In Defense of Family Medicine Certification

My dad was a family physician who trained in the 1950s. That was in the days when general practitioners were looked down upon by many of their colleagues. Many of those same colleagues saw no need for board certification in family medicine, and some of them even fought against the formation of the American Board of Family Practice (ABFP) in 1969. Dad was extremely proud to have been in the first group of ABFP Diplomates. He was no longer a generalist. He was a specialist. As family physicians, we not only had our own certifying board, we went one step further. We were the first specialty to require recertification, and it set us apart from the premise that certification at age 30 meant one still had the same knowledge and skills at age 70.

A lot of time has gone by, and the ABFP is now the American Board of Family Medicine (ABFM), and there are departments of family medicine in virtually all U.S. medical schools. The ABFM has the third-largest number of Diplomates, exceeded only by the American Board of Internal Medicine and the American Board of Pediatrics with their legions of subspecialists and "grandfathered" Diplomates with lifetime certificates. Gone are the days of reviewing paper charts before sitting for the certification exam, replaced by a continuous certification process in which quality improvement plays a prominent role. Working within the parameters set by the American Board of Medical Specialties (ABMS), the ABFM continues to lead the way in developing innovative strategies for continuous certification. Enabling Diplomates to seamlessly report quality metrics required by Medicare and others, thereby reducing administrative burdens, is just one of the many ways the ABFM has attempted to create added value for continuous certification. Projects being field-tested right now may someday eliminate the need for a written high-stakes exam. A growing body of peer-reviewed literature attests to the effectiveness and relevance of the ABFM's program.

Despite being members of the specialty that can best hold its head up to our patients and say that our board certification is a dynamic process constantly reinventing itself, there is unease among some family physicians. Why? Cost is often cited and is described as exorbitant. Yet the yearly cost of maintaining certification for 10 years is $200. Most people I talk to spend roughly that amount a month on cell phone usage. Some colleagues object to the cost of CME to review for the written exam, although that same CME can be used to meet requirements for licensure and membership in medical associations. Others object to taking time out of the office for the written exam when, in fact, it can be taken on a Saturday (although I do give a pass on this one to those of the Jewish faith who cannot work on the Sabbath).

There also are questions about the relevance of the exam to daily practice, but the exam has been developed using actual data collected from family physicians. The questions are directly related and proportional to what family physicians report doing in their practices every day.  

In fairness, the biggest objection I have heard expressed is that board certification isn't really voluntary because so many insurers, physician groups and hospitals require it for credentialing purposes. But how on earth is it logical to blame the certifying boards for the actions of others? That makes the ABFM a victim of its own success.

It is the policy of both the ABFM and the ABMS to not support the use of board certification as the sole criterion for credentialing. Hospital medical staffs -- not certifying boards -- have the power to stop such use. Rather than fighting state licensure boards, we should be insisting that they accept continuous certification as sufficient for licensing purposes with no additional requirements.

At the end of the day, we physicians have to decide whether we want to continue to be members of a profession. Being in a profession means that the members are responsible for self-regulation. Time-unlimited board certificates are gone, and they aren't coming back. Society will not stand for it. The question for us is whether we want to be responsible for professional certification, or do we want someone else to take that responsibility from us?

Is our current system flawless? It is not, but as family physicians, we can be proud of the way the ABFM is rigorously dedicated to continuous quality improvement, Diplomate satisfaction and, last but certainly not least, assuring the public that Diplomates meet rigorous standards designed and administered by family physicians.

Craig Czarsty, M.D., is a family physician in Oakville, Conn. He is a former ABFM Board chair and current member of the AAFP task force on nominations and elections and candidate activities.