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Objective: To measure associations between surgeons' examination performance and obtaining American Board of Surgery certification with the likelihood of having medical malpractice payments. Background: Further research is needed to establish a broader understanding of the association of board certification and patient and practice outcomes. Methods: Retrospective analysis using propensity score–matched surgeons who attempted to obtain American Board of Surgery certification. Surgeons who completed residency between 2000 and 2019 (n=910) and attempted to become certified were categorized as certified or failing to obtain certification. In addition, groups were categorized as either passing or failing their first attempt on the qualifying and certifying examinations. Malpractice payment reports were dichotomized for surgeons who either had a payment report or not. Results: The hazard rate (HR) of malpractice payment reports was significantly greater for surgeons who attempted and failed to obtain certification [HR=1.87; 95% confidence interval (CI), 1.28–2.74] than for surgeons who were certified. Moreover, surgeons who failed either the qualifying (HR=1.64; 95% CI, 1.14–2.37) or certifying examination (HR=1.72; 95% CI, 1.14–2.60) had significantly higher malpractice payment HRs than those who passed the examinations on their first attempt. Conclusions: Failing to obtain board certification was associated with a higher rate of medical malpractice payments. In addition, failing examinations in the certification examination process on the first attempt was also associated with higher rates of medical malpractice payments. This study provides further evidence that board certification is linked to potential indicators for patient outcomes and practice quality. [ABSTRACT FROM AUTHOR]