BRIEF REPORTS. Family Medicine Residency Program Directors Plans to Incorporate Maintenance of Certification Into Residency Training: A CERA Survey

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1 Family Medicine Residency Program Directors Plans to Incorporate Maintenance of Certification Into Residency Training: A CERA Survey Lars E. Peterson, MD, PhD; Brenna Blackburn, MPH; Robert L. Phillips Jr, MD, MSPH; Arch G. Mainous III, PhD BACKGROUND AND OBJECTIVES: Participation in Maintenance of Certification for Family Physicians (MC-FP) is now a requirement for residents to take the American Board of Family Medicine (ABFM) certification examination. The objective of this study was to determine baseline use of MC-FP products prior to this requirement and assess how family medicine residency program directors (FMPD) intended to integrate MC-FP into residency education. METHODS: We used the CERA platform to survey FMPDs. In addition to the core CERA demographic questions, we asked about the use of MC-FP in residency, how FMPDs intended to incorporate MC-FP, and how useful they believe MC-FP will be for resident evaluation. Additionally, we compared select results with the ABFM administrative database. RESULTS: A total of 224 FMPDs responded, for a 50.6% response rate. There was agreement between CERA and ABFM data on the percentage of residencies already using Part 4 modules (39.3% versus 38.8%) but not Part 2 modules (24.7% versus 62.8%). Group MC-FP activities were the preferred method for both Part 2 (45.0%) and Part 4 (54.4%). Most FMPDs agreed that MC-FP will be effective in teaching quality improvement and assessing competencies. Respondents from dually accredited programs were more likely to have used Part 4, but not Part 2, activities prior to CONCLUSIONS: Prior to MC-FP becoming a requirement in residency, a sizeable minority of residencies were already using these tools for education. Assessment of competencies will be crucial in the Next Accreditation System, and MC-FP may help in tracking clinical development over a physician s career. (Fam Med 2014;46(4): ) As of July 2012, all residents entering Accreditation Council for Graduate Medical Education (ACGME)-accredited family medicine residencies are required to participate in Maintenance of Certification for Family Physicians (MC- FP) to sit for the American Board of Family Medicine (ABFM) certification examination. 1 Residents will have to finish two Part 2 activities, which are done through completion of disease or population focused Self- Assessment Modules (SAMs) and one Part 4 activity, which involves a quality improvement (QI) project. Part 2 and 4 products have always been available free of charge to residents. Since requiring MC-FP in residency has just started, our objectives were to examine the baseline use of MC-FP products in residency training and to understand how family medicine program directors (FMPDs) plan to implement MC-FP. Methods Our study was part of the Council of Academic Family Medicine Educational Research Alliance (CERA) omnibus FMPD survey administered in spring CERA survey methodology has been previously described. 2 In addition to core demographic questions, we asked if the program was dually accredited by the ACGME and the American Osteopathic Association. We hypothesized that dually accredited programs may be less likely to use MC-FP products since their osteopathic residents may not take the ABFM boards. 3 The remaining questions asked about incorporating MC-FP in residency, including whether the FMPD previously included SAMs and/or Part From the American Board of Family Medicine, Lexington, KY (Dr Peterson, Ms Blackburn, Dr Phillips); and Department of Family Medicine, University of Florida (Dr Mainous). FAMILY MEDICINE VOL. 46, NO. 4 APRIL

2 4 modules in residency education; if they hadn t, why not; and how they plan to incorporate MC-FP. We also assessed FMPDs opinions regarding how effective MC-FP in residency will be as an educational tool. We used the ABFM administrative database to compare results reported by respondents to actual use of MC-FP products by residents. We identified all family medicine residency graduates from 2010 to 2012 and determined if they participated in a Part 2 or Part 4 activity and aggregated the results by residency program. Because the CERA data are de-identified, we could not directly compare FMPDs answers to the ABFM database. Descriptive statistics were used to characterize the data. We used chisquare tests to assess for differences in planned implementation of MC- FP by dual accreditation status. The CERA survey was approved by the American Academy of Family Physicians Institutional Review Board. Results The survey was sent to 440 FMPDs and 224 responded, yielding a 50.9% response rate. The lowest number of responses to a specific question was 219. Respondents were mostly located in the Midwest (31.1%) and were community based, university affiliated (65.2%) (Table 1). Twentyseven percent of residencies were dually accredited. From the ABFM database we identified 449 unique residency programs. Nearly a quarter of respondents reported that they already used SAMs (24.7%) as part of their residency education (Table 2). In contrast, ABFM data revealed that 62.8% of residencies had at least one resident use a SAM. The numbers of Table 1: Demographic Characteristics of Family Medicine Residency Programs and Their Program Directors From the CERA Data and the American Board of Family Medicine (ABFM) Database Residency characteristics Program affiliation (n=224 CERA respondents) CERA Data n=224 University based 19.2 Community based, university affiliated 65.2 Community based, non-affiliated 11.6 Military 4.0 Census region (n=222) ABFM Data n=449 Northeast Midwest South West Size of community (n=223) <75, , , , Percent of residents who are international medical graduates (IMGs) (n=224) 0% 24% Age of program in years (mean and SD) (n=219) 31.5 (12.0) Dually accredited program (n=222) 27.0 Program director characteristics Length of time as program director (n=223) 0 6 years years 36.6 Male gender (n=223) 67.4 Currently participating in MC-FP (n=223) 98.2 SD standard deviation MC-FP Maintenance of Certification for Family Physicians CERA CAFM Educational Research Alliance 300 APRIL 2014 VOL. 46, NO. 4 FAMILY MEDICINE

3 Table 2: Reported Use of Maintenance of Certification Products in Residency Education Prior to 2012 CERA Survey (n=224) ABFM Data (n=449) Already using SAMs prior to 2012 (n=223 CERA) Already using Part 4 Modules prior to 2012 (n=224) ABFM produced AAFP Metric CERA CAFM Educational Research Alliance ABFM American Board of Family Medicine AAFP American Academy of Family Physicians Table 3: Reported Planned Strategies for Incorporating Maintenance of Certification Into Residency Education Part 2 Self-Assessment Modules (SAMs) (n=220) Group SAMs 45.0 Residents can choose when and which modules to do 17.3 Assign SAMs to specific rotations 29.1 Unsure 8.6 Part 4 Performance in the Practice of Medicine (PPM) (n=223) Direct residents to use any of the ABFM s current Part 4 modules 7.8 Direct residents to use any of the AAFP s current METRIC modules 11.9 Design group QI activities for all residents that would utilize existing ABFM or AAFP modules 48.0 Design group QI activities for all residents that would not utilize existing ABFM or AAFP modules Have residents participate in already designed institutional QI activities 12.3 Unsure 13.7 ABFM American Board of Family Medicine QI quality improvement AAFP American Academy of Family Physicians Requiring residents to complete quality improvement activities through Part 4 modules will decrease scholarly activity in other areas (n=223) Requiring Maintenance of Certification for Family Physicians (MC-FP) in residency is burdensome (n=222) Part 4 Modules will be effective in teaching quality improvement principles and methods (n=222) Table 4: Family Medicine Program Directors Opinions on the Effects of Incorporating Maintenance of Certification in Residency Incorporation of MC-FP activities in my residency: Will be an effective tool for resident education (n=221) Will increase the likelihood of certification during a resident s career (n=221) Will help me evaluate my resident s competency (n=220) Strongly Disagree Disagree Neutral Agree Strongly Agree FAMILY MEDICINE VOL. 46, NO. 4 APRIL

4 residency programs having any resident report a Part 4 module in the ABFM database was nearly identical to that reported by CERA respondents (38.8% versus 39.3%). Common reasons for not using MC-FP products before 2012 were difficulty in setting up group SAMs (23.2%) and not enough added value to resident education (20.7%). Most respondents already have strategies for how to implement MC-FP into their program (Table 3) with group SAMs (45.0%) and Part 4 activities (54%) being common responses. Slightly over half of respondents disagreed that MC- FP in residency will decrease other scholarly activity by residents (Table 4). Nearly 60% agreed that MC- FP will be effective for teaching QI or resident education. Respondents from dually accredited programs were more likely to have used Part 4 products before 2012 (51.7% versus 35.2%) but were similar to respondents from other programs in their opinions of and plans to incorporate MC-FP (Table 5). Discussion Our survey of FMPDs found that a minority were using MC-FP products prior to them being required for certification. We found that the intended strategies for implementing MC-FP into residency education were varied and that many respondents believe MC-FP tools will be effective in evaluating resident competency and in teaching QI. There are multiple ways in which residencies may incorporate Part 2 and Part 4 activities into residency education. Group Part 4 and Part 2 activities were popular choices of respondents, but many also intend to allow residents to choose what to do. We hypothesized that respondents from dually accredited programs would be less likely to use MC-FP tools in their programs, which no prior literature has studied. Given that prior research found that many osteopathic residents in dually accredited program do not take the ABFM examination, 3 we surprisingly found that respondents from dually accredited programs were more likely to have used Part 4 products and were as likely as other programs to use Part 2 products. The 60 responding dually accredited programs represent a majority of the 102 programs identified in prior research, 3 which supports the generalizability of these results. Based on the ABFM database, we found that nearly three times as many programs had residents participating in SAMs than respondents reported. This difference is most likely due to residents learning about this resource in other ways. Our study is not without limitations. First, although our response rate of 51% is reasonably positive in a survey of physicians, there is a possibility that there could be some differences in the experience of nonrespondents. Next, other unmeasured variables may be associated with intentions to use MC-FP products, including QI infrastructure, number of faculty, ability to provide clinical coverage for most residents to participate in group activities, and faculty motivation. Our survey of FMPDs found that a minority were using MC-FP products as a part of residency education prior to it becoming a requirement. Most believe that MC-FP will be an effective educational tool and specifically better teach QI principles. A sizable minority believe MC-FP products will help assess and evaluate residents competency, which will be an integral aspect of the Next Accreditation System. 4 Whether MC-FP products actually improve education and assessment of residents will need further study. CORRESPONDING AUTHOR: Address correspondence to Dr Peterson, American Board of Family Medicine, 1648 McGrathiana Parkway, Suite 550, Lexington, KY Fax: lpeterson@ theabfm.org. Table 5: Family Medicine Program Directors Use of and Opinion of Maintenance of Certification for Family Physicians by Dual Accreditation Status Already using SAMs prior to 2012 (n=221) Already using Part 4 Modules prior to 2012 (n=222) Requiring MC-FP in residency is burdensome (n=222) Incorporating MC-FP into residency will be an effective tool for resident education (n=222) Dually Accredited (n=60) Not Dually Accredited (n=162) * * P value <.05 MC-FP Maintenance of Certification for Family Physicians 302 APRIL 2014 VOL. 46, NO. 4 FAMILY MEDICINE

5 References 1. American Board of Family Medicine. Maintenance of Certification for Family Physicians (MC-FP) is moving into residency training as of June 1, 2012! ABFM News for Family Medicine Residency Directors. July edition. Lexington, KY: American Board of Family Medicine, Mainous AG III, Seehusen D, Shokar N. CAFM Educational Research Alliance (CERA) 2011 Residency Director Survey: background, methods, and respondent characteristics. Fam Med 2012;44: Terry R, Hill F. Analysis of AOA/ACGME accredited family medicine residency programs. Fam Med 2011;43: Nasca TJ, Philibert I, Brigham T, Flynn TC. The next GME accreditation system rationale and benefits. N Engl J Med 2012;366: FAMILY MEDICINE VOL. 46, NO. 4 APRIL