the secrets of our success is that technology is nice, but you have to have process and culture and training around it. We train twice a month still.”

But if you’re willing to put in time, effort, and money, an EHR can definitely help you provide better, more proactive patient care.

has written for the healthcare and practice management industries for more than six years. His work has appeared in

This article originally appeared in the June 2010 issue of

We know EHRs can improve practice efficiency, but can they improve patient care? The evidence is suggesting they can. From disease management tools to automated reminders, EHRs are offering welcome improvements in patient outcomes.

Beyond Paperless


Hard to believe, but only two years ago many of us were looking at our investment portfolios with smiles instead of frowns. If you had money in the stock market or real estate, you probably thought you were doing alright. Better than alright, even. Maybe you planned on an early, comfortable retirement - or maybe you actually took that step and put the working world behind you.

Many physicians, especially those over the age of 50, had accumulated a sizeable nest egg and moved away from daily or active practice to pursue other dreams. Yet with the collapse of the economy, a number of those physicians are finding they need to return to medicine.

It’s time to rethink what retirement means for you. Whether your retirement plans have been derailed or just delayed, it’s important to know what your options are for “



Are those monthly statements from your broker less promising than they were a couple of years ago? It may not be much comfort to you now, but it’s important to know that you’re not alone, says Kurt Mosley, vice president of business development for Merritt Hawkins & Associates, a physician recruitment firm, and Staff Care, a locum tenens staffing firm for the healthcare industry.

“We’re seeing a lot of things combining to create this extension of physicians’ careers,” says Mosley. “Part of the problem was some physicians not putting enough away in 401(k)s. We also saw a lot of doctors who invested in real estate, and that market is struggling right now. So a lot of our physicians are not able to move. In some cases they were thinking of moving, but they’re upside down [in the mortgages on] their homes.”

For a lot of specialists, there is concern not only over the current economy but also what the future may hold. “In the specialty arena, potential CMS cutbacks loom for specialists - up to 30 percent in some cases,” says Mosley. That could drastically affect a practice’s bottom line and put immediate plans on hold for those physicians who were depending on income from their final working years to fund their retirement.

Still other physicians may find their retirement delayed because of circumstances that have nothing to do with the economy. Mosley tells the story of one physician who had planned his retirement so well that he actually notified his partners years in advance of the actual date on which he would be leaving. Then the physician got divorced and remarried. “All of a sudden he had two children that came with his new wife, and he was responsible for them,” says Mosley. “That changed his plans entirely.”

There are many situations currently pushing physicians toward un-retirement, and just as many physicians who would rather be traveling in the opposite direction. In a survey conducted for The Physicians Foundation, Merritt Hawkins & Associates found that 60 percent of doctors over the age of 55 said they were planning on changing or altering their lifestyles in the near future.

So what happens when retirement is not an option for their immediate futures?

“The good news is that there’s such a shortage of physicians that we’re going to need these doctors to work longer and longer in their careers,” says Mosley. That means more opportunities for the not-so-retired older physician.

Some of those who planned to retire can simply extend their working years. If you are a physician in private practice, it’s usually no problem to let your partners know that you’ll be sticking around for another year or two. Even if there were legal agreements in place that specified a retirement date, many partners are willing to renegotiate the date and terms of retirement - especially for a successful physician with her own patient base.

Others may find that full-time clinical work isn’t necessary. For those lucky physicians, there are a wide variety of options. The physician in private practice can work out an arrangement with partners that allows him to see patients only two or three days a week and provides an equitable split of practice profits.

For the solo practitioner, this sort of semi-retirement can present bigger obstacles. It’s all well and good to see patients twice a week, but practice employees still expect to be paid for full-time work. Nor do overhead expenses like rent, utilities, or insurance decrease just because you’ve decided to cut back your working hours. Lowered revenue and high expenses don’t add up to a successful recipe for keeping your practice in business.

One option that is worth investigating, says Mosley, is negotiating an employment arrangement with your local hospital. Under such arrangements, the hospital agrees to take over the business aspects of running your practice. “The physician says ‘I’ll bring my patients,’ and the hospital sets him up on its physician integration program, takes over the practice, and implements central billing and better overhead.”

In these employment models, the hospital also covers the cost of medical malpractice insurance, which can be a major cost savings for physicians. In return, the physician draws a set salary from the hospital.

“In some cases, the physicians may be working for ‘less money,’” says Mosley. “But since the hospital is taking care of their malpractice insurance, financially it may work out better for the doctor.”


Obviously, hospitals are interested in the possible referral of patients, but keep in mind that any formal commitment about referrals is illegal and cannot be contractually specified. Nor can the hospital influence the way physicians practice medicine. “They can’t say go do these tests, but don’t do this,” says Mosley. “That’s illegal, too.”

Just getting away from the business and administrative aspects of running a practice will cut down the number of hours you have to spend in the clinic, but if you’re truly looking to work part-time, a hospital employment agreement might be the way to go. “As long as that commitment is written into the agreement, it’s fine,” explains Mosley. “We’ve seen many doctors who thought they were going to retire, but the hospital said we need one full-time equivalent. They can split that between two doctors, each working part-time.”

Besides avoiding business headaches and malpractice insurance, an employment arrangement could have other upsides. For example, a hospital that implements an EHR system in your practice can help with productivity and cut down on paperwork - yet another time saver!



On the other hand, maybe stepping away from your practice is precisely the reason you want to retire. If you are looking for a change of pace, you might consider locum tenens work as an option for semi-retirement.

Although it once suffered from the unfair stigma of being a place bad doctors went to get work, the truth is that the burgeoning locum tenens industry has evolved into a vital resource for secondary and rural markets that need access to physicians they might otherwise never get to see. “We have a survey that we do every year,” says Mosley. “Eighty percent of the hospitals find the doctors equal or even more capable from a quality standpoint than the doctors they have on staff.”

Currently, over 45,000 doctors - about 5 percent of all physicians in the U.S. - take advantage of locum tenens work every year - to the tune of about $3 billion annually.

One thing that locum tenens work offers is flexibility. Physicians can work as little or as much as they want. But many older physicians facing retirement see locum tenens work as an opportunity to supplement their nest egg.

“That’s where we’re having most of our success - practitioners who are saying, ‘Look, I’d like to make another X number of dollars over the next few years if I can. What if I give you three or four weeks of my 10 or 13 weeks of vacation? How much can I make?’ That becomes very appealing to them,” says Chris Rutherford, president and chief operating officer of Medfinders Physician Staffing, a physician recruitment firm that specializes in locum tenens placement.

Locum tenens physicians might find themselves working in far-flung rural locales in, say, North Dakota, but they can just as easily end up in secondary cities like Roanoke, Va. The employer not only pays the physician’s salary but also travel, housing, and living expenses. Essentially, all of the money a physician makes can go in the bank.

And just how much can a doctor expect to make during four weeks of work? “It really depends on the situation. You might have a neurosurgeon toward one end of the spectrum, and you can have an internist toward the other,” says Rutherford, who notes that earnings can range anywhere from $5,000 to $25,000 depending on the demand. “We’re finding the most demand in the supply-constrained markets such as areas of primary care and some sub-specialty areas. Emergency medicine also continues to be a robust setting.”

There may even be the possibility of some local opportunities, says Mosley. “Many physicians who have never been involved in locum tenens may find out that right next door they can work shifts at a hospital they usually admit to. Physicians usually have two or three hospitals that they deal with, and they may not be aware that a particular hospital needs their services.”

Locum tenens work can also be a good opportunity for the physician who wants to retire but doesn’t want to completely give up practice. “Many doctors have vacation homes, and a lot of doctors that we work with say they usually go to Arizona or Florida in the winter. When they go to their vacation home they want to take time off, but they pick up two or three shifts a week working locum tenens,” says Mosley. “It’s a perfect deal because they’re needed. In a lot of cases, it’s rejuvenating for these doctors because they come to town and get to be a hero, see people that maybe wouldn’t be seen otherwise.”

Yet while opportunities may exist locally, Rutherford cautions that being flexible about time and location opens up far more opportunities in locum tenens work. “If you have a practitioner who is willing to be very flexible for four weeks and says, ‘Use me as you’re able,’ that tends to be a very successful partnership.”



These are good options for physicians who need to restructure or delay their coming retirements, but what about the physician who has to come out of retirement and head back to work? That situation presents more of a challenge.

“What we are actually struggling with are those physicians that may have been out of practice for two, three, or four years who come to us expecting that we can help find locum tenens opportunities,” says Rutherford. “Our standards and most of the industry’s standards require that a practitioner have no more than a six-month gap in clinical practice.”

Not only do most locum tenens companies adhere to that standard, most hospitals have similar policies regarding clinical practice. Some are even stricter, disallowing any physicians with practice gaps of more than three months. “It’s a hurdle across the industry,” acknowledges Rutherford.

The only solution is to get current clinical practice experience, and for that Rutherford suggests approaching the group or practice from which the physician retired. “It provides the best opportunity to bring your clinical orientation back up to speed. We often counsel semi-retired or retired doctors toward that,” he notes. “It’s not dissimilar, interestingly enough, to what we recommend to residents coming right out of school. Our direction to them is to get some practical, hands-on experience under their belt.”

So a physician who has been retired for six months or more may feel like she is starting over again, but Mosley believes that even older physicians who have been away from practice for a long time have good reason to be optimistic about their opportunities. “There’s no such thing in America right now as an unemployed physician. If you want to work, you can come back into the fold,” he says. “Depending on the time out, depending on certain states, you might have to do a little retraining, but you can move right back into it.”

 has written for the healthcare and practice management industries for more than six years. His work has appeared in

This article originally appeared in the March 2010 issue of Physicians Practice.

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Every physician knows medical malpractice claims are out of control. More claims are filed every year, and the average amount of awards has been steadily increasing - by as much as 500 percent over the last decade in some areas. 

Meanwhile, increased claims and rising awards and settlements are driving the cost of medical liability insurance through the roof. Although many states have enacted legislation to cap awards, the effect has been to hold liability insurance costs at already inflated levels. Eventually those costs will rise again, or else insurers will stop providing coverage. 

Everyone from legislators to insurers to physicians knows that something has to give. Even the president is on board with this kind of change. In a recent address to Congress, President Obama talked about the need to put patient safety first, let doctors focus on practicing medicine, and reduce unnecessary costs from medical malpractice. Under the directive of the president, the Department of Health and Human Services is funding a $25 million demonstrative initiative to explore new models that will reduce medical liability premiums. 

While the idea of specialized courts for malpractice claims isn’t yet on the table, they may soon have a place in the debate as tort reform gains momentum. 

Imagine a specialty court that relies on educated judges, neutral experts, evidence-based proceedings, and a schedule of damages that not only keeps liability costs manageable, but also is better for patients. Sound too crazy to be true? It might be, but the idea has prominent supporters and a number of states are looking at ways to put this new malpractice system into practice. 


The idea of health courts isn’t a new one. “It’s a sort of new mutation of an older idea that really dates back about 20 years,” says Michelle M. Mello, JD, PhD, professor of law and public health in the Department of Health Policy and Management at the Harvard School of Public Health. “Virtually every academic commentator on health law agrees that administrative compensation is just much more promising than tort for remedying medical liability.” 

It’s also an idea that has its basis in existing systems. Detractors such as the American Bar Association, which has come out publicly against the concept, claim that health courts deny patients access to a jury trial and full compensation. But specialty courts with presiding adjudicators already oversee areas such as bankruptcy, family law, and tax courts. Perhaps the closest comparison for the health court model is the workers’ compensation court system, where a judge or adjudicating panel hears testimony, determines the liability of employers, and decides on compensation awards. 

Although there are various models under discussion, most ideas about health courts tend to focus on a few essential elements, which we’ll cover here. 


Tort lawyers don’t want to talk publicly about it, but one of the problems with a jury trial for medical malpractice cases is that juries can be swayed by emotion. However, in the area of medicine - and especially when we’re talking about physician liability - what is desperately needed is a sober consideration of facts. 

“Trial lawyers like to get in front of juries because juries are in some cases sympathetic,” says Michael D. Miscoe, JD, CPC, President of Practice Masters Inc., in Central City, Pa. “You venue shop - you look for venues that are more sympathetic and pay higher awards for a particular injury.” 

Miscoe is a lawyer, a certified professional coder, and a compliance consultant who helps physicians avoid the types of documentation mistakes that sometimes end them up in court. In the area of medicine, getting the facts right is important - but juries don’t always understand those facts or their importance. 

“Without any particular expertise in malpractice issues … you run the risk of seeing some of these insane awards for circumstances that kind of make you wonder whether our justice system is really working the right way or not,” says Miscoe. 


Instead of juries, health courts would use experienced adjudicators who would be used to seeing the same kinds of cases again and again. In this way, judges would become accustomed to what injuries are preventable and when a physician is truly liable. While detractors deride this idea as “judges practicing medicine,” nothing could be further from the truth. 

“We’re not talking about sending judges to medical school,” says A. Jenny Foreit, MPH, JD, senior counsel for healthcare at Common Good, a nonprofit organization with offices in New York and Washington, D.C., that has made health courts one of its strategic initiatives. 

Foreit points to the workers’ compensation model and the role judges play in that process. An adjudicator with experience in the medical liability area is far less likely than a jury to be misled by inaccurate testimony and sympathy appeals. 


“One of the things we’ve tried to put forward with the health courts is access to neutral experts,” says Foreit. In fact, the concept of neutral experts is one of the key elements in Common Good’s health court model. 

Because judges aren’t doctors, it’s important that they be able to consult with physicians and other medical experts who can give an honest, unbiased opinion on the medical facts of a case. Although the current system allows each party to bring so-called “experts” to testify, most of these witnesses have a vested interest in supporting whatever side is paying them. Lawyers from both sides end up bringing experts who will back up their case, and an entire profession of supposedly expert testimony has grown up around the medical liability system. But it’s basically devolved into a case of my expert vs. yours. 

“I think in tort circumstances or malpractice cases it becomes all about the experts and who’s more credible and who’s not,” says Miscoe. 

Medical experts with no vested interest in the outcome of a case can provide neutral testimony and help judges sort through the often complicated medical facts. Common Good and Mello, along with her colleagues at the Harvard School of Public Health, have suggested a model where independent experts would be drawn from outside the court’s geographic area and have no relation to that medical field in a particular state. “You wouldn’t have a Florida doctor weighing in on a Florida case,” says Foreit. 

One of the criticisms of neutral experts is that such a system might tend to favor physicians. The theory is that doctors are less likely to negatively evaluate medical decisions made by their colleagues. 

“I don’t know that that’s a valid criticism,” Foreit says. “You have bodily experts on both sides [in the current system]. You have physicians all the time who are willing to testify against physicians.” 


One thing physicians and insurers both like about the health court concept is the idea of limiting awards to claimants. Most health court models propose a ladder or schedule of claim awards where a patient is compensated for his or her specific economic losses (e.g., medical bills, lost wages, etc.) and also according to the extent of damage suffered for noneconomic claims (what is sometimes called “pain and suffering”). But is that really any different than imposing a cap on awards? 

“We believe that health courts are a better alternative than caps on awards because what we’re talking about is not limiting access to compensation but actually expanding it and simplifying compensation for medical injuries,” says Foreit. 

You bet. The 1991 Harvard Medical Practice Study found that less than 2 percent of patients injured due to negligence ever file a claim. Of the meritorious claims that are filed, about 25 percent never get paid. Even for those few patients who do get compensated, almost 60 percent of the current system’s total costs go to attorney fees, paid expert testimony, and various administrative costs. Part of the reason costs are so high is because medical liability cases can drag on for years as attorneys on both sides file motion after motion, appeal after appeal. 

“We see [health courts] as a system that is very promising for remedying the problem of undercompensation that we see in the system right now,” says Mello. “Although a few people get very large awards, the overwhelming majority of injured patients get nothing.” 

By keeping administrative costs low and adhering to a schedule of awards correlated to injury, health courts not only can provide restitution to patients who deserve it, but they also can expedite the process so that needy patients aren’t kept waiting for years and years. Workers’ compensation courts, which work similarly, often grant awards within six to nine months of filing. 

While physicians and insurers see the benefit of such a system, do patients? After all, who wants to limit the potential size of their litigation award? 

In a 2004 survey commissioned by Common Ground, 62 percent of respondents favored having medical malpractice cases tried in special courts. Only about 20 percent opposed setting up special courts for medical malpractice actions. “We’ve had really good response from consumer safety groups, consumer organizations, and patient safety organizations,” says Foreit. “The possibility under the current system of getting any sort of compensation is actually fairly low. What we’re talking about is broadening that.” 

There are two things everyone needs to acknowledge if medical liability is ever going to change. First, Miscoe observes, “Sometimes bad things happen to people who aren’t really healthy.” True enough, but claimants often look to place blame for unfortunate and unhappy events. 

The flip side of that idea is that doctors make mistakes. 

“Doctors are people. They’re human,” says Miscoe. “We expect them to be perfect, but they can’t possibly be. What we can expect them to do is do the best job they can do. Malpractice is there for gross negligence, and what has become gross negligence is in some cases a mistake or an oversight.” 


One of the most interesting concepts of Common Good’s health court model is the idea of changing the standard for compensation. Currently, medical liability rests on the notion of 

. Was injury caused by the act or omission of a physician? Or, to put it another way, did the physician make a mistake? 

Common Good’s model seeks to replace the standard of negligence with the concept of 

. The avoidability standard asks if the injury happened as a result of medical care or the withholding of medical care. Would it have been avoidable if best practices had been followed? In other words, not so much “Whose fault is it?” but “Could it have been avoided?” 

“The idea with the avoidability standard is to decouple the compensation from provider malfeasance essentially,” explains Foreit. “What we’re talking about is separating those two concepts further so that provider discipline follows a different track than patient compensation.” 

Too often, jury awards are used as a kind of penalty or punishment for a perceived injustice. The problem with this kind of system is that it relies heavily on both blame and sympathy - and neither of those do much to right either mistakes 

The current malpractice system has given rise to a culture of defensive medicine. According to a 2005 study in the 

, more than 90 percent of physicians admitted to ordering unneeded tests and performing unnecessary procedures to protect against the possibility of future malpractice claims. The Department of Health and Human Services puts the cost of these practices at around $60 billion a year. A medical liability system where physicians no longer have to fear admitting mistakes would not only put an end to such “over-practicing,” but it also might even make patients safer. 

“By getting rid of the negligence standard, we think you open up conversations about medical errors a great deal more,” says Mello. “You remove the stigma associated with reporting and disclosing errors.” 

Mello and her colleagues at the Harvard School of Public Health envision a system that can collect data on medical injuries and errors that can be used to improve healthcare systems and safety procedures. Can you imagine a medical malpractice system that actually helps physicians provide better care? 


If health courts are such a great idea, why isn’t anyone doing it yet? While the overall concept hasn’t gotten much further than the investigation stage in the U.S., several countries have already put health courts to work. 

New Zealand’s health courts began with a compensation standard similar to the U.S. concept of negligence but have since transitioned to a treatment injury standard. Basically, all injuries due to medical management are compensated, regardless of physician error or whether the injury was avoidable. About three out of every five claims results in compensation, but overall claim rates are fairly low with only around 3,000 claims each year out of a population of four million people. And administrative costs are very low, too, at only 10 percent of the total system cost (as opposed to 60 percent under the current U.S. system). 

The Scandinavian countries (Sweden, Denmark, Finland, Norway, and Iceland) all use the concept of avoidability in their health courts. In fact, Sweden pioneered the idea in 1975. The system uses expert reviewers and in-house claims adjusters who determine the total amount of awards. Like in New Zealand, the compensation rates under Scandinavian systems are fairly high, with Sweden compensating 40 percent to 45 percent of all claims filed. Actual awards tend to be fairly modest. Most of the claims are resolved with six to nine months of filing. Because of the “no-blame” nature of the system, physicians in Sweden help patients file for compensation in as much as 80 percent of cases. 

Of course, both New Zealand and the Scandinavian countries have universal healthcare systems that help defray the costs of medical liability and health courts. In the U.S., Florida and Virginia have enacted similar, though smaller, programs specifically for birth injuries. The Florida Birth-Related Neurological Injury Compensation Plan, created in 1988, and Virginia’s Birth-Related Neurological Injury Compensation Program, started in 1987, both aim to manage the astronomical increases in malpractice insurance premiums for OB/GYNs within their respective states. 

Each plan pays healthcare costs for infants who are born with specific neurological injuries, and neither plan relies on the negligence standard for patient eligibility. The Virginia system uses the Worker’s Compensation Commission to adjudicate claims, whereas the Florida plan has a separate oversight commission that coordinates medical review and decides on eligibility. Research shows that more than two-thirds of patients in the Virginia system would have chosen the program over a malpractice lawsuit. In Florida, patients are compensated much faster than they would be under a typical medical liability system. 

A similar model that is gaining traction is the idea of arbitration. Arbitration already exists for private disputes of many kinds, and many states are looking at the arbitration model for handling medical liability without completely changing the current court system. “With arbitration, both parties would agree prior to the commencement of a treatment relationship that any disputes that arose from that relationship would be handled via arbitration rather than via the courts or via litigation,” explains Foreit. 

Like a health court, arbitration uses an experienced adjudicator and, usually, neutral expert testimony. It also keeps administrative costs lower than the typical malpractice court system. Health insurers are really taking the lead on using arbitration to lower costs, and many health plans already offer or require arbitration. The Kaiser Permanente managed care health plan in California, for example, requires all members of the plan to settle injury disputes through its own independent arbitration board. And the Utah Medical Insurance Association, which provides medical liability insurance for physicians, offers a discount for physicians who merely offer arbitration as an alternative to their patients. 


While health courts could eventually change the way medical liability is handled in the U.S., what can physicians do now to protect themselves? 

Ever hear of the old adage, “Bad facts make bad law?” 

Michael D. Miscoe, JD, CPC, a lawyer and a certified professional coder, knows the value of getting your facts right - and getting them down on paper. He’s seen more than a few malpractice cases won and lost on a physician’s documentation and coding. 

“Those malpractice suits look to capitalize on an omission in the documented record to substantiate that the doctor did something wrong - when in actuality the doctor did everything right but just forgot to write it down.” 

Miscoe recommends that physicians learn to document better and trust in-house experts who know coding and documentation rules. “More efficiency in documentation so that doctors can capture the work that they’re doing and their decision-making processes - that’s going to minimize malpractice risk,” says Miscoe. “Whether it’s the current judicial jury trial system or a specialized court, it won’t matter because you’ve taken the case away.” 

Physicians who aren’t sure of best coding and documentation practices can rely on in-house certified professional coders or approach a risk management consultant who can visit their practice, evaluate their documentation, and give them an idea of what needs to be improved. 

“Better documentation won’t eliminate medical mistakes in their entirety,” says Miscoe, “but it will eliminate the number of cases that are brought not because a mistake was made but because a doctor didn’t write something down.” 

 He is based in Baltimore, Md., and can be reached via 

This article originally appeared in the January 2010 issue of

Could the answer to the malpractice crisis be a whole new kind of court? Federal caps on pain-and-suffering awards aren’t coming soon, so we investigate another possibility.

Author | Robert Anthony

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