J Am Board Fam Med: first published as 10.3122/jabfm.2023.230201R0 on 15 June 2023. Downloaded from [Link] on 16 June 2023 by guest.

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BOARD NEWS

Implementing Competency Based ABFM Board

Eligibility
Warren P. Newton, MD, MPH, Michael Magill, MD,
Wendy Barr, MD, MPH, MSCE, FAAFP, Grant Hoekzema, MD, FAAFP,
Saby Karuppiah, MD, MPH, DFM, FAAFP, and Kim Stutzman, MD, FAAFP

( J Am Board Fam Med 2023;00:000–000.)

Keywords: ACGME, Competency-Based Education, Entrustable Professional Activities, Medical Education, Specialty Boards

The transition from residency education that empha- including emphasizing the practice as the curricu-
sizes counts and hours to competency assessment is a lum, community engagement to address disparities,
major change for Family Medicine. Starting July 1, flexibility for residencies and residents, participation
2023, it will affect all program directors, faculty, and resi- in residency learning networks, transition to compe-
dents. How should our community support this change? tency-based medical education (CBME) and more
Keeping in mind the “why” of residency redesign is faculty time dedicated to education and evaluation.
important. Despite rhetoric of transformation and A first task—and 1 that will require engagement
tech-driven innovation, the outcomes of health care in across the discipline over many years—is the imple-
the US are getting steadily worse in comparison to
mentation of CBME across the specialty. Of course,
other affluent countries1; life expectancy is declining,2
CBME, is not new—the WHO described it in 1978
even as costs rise unsustainably. Moreover, the pandemic
—and it has been incorporated into undergraduate
has driven us to rediscover3 disparities and has accelerated
medical education and widely across other health
burnout and moral injury among family physicians and
professions over the past 20 years.4 Now it is coming
their teams. To meet the needs of our patients, commun-
to graduate medical education, propelled by an
ities, and health teams, Family Medicine must step up.
We in Family Medicine believe that well trained ABMS/ACGME collaboration with leadership from
personal family physicians supported by robust Pediatrics, Surgery and Family Medicine.
teams and policy can be an antidote to the crisis in The challenges of spreading CBME in Family
health and health care. The goal of the major revi- Medicine are great. We have 7451 residencies,
sion of the ACGME Requirements for Family distributed across a vast geography, with greatly
Medicine is to train the family physicians who can variable resources in faculty and faculty develop-
meet these needs. The new requirements represent ment, and many have been wounded deeply by the
the most significant changes since our founding and pandemic in terms of finances, support staff and
envision many changes in how we train residents, burnout. So how to start? The ABFM believes
that we should start with the “end in mind”—
This is the Ahead of Print version of the article. the core outcomes we want from family medi-
From the American Board of Family Medicine, cine residency education. We use the term “core
Department of Family Medicine, University of North Carolina
(WN); American Board of Family Medicine, Dept. of Family & outcomes” because ABFM research last summer
Preventive Medicine, University of Utah (MM); American showed that only approximately 40% of family
Board of Family Medicine, Lexington, KY (WB, SK); ACGME
Review Committee, Mercy Family Medicine Residency (GH); medicine program directors reported they are using
Association of Family Medicine Residency Directors (KS). the term Entrustable Professional Activities (EPAs),
Conflict of interest: The authors are employees of the
ABFM. and what they mean by EPAs varies greatly.
Corresponding author: Warren P. Newton, MD, MPH, From December 2022 through March 2023,
American Board of Family Medicine, 1648 McGrathiana
Pkwy, Ste 550, Lexington, KY 40511-1247 (E-mail: the ACGME Family Medicine Review Committee
wnewton@[Link]). (FMRC) and the ABFM established the “core

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 J Am Board Fam Med: first published as 10.3122/jabfm.2023.230201R0 on 15 June 2023. Downloaded from [Link] on 16 June 2023 by guest. Protected by copyright.
outcomes” of family medicine residency education, resident has finished residency and that they are
building on the EPAs developed previously in “ready for autonomous practice.” Starting in June of
Family Medicine and with input from all the organi- 2024, we will ask program directors to attest both that
zations of Family Medicine.5 The core outcomes each resident has finished their residency and is com-
capture the broad scope of practice we want all grad- petent in each of the core outcomes, which represent
uates to be able to do on graduation; they represent specific components of readiness for autonomous
observable behaviors that can be improved with practice. Our plan is to implement this requirement
deliberate practice. We also believe that both mile- gradually over the 3 years: 2024, 2025, and 2026. We
stones and core outcomes are important. Milestones will not ask for submission of documentation of compe-
focus on ACGME core competencies and allow con- tence, but rather attestation of competence for individual
sideration of how residents develop, whereas the core residents for each core outcome by Program Directors,
outcomes combine multiple ACGME competencies knowing that they will work with their Clinical
and underscore the transition to independent practice. Competence Committees (CCC), program faculty and
We anticipate that all residencies will continue to track residency administration to determine competence.
both milestones and whether each resident is ready for Table 1 provides a proposed 3-year schedule,
autonomous practice in each of the 12 core outcomes. which includes all the core outcomes, with an addi-
With this shared mental model, the Family tional focus on robust continuity of care, the care
Medicine Review Committee has begun to work of children and more specific aspects of the care of
with the ACGME informatics leadership to redesign pregnant women. In considering the sequence of
the Accreditation Data System and faculty/resident the 3-year schedule, we sought input from the lead-
surveys to get the information they will need to mon- ership of the Association of Family Medicine
itor the quality of residencies. ABFM’s focus is on Residency Directors, many current and former RC
competency-based Board Eligibility. Traditionally, members and many current faculty and program
ABFM has asked program directors to attest that a directors. The final list is based on the 12 core

Table 1. Schedule of Competency Attestation for ABFM Board Eligibility

In June 2024, we Propose That Program Directors and CCCs will attest that each graduating resident is competent to:
 Practice as personal physicians, providing first contact, comprehensive and continuity care, to include excellent doctor-patient
relationships, excellent care of chronic disease and routine preventive care and effective practice management.
 Diagnose and manage acute illness and injury for people of all ages in the emergency room or hospital.
 Provide comprehensive care of children, including diagnosis and management of the acutely ill child and routine preventive
care.
 Develop effective communication and constructive relationships with patients, clinical teams, and consultants
 Model Professionalism and be trustworthy for patients, peers, and communities.

We will monitor progress and seek further input, but for June 2025, we would extend attestation of assessment of competency by
Program Directors and CCCs for each graduating resident to include competence in:
 Practice as personal physicians, to include care of women, the elderly, and patients at the end of life, with excellent rate of
continuity and appropriate referrals.
 Provide care for low-risk patients who are pregnant, to include management of early pregnancy, medical problems during
pregnancy, prenatal care, postpartum care and breastfeeding, with or without competence in labor and delivery.
 Diagnose and manage of common mental health problems in people of all ages.
 Perform the procedures most frequently needed by patients in continuity and hospital practices.
 Model lifelong learning and engage in self-reflection.

Then, in June 2026, with continuing monitoring of progress, we would extend attestation by the Program Director and CCCs to
include the following competencies for each graduating resident:
 Practice as personal physicians, to include musculoskeletal health, appropriate medication use and coordination of care by
helping patients navigate a complex health system.
 Provide preventive care that improves wellness, modifies risk factors for illness and injury, and detects illness in early,
treatable, stages for people of all ages while supporting patients’ values and preferences.
 Assess priorities of care for individual patients across the continuum of care—in-office visits, emergency, hospital, and other
settings, balancing the preferences of patients and medical priorities.
 Evaluate, diagnose, and manage patients with undifferentiated symptoms, chronic medical conditions, and multiple
comorbidities.
 Effectively lead, manage, and participate in teams that provide care and improve outcomes for the diverse populations and
communities they serve.

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 J Am Board Fam Med: first published as 10.3122/jabfm.2023.230201R0 on 15 June 2023. Downloaded from [Link] on 16 June 2023 by guest. Protected by copyright.
outcomes but adds more detail in competencies Our hope is that assessment of the outcomes tar-
related to continuity practice and adds focus to the geted for 2024 will be readily attainable for most
care of children and the care of pregnant women. residencies using existing approaches with minor
As much as possible, the language of the competen- changes. The first outcome is competence in prac-
cies comes from our published list. The final tice as a personal family physician, with excellent
sequence was also informed by our community’s doctor patient relationships, excellence in care of
emphasis on supporting broad scope of practice, chronic disease and clinical prevention and effective
judgment about the ease of obtaining good assess- practice management. We believe that many pro-
ments, the importance of enhancing the practice as grams already measure quality of chronic disease
the curriculum and putting core skills such as com- and/or preventive care and manage efficiency and
munication earlier. The ABFM plans to monitor billing and coding. Some programs also address resi-
and adjust as necessary as the community and resi- dent effectiveness in managing clinic teams and other
dency practices change in response to the new higher order competencies. In addition, receptors and
requirements. behavioral health faculty already have opportunities
Thus, for June 2024, we will ask that program to directly assess residents’ doctor patient relation-
directors attest that each resident applying for ABFM ships. Faculty may be able to provide end-of-precept-
Board Eligibility has completed residency and is com- ing shift assessments such as those developed by
petent in the following core outcomes of residency: Emergency Medicine for end of shift assessments.
We hope that program directors developing their
 Practice as personal physicians, providing first con-
assessment strategy will also consider the aspects of
tact, comprehensive and continuity care, to include
excellent doctor-patient relationships, excellent continuity care we emphasize in later years, such as
care of chronic disease and routine preventive care measured rates of continuity and appropriate refer-
and effective panel and patient management. rals, cost of care, competence in common proce-
 Diagnose and manage acute illness and injury dures, care for special populations, management of
for people of all ages in the emergency room medications, and care for patients with undifferenti-
or hospital. ated symptoms or multimorbidity. We believe that
 Provide comprehensive care of children, the right kinds of assessments will help create the
including diagnosis and management of the personal physicians our society needs.
acutely ill child and routine preventive care. How should diagnosis and management of acute
 Develop effective communication and con-
illness in the hospital be assessed? Broadly speaking,
structive relationships with patients, clinical
teams, and consultants. this outcome addresses resident competence with
 Model professionalism and be trustworthy for assessing and managing complex and acutely ill
patients, peers, and communities. adults in the hospital or emergency department.
Hospital rotations allow assessment of many of the
What assessments should be used for the first
core ACGME competencies beyond patient care
installments? Literature on assessment is burgeoning
and knowledge, to include communication with
and is available on the ACGME Learn portal and
patients, colleagues, and other health professionals,
other settings. ABFM and the FMRC look to family
systems-based practice in sign outs and discharges,
medicine academic organizations for guidance on best
and problem-based learning. In designing a rota-
assessments as well as support for further develop-
ment, testing and dissemination of new assessments. tion assessment related to the core outcomes, it is
While optimizing assessment is critical, however, per- also important to consider what the key elements of
haps most important for the transition to CBME is a inpatient care include—such as assessments of effi-
shared understanding of outcomes among the faculty ciency and thoroughness of initial patient evalua-
who assess and give feedback to residents, and a robust tion, ongoing inpatient management and managing
and targeted faculty development program. To meet discharges. Like all assessments, rotation evalua-
this need, the STFM Task Force on Assessment is tions should be anchored in specific behaviors,
developing recommendations for assessment and fac- summarize multiple assessments, and conclude with
ulty development and also mapping the ACGME whether the resident has met the outcomes of resi-
competencies to the core outcomes. We look forward dency. Depending on the duration of rotations and
to their wisdom. continuity of teachers, hospital assessments should

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 J Am Board Fam Med: first published as 10.3122/jabfm.2023.230201R0 on 15 June 2023. Downloaded from [Link] on 16 June 2023 by guest. Protected by copyright.
Table 2. Examples of Assessments for the 2024 Family Medicine Outcomes
Core Outcome Example Assessments

Practice as personal physicians, providing first contact,  Feedback to residents on quality of care or preventive care
comprehensive and continuity care, to include excellent  Efficiency of patient care assessments such as timeliness of
doctor-patient relationships, excellent care of chronic seeing patients, completion of charting, and coding.
disease, routine preventive care and effective practice  Preceptor and behavioral health faculty assessments of
management. effectiveness of doctor-patient relationship
8 End of clinic shift cards
8 Clinic Field Notes
Diagnose and manage acute illness and injury for people of all  End of inpatient hospital rotation evaluation that includes:
ages in the emergency room or hospital. 8 Efficiency and thoroughness of initial assessment and
floor management
8 Managing discharges and other transitions of care
8 Effective collaboration with teammates, nurses and other
professionals
8 Trustworthiness with team members and consultants
 Use of multi-source feedback of all members of hospital teams

Provide comprehensive care of children, including diagnosis  Existing rotational assessments of pediatric inpatient,
and management of the acutely ill child and routine emergency department, and outpatient rotations that include:
preventive care. 8 Recognition and management of emergencies
8 Key procedures and communication with patients,
families and other professional on the team
 Precepting assessments in continuity clinic

Develop effective communication and constructive  Likely included in all rotational assessments
relationships with patients, clinical teams, and consultants. 8 Ideally develop way for CCC to monitor across rotations
and settings so can request additional assessments as
necessary.
 Assessments from special curricula in behavioral health

Model Professionalism and be trustworthy for patients, peers,  Routine rotation assessments and reviews by faculty advisors
and communities or coaches should include a component of professionalism.
 Recommend asking specifically about trustworthiness from
peers, faculty and rotation leads in all rotation evaluations

also address how well residents respond to feed- systems that can allow assessments of resident com-
back, a key component of professionalism. munication skills to be separated by source—patients,
The third core outcome for attestation in 2024 is team members, staff—and also aggregated across set-
comprehensive care of children, both the acutely ill tings. An important lesson from Canada is that a key
and the well child. Because resources vary widely by role of CCCs should be to ensure that assessment of
program, the new residency requirements allow con- competence is being performed across the continuum
siderable flexibility in how residencies train residents of care—and, if necessary, to request additional
in the care of children. These variations will shape assessments as necessary.
the assessment strategy for any specific residency. The final important priority for 2024 is foundational
Even so, we believe that in most cases, existing resi- to many others, and is also 1 that should be assessed
dent rotation evaluations provide a good starting across multiple settings: modeling professionalism
point, if anchored in observed behaviors, and with and being trustworthy for patients, peers, and
emphasis on management of childhood emergencies, communities. As with communication skills, pro-
key procedures, and communication with patients, fessionalism should be embedded in many differ-
families and other professionals on the team. ent rotation assessments. An important first step is
Effective communication and constructive relation- for faculty to consider what they think the key
ships with patients, clinical teams, and consultants are components of professionalism are—including
foundational to future residency education, and were confidentiality, commitment to patients, learning
therefore also prioritized for 2024. We think that this from feedback, trustworthiness to patients and
competency can be assessed in almost every rotation peers—and to assess each of these explicitly.
assessment as well as in special curricula on behavioral Of course, all assessments, whether they be rota-
health. One challenge will be to develop the data tion evaluations, direct observations, multisource

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 J Am Board Fam Med: first published as 10.3122/jabfm.2023.230201R0 on 15 June 2023. Downloaded from [Link] on 16 June 2023 by guest. Protected by copyright.
feedback or new assessments developed by the spe- References
cialty, should be integrated into an assessment system 1. National Research Council, Institute of Medicine.
for each residency which collates and summarizes The National Academies Collection: Reports funded
the quantitative data and makes all comments easily by National Institutes of Health. In: Woolf SH, Aron
L, eds. U.S. Health in International Perspective: Shorter
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systems like the M36 app also facilitate this process. mortality rates in the United States, 1959–2017.
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CBME easier. We believe that full implementation racial and ethnic disparities in health care. Washington,
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Ultimately, of course, portfolios will need to become 5. Newton W, Cagno CK, Hoekzema G, Edje L. Core
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