From Resident to Diplomate: The Purpose and Process of Becoming Board Certified

To All Family Medicine Residents:

Welcome to the Journal of the American Board of Family Medicine (JABFM)! With this issue, all family medicine residents who have taken the American Board of Family Medicine (ABFM) In-Training Examination become subscribers to the JABFM, which publishes 6 issues per year devoted to knowledge that improves health care for the people, family, and communities of practicing family physicians.

The purpose of this editorial is to share with you the history, purpose, and value of board certification and to describe the process by which you can become board certified at the end of residency. Up to now, your time has been spent in formal medical education—4 years of medical school and up to 3 years in residency training, depending on your current training year. Your professional career, however, will last 30 to 40 years after residency! Board certification focuses on the rest of your career and can help you keep up with new knowledge and ongoing practice transformation.

The first question is: why become board certified? ABFM board certification is a credential beyond state licensure, with standards set by family physicians for family physicians. While many employers want physicians to be board certified, board certification is ultimately voluntary—a personal commitment you make that demonstrates your commitment to assessing your ongoing educational needs and participating in lifelong learning, as well as maintaining standards of professionalism and continuously seeking ways to improve the care you deliver. Board certification is recognized by patients, the public, and peers as a marker of a high-quality physician. There have been numerous studies, done across specialties (including family medicine), that demonstrate the association of board certification with improved knowledge, better patient outcomes, and fewer adverse licensure actions for professionalism reasons.

The American Board of Family Medicine—initially named the American Board of Family Practice—was launched in 1969 after national reports emphasized the importance of personal doctors providing comprehensive, continuous care in communities. From the beginning, our specialty made a commitment to regular re-examinations to help assure the public that Diplomates were up to date; moreover, at the first re-examination, a chart audit was taken to assess whether Diplomates’ knowledge was put into practice. Since 1969, all other specialty certification boards have adopted this continuous certification model, and advances in cognitive science have confirmed the key premises of board certification. As physicians, we simply do not know what we do not know (the “Dunning–Kruger” effect) and that we overestimate how well we retain information learned. Ongoing independent assessments of cognitive expertise are necessary.^1,2

What is needed to become ABFM board certified? Probably most important is a personal commitment to professionalism. As physicians, and as family physicians, we live according to a kind of “social contract,” ³ in which we physicians are given honor, relative affluence, and significant autonomy in return for service to patients and society and for the privilege of self-regulation. An early expression of this professionalism is a full, active, and unlimited medical license. But board certification is more than medical licensure; it includes adherence to a set of ethical rules for the benefit of patients and society. ABFM believes that professionalism should be an active and ongoing commitment; it is in service of professionalism, for example, that ABFM has taken a stand on disinformation and distinguishes between physicians’ responsibilities to their employers and their responsibility to their patients and society. The ABFM Guidelines for Professionalism, Licensure, and Personal Conduct⁴ describe our standards and how we implement them.

Another pillar of ABFM board certification is the cognitive expertise necessary to be board certified—this means passing the ABFM examination, which about 90% of residents take in April of their PGY-3 year. To estimate your likelihood of passing the board certification examination, use the online Bayesian score predictor with your in-training examination scores. The initial board certification examination is taken on a single day in a secure test center, much like your experience with the United States Medical Licensing Examination. After passing the initial certification examination, you will have the future choice of completing subsequent examinations in 1 day at a secure center or through the Family Medicine Certification Longitudinal Assessment (FMCLA) program, in which you answer online 25 questions per quarter over 3 to 4 years, on your own time, and with the ability to use references. Over the last 4 years, about 75% of Diplomates have chosen the longitudinal assessment.

During residency, you will also participate in activities that support ongoing knowledge self-assessment and learning as well as those aimed at helping you learn how to improve care in practice. Like Diplomates over their career, residents must complete activities that will add up to at least 50 certification points. As a resident, you have access to all ABFM activities online and free of charge to help you prepare for the initial certification examination. Log on to your MyABFM Portfolio at Log on (theabfm.org) to see your options and track your progress.

ABFM offers 3 types of activities to help with assessing your current knowledge strengths and needs. The first type is 60-question Knowledge Self-Assessments (KSAs) that cover important diseases like diabetes or heart disease or assess the broad scope of care provided by family physicians, such as the care of children, behavioral health care, or palliative care. KSAs emphasize recent evidence and are designed to be challenging; only a small percentage of Diplomates pass the modules on the first time. But they are also designed to be learning exercises, with critiques that explain why the correct answers are right and the incorrect answers are wrong, and they can be retaken as many times as necessary to pass. Each KSA is worth 10 points toward your 50-point total. For residents, there is evidence that completing more KSAs improves the likelihood of passing the examination. Many residency programs are incorporating KSAs as their formal conference curriculum or in advance of specific rotations.

Another activity ABFM offers is the Continuous Knowledge Self-Assessment (CKSA), which is also available in your MyABFM Portfolio. Like the FMCLA, CKSA provides 25 multiple-choice questions online each quarter that cover the breadth of family medicine. Once you answer a question, you learn immediately whether you were correct and receive a critique that explains the reasons for the correct and incorrect answers. You also receive related references for further learning. After introduction in 2017, the number of people participating in CKSA has grown every quarter; more than 30,000 family physicians participate every 3 months. A year of participation in CKSA garners 10 KSA points. For residents, CKSAs offer an opportunity to test your knowledge against the standard of what board-certified family physicians know. They are also fun to do!

A third option is the ABFM National Journal Club, which allows you to select from a group of approximately 100 recently published articles a year. The goal of the Journal Club is to help family physicians apply the most important recent evidence in their practice and advocate for their patients with subspecialists, hospitals systems, and payers. The articles are selected by a committee of practicing family physicians with expertise in evidence-based medicine with relevance to family medicine, potential to change practice, and methodological rigor. You will have access to a PDF of the article; after reading, you must answer 4 questions correctly to receive credit. There is a critique that puts the article in the context of other current literature. Finishing 10 articles gets 10 KSA points and 10 continuing medical education credits, but there is no limit to the number of articles you can review and receive credit for. Many residencies are beginning to build the ABFM National Journal Club into the formal residency curriculum.

Participation in Performance Improvement (PI) is also required for board certification. ABFM believes that knowledge is important but not sufficient and that putting knowledge into practice is critical. Family physicians must demonstrate that they know how to reflectively look at their own practice, identify a gap in care delivery or outcomes, intervene to close those gaps, and then remeasure to assess for improvement. These efforts can address any kind of clinical problem, from condition-specific quality measures to access to care, patient experience, cost of care, and more!

There are numerous options to choose from for your PI activity. Many residency programs and health systems participate in group PI projects, where larger groups of physicians develop a common focus for improvement and an organizational sponsor reports participation. The most commonly used pathway for individual Diplomates is the Self-Directed PI activity,⁵ designed for physicians to report easily on what they are already doing. For those who would like a step-by-step introduction to performance improvement, ABFM has also developed PI activity options for 15 clinical conditions or content areas in family medicine using a specific topic, such as sports medicine, emergent/urgent care, or asthma. Each PI activity you have approved will provide 20 points toward your 50-point total.

The final step to becoming board eligible is the successful completion of your residency program. Your residency director must attest that you have met all requirements set by the American Council on Graduate Medical Education (ACGME) and that you are ready for autonomous practice.

All in all, then, there are 5 criteria that must be met for board certification: (1) completing your residency training; (2) finishing 50 points of certification activities; (3) passing the initial certification examination; (4) remaining in compliance with ABFM’s Guidelines for Professionalism, Licensure, and Personal Conduct; and (5) obtaining a full, active, and unlimited medical license (not your residency training license). You will have achieved ABFM board certification and formally entered the specialty of family medicine. These steps are the same for both MD and DO graduates of ACGME accredited residency programs.

Board certification recognizes rigorous clinical training and the hard work of studying: it is a mark of your commitment to ongoing improvement and to professionalism. It is also a promise to society. In a time in which the outcomes of health care⁶ are worsening, US life expectancy is dropping,⁷ and unjust disparities⁸ persist, family physicians can make a positive difference in the lives of their patients and their communities. ABFM is proud to have you as colleagues and looks forward to working with you over your careers.