The ABFM Core Outcomes: The Next Step to Outcome-Based, Time-Variable Training in Family Medicine

In 2023, the American Board of Family Medicine (ABFM) released the core outcomes, a family medicine specific competency framework that encompasses the skills required for board certification in family medicine. ¹ The implementation of these standards represents an important characteristic of competency based medical education and paves the way for outcome-based, time-variable progression through family medicine graduate medical education. This goal of time-variable progression, though, is in stark contrast to the current outcome-variable, time-based progression of residency education. ²

Residency programs have an ethical obligation to ensure that graduates are capable of independent practice. In the current state, residency programs graduate based on time completed rather than achievement of benchmark outcomes; only the few residents with major deficiencies undergo extension of training or remediation. Residency program clinical competency committees make high-stakes summative decisions as to whether family medicine residents are prepared to enter independent practice partly by using the Accreditation Council for Graduate Medical Education family medicine milestones. ³ Although commonly understood to be a linear progression from a level 1 to a level 5 milestone, these milestones are a nonlinear scale; for example, a resident may display level 3 behaviors without performing level 2 behaviors within a subcompetency. ³ Compounding this deficiency is the lack of evidence that milestone achievement indicates readiness for independent practice. ³

The ABFM core outcomes set benchmarks for family medicine graduate medical education. ¹ These benchmarks now allow family medicine graduate medical education to explore outcome-based, time-variable residency training. Outcome-based, time-variable progression allows learners to advance at an individual pace. ² While this system may accelerate the path to independent practice for some, it may extend training for others. The opportunities afforded by such an outcome-based, time-variable approach include development of a growth mindset, population health competency, and patient care expertise. ²

Undertaking outcome-based, time-variable training, however, would require a major culture shift to overcome personnel, economic, and logistic barriers. Specifically, funding of residency programs through the Centers for Medicare and Medicaid Services does not make this form of training feasible. Moving toward this form of training would require a massive overhaul of the funding structures for US graduate medical education into a structure like that of Canada, whose goal is to create outcome-based, time-variable medical education from the undergraduate to graduate level of medical education. ⁴ The benefits to learner professional development, individualized learning, and autonomy can improve patient outcomes and more rigorously enforce the ethical contract graduate medical education has with society. An outcomes-based, time-variable training system is the future of US medical education, and the implementation of the ABFM core outcomes equips family medicine to be at the forefront of this opportunity.