Acquisition of competence in performing a variety of procedures is essential during Internal Medicine (IM) residency training.
Determine the rate of procedural complications by IM residents; determine whether there was a correlation between having 1 or more complications and institutional procedural certification status or attending ratings of resident procedural skill competence on the American Board of Internal Medicine (ABIM) monthly evaluation form (ABIM-MEF). Assess if an association exists between procedural complications and in-training examination and ABIM board certification scores.
We retrospectively reviewed all procedure log sheets, procedural certification status, ABIM-MEF procedural skills ratings, in-training exam and certifying examination (ABIM-CE) scores from the period 1990–1999 for IM residency program graduates from a training program.
Among 69 graduates, 2,212 monthly procedure log sheets and 2,475 ABIM-MEFs were reviewed. The overall complication rate was 2.3/1,000 procedures (95% CI: 1.4–3.1/1,000 procedure). With the exception of procedural certification status as judged by institutional faculty, there was no association between our resident measurements and procedural complications.
Our findings support the need for a resident procedural competence certification system based on direct observation. Our data support the ABIM’s action to remove resident procedural competence from the monthly ABIM-MEF ratings.
procedural skills; Internal Medicine residency training program; ABIM evaluation
The American Board of Internal Medicine Certification Examination (ABIM-CE) is one of several methods used to assess medical knowledge, an Accreditation Council for Graduate Medical Education (ACGME) core competency for graduating internal medicine residents. With recent changes in graduate medical education program directors and internal medicine residents are seeking evidence to guide decisions regarding residency elective choices. Prior studies have shown that formalized elective curricula improve subspecialty ABIM-CE scores. The primary aim of this study was to evaluate whether the number of subspecialty elective exposures or the specific subspecialties which residents complete electives in impact ABIM-CE scores.
ABIM-CE scores, elective exposures and demographic characteristics were collected for MedStar Georgetown University Hospital internal medicine residents who were first-time takers of the ABIM-CE in 2006–2010 (n=152). Elective exposures were defined as a two-week period assigned to the respective subspecialty. ABIM-CE score was analyzed using the difference between the ABIM-CE score and the standardized passing score (delta-SPS). Subspecialty scores were analyzed using percentage of correct responses. Data was analyzed using GraphPad Prism version 5.00 for Windows.
Paired elective exposure and ABIM-CE scores were available in 131 residents. There was no linear correlation between ABIM-CE mean delta-SPS and the total number of electives or the number of unique elective exposures. Residents with ≤14 elective exposures had higher ABIM-CE mean delta-SPS than those with ≥15 elective exposures (143.4 compared to 129.7, p=0.051). Repeated electives in individual subspecialties were not associated with significant difference in mean ABIM-CE delta-SPS.
This study did not demonstrate significant positive associations between individual subspecialty elective exposures and ABIM-CE mean delta-SPS score. Residents with ≤14 elective exposures had higher ABIM-CE mean delta-SPS than those with ≥15 elective exposures suggesting there may be an “ideal” number of elective exposures that supports improved ABIM-CE performance. Repeated elective exposures in an individual specialty did not correlate with overall or subspecialty ABIM-CE performance.
Resident education; Gender; Elective; Subspecialty; Graduate medical education
Although the American Board of Internal Medicine (ABIM) certification is valued as a reflection of physicians’ experience, education, and expertise, limited methods exist to predict performance in the examination.
The objective of this study was to develop and validate a predictive tool based on variables common to all residency programs, regarding the probability of an internal medicine graduate passing the ABIM certification examination.
The development cohort was obtained from the files of the Cleveland Clinic internal medicine residents who began training between 2004 and 2008. A multivariable logistic regression model was built to predict the ABIM passing rate. The model was represented as a nomogram, which was internally validated with bootstrap resamples. The external validation was done retrospectively on a cohort of residents who graduated from two other independent internal medicine residency programs between 2007 and 2011.
Of the 194 Cleveland Clinic graduates used for the nomogram development, 175 (90.2%) successfully passed the ABIM certification examination. The final nomogram included four predictors: In-Training Examination (ITE) scores in postgraduate year (PGY) 1, 2, and 3, and the number of months of overnight calls in the last 6 months of residency. The nomogram achieved a concordance index (CI) of 0.98 after correcting for over-fitting bias and allowed for the determination of an estimated probability of passing the ABIM exam. Of the 126 graduates from two other residency programs used for external validation, 116 (92.1%) passed the ABIM examination. The nomogram CI in the external validation cohort was 0.94, suggesting outstanding discrimination.
A simple user-friendly predictive tool, based on readily available data, was developed to predict the probability of passing the ABIM exam for internal medicine residents. This may guide program directors’ decision-making related to program curriculum and advice given to individual residents regarding board preparation.
board examination; in-training examination; internal medicine; residents; program directors
Several residency program characteristics have been suggested as measures of program quality, but associations between these measures are unknown. We set out to determine associations between these potential measures of program quality.
Survey of internal medicine residency programs that shared an online ambulatory curriculum on hospital type, faculty size, number of trainees, proportion of international medical graduate (IMG) trainees, Internal Medicine In-Training Examination (IM-ITE) scores, three-year American Board of Internal Medicine Certifying Examination (ABIM-CE) first-try pass rates, Residency Review Committee-Internal Medicine (RRC-IM) certification length, program director clinical duties, and use of pharmaceutical funding to support education. Associations assessed using Chi-square, Spearman rank correlation, univariate and multivariable linear regression.
Fifty one of 67 programs responded (response rate 76.1%), including 29 (56.9%) community teaching and 17 (33.3%) university hospitals, with a mean of 68 trainees and 101 faculty. Forty four percent of trainees were IMGs. The average post-graduate year (PGY)-2 IM-ITE raw score was 63.1, which was 66.8 for PGY3s. Average 3-year ABIM-CE pass rate was 95.8%; average RRC-IM certification was 4.3 years. ABIM-CE results, IM-ITE results, and length of RRC-IM certification were strongly associated with each other (p < 0.05). PGY3 IM-ITE scores were higher in programs with more IMGs and in programs that accepted pharmaceutical support (p < 0.05). RRC-IM certification was shorter in programs with higher numbers of IMGs. In multivariable analysis, a higher proportion of IMGs was associated with 1.17 years shorter RRC accreditation.
Associations between quality indicators are complex, but suggest that the presence of IMGs is associated with better performance on standardized tests but decreased duration of RRC-IM certification.
program quality; Residency Review Committee; American Board of Internal Medicine Certifying Examination
The Accreditation Council for Graduate Medical Education (ACGME) Outcome Project requires that residency program directors objectively document that their residents achieve competence in 6 general dimensions of practice.
In November 2007, the American Board of Internal Medicine (ABIM) and the ACGME initiated the development of milestones for internal medicine residency training. ABIM and ACGME convened a 33-member milestones task force made up of program directors, experts in evaluation and quality, and representatives of internal medicine stakeholder organizations. This article reports on the development process and the resulting list of proposed milestones for each ACGME competency.
The task force adopted the Dreyfus model of skill acquisition as a framework the internal medicine milestones, and calibrated the milestones with the expectation that residents achieve, at a minimum, the “competency” level in the 5-step progression by the completion of residency. The task force also developed general recommendations for strategies to evaluate the milestones.
The milestones resulting from this effort will promote competency-based resident education in internal medicine, and will allow program directors to track the progress of residents and inform decisions regarding promotion and readiness for independent practice. In addition, the milestones may guide curriculum development, suggest specific assessment strategies, provide benchmarks for resident self-directed assessment-seeking, and assist remediation by facilitating identification of specific deficits. Finally, by making explicit the profession's expectations for graduates and providing a degree of national standardization in evaluation, the milestones may improve public accountability for residency training.
Our objective was to determine the ability of the internal medicine In-Training Examination (ITE) to predict pass or fail outcomes on the American Board of Internal Medicine (ABIM) certifying examination and to develop an externally validated predictive model and a simple equation that can be used by residency directors to provide probability feedback for their residency programs. We collected a study sample of 155 internal medicine residents from the three Virginia internal medicine programs and a validation sample of 64 internal medicine residents from a residency program outside Virginia. Scores from both samples were collected across three class cohorts. The Kolmogorov-Smirnov z test indicated no statistically significant difference between the distribution of scores for the two samples (z = 1.284, p = .074). Results of the logistic model yielded a statistically significant prediction of ABIM pass or fail performance from ITE scores (Wald = 35.49, SE = 0.036, df = 1, p < .005) and overall correct classifications for the study sample and validation sample at 79% and 75%, respectively. The ITE is a useful tool in assessing the likelihood of a resident's passing or failing the ABIM certifying examination but is less predictive for residents who received ITE scores between 49 and 66.
certifying examination; in-training examination; education; predictions; residents
The American Board of Internal Medicine (ABIM) has recommended a specific number of procedures be done as a minimum standard for ensuring competence in various medical procedures. These minimum standards were determined by consensus of an expert panel and may not reflect actual procedural comfort or competence.
To estimate the minimum number of selected procedures at which a majority of internal medicine trainees become comfortable performing that procedure.
Cross-sectional, self-administered survey.
A military-based, a community-based, and 2 university-based programs.
Two hundred thirty-two internal medicine residents.
Survey questions included number of specific procedures performed, comfort level with performing specific procedures, and whether respondents desired further training in specific procedures. The comfort threshold for a given procedure was defined as the number of procedures at which two thirds or more of the respondents reported being comfortable or very comfortable performing that procedure.
For three of seven procedures selected, residents were comfortable performing the procedure at or below the number recommended by the ABIM as a minimum requirement. However, residents needed more procedures than recommended by the ABIM to feel comfortable with central venous line placement, knee joint aspiration, lumbar puncture, and thoracentesis. Using multivariate logistic regression analysis, variables independently associated with greater comfort performing selected procedures included increased number performed, more years of training, male gender, career goals, and for skin biopsy, training in the community-based program. Except for skin biopsy, comfort level was independent of training site. A significant number of advanced-year house officers in some programs had little experience in performing selected common ambulatory procedures.
Minimum standards for certifying internal medicine residents may need to be reexamined in light of house officer comfort level performing selected procedures.
ABIM; procedure comfort level; residents
Standard curricula to teach Internal Medicine residents about quality assessment and improvement, important components of the Accreditation Council for Graduate Medical Education core competencies practiced-based learning and improvement (PBLI) and systems-based practice (SBP), have not been easily accessible.
Using the American Board of Internal Medicine’s (ABIM) Clinical Preventative Services Practice Improvement Module (CPS PIM), we have incorporated a longitudinal quality assessment and improvement curriculum (QAIC) into the 2 required 1-month ambulatory rotations during the postgraduate year 2. During the first block, residents complete the PIM chart reviews, patient, and system surveys. The second block includes resident reflection using PIM data and the group performing a small test of change using the Plan–Do–Study–Act (PDSA) cycle in the resident continuity clinic.
To date, 3 resident quality improvement (QI) projects have been undertaken as a result of QAIC, each making significant improvements in the residents’ continuity clinic. Resident confidence levels in QI skills (e.g., writing an aim statement [71% to 96%, P < .01] and using a PDSA cycle [9% to 89%, P < .001]) improved significantly.
The ABIM CPS PIM can be used by Internal Medicine residency programs to introduce QI concepts into their residents’ outpatient practice through encouraging practice-based learning and improvement and systems-based practice.
Internal Medicine residents; quality improvement; practiced-based learning and improvement; systems-based practice; practice improvement module
The clinical practice of internal medicine continues to evolve with the addition of new information and new technology. Most internists in practice will have erosion of their knowledge after they complete training unless life-long learning occurs. The American Board of Internal Medicine (ABIM) began to issue time-limited certification in 1990 and asserts that the Maintenance of Certification (MOC) program promotes the professional development of internists. However, the available medical literature does not provide strong support for the assumption that internists with certification or recertification have better patient outcomes. This relationship between recertification and patient outcomes needs more study. In addition, the participation in the Maintenance of Certification program by internists with lifetime certifications has been low, and recertification by leaders in internal medicine has also been relatively low. Some physicians in practice have concerns about the relevance of the program and the cost. Our review suggests that the ABIM needs to review its current Maintenance of Certification program and make changes to enhance its clinical relevance and educational value. We suggest that professional development should be based on focused reviews of the current literature, which is immediately relevant to clinical practice, and that recertification could be based on completion of modules and more frequent, less onerous testing.
certification; recertification; internal medicine; patient outcomes; mortality
Effective communication skills and professionalism are critical for physicians in order to provide optimum care and achieve better health outcomes. The aims of this study were to evaluate residents' self-assessment of their communication skills and professionalism in dealing with patients, and to evaluate the psychometric properties of a self-assessment questionnaire.
A modified version of the American Board of Internal Medicine's (ABIM) Patient Assessment survey was completed by 130 residents in 23 surgical and non-surgical training programs affiliated with a single medical school. Descriptive, regression and factor analyses were performed. Internal consistency, inter-item gamma scores, and discriminative validity of the questionnaire were determined.
Factor analysis suggested two groups of items: one group relating to developing interpersonal relationships with patients and one group relating to conveying medical information to patients. Cronbach's alpha (0.86) indicated internal consistency. Males rated themselves higher than females in items related to explaining things to patients. When compared to graduates of U.S. medical schools, graduates of medical schools outside the U.S. rated themselves higher in items related to listening to the patient, yet lower in using understandable language. Surgical residents rated themselves higher than non-surgical residents in explaining options to patients.
This appears to be an internally consistent and reliable tool for residents' self-assessment of communication skills and professionalism. Some demographic differences in self-perceived communication skills were noted.
We assessed the ability of a novel ambulatory morning report format to expose internal medicine residents to the breadth of topics covered by the American Board of Internal Medicine (ABIM) exam. Cases were selected by the Ambulatory Assistant Chief Residents and recorded in a logbook to limit duplication. We conducted a retrospective review of 406 cases discussed from July 1998 to July 2000 and cataloged each according to the primary content area. The percentage of cases in each area accurately reflected that covered by the ABIM exam, with little redundancy or over-selection of esoteric diseases. Our data suggest that a general medicine clinic is capable of exposing house staff to the wide breadth of internal medicine topics previously thought to be unique to subspecialty clinics.
postgraduate education; ambulatory care; internal medicine residency; morning report
To determine whether family medicine residents graduating from rural programs
assess themselves as more experienced and competent in a range of procedural
skills than graduates of urban programs do.
Self-administered written survey.
Residents from 5 Ontario family medicine programs in 2000 and 2001; a total
of 535 surveys were available for analysis (response rate of 78%).
MAIN OUTCOME MEASURES
Mean self-assessed experience and competence scores for 53 procedures at
residency entry, end of year 1, and graduation.
Upon entry, there was no difference in mean procedural experience (2.89 vs
2.85, P = .54) or mean competence
(2.34 vs 2.36, P = .88) scores
between rural residents and their urban counterparts. There was a
significant increase in procedural experience
(P < .001) and competence
(P < .001) scores during
residency training. At graduation, mean experience (3.98 vs 3.70,
P < .001) and competence (3.67
vs 3.39, P = .004) scores were
significantly higher for rural residents than for their urban colleagues. A
statistically larger proportion of residents graduating from rural programs
assessed themselves as competent in 16 procedures. These included skills
necessary for treating patients in emergency settings (establish intravenous
lines for adults and infants, obtain arterial blood gas measurements,
intubate adults and neonates, perform cautery for epistaxis, remove corneal
foreign body, aspirate or inject knee and shoulder joints, and apply forearm
or walking casts), for diagnostic procedures (endometrial biopsy and bone
marrow aspiration), and for management of labour and delivery (vaginal
delivery; vacuum extraction; and repair of first-, second-, and third-degree
Graduates of rural programs who have had a substantial component of training
in communities of fewer than 10 000 people report greater
self-assessed experience and competence in procedural skills than graduates
of urban programs do. The difference likely reflects the unique aspects of
rural training sites, including preceptors’ competence in performing
End-of- rotation global evaluations can be subjective, produce inflated grades, lack interrater reliability, and offer information that lacks value. This article outlines the generation of a unique developmental criterion-referenced assessment that applies adult learning theory and the learner, manager, teacher model, and represents an innovative application to the American Board of Internal Medicine (ABIM) 9-point scale.
We describe the process used by Southern Illinois University School of Medicine to develop rotation-specific, criterion-based evaluation anchors that evolved into an effective faculty development exercise.
The intervention gave faculty a clearer understanding of the 6 Accreditation Council for Graduate Medical Education competencies, each rotation's educational goals, and how rotation design affects meaningful work-based assessment. We also describe easily attainable successes in evaluation design and pitfalls that other institutions may be able to avoid. Shifting the evaluation emphasis on the residents' development of competence has made the expectations of rotation faculty more transparent, has facilitated conversations between program director and residents, and has improved the specificity of the tool for feedback. Our findings showed the new approach reduced grade inflation compared with the ABIM end-of-rotation global evaluation form.
We offer the new developmental criterion-referenced assessment as a unique application of the competences to the ABIM 9-point scale as a transferable model for improving the validity and reliability of resident evaluations across graduate medical education programs.
This study seeks to evaluate the practice patterns of current combined emergency medicine/internal medicine (EM/IM) residents during their training and compare them to the typical practice patterns of EM/IM graduates. We further seek to characterize how these current residents perceive the EM/IM physician's niche.
This is a multi-institution, cross-sectional, survey-based cohort study. Between June 2008 and July 2008, all 112 residents of the 11 EM/IM programs listed by the Accreditation Council for Graduate Medical Education were contacted and asked to complete a survey concerning plans for certification, fellowship, and practice setting.
The adjusted response rate was 71%. All respondents anticipated certifying in both specialties, with 47% intending to pursue fellowships. Most residents (97%) allotted time to both EM and IM, with a median time of 70% and 30%, respectively. Concerning academic medicine, 81% indicated intent to practice academic medicine, and 96% planned to allocate at least 10% of their future time to a university/academic setting. In evaluating satisfaction, 94% were (1) satisfied with their residency choice, (2) believed that a combined residency will advance their career, and (3) would repeat a combined residency if given the opportunity.
Current EM/IM residents were very content with their training and the overwhelming majority of residents plan to devote time to the practice of academic medicine. Relative to the practice patterns previously observed in EM/IM graduates, the current residents are more inclined toward pursuing fellowships and practicing both specialties.
To evaluate the training of graduating internal medicine residents to perform 13 common ambulatory procedures, 3 inpatient procedures, and 3 screening examinations.
Self-administered descriptive survey.
Internal medicine training programs associated with 9 medical schools in the eastern United States.
Graduating residents (N = 128); response rate, 60%.
MEASUREMENTS AND MAIN RESULTS
The total number of procedures performed during residency, importance for primary care physicians to perform these procedures, confidence to perform these procedures, and helpfulness of rotations for learning procedures were assessed. The majority of residents performed only 2 of 13 outpatient procedures 10 or more times during residency: simple spirometry and minor wound suturing. For all other procedures, the median number performed was 5 or fewer. The percentage of residents attributing high importance to a procedure was significantly greater than the percentage reporting high confidence for 8 of 13 ambulatory procedures; for all inpatient procedures, residents reported significantly higher confidence than importance. Continuity clinic and block ambulatory rotations were not considered helpful for learning ambulatory procedures.
Though residents in this sample considered most ambulatory procedures important for primary care physicians, they performed them infrequently, if at all, during residency and did not consider their continuity clinic experience helpful for learning these skills. Training programs need to address this deficiency by modifying the curriculum to ensure that these skills are taught to residents who anticipate a career in primary care medicine.
residents; confidence; training; ambulatory procedures
Training residents in medical procedures is an area of growing interest. Studies demonstrate that internal medicine residents are inadequately trained to perform common medical procedures, and program directors report residents do not master these essential skills. The American Board of Internal Medicine requires substantiation of competence in procedure skills for all internal medicine residents; however, for most procedures, standards of competence do not exist.
1) Create a new and standardized approach to teaching, performing, and evaluating inpatient medical procedures; 2) Determine the number of procedures required until trainees develop competence, by assessing both clinical knowledge and psychomotor skills; 3) Improve patient safety.
A Medical Procedure Service (MPS), consisting of select faculty who are experts at common inpatient procedures, was established to supervise residents performing medical procedures. Faculty monitor residents’ psychomotor performance, while clinical knowledge is taught through a complementary, comprehensive curriculum. After the completion of each procedure, the trainee and supervising faculty member independently complete online questionnaires.
During this pilot program, 246 procedures were supervised, with a pooled major complication rate of 3.7%. 123 thoracenteses were supervised, with a pneumothorax rate of 3.3%; this compares favorably with a pooled analysis of the literature. 87% of surveyed house staff felt the procedure service helped in their education of medical procedures.
The “see one, do one, teach one” model of procedure education is dangerously inadequate. Through the development of a Medical Procedure Service, and an associated procedure curriculum and a mechanism of evaluation, we hope to reduce the rate of complications and errors related to medical procedures and to determine at what point competency is achieved for these procedures.
procedures; education; competence; complications
Internal medicine residents must be competent in advanced cardiac life support (ACLS) for board certification.
To use a medical simulator to assess postgraduate year 2 (PGY-2) residents' baseline proficiency in ACLS scenarios and evaluate the impact of an educational intervention grounded in deliberate practice on skill development to mastery standards.
Pretest-posttest design without control group. After baseline evaluation, residents received 4, 2-hour ACLS education sessions using a medical simulator. Residents were then retested. Residents who did not achieve a research-derived minimum passing score (MPS) on each ACLS problem had more deliberate practice and were retested until the MPS was reached.
Forty-one PGY-2 internal medicine residents in a university-affiliated program.
Observational checklists based on American Heart Association (AHA) guidelines with interrater and internal consistency reliability estimates; deliberate practice time needed for residents to achieve minimum competency standards; demographics; United States Medical Licensing Examination Step 1 and Step 2 scores; and resident ratings of program quality and utility.
Performance improved significantly after simulator training. All residents met or exceeded the mastery competency standard. The amount of practice time needed to reach the MPS was a powerful (negative) predictor of posttest performance. The education program was rated highly.
A curriculum featuring deliberate practice dramatically increased the skills of residents in ACLS scenarios. Residents needed different amounts of training time to achieve minimum competency standards. Residents enjoy training, evaluation, and feedback in a simulated clinical environment. This mastery learning program and other competency-based efforts illustrate outcome-based medical education that is now prominent in accreditation reform of residency education.
mastery learning; medical simulation; residency education
IMGs constitute about a third of the United States (US) internal medicine graduates. US residency training programs face challenges in selection of IMGs with varied background features. However data on this topic is limited. We analyzed whether any pre-selection characteristics of IMG residents in our internal medicine program are associated with selected outcomes, namely competency based evaluation, examination performance and success in acquiring fellowship positions after graduation.
We conducted a retrospective study of 51 IMGs at our ACGME accredited teaching institution between 2004 and 2007. Background resident features namely age, gender, self-reported ethnicity, time between medical school graduation to residency (pre-hire time), USMLE step I & II clinical skills scores, pre-GME clinical experience, US externship and interest in pursuing fellowship after graduation expressed in their personal statements were noted. Data on competency-based evaluations, in-service exam scores, research presentation and publications, fellowship pursuance were collected. There were no fellowships offered in our hospital in this study period. Background features were compared between resident groups according to following outcomes: (a) annual aggregate graduate PGY-level specific competency-based evaluation (CBE) score above versus below the median score within our program (scoring scale of 1 – 10), (b) US graduate PGY-level specific resident in-training exam (ITE) score higher versus lower than the median score, and (c) those who succeeded to secure a fellowship within the study period. Using appropriate statistical tests & adjusted regression analysis, odds ratio with 95% confidence intervals were calculated.
94% of the study sample were IMGs; median age was 35 years (Inter-Quartile range 25th – 75th percentile (IQR): 33–37 years); 43% women and 59% were Asian physicians. The median pre-hire time was 5 years (IQR: 4–7 years) and USMLE step I & step II clinical skills scores were 85 (IQR: 80–88) & 82 (IQR: 79–87) respectively. The median aggregate CBE scores during training were: PG1 5.8 (IQR: 5.6–6.3); PG2 6.3 (IQR 6–6.8) & PG3 6.7 (IQR: 6.7 – 7.1). 25% of our residents scored consistently above US national median ITE scores in all 3 years of training and 16% pursued a fellowship.
Younger residents had higher aggregate annual CBE score than the program median (p < 0.05). Higher USMLE scores were associated with higher than US median ITE scores, reflecting exam-taking skills. Success in acquiring a fellowship was associated with consistent fellowship interest (p < 0.05) and research publications or presentations (p <0.05). None of the other characteristics including visa status were associated with the outcomes.
Background IMG features namely, age and USMLE scores predict performance evaluation and in-training examination scores during residency training. In addition enhanced research activities during residency training could facilitate fellowship goals among interested IMGs.
The impact of managed care in the 1990s and the need for more broadly trained primary care physicians led the American Board of Internal Medicine and the American Board of Family Practice to explore ways to collaboratively train primary care physicians. One proposed solution was a combined residency incorporating the training curriculums of both boards in an integrated fashion. In 1995, the Alton Ochsner Medical Foundation Combined Family Practice and Internal Medicine Residency Program was one of the first to be approved by the two boards. The first residents began training in July 1996. Due to overlap in curriculums, completion for both boards is possible in 48 months as opposed to the 72 months a consecutive approach would require. The first graduates completed the program in July 2000.
The combined residents rotate on both the Family Practice inpatient service and the General Internal Medicine wards and participate in continuity care clinics and precepting in both core programs. Facilities for the program involve only existing clinics and administrative personnel. Residents serve as primary care physicians for a mixed ethnic, middle-class patient population atOchsner's New Orleans East satellite clinic, provide longitudinal obstetric and pediatric care at an inner city clinic, and complete a rural primary care rotation. Inservice examination scores have been consistently high with several combined residents scoring at the top United States level on both examinations. The program has matched with our highest ranked students over each year of the program despite a marked decline in US graduates entering primary care fields. Graduates of the combined program are ideal staff for either medical schools or residency programs of either core program.
While this residency is in its early stages, both boards have mandated an indepth evaluation to determine the quality and outcomes of training. The results of a recent survey of current Ochsner residents assessing their perceptions of the combined program were encouraging. We plan to track our graduates and compare them with recent graduates of the two core programs in order to document long-term impact.
To review the success of international medical graduates (IMGs) who are pursuing or have completed a Quebec residency training program and examinations.
We retrospectively reviewed IMGs’ success rates on the pre-residency Collège des médecins du Québec medical clinical sciences written examination and objective structured clinical examination, as well as on the post-residency Certification Examination in Family Medicine.
All IMGs taking their examinations between 2001 and 2008, inclusive, and Canadian and American graduates taking their examinations during this same period.
MAIN OUTCOME MEASURES
Success rates for IMGs on the pre-residency and post-residency examinations, compared with success rates for Canadian and American graduates.
Success rates on the pre-residency clinical examinations remained below 50% from 2001 to 2008 for IMGs. Similarly, during the same period, the average success rate on the Certification examination was 56.0% for IMGs, compared with 93.5% for Canadian and American medical graduates.
Despite pre-residency competency screening and in-program orientation and supports, a substantial number of IMGs in Quebec are not passing their Certification examinations. Another study is under way to analyze reasons for some IMGs’ lack of success and to find ways to help IMGs complete residency training successfully and pass the Certification examination.
To graduate internal medicine residents with basic competency in palliative care, we employ a two-pronged strategy targeted at both residents and attending physicians as learners. The first prong provides a knowledge foundation using web-based learning programs designed specifically for residents and clinical faculty members. The second prong is assessment of resident competency in key palliative care domains by faculty members using direct observation during clinical rotations. The faculty training program contains Competency Assessment Tools addressing 19 topics distributed amongst four broad palliative care domains designed to assist faculty members in making the clinical competency assessments. Residents are required to complete their web-based training by the end of their internship year; they must demonstrate competency in one skill from each of the four broad palliative care domains prior to graduation. Resident and faculty evaluation of the training programs is favorable. Outcome-based measures are planned to evaluate long-term program effectiveness.
Internal medicine residents; Palliative care; Faculty members; Competency Assessment Tools; Faculty training program
SGIM endoreses seven principles related to current thinking about internal medicine training: 1) internal medicine requires a full three years of residency training before subspecialization; 2) internal medicine residency programs must dramatically increase support for training in the ambulatory setting and offer equivalent opportunities for training in both inpatient and outpatient medicine; 3) in settings where adequate support and time are devoted to ambulatory training, the third year of residency could offer an opportunity to develop further expertise or mastery in a specific type or setting of care; 4) further certification in specific specialties within internal medicine requires the completion of an approved fellowship program; 5) areas of mastery in internal medicine can be demonstrated through modified board certification and recertification examinations; 6) certification processes throughout internal medicine should focus increasingly on demonstration of clinical competence through adherence to validated standards of care within and across practice settings; and 7) regardless of the setting in which General Internists practice, we should unite to promote the critical role that this specialty serves in patient care.
education; medical; graduate; certification; internal medicine; hospitalists; ambulatory care
Objective: To review the current status and recent trends in the American Board of Psychiatry and Neurology (ABPN) specialties and neurologic subspecialties and discuss the implications of those trends for subspecialty viability.
Methods: Data on numbers of residency and fellowship programs and graduates and ABPN certification candidates and diplomates were drawn from several sources, including ABPN records, Web sites of the Accreditation Council for Graduate Medical Education and the American Medical Association, and the annual medical education issues of the Journal of the American Medical Association.
Results: About four-fifths of neurology graduates pursue fellowship training. While most recent neurology and child neurology graduates attempt to become certified by the ABPN, many clinical neurophysiologists elect not to do so. There appears to have been little interest in establishing fellowships in neurodevelopmental disabilities. The pass rate for fellowship graduates is equivalent to that for the “grandfathers” in clinical neurophysiology. Lower percentages of clinical neurophysiologists than specialists participate in maintenance of certification, and maintenance of certification pass rates are high.
Conclusion: The initial enthusiastic interest in training and certification in some of the ABPN neurologic subspecialties appears to have slowed, and the long-term viability of those subspecialties will depend upon the answers to a number of complicated social, economic, and political questions in the new health care era.
ABMS = American Board of Medical Specialties; ABPN = American Board of Psychiatry and Neurology; ACGME = Accreditation Council for Graduate Medical Education; MOC = maintenance of certification; RRC-N = Residency Review Committee in Neurology.
The Residency Review Committee training requirements for emergency medicine residents (EM) are defined by consensus panels, with specific topics abstracted from lists of patient complaints and diagnostic codes. The relevance of specific curricular topics to actual practice has not been studied. We compared residency graduates’ self-assessed preparation during training to importance in practice for a variety of EM procedural skills.
We distributed a web-based survey to all graduates of the Denver Health Residency Program in EM over the past 10 years. The survey addressed: practice type and patient census; years of experience; additional procedural training beyond residency; and confidence, preparation, and importance in practice for 12 procedures (extensor tendon repair, transvenous pacing, lumbar puncture, applanation tonometry, arterial line placement, anoscopy, CT scan interpretation, diagnostic peritoneal lavage, slit lamp usage, ultrasonography, compartment pressure measurement and procedural sedation). For each skill, preparation and importance were measured on four-point Likert scales. We compared mean preparation and importance scores using paired sample t-tests, to identify areas of under- or over-preparation.
Seventy-four residency graduates (59% of those eligible) completed the survey. There were significant discrepancies between importance in practice and preparation during residency for eight of the 12 skills. Under-preparation was significant for transvenous pacing, CT scan interpretation, slit lamp examinations and procedural sedation. Over-preparation was significant for extensor tendon repair, arterial line placement, peritoneal lavage and ultrasonography. There were strong correlations (r>0.3) between preparation during residency and confidence for 10 of the 12 procedural skills, suggesting a high degree of internal consistency for the survey.
Practicing emergency physicians may be uniquely qualified to identify areas of under- and over-preparation during residency training. There were significant discrepancies between importance in practice and preparation during residency for eight of 12 procedures. There was a strong correlation between confidence and preparation during residency for almost all procedural skills, reenforcing the tenet that residency training is the primary locus of instruction for clinical procedures.
To obtain a quantitative measure of the extent to which graduate education and qualification for specialty practice have become an integral part of the total educational experience, samples of the graduating classes of 1960, 1964, 1968 and 1970 of Canadian medical schools were tracked through postgraduate educational training and into specialty certification. From the 1960 cohort 65% chose a career recognized by special certifying exams in Canada and/or the United States, entered a residency, completed it and achieved certification of special competence. From the 1970 cohort, by the end of 1972 approximately 50% had entered a recognized specialty training program leading to certification. The diminishing trend toward specialty practice is demonstrated by reviewing the comparative figures in the 1964 and 1968 cohorts. Evidence garnered in this study indicates a continuing strong motivation for specialty practice although family medicine and/or general practice appear increasingly attractive as career choices. Strong provincial educational forces as well as social and other forces will probably continue to modify career selection and may lead an increasing number of Canadian medical graduates into family practice.