The Maintenance of Certification Reform Movement

I am writing this blog immediately after taking the American Board of Family Medicine (ABFM) Certification/Re-Certification Examination all day yesterday. I wanted to write this now, before I get the results, so that I can’t be accused of claiming sour grapes. This will be the sixth time I have taken this examination since completing my family practice residency in 1979 (that’s what the specialty was called in those days). At the time I was proud to be a member of the first specialty that required its members to ensure our competence throughout our career. I had no idea what was in store.

The only good thing about the “old” exam procedure is that I reported to a regional hotel with several hundred other family physicians and it was an experience like going into battle with an army of fellow sufferers. The “new” exam is done on a personal computer inside a local test center. The good news is that I had to drive only fifteen minutes from home and the exam results would be given to me within a few days of the testing. However, the experience of this “secure testing facility” is exactly like an accused criminal being processed into a detention facility. Even my eyeglasses were examined to be sure they didn’t contain any “weapons of knowledge”. I find it particularly ironic that for a specialty that prides itself on professionalism and self assessment and has earned the trust of our patients and community is treated by our certifying board as totally untrustworthy and measures our worthiness to be “certified” as specialists by what some supposed experts in my specialty consider so important that I should have it stored in my hippocampi. God forbid I should have a 5-ounce device in my pocket which has instant access to more evidence-based medical knowledge than existed in the entire world in 1979.

Regardless of how much continuing medical education you have done and how well you demonstrated your mastery of the skills, knowledge, and attitudes necessary to maintain licensure and credentials to your state medical board, the privilege granting committee of your healthcare system, and your third party payers, if you don’t do well on this one day, you are likely to lose the support of at least the latter two.

I personally have devoted my entire career to developing methodology to get evidence to the point of care to assist in decision-making. In my opinion, the best family physicians (and any other clinician) needs to acknowledge that humans are fallible and even teams of humans need to constantly examine both the process and content of their care continuously.

I appreciate the difficulty of measuring competence in a profession in which adherence to the best standards of care for diagnosis and treatment still results in what are sometimes disastrous outcomes. I know that ABFM has considered other methods of assessing maintenance of competence. I was invited to consult for the ABFM about twenty years ago when I was at National Library of Medicine working on health information technology (HIT) vocabulary standards. Electronic health records (EHR) systems were becoming common in family medicine practice. We all agreed that it would be helpful both to the ABFM and its diplomates to observe both clinician’s process and content of care. The other medical informaticians invited and I explained the technical barriers extracting information from EHR systems was far more difficult than today and interoperability is still a challenge. I don’t know if the ABFM has revisited that idea, but I would suggest that approach.

The very week before my exam I learned of at least a possibility of maintaining board certification without this periodic all-day root canal without anesthesia.

The American Board of Family Medicine is pleased to announce a pilot program to begin in January 2019 that will assess the value and feasibility of a longitudinal assessment option to the 10-year secure examination. Jerry Kruse, MD, Chair of the ABFM Board of Directors, announced this news to family physicians attending the 2018 American Academy of Family Physicians Congress of Delegates in New Orleans. Physicians who are current with continuous certification and are due to take the examination in 2019 would be eligible to participate in the pilot. Dr. Kruse stated, “based on the popular Continuous Knowledge Self-Assessment (CKSA) platform, the longitudinal assessment pathway will deliver 25 questions online each quarter to those Diplomates who choose this new option. This approach is more aligned with the ongoing changes in medicine and draws upon adult learning principles, combined with modern technology, to promote learning, retention and transfer of information. Over time, we will be able to assess the core clinical knowledge of board-certified family physicians and recognize the vast majority who work to keep up to date to take care of their patients.”

The ABFM has since clarified that “If the pilot program is successful, all Diplomates will have the flexibility to choose longitudinal assessment over the examination in a secure testing facility going forward. For those who prefer the 10-year examination and would rather not participate in the longitudinal assessment pathway, that will continue to be an option.”

I am proud that it was my specialty board that was the first to make this move. American Board of Internal Medicine and American Board of Emergency Medicine, are you listening?

Addendum: I received an email from the ABFM three days after my exam to log in and get my results. PASS!

Charles A. Sneiderman, MD, PhD, DABFP
Medical Director, Culmore Free Clinic
Bailey’s Crossroads, VA

Published on 12/10/18