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1.  A nomogram to predict the probability of passing the American Board of Internal Medicine examination 
Medical Education Online  2012;17:10.3402/meo.v17i0.18810.
Background
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.
Purpose
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.
Methods
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.
Results
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.
Conclusions
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.
doi:10.3402/meo.v17i0.18810
PMCID: PMC3475012  PMID: 23078794
board examination; in-training examination; internal medicine; residents; program directors
2.  Predicting performance using background characteristics of international medical graduates in an inner-city university-affiliated Internal Medicine residency training program 
Background
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.
Methods
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.
Results
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.
Conclusion
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.
doi:10.1186/1472-6920-9-42
PMCID: PMC2717068  PMID: 19594918
3.  Examination outcomes for international medical graduates pursuing or completing family medicine residency training in Quebec 
Canadian Family Physician  2010;56(9):912-918.
ABSTRACT
OBJECTIVE
To review the success of international medical graduates (IMGs) who are pursuing or have completed a Quebec residency training program and examinations.
DESIGN
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.
SETTING
Quebec.
PARTICIPANTS
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.
RESULTS
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.
CONCLUSION
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.
PMCID: PMC2939121  PMID: 20841596
4.  How do IMGs compare with Canadian medical school graduates in a family practice residency program? 
Canadian Family Physician  2010;56(9):e318-e322.
ABSTRACT
OBJECTIVE
To compare international medical graduates (IMGs) with Canadian medical school graduates in a family practice residency program.
DESIGN
Analysis of the results of the in-training evaluation reports (ITERs) and the Certification in Family Medicine (CCFP) examination results for 2 cohorts of IMGs and Canadian-trained graduates between the years 2006 and 2008.
SETTING
St Paul’s Hospital (SPH) in Vancouver, BC, a training site of the University of British Columbia (UBC) Family Practice Residency Program.
PARTICIPANTS
In-training evaluation reports were examined for 12 first-year and 9 second-year Canadian-trained residents at the SPH site, and 12 first-year and 12 second-year IMG residents at the IMG site at SPH; CCFP examination results were reviewed for all UBC family practice residents who took the May 2008 examination and disclosed their results.
MAIN OUTCOME MEASURES
Pass or fail rates on the CCFP examination; proportions of evaluations in each group of residents given each of the following designations: exceeds expectations, meets expectations, or needs improvement. The May 2008 CCFP examination results were reviewed.
RESULTS
Compared with the second-year IMGs, the second-year SPH Canadian-trained residents had a greater proportion of exceeds expectations designations than the IMGs. For the first-year residents, both the SPH Canadian graduates and IMGs had similar results in all 3 categories. Combining the results of the 2 cohorts, the Canadian-trained residents had 310 (99%) ITERs that were designated as either exceeds expectations or meets expectations, and only 3 (1%) ITERs were in the needs improvement category. The IMG results were 362 (97.6%) ITERs in the exceeds expectations or meets expectations categories; 9 (2%) were in the needs improvement category. Statistically these are not significant differences. Seven of the 12 (58%) IMG candidates passed the CCFP examination compared with 59 of 62 (95%) of the UBC family practice residents.
CONCLUSION
The IMG residents compared favourably with their Canadian-trained colleagues when comparing ITERs but not in passing the CCFP examination. Further research is needed to elucidate these results.
PMCID: PMC2939132  PMID: 20841570
5.  Protocol-directed care in the ICU: making a future generation of intensivists less knowledgeable? 
Critical Care  2012;16(2):307.
Expanded abstract
Citation
Prasad M, Holmboe ES, Lipner RS, Hess BJ, Christie JD, Bellamy SL, Rubenfeld GD, Kahn JM. Clinical Protocols and Trainee Knowledge About Mechanical Ventilation. JAMA. 2011; 306(9):935-941. PubMed PMID: 21900133 This is available on http://www.pubmed.gov
Background
Clinical protocols are associated with improved patient outcomes; however, they may negatively affect medical education by removing trainees from clinical decision making.
Methods
Objective: To study the relationship between critical care training with mechanical ventilation protocols and subsequent knowledge about ventilator management.
Design: A retrospective cohort equivalence study linking a national survey of mechanical ventilation protocol availability with knowledge about mechanical ventilation. Exposure to protocols was defined as high intensity if an intensive care unit had 2 or more protocols for at least 3 years and as low intensity if 0 or 1 protocol.
Setting: Accredited US pulmonary and critical care fellowship programs.
Subjects: First-time examinees of the American Board of Internal Medicine (ABIM) Critical Care Medicine Certification Examination in 2008 and 2009.
Intervention: N/A
Outcomes: Knowledge, measured by performance on examination questions specific to mechanical ventilation management, calculated as a mechanical ventilation score using item response theory. The score is standardized to a mean (SD) of 500 (100), and a clinically important difference is defined as 25. Variables included in adjusted analyses were birth country, residency training country, and overall first-attempt score on the ABIM Internal Medicine Certification Examination.
Results
The 90 of 129 programs (70%) responded to the survey. Seventy seven programs (86%) had protocols for ventilation liberation, 66 (73%) for sedation management, and 54 (60%) for lung-protective ventilation at the time of the survey. Eighty eight (98%) of these programs had trainees who completed the ABIM Critical Care Medicine Certification Examination, totaling 553 examinees. Of these 88 programs, 27 (31%) had 0 protocols, 19 (22%) had 1 protocol, 24 (27%) had 2 protocols, and 18 (20%) had 3 protocols for at least 3 years. 42 programs (48%) were classified as high intensity and 46 (52%) as low intensity, with 304 trainees (55%) and 249 trainees (45%), respectively. In bi-variable analysis, no difference in mean scores was observed in high-intensity (497; 95% CI, 486-507) vs low-intensity programs (497; 95% CI, 485-509). Mean difference was 0 (95% CI, -16 to 16), with a positive value indicating a higher score in the high-intensity group. In multivariable analyses, no association of training was observed in a high-intensity program with mechanical ventilation score (adjusted mean difference, -5.36; 95% CI, -20.7 to 10.0).
Conclusions
Among first-time ABIM Critical Care Medicine Certification Examination examinees, training in a high-intensity ventilator protocol environment compared with a low-intensity environment was not associated with worse performance on examination questions about mechanical ventilation management.
doi:10.1186/cc11257
PMCID: PMC3681378  PMID: 22494787
6.  Are Commonly Used Resident Measurements Associated with Procedural Skills in Internal Medicine Residency Training? 
Background
Acquisition of competence in performing a variety of procedures is essential during Internal Medicine (IM) residency training.
Purposes
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.
Methods
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.
Results
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.
Conclusions
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.
doi:10.1007/s11606-006-0068-1
PMCID: PMC1824756  PMID: 17356968
procedural skills; Internal Medicine residency training program; ABIM evaluation
7.  Are Commonly Used Resident Measurements Associated with Procedural Skills in Internal Medicine Residency Training? 
Background
Acquisition of competence in performing a variety of procedures is essential during Internal Medicine (IM) residency training.
Purposes
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.
Methods
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.
Results
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.
Conclusions
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.
doi:10.1007/s11606-006-0068-1
PMCID: PMC1824756  PMID: 17356968
procedural skills; Internal Medicine residency training program; ABIM evaluation
8.  Physician Emigration from Sub-Saharan Africa to the United States: Analysis of the 2011 AMA Physician Masterfile 
PLoS Medicine  2013;10(9):e1001513.
Siankam Tankwanchi and colleagues used the AMA Physician Masterfile and the WHO Global Health Workforce Statistics on physicians in sub-Saharan Africa to determine trends in physician emigration to the United States.
Please see later in the article for the Editors' Summary
Background
The large-scale emigration of physicians from sub-Saharan Africa (SSA) to high-income nations is a serious development concern. Our objective was to determine current emigration trends of SSA physicians found in the physician workforce of the United States.
Methods and Findings
We analyzed physician data from the World Health Organization (WHO) Global Health Workforce Statistics along with graduation and residency data from the 2011 American Medical Association Physician Masterfile (AMA-PM) on physicians trained or born in SSA countries who currently practice in the US. We estimated emigration proportions, year of US entry, years of practice before emigration, and length of time in the US. According to the 2011 AMA-PM, 10,819 physicians were born or trained in 28 SSA countries. Sixty-eight percent (n = 7,370) were SSA-trained, 20% (n = 2,126) were US-trained, and 12% (n = 1,323) were trained outside both SSA and the US. We estimated active physicians (age ≤70 years) to represent 96% (n = 10,377) of the total. Migration trends among SSA-trained physicians increased from 2002 to 2011 for all but one principal source country; the exception was South Africa whose physician migration to the US decreased by 8% (−156). The increase in last-decade migration was >50% in Nigeria (+1,113) and Ghana (+243), >100% in Ethiopia (+274), and >200% (+244) in Sudan. Liberia was the most affected by migration to the US with 77% (n = 175) of its estimated physicians in the 2011 AMA-PM. On average, SSA-trained physicians have been in the US for 18 years. They practiced for 6.5 years before US entry, and nearly half emigrated during the implementation years (1984–1999) of the structural adjustment programs.
Conclusion
Physician emigration from SSA to the US is increasing for most SSA source countries. Unless far-reaching policies are implemented by the US and SSA countries, the current emigration trends will persist, and the US will remain a leading destination for SSA physicians emigrating from the continent of greatest need.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Population growth and aging and increasingly complex health care interventions, as well as existing policies and market forces, mean that many countries are facing a shortage of health care professionals. High-income countries are addressing this problem in part by encouraging the immigration of foreign health care professionals from low- and middle-income countries. In the US, for example, international medical graduates (IMGs) can secure visas and permanent residency by passing examinations provided by the Educational Commission of Foreign Medical Graduates and by agreeing to provide care in areas that are underserved by US physicians. Inevitably, the emigration of physicians from low- and middle-income countries undermines health service delivery in the emigrating physicians' country of origin because physician supply is already inadequate in those countries. Physician emigration from sub-Saharan Africa, which has only 2% of the global physician workforce but a quarter of the global burden of disease, is particularly worrying. Since 1970, as a result of large-scale emigration and limited medical education, there has been negligible or negative growth in the density of physicians in many countries in sub-Saharan Africa. In Liberia, for example, in 1973, there were 7.76 physicians per 100,000 people but by 2008 there were only 1.37 physicians per 100,000 people; in the US, there are 250 physicians per 100,000 people.
Why Was This Study Done?
Before policy proposals can be formulated to address global inequities in physician distribution, a clear picture of the patterns of physician emigration from resource-limited countries is needed. In this study, the researchers use data from the 2011 American Medical Association Physician Masterfile (AMA-PM) to investigate the “brain drain” of physicians from sub-Saharan Africa to the US. The AMA-PM collects annual demographic, academic, and professional data on all residents (physicians undergoing training in a medical specialty) and licensed physicians who practice in the US.
What Did the Researchers Do and Find?
The researchers used data from the World Health Organization (WHO) Global Health Workforce Statistics and graduation and residency data from the 2011 AMA-PM to estimate physician emigration rates from sub-Saharan African countries, year of US entry, years of service provided before emigration to the US, and length of time in the US. There were 10,819 physicians who were born or trained in 28 sub-Saharan African countries in the 2011 AMA-PM. By using a published analysis of the 2002 AMA-PM, the researchers estimated that US immigration among sub-Saharan African-trained physicians had increased over the past decade for all the countries examined except South Africa, where physician emigration had decreased by 8%. Overall, the number of sub-Saharan African IMGs in the US had increased by 38% since 2002. More than half of this increase was accounted for by Nigerian IMGs. Liberia was the country most affected by migration of its physicians to the US—77% of its estimated 226 physicians were in the 2011 AMA-PM. On average, sub-Saharan African IMGs had been in the US for 18 years and had practiced for 6.5 years before emigration. Finally, nearly half of the sub-Saharan African IMGs had migrated to US between 1984 and 1995, years during which structural adjustment programs, which resulted in deep cuts to public health care services, were implemented in developing countries by international financial institutions as conditions for refinancing.
What Do These Findings Mean?
Although the sub-Saharan African IMGs in the 2011 AMA-PM only represent about 1% of all the physicians and less than 5% of the IMGs in the AMA-PM, these findings reveal a major loss of physicians from sub-Saharan Africa. They also suggest that emigration of physicians from sub-Saharan Africa is a growing problem and is likely to continue unless job satisfaction for physicians is improved in their country of origin. Moreover, because the AMA-PM only lists physicians who qualify for a US residency position, more physicians may have moved from sub-Saharan Africa to the US than reported here and may be working in other jobs incommensurate with their medical degrees (“brain waste”). The researchers suggest that physician emigration from sub-Saharan Africa to the US reflects the complexities in the labor markets for health care professionals in both Africa and the US and can be seen as low- and middle-income nations subsidizing the education of physicians in high-income countries. Policy proposals to address global inequities in physician distribution will therefore need both to encourage the recruitment, training, and retention of health care professionals in resource-limited countries and to persuade high-income countries to train more home-grown physicians to meet the needs of their own populations.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001513.
The Foundation for Advancement of International Medical Education and Research is a non-profit foundation committed to improving world health through education that was established in 2000 by the Educational Commission for Foreign Medical Graduates
The Global Health Workforce Alliance is a partnership of national governments, civil society, international agencies, finance institutions, researchers, educators, and professional associations dedicated to identifying, implementing and advocating for solutions to the chronic global shortage of health care professionals (available in several languages)
Information on the American Medical Association Physician Masterfile and the providers of physician data lists is available via the American Medical Associations website
The World Health Organization (WHO) annual World Health Statistics reports present the most recent health statistics for the WHO Member States
The Medical Education Partnership Initiative is a US-sponsored initiative that supports medical education and research in sub-Saharan African institutions, aiming to increase the quantity, quality, and retention of graduates with specific skills addressing the health needs of their national populations
CapacityPlus is the USAID-funded global project uniquely focused on the health workforce needed to achieve the Millennium Development Goals
Seed Global Health cultivates the next generation of health professionals by allying medical and nursing volunteers with their peers in resource-limited settings
"America is Stealing the Worlds Doctors", a 2012 New York Times article by Matt McAllester, describes the personal experience of a young doctor who emigrated from Zambia to the US
Path to United States Practice Is Long Slog to Foreign Doctors, a 2013 New York Times article by Catherine Rampell, describes the hurdles that immigrant physicians face in practicing in the US
doi:10.1371/journal.pmed.1001513
PMCID: PMC3775724  PMID: 24068894
9.  Impact of subspecialty elective exposures on outcomes on the American board of internal medicine certification examination 
BMC Medical Education  2012;12:94.
Background
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.
Methods
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.
Results
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.
Conclusions
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.
doi:10.1186/1472-6920-12-94
PMCID: PMC3480921  PMID: 23057635
Resident education; Gender; Elective; Subspecialty; Graduate medical education
10.  International medical graduates (IMGs) needs assessment study: comparison between current IMG trainees and program directors 
Background
International Medical Graduates (IMGs) training within the Canadian medical education system face unique difficulties. The purpose of this study was to explore the challenges IMGs encounter from the perspective of trainees and their Program Directors.
Methods
Program Directors of residency programs and IMGs at the University of Toronto were anonymously surveyed and asked to rate (using a 5-point Likert scale; 1 = least important – 5 = most important) the extent to which specific issues were challenging to IMGs and whether an orientation program (in the form of a horizontal curriculum) should be implemented for incoming IMGs prior to starting their residency.
Results
Among the IMGs surveyed, Knowledge of the Canadian Healthcare System received the highest mean score (3.93), followed by Knowledge of Pharmaceuticals and Hospital formularies (3.69), and Knowledge of the Hospital System (3.69). In contrast, Program Directors felt that Communication with Patients (4.40) was a main challenge faced by IMGs, followed by Communication with Team Members (4.33) and Basic Clinical Skills (4.28).
Conclusion
IMGs and Program Directors differ in their perspectives as to what are considered challenges to foreign-trained physicians entering residency training. Both groups agree that an orientation program is necessary for incoming IMGs prior to starting their residency program.
doi:10.1186/1472-6920-8-42
PMCID: PMC2546389  PMID: 18759968
11.  Clerkship pathway 
Canadian Family Physician  2012;58(6):662-667.
Abstract
Objective
To identify factors that help predict success for international medical graduates (IMGs) who train in Canadian residency programs and pass the Canadian certification examinations.
Design
A retrospective analysis of 58 variables in the files of IMGs who applied to the Collège des médecins du Québec between 2000 and 2008.
Setting
Quebec.
Participants
Eight hundred ten IMGs who applied to the Collège des médecins du Québec through either the “equivalency pathway” (ie, starting training at a residency level) or the “clerkship pathway” (ie, relearning at the level of a medical student in the last 2 years of the MD diploma).
Main outcome measures
Success factors in achieving certification. Data were analyzed using descriptive statistics and ANOVA (analysis of variance).
Results
International medical graduates who chose the “clerkship pathway” had greater success on certification examinations than those who started at the residency level did.
Conclusion
There are several factors that influence IMGs’ success on certification examinations, including integration issues, the acquisition of clinical decision-making skills, and the varied educational backgrounds. These factors perhaps can be better addressed by a regular clerkship pathway, in which IMGs benefit from learner-centred teaching and have more time for reflection on and understanding of the North American approach to medical education. The clerkship pathway is a useful strategy for assuring the integration of IMGs in the North American health care system. A 2-year relearning period in medical school at a clinical clerkship level deserves careful consideration.
PMCID: PMC3374691  PMID: 22859630
12.  Canadian and immigrant international medical graduates 
Canadian Family Physician  2005;51(9):1243.
OBJECTIVE
To compare the demographic and educational characteristics of Canadian international medical graduates (IMGs) and immigrant IMGs who applied to the second iteration of the Canadian Resident Matching Service (CaRMS) match in 2002.
DESIGN
Web-based questionnaire survey.
SETTING
The study was conducted during the second-iteration CaRMS match in Canada.
PARTICIPANTS
The sampling frame included the entire population of IMG registrants for the 2002 CaRMS match in Canada who expressed interest in applying for a ministry-funded residency position in the 13 English-speaking Canadian medical schools. Those who immigrated to Canada with medical degrees were categorized as immigrant IMGs. Canadian citizens and landed immigrants or permanent residents who left Canada to obtain a medical degree in another country were defined as Canadian IMGs.
MAIN OUTCOME MEASURES
Demographic characteristics, education and training outside Canada, examinations taken, previous applications for a residency position, preferred type of practice, and barriers and supports were compared.
RESULTS
Out of 446 respondents who indicated their immigration status and education, 396 (88.8%) were immigrant IMGs and 50 (11.2%) were Canadian IMGs. Immigrant IMGs tended to be older, be married, and have dependent children. Immigrant IMGs most frequently obtained their medical education in Asia, Eastern Europe, the Middle East, or Africa, whereas Canadian IMGs most frequently obtained their medical degrees in Asia, the Caribbean, or Europe. Immigrant IMGs tended to have more years of postgraduate training and clinical experience. A significantly greater proportion of immigrant IMGs had perceived that there were insufficient opportunities for assessment, financial barriers to training, and licensing barriers to practice. Nearly half (45.5%) of all IMGs selected family medicine as their first choice of clinical discipline to practise in Canada. There were no significant differences between Canadian and immigrant IMGs in terms of first choice of clinical discipline (family medicine vs specialty). There were no significant differences between the groups in the number of times they applied to CaRMS in the past, but a relatively greater proportion of Canadian IMGs obtained residency positions.
CONCLUSION
There are notable similarities and some significant differences between Canadian and immigrant IMGs seeking to practise medicine in Canada.
PMCID: PMC1479472  PMID: 16926941
13.  A Multiple Choice Testing Program Coupled with a Year-long Elective Experience is Associated with Improved Performance on the Internal Medicine In-Training Examination 
Journal of General Internal Medicine  2011;26(11):1253-1257.
Background
The Internal Medicine In-Training Exam (IM-ITE) assesses the content knowledge of internal medicine trainees. Many programs use the IM-ITE to counsel residents, to create individual remediation plans, and to make fundamental programmatic and curricular modifications.
Objective
To assess the association between a multiple-choice testing program administered during 12 consecutive months of ambulatory and inpatient elective experience and IM-ITE percentile scores in third post-graduate year (PGY-3) categorical residents.
Design
Retrospective cohort study.
Participants
One hundred and four categorical internal medicine residents. Forty-five residents in the 2008 and 2009 classes participated in the study group, and the 59 residents in the three classes that preceded the use of the testing program, 2005–2007, served as controls.
Intervention
A comprehensive, elective rotation specific, multiple-choice testing program and a separate board review program, both administered during a continuous long-block elective experience during the twelve months between the second post-graduate year (PGY-2) and PGY-3 in-training examinations.
Measures
We analyzed the change in median individual percent correct and percentile scores between the PGY-1 and PGY-2 IM-ITE and between the PGY-2 and PGY-3 IM-ITE in both control and study cohorts. For our main outcome measure, we compared the change in median individual percentile rank between the control and study cohorts between the PGY-2 and the PGY-3 IM-ITE testing opportunities.
Results
After experiencing the educational intervention, the study group demonstrated a significant increase in median individual IM-ITE percentile score between PGY-2 and PGY-3 examinations of 8.5 percentile points (p < 0.01). This is significantly better than the increase of 1.0 percentile point seen in the control group between its PGY-2 and PGY-3 examination (p < 0.01).
Conclusion
A comprehensive multiple-choice testing program aimed at PGY-2 residents during a 12-month continuous long-block elective experience is associated with improved PGY-3 IM-ITE performance.
doi:10.1007/s11606-011-1696-7
PMCID: PMC3208479  PMID: 21499831
Internal Medicine In-Training Exam; multiple-choice testing; medical knowledge
14.  Predicting international medical graduate success on college certification examinations 
Canadian Family Physician  2014;60(10):e478-e484.
Abstract
Objective
To determine predictors of international medical graduate (IMG) success in accordance with the priorities highlighted by the Thomson and Cohl judicial report on IMG selection.
Design
Retrospective assessment using regression analyses to compare the information available at the time of resident selection with those trainees’ national certification examination outcomes.
Setting
McMaster University in Hamilton, Ont.
Participants
McMaster University IMG residents who completed the program between 2005 and 2011.
Main outcome measures
Associations between IMG professional experience or demographic characteristics and examination outcomes.
Results
The analyses revealed that country of study and performance on the Medical Council of Canada Evaluating Examination are among the predictors of performance on the College of Family Physicians of Canada and the Royal College of Physicians and Surgeons of Canada certification examinations. Of interest, the analyses also suggest discipline-specific relationships between previous professional experience and examination success.
Conclusion
This work presents a useful technique for further improving our understanding of the performance of IMGs on certification examinations in North America, encourages similar interinstitutional analyses, and provides a foundation for the development of tools to assist with IMG education.
PMCID: PMC4196833  PMID: 25316762
15.  Comparison of International Medical Graduates with US Medical Students and Residents after a Four-Week Course in Palliative Medicine: A Pilot Study 
Journal of Palliative Medicine  2013;16(5):471-477.
Abstract
Background
The need for doctors who have skills in pain management and palliative medicine is greatest in low and moderate resource countries where patients most frequently present to their health care system with advanced illness and greater than 80% of the global deaths occur. While medical students trained in the United States are required to have training in palliative medicine, international medical graduates (IMGs), who have completed medical school outside North America, may not have the same exposure to palliative medicine training as U.S. physicians. The goal of this study was to evaluate whether a four-week course in palliative medicine could bring IMG attitudes, concerns, competence, and knowledge to the level of U.S. trainees.
Methods
As part of a prospective cohort study, 21 IMGs from 14 countries participated in a four-week course in palliative medicine. Attitudes, concerns, self-reported competence, and knowledge were assessed pre-course and post-course. The course was evaluated weekly and at the end of the four-week program. The data from the IMGs was compared to data from U.S. medical students and residents using the same assessment tools.
Results
After the course, IMGs had significantly decreased concern about ethical and legal issues in palliative medicine to the level of U.S.-trained residents and a significant increase in knowledge and self-rated competence equivalent to the level of U.S. trainees.
Conclusions
A four-week course in palliative medicine can improve the levels of concern, knowledge and self-assessed competence in IMGs to the level of US trainees.
doi:10.1089/jpm.2012.0478
PMCID: PMC3713437  PMID: 23448688
16.  Burnout and Distress Among Internal Medicine Program Directors: Results of A National Survey 
Journal of General Internal Medicine  2013;28(8):1056-1063.
BACKGROUND
Physician burnout and distress has been described in national studies of practicing physicians, internal medicine (IM) residents, IM clerkship directors, and medical school deans. However, no comparable national data exist for IM residency program directors.
OBJECTIVE
To assess burnout and distress among IM residency program directors, and to evaluate relationships of distress with personal and program characteristics and perceptions regarding implementation and consequences of Accreditation Council for Graduate Medical Education (ACGME) regulations.
DESIGN AND PARTICIPANTS
The 2010 Association of Program Directors in Internal Medicine (APDIM) Annual Survey, developed by the APDIM Survey Committee, was sent in August 2010 to the 377 program directors with APDIM membership, representing 99.0 % of the 381 United States categorical IM residency programs.
MAIN MEASURES
The 2010 APDIM Annual Survey included validated items on well-being and distress, including questions addressing quality of life, satisfaction with work-life balance, and burnout. Questions addressing personal and program characteristics and perceptions regarding implementation and consequences of ACGME regulations were also included.
KEY RESULTS
Of 377 eligible program directors, 282 (74.8 %) completed surveys. Among respondents, 12.4 % and 28.8 % rated their quality of life and satisfaction with work-life balance negatively, respectively. Also, 27.0 % reported emotional exhaustion, 10.4 % reported depersonalization, and 28.7 % reported overall burnout. These rates were lower than those reported previously in national studies of medical students, IM residents, practicing physicians, IM clerkship directors, and medical school deans. Aspects of distress were more common among younger program directors, women, and those reporting greater weekly work hours. Work–home conflicts were common and associated with all domains of distress, especially if not resolved in a manner effectively balancing work and home responsibilities. Associations with program characteristics such as program size and American Board of Internal Medicine (ABIM) pass rates were not found apart from higher rates of depersonalization among directors of community-based programs (23.5 % vs. 8.6 %, p = 0.01). We did not observe any consistent associations between distress and perceptions of implementation and consequences of program regulations.
CONCLUSIONS
The well-being of IM program directors across domains, including quality of life, satisfaction with work-life balance, and burnout, appears generally superior to that of medical trainees, practicing physicians, and other medical educators nationally. Additionally, it is reassuring that program directors' perceptions of their ability to respond to current regulatory requirements are not adversely associated with distress. However, the increased distress levels among younger program directors, women, and those at community-based training programs reported in this study are important concerns worthy of further study.
doi:10.1007/s11606-013-2349-9
PMCID: PMC3710382  PMID: 23595924
graduate medical education; residency; burnout; well-being
17.  Sponsorship of Internal Medicine Subspecialty Fellowships Since 2000: Trends and Community Hospital Involvement 
Background:
Since 2002, market studies have predicted a physician shortage with an increasing need for future subspecialists. A Residency Review Committee (RRC) rule that restricted sponsorship of fellowships was eliminated in 2005, but the influence of this change on the number of fellowships is not known. We believed that the rules change might make it possible for community hospitals to offer fellowships. Our objectives were to determine the extent of change in the number of fellowships in university and community hospitals from 2000 through 2008, both before and after the RRC regulation change in 2005, and to determine whether community hospitals contributed substantially to the number of new fellowships available to internal medicine graduates.
Methods:
We used archived Accreditation Council for Graduate Medical Education (ACGME) data from July 2000 through June 2008. The community hospital category included multispecialty clinics, community programs, and municipal hospitals.
Results:
Of the 94 newly approved internal medicine subspecialty fellowships in this time period, 59 (63%) were community sponsored. As of 6/02/08, all were in good standing. Thirteen programs were started as a department of medicine solo fellowship since 2005. The number of new programs approved between 2005 and 2008 was roughly three times the number approved between 2000 and 2004.
Conclusions:
The number of subspecialty fellowship programs and approved positions has increased dramatically in the last 8 years. Many of the new programs were at community hospitals. The change in RRC rules has been associated with increased availability of fellowship programs in the university and community hospital setting for subspecialty training.
doi:10.3885/meo.2009.Res00307
PMCID: PMC2779615  PMID: 20165522
Specialists; workforce; supply
18.  Initial Practice Locations of International Medical Graduates 
Health Services Research  2002;37(4):907-928.
Objective
To examine the influence of place of graduate medical education (GME), state licensure requirements, presence of established international medical graduates (IMGs), and ethnic communities on the initial practice location choices of new IMGs.
Data Sources
The annual Graduate Medical Education (GME) Survey of the American Medical Association (AMA) and the AMA Physician Masterfile.
Study Design
We identified 19,940 IMGs who completed GME in the United States between 1989 and 1994 and who were in patient care practice 4.5 years later. We used conditional logit regression analysis to assess the effect of market area characteristics on the choice of practice location. The key explanatory variables in the regression models were whether the market area was in the state of GME, the years of GME required for state licensure, the proportion of IMGs among established physicians, and the ethnic composition of the market area.
Principal Findings
The IMGs tended to locate in the same state as their GME training. Foreign-born IMGs were less likely to locate in markets with more stringent licensure requirements, and were more likely to locate in markets with higher proportions of established IMG physicians. The IMGs born in Hispanic or Asian countries were more likely to locate in markets with higher proportions of the corresponding ethnic group.
Conclusions
Policymakers may influence the flow of new IMGs into states by changing the availability of GME positions. IMGs tend to favor the same markets over time, suggesting that networks among established IMGs play a role in attracting new IMGs. Further, IMGs choose their practice locations based on ethnic matching.
doi:10.1034/j.1600-0560.2002.58.x
PMCID: PMC1464010  PMID: 12236390
Physicians; international medical graduates; health economics; physician labor markets; ethnic matching
19.  International medical graduates in family medicine in the United States of America: an exploration of professional characteristics and attitudes 
Background
The number of international medical graduates (IMGs) entering family medicine in the United States of America has steadily increased since 1997. Previous research has examined practice locations of these IMGs and their role in providing care to underserved populations. To our knowledge, research does not exist comparing professional profiles, credentials and attitudes among IMG and United States medical graduate (USMG) family physicians in the United States. The objective of this study is to determine, at the time when a large influx of IMGs into family medicine began, whether differences existed between USMG and IMG family physicians in regard to personal and professional characteristics and attitudes that may have implications for the health care system resulting from the increasing numbers of IMGs in family medicine in the United States.
Methods
This is a secondary data analysis of the 1996–1997 Community Tracking Study (CTS) Physician Survey comparing 2360 United States medical graduates and 366 international medical graduates who were nonfederal allopathic or osteopathic family physicians providing direct patient care for at least 20 hours per week.
Results
Compared to USMGs, IMGs were older (p < 0.001) and practised in smaller (p = 0.0072) and younger practices (p < 0.001). Significantly more IMGs practised in metropolitan areas versus rural areas (p = 0.0454). More IMG practices were open to all new Medicaid (p = 0.018) and Medicare (p = 0.0451) patients, and a greater percentage of their revenue was derived from these patients (p = 0.0020 and p = 0.0310). Fewer IMGs were board-certified (p < 0.001). More IMGs were dissatisfied with their overall careers (p = 0.0190). IMGs and USMGs did not differ in terms of self-rated ability to deliver high-quality care to their patients (p = 0.4626). For several of the clinical vignettes, IMGs were more likely to order tests, refer patients to specialists or require office visits than USMGs.
Conclusion
There are significant differences between IMG and USMG family physicians' professional profiles and attitudes. These differences from 1997 merit further exploration and possible follow-up, given the increased proportion of family physicians who are IMGs in the United States.
doi:10.1186/1478-4491-4-17
PMCID: PMC1543651  PMID: 16848909
20.  Differences in residents’ self-reported confidence and case experience between two post-graduate rotation curricula: results of a nationwide survey in Japan 
BMC Medical Education  2014;14:141.
Background
In Japan, all trainee physicians must begin clinical practice in a standardized, mandatory junior residency program, which encompasses the first two years of post-graduate medical training (PGY1 – PGY2). Implemented in 2004 to foster primary care skills, the comprehensive rotation program (CRP) requires junior residents to spend 14 months rotating through a comprehensive array of clinical departments including internal medicine, surgery, anesthesiology, obstetrics-gynecology (OBGYN), pediatrics, psychiatry, and rural medicine. In 2010, Japan’s health ministry relaxed this curricular requirement, allowing training programs to offer a limited rotation program (LRP), in which core departments constitute 10 months of training, with electives geared towards residents’ choice of career specialty comprising the remaining 14 months. The effectiveness of primary care skill acquisition during early training warrants evaluation. This study assesses self-reported confidence with clinical competencies, as well as case experience, between residents in CRP versus LRP curricula.
Methods
A nation-wide cross-sectional study of all PGY2 physicians in Japan was conducted in March 2011. Primary outcomes were self-report confidence for 98 clinical competency items, and number of cases experienced for 85 common diseases. We compared confidence scores and case experience between residents in CRP and LRP programs, adjusting for parameters relevant to training.
Results
Among 7506 PGY2 residents, 5052 replied to the survey (67.3%). Of 98 clinical competency items, CRP residents reported higher confidence in 12 items compared to those in an LRP curriculum, 10 of which remained significantly higher after adjustment. CRP trainees reported lower confidence scores in none of the items. Out of 85 diseases, LRP residents reported less experience with 11 diseases. CRP trainees reported lower case experience with one disease, though this did not remain significant on adjusted analysis. Confidence and case experience with OBGYN- and pediatrics-related items were particularly low among LRP trainees.
Conclusions
Residents in the specialty-oriented LRP curriculum showed less confidence and less case experience compared to peers training in the broader CRP residency curriculum. In order to foster competence in independent primary care practice, junior residency programs requiring experience in a breadth of core departments should continue to be mandated to ensure adequate primary care skills.
doi:10.1186/1472-6920-14-141
PMCID: PMC4105122  PMID: 25016304
Japanese junior residency education; Clinical competency
21.  Career Satisfaction in Primary Care: A Comparison of International and US Medical Graduates 
ABSTRACT
BACKGROUND
International medical graduates (IMGs) have substantial representation among primary care physicians in the USA and consistently report lower career satisfaction compared with US medical graduates (USMGs). Low career satisfaction has adverse consequences on physician recruitment and retention.
OBJECTIVE
This study aims to identify factors that may account for or explain lower rates of career satisfaction in IMGs compared with USMGs.
DESIGN
Using data from the 2008 Health Tracking Physician Survey, a nationally representative survey, we examined the association between IMG status and career satisfaction among primary care physicians. We used multivariable logistic regression modeling to adjust for a broad range of potential explanatory factors and physician characteristics.
PARTICIPANTS
The study participants comprise primary care physicians who reported at least 20 h a week of direct patient care activities (N = 1,890).
MAIN MEASURES
The main measures include respondents’ overall satisfaction with their careers in medicine.
KEY RESULTS
IMGs were statistically significantly less likely than USMGs to report career satisfaction (75.7% vs. 82.3%; p = 0.005). This difference persisted after adjusting for physician characteristics and variables describing the practice environment (adjusted odds ratio = 0.62; 95% confidence interval, 0.43–0.90). Pediatricians (vs. internists) and those who earned $200,001–250,000 (vs. <$100,000) or >$250,000 were more likely to report career satisfaction, while solo practitioners and those who reported being unable to provide high-quality patient care were less likely to report career satisfaction.
CONCLUSIONS
After adjusting for a number of variables previously shown to have an impact on career satisfaction, we were unable to identify additional factors that could account for or explain differences in career satisfaction between IMGs and USMGs. In light of the central role of IMGs in primary care, the potential impact of poorer satisfaction among IMGs may be substantial. Improved understanding of the causes of this differential satisfaction is important to appropriately support the primary care physician workforce.
doi:10.1007/s11606-011-1832-4
PMCID: PMC3270248  PMID: 21866306
workforce; primary care; physician satisfaction
22.  Professional Challenges of Non-U.S.-Born International Medical Graduates and Recommendations for Support During Residency Training 
Academic Medicine  2011;86(11):1383-1388.
Purpose
Despite a long history of international medical graduates (IMGs) coming to the United States for residencies, little research has been done to find systematic ways in which residency programs can support IMGs during this vulnerable transition. The authors interviewed a diverse group of IMGs to identify challenges that might be eased by targeted interventions provided within the structure of residency training.
Method
In a qualitative study conducted between March 2008 and April 2009, the authors contacted 27 non-U.S.-born IMGs with the goal of conducting qualitative interviews with a purposeful sample. The authors conducted in-person, in-depth interviews using a standardized interview guide with potential probes. All participants were primary care practitioners in New York, New Jersey, or Connecticut.
Results
A total of 25 IMGs (93%) participated. Interviews and subsequent analysis produced four themes that highlight challenges faced by IMGs: (1) Respondents must simultaneously navigate dual learning curves as immigrants and as residents, (2) IMGs face insensitivity and isolation in the workplace, (3) IMGs’ migration has personal and global costs, and (4) IMGs face specific needs as they prepare to complete their residency training. The authors used these themes to inform recommendations to residency directors who train IMGs.
Conclusions
Residency is a period in which key elements of professional identity and behavior are established. IMGs are a significant and growing segment of the physician workforce. Understanding particular challenges faced by this group can inform efforts to strengthen support for them during postgraduate training.
doi:10.1097/ACM.0b013e31823035e1
PMCID: PMC3257160  PMID: 21952056
23.  Validation of a large-scale clinical examination for international medical graduates 
Canadian Family Physician  2012;58(7):e408-e417.
Abstract
Objective
To evaluate a new examination process for international medical graduates (IMGs) to ensure that it is able to reliably assign candidates to 1 of 4 competency levels, and to determine if a global rating scale can accurately stratify examinees into 4 levels of learners: clerks, first-year residents, second-year residents, or practice ready.
Design
Validation study evaluating a 12-station objective structured clinical examination.
Setting
Ontario.
Participants
A total of 846 IMGs, and an additional 63 randomly selected volunteers from 2 groups: third-year clinical clerks (n = 42) and first-year family medicine residents (n = 21).
Main outcome measures
The accuracy of the stratification of the examinees into learner levels, the impact of the patient-encounter ratings and postencounter oral questions, and between-group differences in total score.
Results
Reliability of the patient-encounter scores, postencounter oral question scores, and the total between-group difference scores was 0.93, 0.88, and 0.76, respectively. Third-year clerks scored the lowest, followed by the IMGs. First-year residents scored highest for all 3 scores. Analysis of variance demonstrated significant between-group differences for all 3 scores (P < .05). Postencounter oral question scores differentiated among all 3 groups.
Conclusion
Clinical examination scores were capable of differentiating among the 3 groups. As a group, the IMGs seemed to be less competent than the first-year family medicine residents and more competent than the third-year clerks. The scores generated by the postencounter oral questions were the most effective in differentiating between the 2 training levels and among the 3 groups of test takers.
PMCID: PMC3395548  PMID: 22859643
24.  Evaluating applicants to a new emergency medicine residency program: subjective assessment of applicant characteristics 
Background
Because of the Accreditation Council for Graduate Medical Education (ACGME) and the Residency Review Committee (RRC) approval timelines, new residency programs cannot use Electronic Residency Application Service (ERAS) during their first year of applicants.
Aim
We sought to identify differences between program directors’ subjective ratings of applicants from an emergency medicine (EM) residency program’s first year (in which ERAS was not used) to their ratings of applicants the following year in which ERAS was used.
Method
The University of Utah Emergency Medicine Residency Program received approval from the ACGME in 2004. Applicants for the entering class of 2005 (year 1) did not use ERAS, submitting a separate application, while those applying for the following year (year 2) used ERAS. Residency program directors rated applicants using subjective components of their applications, assigning scores on scales from 0–10 or 0–5 (10 or 5 = highest score) for select components of the application. We retrospectively reviewed and compared these ratings between the 2 years of applicants.
Results
A total of 130 and 458 prospective residents applied during year 1 and year 2, respectively. Applicants were similar in average scores for research (1.65 vs. 1.81, scale 0–5, p = 0.329) and volunteer work (5.31 vs. 5.56, scale 0–10, p = 0.357). Year 1 applicants received higher scores for their personal statement (3.21 vs. 2.22, scale 0–5, p < 0.001), letters of recommendation (7.0 vs. 5.94, scale 0–10, p < 0.001), dean’s letter (3.5 vs. 2.7, scale 1–5, p < 0.001), and in their potential contribution to class characteristics (4.64 vs. 3.34, scale 0–10, p < 0.001).
Conclusion
While the number of applicants increased, the use of ERAS in a new residency program did not improve the overall subjective ratings of residency applicants. Year 1 applicants received higher scores for the written components of their applications and in their potential contributions to class characteristics.
doi:10.1007/s12245-010-0209-5
PMCID: PMC3047854  PMID: 21373291
Residency application; ERAS; Subjective Ratings
25.  Learning Curves for Direct Laryngoscopy and GlideScope® Video Laryngoscopy in an Emergency Medicine Residency 
Introduction
Our objective is to evaluate the resident learning curves for direct laryngoscopy (DL) and GlideScope® video laryngoscopy (GVL) over the course of an emergency medicine (EM) residency training program.
Methods
This was an analysis of intubations performed in the emergency department (ED) by EM residents over a seven-year period from July 1, 2007 to June 30, 2014 at an academic ED with 70,000 annual visits. After EM residents perform an intubation in the ED they complete a continuous quality improvement (CQI) form. Data collected includes patient demographics, operator post- graduate year (PGY), difficult airway characteristics (DACs), method of intubation, device used for intubation and outcome of each attempt. We included in this analysis only adult intubations performed by EM residents using a DL or a standard reusable GVL. The primary outcome was first pass success, defined as a successful intubation with a single laryngoscope insertion. First pass success was evaluated for each PGY of training for DL and GVL. Logistic mixed-effects models were constructed for each device to determine the effect of PGY level on first pass success, after adjusting for important confounders.
Results
Over the seven-year period, the DL was used as the initial device on 1,035 patients and the GVL was used as the initial device on 578 patients by EM residents. When using the DL the first past success of PGY-1 residents was 69.9% (160/229; 95% CI 63.5%–75.7%), of PGY-2 residents was 71.7% (274/382; 95% CI 66.9%–76.2%), and of PGY-3 residents was 72.9% (309/424; 95% CI 68.4%–77.1%). When using the GVL the first pass success of PGY-1 residents was 74.4% (87/117; 95% CI 65.5%–82.0%), of PGY-2 residents was 83.6% (194/232; 95% CI 76.7%–87.7%), and of PGY-3 residents was 90.0% (206/229; 95% CI 85.3%–93.5%). In the mixed-effects model for DL, first pass success for PGY-2 and PGY-3 residents did not improve compared to PGY-1 residents (PGY-2 aOR 1.3, 95% CI 0.9–1.9; p-value 0.236) (PGY-3 aOR 1.5, 95% CI 1.0–2.2, p-value 0.067). However, in the model for GVL, first pass success for PGY-2 and PGY-3 residents improved compared to PGY-1 residents (PGY-2 aOR 2.1, 95% CI 1.1–3.8, p-value 0.021) (PGY-3 aOR 4.1, 95% CI 2.1–8.0, p<0.001).
Conclusion
Over the course of residency training there was no significant improvement in EM resident first pass success with the DL, but substantial improvement with the GVL.
doi:10.5811/westjem.2014.9.23691
PMCID: PMC4251257  PMID: 25493156

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