Changes in store for ABFM’s Maintenance
of Certification

By Kate McCann

Nearly a third of the way through the transition process that will place all family physicians under the new Maintenance of Certification program, the American Board of Family Medicine announced in January 2006 that the board is implementing changes to address physician concerns. The changes will go into effect January 2007 and attend to the grumbles about tedious testing, a redundancy of the whole certification idea and methods, and high cost.

“We’ve tried to be very consistent in our message to diplomates,” says James Puffer, M.D., executive director of ABFM. “This is a dynamic process, it will continue to evolve and change over time as we increase our ability to develop components that help physicians develop high quality care.”

One of the most important enhancements of the program is the option for diplomates to extend their current seven-year certification to a 10-year certification period. ABFM officials hope that a longer certification period will allow physicians to complete requirements at a more relaxed pace.

In the current seven-year program, diplomates have six years to complete six Part II modules and one Part IV module before taking the cognitive examination during the cycle’s final year.

Those who choose to extend their cycle to 10 years will split the four-part certification period into three three-year windows, or stages. Parts I and III are unchanged. Part I still calls for proof of a valid and unrestricted license in all states in which the physician practices, and will eventually include a peer review survey and patient satisfaction component. In year 10, physicians complete Part III, the cognitive examination. The difference between the seven- and 10-year periods is in the makeup of parts II and IV within the stages. Each stage in the 10-year program requires the completion of two modules from Part II, either Self-Assessment Modules or other approved external provider modules, and one module from Part IV, comprised of Performance in Practice Modules, two newly added modules, or another approved external provider module.

The SAMs of Part II have been the most controversial and criticized aspect of the MC-FP. The tests, containing 60 knowledge assessment questions and a clinical simulation, are cited for lack of relevant topics or unclear testing methods. Puffer says that most of the criticism of the SAMs comes from diplomates who have not yet taken the self-assessment and, drawing from respondents’ surveys, most participants are actually pleased with the testing style and material. This year, there will be six SAM topics from which physicians can choose. SAMs currently available cover asthma, coronary heart disease, diabetes and hypertension, with more topics in development.

Part IV has been expanded to require two more modules. In addition to the Performance in Practice Module are two additional methods, the Methods in Medicine Module and the Patient Safety Module. AAFP’s METRIC system, or Measuring, Evaluating and Translating Research Into Care, is currently the only external module approved for use. Now physicians in traditional or non-traditional practice may choose the most helpful modules for their practice.

“I never objected to Part IV, Performance in Practice,” says Richard Feldman, M.D., past president and director-at-large of the Indiana Academy of Family Physicians. He also serves as the director of medical education and the family practice residency program at St. Francis Hospitals and Health Centers, Indianapolis. “That really translates into better quality care. In the end, I tell my residents that there is no substitution for reading literature about a patient’s condition and using evidence-based medicine. The most valuable exercise is when you read about a patient’s case.”

Because the full cost of the MC-FP program remains the same, extending the certification period to 10 years alleviates some concern over cost by spreading the full amount over more years. ABFM offers three payment options from which diplomates may choose, compatible with either the seven-year or 10-year periods. Payment Plan I allows physicians to pay a single, one-time fee at the beginning of the MC-FP cycle to cover the cost of all modules and the exam. Payment Plan II offers an annual payment for modules and the exam. Payment Plan III users must pay a fee for each module plus the balloon payment for the year of the exam, determined that year.

Physicians would probably agree that a periodic competence check-up and commitment to continuing education fit within reasonable expectations of the medical profession. Obligations to professionalism, self-assessment and lifelong learning, cognitive expertise and performance in practice — the foundation of the MC-FP program — fit well into goals of achieving clinical excellence and enhancing the quality of care for patients.

“Most of the objections from family doctors weren’t that they were outraged with the concept,” Feldman says. “They don’t have a problem with continuing education, but rather the methods of certification, how it is carried out.”

Physicians like Feldman credit the board’s work on improving the process and making certification more relevant for medical practice, but some still have concerns.

“What [the board] still hasn’t addressed is the issue many docs face of not having access to a computer,” Feldman says. “They are intimidated by the electronic version [of the tests]. There are many areas that still don’t have high-speed access, which slows the testing and can make the clinical simulation impossible.”

While a non-electronic version is offered, according to Puffer, only 50 diplomates out of 11,000 took their cognitive examination with paper and pencil at the testing site last year. He also stressed that all MC-FP components are accessible through both high-speed and dial-up connections, although a high-speed connection provides for higher efficiency. ABFM will continue to review the process and implement enhancements that promise to smooth the system and provide for continued improvement.