Evolving Certification to Meet Today’s Needs: The ABFM’s KSA Revision Initiative

Why Knowledge Self-Assessment? The American Board of Medical Specialties (ABMS) implemented the Maintenance of Certification Program as a way to provide a comprehensive approach to lifelong learning, self-assessment, and quality improvement for physicians in all specialties.1 As demonstrated in a systematic review of 62 studies, physician knowledge, skills, and adherence to evidence-based medicine tend to decline as a function of time from initial training.2 In addition, there is robust evidence that physicians, like other experts, are inaccurate in their own self-assessment—we simply do not always realize what we don’t know.3 Thus, a key role of Board Certification is to provide a guided, objective, independent, self-assessment program that goes beyond traditional, self-selected continuing medical education (CME). Ongoing self-assessment also supports acquisition of new knowledge and skills as changes in medical knowledge necessitate changes in practice, and it reinforces a broad knowledge base when physicians’ scope of practice narrows over time. Participation in continuous certification empowers physicians to develop their own learning strategies supported by tools that can help direct their lifelong learning, while at the same time helping to assure the public they have demonstrated that they have the tools to provide high-quality care. In 2004, the American Board of Family Medicine (ABFM) introduced self-assessment modules (SAMs), which consisted of a 60-item knowledge assessment followed by a corresponding computerized clinical simulation. Each SAM was divided into specific competencies and diplomates had to correctly answer 80% of the items in each competency to successfully complete the requirement. Diplomates were also presented with rationales and references for questions they missed and were allowed multiple attempts to complete the activity successfully. SAMs were purposefully created to present an in-depth and challenging exposure to the content area in order to assist in the identification of knowledge gaps, not to simply reinforce what one already knew.4 By 2012, SAMs covering 16 different topic areas had been created, drawn from the 20 priority areas identified by the Institute of Medicine.5 In 2016, the ABFM announced several changes in the continuous certification process, resulting from feedback provided by diplomates and the commitment to ensure that its programs were aligned with best practices in assessment, measurement, and quality improvement. Feedback on the knowledge assessment portion of the SAMs was very favorable; however, diplomates were less favorable about the clinical simulation.6,7 Therefore, the knowledge assessment portion of the SAMS was uncoupled from the clinical simulation and the simulations were made optional. The knowledge assessments were renamed Knowledge Self-Assessments (KSAs) and the simulations were discontinued in 2019. In the current continuous certification program, physicians are required to earn 50 certification points and acquire 150 CME credits during each 3-year stage. Self-Assessment and Lifelong Learning requirements now offer 2 options: (1) completing at least 1 ABFM-developed 60-question, topic-specific KSA activity, or (2) completing 4 quarters of Continuous Knowledge Self-Assessment (CKSA), consisting of 25 questions each quarter across a broad range of topics.