It’s time to stop mandating board exams for family physicians

I am a family physician who has been in practice since 2007. My practice is broad in scope; immediately out of residency I worked in a community health center where I practiced obstetrics, newborn care, and inpatient medicine and pediatrics, along with my outpatient obligations. Since 2011 I have been a locum tenens physician working in rural Colorado in emergency departments, clinics, and hospitals.

I recently received your American Board of Family Medicine (ABFM) pamphlet outlining the upcoming changes to the family medicine boards for those of us who must re-certify in April 2017 and beyond. I have an even better suggestion that would improve the maintenance of certification (MOC) process and likely increase the current number of practicing family physicians. It’s time the ABFM stop mandating board exams as a requirement for family physicians.

Last summer the American Medical Association passed a resolution to stop board recertification for physicians as there is no evidence that these exams improve patient outcomes or are productive for physicians’ daily practice. The American Board of Internal Medicine will no longer require its members to complete closed-book board exams in 2018. Anesthesiologists do not need to take board exams, but rather, complete annual CME to fulfill their active status with their board. The American Board of Pediatrics may also discontinue board recertification as a practice requirement. It’s time for the ABFM to join this growing group of organizations who decided that it was not in their members’ best interest to sit for boards when that time would be better spent on other endeavors.

Board exams should not be eliminated completely. They should still be required as an initial examination to practice once a resident completes his/her training, so that knowledge deficits can be addressed promptly and allow that person to move on with their career goals. Family medicine nurse practitioners take their boards once — upon completion of their training — then never take them again. This is the goal toward which the ABFM should strive.

In place of board exams, practicing physicians’ time would be best spent taking online quizzes relevant to the focus of their practice. For example, I could select quizzes among various topics in emergency and hospital medicine and outpatient practice. A physician who works with athletes can focus on sports medicine-related CME, and so forth. This would allow us to maintain our active status with the ABFM and fulfill recertification requirements that can also improve our daily patient care.

Here are the reasons we should no longer be required to board re-certify:

Board study is a poor use of CME time. Preparing for the boards consumes precious CME time that would be better applied toward conferences within our areas of professional interest. This would directly improve patient care by allowing us to learn the latest advances in areas relevant to how we practice. For example, I have taken numerous courses in adult and pediatric life support, trauma, difficult airway, and EM/urgent care. I also have a personal interest in wilderness and international medicine, and have traveled to Haiti for medical mission trips. It is much more important to me and my patients that I learn subject matter relevant to my personal practice rather than spend my time completing board review courses and sitting for a test that does not reflect my clinical knowledge.

Disruption of work-life balance. Clinical practice is already time-consuming, due to the ever-growing demands of patient care. Having to take the time to study for boards in today’s medical climate is a great way to ensure higher rates of physician stress and burnout. Family physicians are among those physicians with the highest rate of burnout. Doctors are human too, and we prefer to devote our personal time to non-clinical activities such as hobbies and family life. Boards are one more obstacle toward achieving that balance.

Some specialties (anesthesia) no longer require board exams. As I briefly mentioned above, the field of anesthesiology has revamped its board recertification process and no longer requires that physicians sit for a test. FM and other primary care specialties are already losing bright minds to fields such as anesthesia due to the perception that these areas offer a more lucrative lifestyle. Med school grads may lean toward a specialty that doesn’t require boards and use this as another criterion when choosing their career path. The emphasis on lifestyle is strong.

Boards do not improve patient care. Boards have not been shown to improve patient care, but merely add to the busy work already crowding a busy family physician’s daily schedule. An individual’s ability to perform on a test does not adequately reflect their clinical knowledge or their bedside manner. Our patients are unique individuals with psychosocial and medical complexities that can make diagnosis more difficult. They are not multiple choice questions with a straightforward “one size fits all” answer. Additionally, board exams take physicians away from their practice as they must spend a day taking the test and extra time before that to prepare for it. In some cases, they must take additional time off to travel to their test. I noticed that all but two of the dates available to take the boards in April fall on weekdays. Most family physicians work Monday to Friday in outpatient practices, so will need to use a vacation or sick day, or perhaps take an unpaid day off, for this exam. This time away from practice can result in lost patient revenue and restrict patients’ access to their health care provider.

Medicine is teamwork. Whenever I don’t know an answer to a question or a clinical scenario, I look it up in a book or online resource or ask for help from a colleague, staff member, or specialist. A 400-minute test does not in any way simulate this real life experience. The practice of medicine is an art and an ongoing, dynamic process — not a one-day exam.

Boards are just one more expense in an already-costly MOC process. My upcoming board exam will cost $1,300 (I prepaid for my boards when I signed up for MOC in 2010). This is in addition to expenses I’ve accumulated through the years for CME and MOC. Not only that, I must complete the ABFM’s MOC requirements and obtain at least 300 hours of CME to sit for the test. It seems to me that my almost-ten years of diverse practice experience, 300-plus hours of CME, and medical mission work in Haiti are much more reflective of my ability to practice medicine than a one-day test.

In conclusion, the ABFM needs to overhaul physicians’ board recertification process for the reasons noted above, including work-life balance; the inability of a test to assess a physician’s ability to provide quality patient care; and cost, both financially and in terms of time for board preparation. As we enter 2017, please reconsider whether it’s prudent for the ABFM to continue to require us to take this test and whether we’d be better off completing other activities to maintain our active status.