As with most medical specialties, there has been controversy over the past decade regarding changes to the maintenance of certification process for board-certified family medicine physicians (MC-FP) and, in particular, changes to the American Board of Family Medicine’s high-stakes board exam process. Beginning in 2006, the ABFM:
- Computerized and began offering its exam at an increased number of locations and times than in the past; this essentially required a major transition in the underlying testing theory and scoring process as well as an expansion in the exam’s question bank to enable the auto-generation of different exam versions that would be both secure and consistent in terms of knowledge-assessment integrity
- Undertook a major overhaul of its exam blueprint, expanding from eight topic areas to 14, including population-based care and patient-based systems, plus eight additional modules from which test takers may choose the two they believe most salient to their clinical experience
These changes were followed by a deep, yet short-lived decline in exam pass rates. And, while the decline was attributed ultimately to a different cause – namely the ABFM’s 2007 extension of board certification tenure from seven to 10 years (with conditions) – other trends have helped to perpetuate the idea that the exam process has become increasingly challenging for family medicine physicians. For example, the evolving structure of care delivery – in particular the dramatic increase in hospitalists as well as strong, steady growth in rates at which primary care physicians refer patients to specialists for clinical diagnosis and treatment – has reduced family medicine physicians’ direct exposure to wider varieties of clinical cases, increasing the challenges of staying current with medical knowledge compared with physicians practicing in narrower specialty areas.
Family medicine physicians also practice in a much wider variety of clinical settings. For example, a PCP working for a large group practice in a wealthy suburb that encompasses separate OB, pediatric, and other subspecialties, might have a much narrower breadth of direct clinical experience from which to build new medical knowledge over time. They may also be less consistently exposed to cases more typically seen in poor, more ethnically diverse inner-city settings. Meanwhile, a PCP working for 10 years in a rural private practice might see a greater variety of cases, but would be less likely to be in regular communication and sharing with other physicians and specialists. The isolated rural family practitioner might also have less ready access to up-to-the-minute medical learning resources, be less likely to make large personal investments in such resources, and may encounter real difficulty in taking time off from practice to attend medical conferences and the like.
While the addition of selectable exam modules seems intended to address real-world variability in family medicine practice, FM physicians are still challenged to keep up with ever expanding and changing arrays of medical knowledge across 14 specialty areas, quite a number of which they may never touch in daily practice. So, given these added challenges for family medicine physicians, what is the best way to go about preparing for the high-stakes ABFM recertification exam?
Top Advice for ABFM Exam Prep
Preparation leads to confidence, and confidence leads to success, says Dr. Mark Nadeau, a clinical professor and residency director in the Department of Family and Community Medicine at the University of Texas Health Science Center San Antonio, who has passed the ABFM exam on five separate occasions over the course of his career and now serves also as a senior reviewer with NEJM Knowledge+ Family Medicine Board Review. (For the full story of how Dr. Nadeau has learned to approach successful board-exam preparation, check out ABFM Exam Prep: Make Time and Make a Plan.)
Question banks (both online and print) have also become hugely popular, especially among younger physicians, because the activity of answering questions is often supported by mobile technology and can be worked into small increments of spare time during each day. In choosing question banks, focus on ones that offer plenty of practice answering clinically focused, exam-style questions that require high-level cognitive tasks such as application, analysis, and strategy versus just definition or understanding. Consider also taking advantage of adaptive learning technology (utilized by platforms such as NEJM Knowledge+) to zero in rapidly on weak spots. And be sure to complete practice questions in roughly the same distribution as the exam blueprint, as this will help in pinpointing specific knowledge gaps and directing more focused follow-up study for family physicians with major time constraints.
When to Consider Taking a Family Medicine Board Review Course
Materials set forth by board review course providers — including location-based, CD/DVD, and online-only programs — suggest that broad family medicine review courses might be best suited for physicians who:
- Have left exam prep until very late in their recertification cycles
- Are not especially disciplined about studying independently
- Are not typically strong test takers
- Have yet to experience computer-based versions of the exam
- Do not make a regular habit of keeping current with general medical knowledge via journals, conferences, peer networking, question banks, self-assessment tools, and so forth
- Have daily responsibilities such as child or elder care that can make it difficult to carve out focused time for self-directed study
- Practice family medicine in relative isolation (rural, private practice) or among patient populations lacking in ethnic, age, economic, or other forms of diversity
- Show downwardly trending test scores over time (a function of distance from academic settings and regular study)
- Have taken practice tests or utilized question banks and have performed poorly across the board (versus in just a few specific areas)
Board prep tools have weak and strong contenders, so careful research is always needed in deciding how to invest one’s time and money on specific board-review offerings.
Many review courses and other resources can be purchased conveniently online, but checking original publication dates for content as well as content-revision frequencies is a must to ensure they are up to date with advances in medical knowledge (but not so up-to-date, that it overshoots the exam revision cycle) and up to date with changes in how the ABFM structures its exam to assesses knowledge.
While it is a reasonable assumption that family medicine board review courses have been developed using the ABFM exam blueprint — meaning they portion course time appropriately across the breadth of subject areas covered in the exam — this is not a given and should always be verified when weighing family medicine board review course options.
A big positive for many family medicine board review courses is that — in addition to medical knowledge — they teach specific test-taking strategies, including how to rapidly deconstruct and decode exam questions. Family medicine review courses may also provide key insights into how questions are developed for the exam, how the exam is structured and scored, why it is important to answer every question (even by guessing), and specific strategies for making best-possible guesses.
Family medicine board review courses may also train physicians to work more effectively in timed and computer-based testing environments. When taking the actual exam, one has approximately 60 seconds to read, digest and answer each question; due to exam scoring methods, it is always best to answer every question. Practicing questions repeatedly within realistic time constraints can go a long way to relieving test-takers’ anxiety.
While many family medicine review courses offer money-back guarantees, they are not as fail-safe as exam pass rates suggest. At the end of the day, each family medicine physician must make a clear and honest assessment of his or her own learning styles, capacities for retaining information and testing, and career-path priorities.
Please join our ongoing conversation about best practices for family medicine board exam review by sharing your own experiences with review courses in the comments below.