Blueprint for the ABFM Cognitive Examination
The American Board of Family Medicine (ABFM) is committed to offering cognitive examinations that are both pertinent to the specialty of family medicine and psychometrically sound. This article reviews the history of the development of the blueprint of the ABFM certification and recertification cognitive examinations and describes the creation of a new one. The design of the new blueprint represents a significant change. The intention of the new plan is to create a continuously evolving approach that will assure family physicians that the content of their specialty board certification/recertification examination is relevant to their practices and to the discipline. The ABFM anticipates that assessments based on the new blueprint will assist family physicians in attaining and maintaining the knowledge required to practice high quality family medicine by focusing their certification and recertification examinations and, therefore, studies for those examinations on material that is relevant to their practices.

Construction of high stakes cognitive examinations that are psychometrically sound is usually dependent on the utilization of a blueprint or design for the examination. The American Board of Family Medicine (ABFM) has, for over 20 years, used a "content blueprint" that represents areas of practice in the discipline of family medicine and that defined both the subject areas and the proportion of questions in ABFM certification and recertification examinations. Norcini and colleagues have described the essential structure of this type of content-based definition of medical practice. The old basic ABFM content blueprint is shown in Table 1 .

The development and implementation of Maintenance of Certification for Family Physicians (MC-FP) provided an impetus for the ABFM to review and evolve the Family Medicine Board Examination. Maintenance of Certification for all specialty boards under the American Board of Medical Specialties umbrella includes a secure cognitive examination as one of its components. In early 2003, the ABFM, in consultation with a cadre of family medicine educators, determined that the cognitive examination Content Blueprint in use at that time required revision. The goals of the decision were to adjust the test to the maturation of the field of family medicine as more than the summation of parts of other fields, to connect board certification to the quality movement in the United States, and to maintain fidelity in a defensible process. The ABFM also anticipated introducing computerized examinations and offering the examinations multiple times each year, which would require generating additional test items to maintain security and validity. Both changes also required precise assignment of each test question to appropriate categories and sub-categories in "test item banks" to accurately retrieve questions and assign them to an examination based on the blueprint.

Equally important in the decision to revise the original blueprint was the planned move in 2006 from a classical test theory psychometric model to one that will rely on item response theory (IRT) (see definitions in Table 2 ). IRT offers advantages over classical test theory, including the ability to fashion an examination that focuses measurement on a selected level of knowledge, rather than a comparison of persons across tests and test items. This allows the administration of multiple tests each year with better assurance of comparability between the multiple tests. In the case of the ABFM examination, it would be very useful to have very precise measurement in the region of the cut score (ie, pass fail score). Because the current examination is a relatively random sample of items from the examination pool, its measurement precision is probably to be distributed normally around the average level of difficulty of the items in the pool. This means that it measures most precisely at that level, rather than at the level of the passing threshold. This method of measuring knowledge is less effective than desirable or achievable.

IRT provides a better method of equating, or comparing and adjusting, the difficulty of different versions of the examination. This has practical importance especially for those candidates who take 2 or more consecutive examinations. The use of a more robust and well-grounded theoretical measurement model such as IRT improves the equating procedure. Therefore, a more precise blueprint was required to guarantee that test items were appropriately categorized by content as well as by difficulty as measured by IRT within specific content areas.

Throughout this article, a number of terms will be used that may not be familiar to the reader. Definitions of these terms are provided in Table 2 .

In the remainder of this article, we will outline the process used to develop and define a new examination blueprint, elucidate the specific blueprint components, and explore implementation plans and future directions.