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1.  Education Research: Bias and poor interrater reliability in evaluating the neurology clinical skills examination 
Neurology  2009;73(11):904-908.
Objective:
The American Board of Psychiatry and Neurology (ABPN) has recently replaced the traditional, centralized oral examination with the locally administered Neurology Clinical Skills Examination (NEX). The ABPN postulated the experience with the NEX would be similar to the Mini-Clinical Evaluation Exercise, a reliable and valid assessment tool. The reliability and validity of the NEX has not been established.
Methods:
NEX encounters were videotaped at 4 neurology programs. Local faculty and ABPN examiners graded the encounters using 2 different evaluation forms: an ABPN form and one with a contracted rating scale. Some NEX encounters were purposely failed by residents. Cohen’s kappa and intraclass correlation coefficients (ICC) were calculated for local vs ABPN examiners.
Results:
Ninety-eight videotaped NEX encounters of 32 residents were evaluated by 20 local faculty evaluators and 18 ABPN examiners. The interrater reliability for a determination of pass vs fail for each encounter was poor (kappa 0.32; 95% confidence interval [CI] = 0.11, 0.53). ICC between local faculty and ABPN examiners for each performance rating on the ABPN NEX form was poor to moderate (ICC range 0.14-0.44), and did not improve with the contracted rating form (ICC range 0.09-0.36). ABPN examiners were more likely than local examiners to fail residents.
Conclusions:
There is poor interrater reliability between local faculty and American Board of Psychiatry and Neurology examiners. A bias was detected for favorable assessment locally, which is concerning for the validity of the examination. Further study is needed to assess whether training can improve interrater reliability and offset bias.
GLOSSARY
= American Board of Internal Medicine;
= American Board of Psychiatry and Neurology;
= confidence interval;
= Henry Ford Hospital;
= intraclass correlation coefficients;
= internal medicine;
= Mini-Clinical Evaluation Exercise;
= Neurology Clinical Skills Examination;
= residency inservice training examination;
= University of Cincinnati;
= University of Michigan;
= University of South Florida.
doi:10.1212/WNL.0b013e3181b35212
PMCID: PMC2839551  PMID: 19605769
2.  Different tracks for pathology informatics fellowship training: Experiences of and input from trainees in a large multisite fellowship program 
Background:
Pathology Informatics is a new field; a field that is still defining itself even as it begins the formalization, accreditation, and board certification process. At the same time, Pathology itself is changing in a variety of ways that impact informatics, including subspecialization and an increased use of data analysis. In this paper, we examine how these changes impact both the structure of Pathology Informatics fellowship programs and the fellows’ goals within those programs.
Materials and Methods:
As part of our regular program review process, the fellows evaluated the value and effectiveness of our existing fellowship tracks (Research Informatics, Clinical Two-year Focused Informatics, Clinical One-year Focused Informatics, and Clinical 1 + 1 Subspecialty Pathology and Informatics). They compared their education, informatics background, and anticipated career paths and analyzed them for correlations between those parameters and the fellowship track chosen. All current and past fellows of the program were actively involved with the project.
Results:
Fellows’ anticipated career paths correlated very well with the specific tracks in the program. A small set of fellows (Clinical – one or two year – Focused Informatics tracks) anticipated clinical careers primarily focused in informatics (Director of Informatics). The majority of the fellows, however, anticipated a career practicing in a Pathology subspecialty, using their informatics training to enhance that practice (Clinical 1 + 1 Subspecialty Pathology and Informatics Track). Significantly, all fellows on this track reported they would not have considered a Clinical Two-year Focused Informatics track if it was the only track offered. The Research and the Clinical One-year Focused Informatics tracks each displayed unique value for different situations.
Conclusions:
It seems a “one size fits all” fellowship structure does not fit the needs of the majority of potential Pathology Informatics candidates. Increasingly, these fellowships must be able to accommodate the needs of candidates anticipating a wide range of Pathology Informatics career paths, be able to accommodate Pathology's increasingly subspecialized structure, and do this in a way that respects the multiple fellowships needed to become a subspecialty pathologist and informatician. This is further complicated as Pathology Informatics begins to look outward and takes its place in the growing, and still ill-defined, field of Clinical Informatics, a field that is not confined to just one medical specialty, to one way of practicing medicine, or to one way of providing patient care.
doi:10.4103/2153-3539.100362
PMCID: PMC3445299  PMID: 23024889
Clinical informatics training; clinical informatics; fellowship tracks; informatics fellowship training; informatics teaching; pathology informatics fellowship; pathology informatics training; pathology informatics
3.  Global health opportunities within pediatric subspecialty fellowship training programs: surveying the virtual landscape 
BMC Medical Education  2013;13:88.
Background
There is growing interest in global health among medical trainees. Medical schools and residencies are responding to this trend by offering global health opportunities within their programs. Among United States (US) graduating pediatric residents, 40% choose to subspecialize after residency training. There is limited data, however, regarding global health opportunities within traditional post-residency, subspecialty fellowship training programs. The objectives of this study were to explore the availability and type of global health opportunities within Accreditation Council for Graduate Medical Education (ACGME)-accredited pediatric subspecialty fellowship training programs, as noted by their online report, and to document change in these opportunities over time.
Methods
The authors performed a systematic online review of ACGME-accredited fellowship training programs within a convenience sample of six US pediatric subspecialties. Utilizing two data sources, the American Medical Association-Fellowship and Residency Electronic Interactive Database Access (AMA-FREIDA) and individual program websites, all programs were coded for global health opportunities and opportunity types were stratified into predefined categories. Comparisons were made between 2008 and 2011 using Fisher exact test. All analyses were conducted using SAS Software v. 9.3 (SAS Institute Inc., Cary, NC).
Results
Of the 355 and 360 programs reviewed in 2008 and 2011 respectively, there was an increase in total number of programs listing global health opportunities on AMA-FREIDA (16% to 23%, p=0.02) and on individual program websites (8% to 16%, p=0.004). Nearly all subspecialties had an increased percentage of programs offering global health opportunities on both data sources; although only critical care experienced a significant increase (p=0.04, AMA-FREIDA). The types of opportunities differed across all subspecialties.
Conclusions
Global health opportunities among ACGME-accredited pediatric subspecialty fellowship programs are limited, but increasing as noted by their online report. The availability and types of these opportunities differ by pediatric subspecialty.
doi:10.1186/1472-6920-13-88
PMCID: PMC3691626  PMID: 23787005
Global health; Pediatrics; Graduate medical education; Subspecialty; Fellowship training
4.  Relationship Between Performance on Child and Adolescent Psychiatry In-Training and Certification Examinations 
Background
Studies across a range of specialties have consistently yielded positive associations between performance on in-training examinations and board certification examinations, supporting the use of the in-training examination as a valuable formative feedback tool for residents and residency programs. That association to date, however, has not been tested in child and adolescent psychiatry residents.
Objective
This is the first study to explore the relationship between performance on the American College of Psychiatrists' Child Psychiatry Resident In-Training Examination (CHILD PRITE) and subsequent performance on the American Board of Psychiatry and Neurology's (ABPN) subspecialty multiple-choice examination (Part I) in child and adolescent psychiatry (CAP).
Methods
Pearson correlation coefficients were used to examine the relationship between performance on the CHILD PRITE and the CAP Part I examination for 342 fellows.
Results
Second-year CAP fellows performed significantly better on the CHILD PRITE than did the first-year fellows. The correlation between the CHILD PRITE total score and the CAP Part I examination total score was .41 (P  =  .01) for first-year CAP fellows; it was .52 (P  =  .01) for second-year CAP fellows.
Conclusions
The significant correlations between scores on the 2 tests show they assess the same achievement domain. This supports the use of the CHILD PRITE as a valid measure of medical knowledge and formative feedback tool in child and adolescent psychiatry.
doi:10.4300/JGME-D-12-00088.1
PMCID: PMC3693691  PMID: 24404270
5.  Current pediatric rheumatology fellowship training in the United States: what fellows actually do 
Background
Pediatric Rheumatology (PR) training in the US has existed since the 1970’s. In the early 1990’s, the training was formalized into a three year training program by the American College of Graduate Medical Education (ACGME) and American Board of Pediatrics (ABP). Programs have been evaluated every 5 years by the ACGME to remain credentialed and graduates had to pass a written exam to be certified. There has been no report yet that details not just what training fellows should receive in the 32 US PR training programs but what training the trainees are actually receiving.
Methods
After a literature search, a survey was constructed by the authors, then reviewed and revised with the help members of the Executive Committee of the Rheumatology Section of the American Academy of Pediatrics (AAP) using the Delphi technique. IRB approval was obtained from the AAP and Nationwide Children’s Hospital. The list of fellows was obtained from the ABP and the survey sent out to 81 current fellows or fellows just having finished. One repeat e-mail was sent out.
Results
Forty-seven fellows returned the survey by e-mail (58%) with the majority being 3rd year fellows or fellows who had completed their training. The demographics were as expected with females > males and Caucasians> > non-Caucasians. Training appeared quite appropriate in the number of ½ day continuity clinics per week (1–2, 71%), number of patients per clinic (4–5, 60%), inpatient exposure (2–4 inpatients per week, 40%; 5 or greater, 33%), and weekday/weekend call. Fellows attended more didactic activities than required, had ample time for research (54% 21-60/hours per week), and had multiple teaching opportunities. Seventy-seven percent of the trainees presented abstracts at national meetings, 41% had publication. Disease exposure was excellent and joint injection experience sufficient.
Conclusions
Most US PR training programs as a whole provide an appropriate training by current ACGME, American College of Rheumatology (ACR), and ABP standards in: 1) number of continuity clinics; 2) sufficient on-call activities for weekday nights and weekends; 3) joint interdisciplinary conferences; 4) electives 5) didactic activities; 6) scholarly activities; and 7) exposure to diverse rheumatology diseases. Areas of concern were uniformity & standardization of training, need for a customized PR training curriculum, more mentorship, free electives, training in musculoskeletal ultrasound, need for a hands-on OSCE certification exam and more exposure to ACGME competencies.
doi:10.1186/1546-0096-12-8
PMCID: PMC3922187  PMID: 24507769
6.  Clinical fellowship training in pathology informatics: A program description 
Background:
In 2007, our healthcare system established a clinical fellowship program in pathology informatics. In 2011, the program benchmarked its structure and operations against a 2009 white paper “Program requirements for fellowship education in the subspecialty of clinical informatics”, endorsed by the Board of the American Medical Informatics Association (AMIA) that described a proposal for a general clinical informatics fellowship program.
Methods:
A group of program faculty members and fellows compared each of the proposed requirements in the white paper with the fellowship program's written charter and operations. The majority of white paper proposals aligned closely with the rules and activities in our program and comparison was straightforward. In some proposals, however, differences in terminology, approach, and philosophy made comparison less direct, and in those cases, the thinking of the group was recorded. After the initial evaluation, the remainder of the faculty reviewed the results and any disagreements were resolved.
Results:
The most important finding of the study was how closely the white paper proposals for a general clinical informatics fellowship program aligned with the reality of our existing pathology informatics fellowship. The program charter and operations of the program were judged to be concordant with the great majority of specific white paper proposals. However, there were some areas of discrepancy and the reasons for the discrepancies are discussed in the manuscript.
Conclusions:
After the comparison, we conclude that the existing pathology informatics fellowship could easily meet all substantive proposals put forth in the 2009 clinical informatics program requirements white paper. There was also agreement on a number of philosophical issues, such as the advantages of multiple fellows, the need for core knowledge and skill sets, and the need to maintain clinical skills during informatics training. However, there were other issues, such as a requirement for a 2-year fellowship and for informatics fellowships to be done after primary board certification, that pathology should consider carefully as it moves toward a subspecialty status and board certification.
doi:10.4103/2153-3539.93893
PMCID: PMC3327041  PMID: 22530179
Pathology informatics fellowship; clinical informatics; clinical informatics fellowship; pathology informatics; pathology informatics teaching; clinical informatics teaching
7.  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
8.  Certification by the American Board of Surgery among U.S. Medical Graduates 
Background
We sought to identify variables associated with American Board of Medical Specialties (ABMS)-member-board certification and lack thereof among U.S. medical graduates who planned at medical-school graduation to become certified in surgery and entered graduate medical education (GME) in general surgery.
Study Design
De-identified, individualized records updated through March 2009 for all 1993–2000 U.S. medical school matriculants who graduated by 2002, intended to become certified in surgery, and entered general surgery training were analyzed using multivariable logistic regression to identify variables associated with graduates’ board certification status, including American Board of Surgery (ABS)-board certified (BC), other ABMS-member-BC (other-BC) and non-BC.
Results
Of 3373 graduates included in the study sample, 2036 (60.4 %) were ABS-BC, 342 (10.1 %) were other-BC, and 995 (29.5 %) were non-BC. Graduates who were women, > 26 years old at graduation, and initially failed United States Medical Licensing Examination (USMLE) Step 2 Clinical Knowledge (2CK) were more likely, and graduates who rated the quality of their surgery clerkship in medical school more highly were less likely, to be other-BC vs. ABS-BC. Graduates who were women, underrepresented minority race/ethnicity, Asian/Pacific Islander race/ethnicity, > 28 years old at graduation, initially failed USMLE Step 1, initially failed or received low passing scores on USMLE Step 2CK and graduated in more recent years were more likely to be non-BC vs. ABS-BC.
Conclusions
Demographic and professional development variables were associated with ABMS-member-board certification status among U.S. medical graduates who had intended at medical-school graduation to become certified in surgery.
doi:10.1016/j.jamcollsurg.2012.01.049
PMCID: PMC3334469  PMID: 22464660
9.  Association between performance on Neurology In-Training and Certification Examinations 
Neurology  2013;80(2):206-209.
Objective:
This study analyzed the relationship between performance on the American Academy of Neurology Residency In-Service Training Examination (RITE) and subsequent performance on the American Board of Psychiatry and Neurology (ABPN) Certification Examination.
Methods:
Pearson correlation coefficients were used to examine the relationship between performance on the RITE and the Certification Examination for 2 cohorts of adult neurologists and 2 cohorts of child neurologists. The 2 cohorts represented test takers for 2008 and 2009.
Results:
For adult neurologists, the correlation between the total RITE and the Certification Examination scores was 0.77 (p < 0.01) in 2008 and 0.65 (p < 0.01) in 2009. For child neurologists, it was 0.74 (p < 0.01) in 2008 and 0.56 (p < 0.01) in 2009.
Discussion:
For 2 consecutive years, there was a significant correlation between performance on the RITE and performance on the ABPN Certification Examination for both adult and child neurologists. The RITE is a self-assessment examination, and performance on the test is a positive predictor of future performance on the ABPN Certification Examination.
doi:10.1212/WNL.0b013e31827b92a3
PMCID: PMC3589193  PMID: 23296130
10.  Factors Associated with American Board of Medical Specialties Member Board Certification among US Medical School Graduates 
Context
Certification by an American Board of Medical Specialties (ABMS) member board is emerging as a measure of physician quality.
Objective
To identify demographic and educational factors associated with ABMS-member-board certification of US medical graduates.
Design, Setting, Participants
Retrospective study of a national cohort of 1997–2000 US medical graduates, grouped by specialty choice at graduation and followed up through March 2, 2009. In separate multivariable logistic regression models for each specialty category, factors associated with ABMS-member-board certification were identified.
Main Outcome Measure
ABMS-member-board certification
Results
Of 42 440 graduates in the study sample, 37 054 (87.3%) were board certified. Graduates in all specialty categories with first-attempt passing scores in the highest tertile (vs first-attempt failing scores) on US Medical Licensing Examination Step 2 Clinical Knowledge were more likely to be board certified; adjusted odds ratios (aOR) varied by specialty category with the lowest odds for emergency medicine (87.4% vs 73.6%; aOR, 1.82; 95% confidence interval [CI], 1.03–3.20) and highest odds for radiology (98.1% vs 74.9%; aOR, 13.19; 95% CI, 5.55–31.32). In each specialty category except family medicine, graduates self-identified as underrepresented racial/ethnic minorities (vs white) were less likely to be board certified, ranging from 83.5% vs 95.6% in the pediatrics category (aOR, 0.44; 95% CI, 0.33–0.58) to 71.5% vs 83.7% in the other non-generalist specialties category (aOR, 0.79; 95% CI, 0.64–0.96). With each $50 000 unit increase in debt (vs no debt), graduates choosing obstetrics/gynecology were less likely to be board certified (aOR, 0.89; 95% CI, 0.83–0.96), and graduates choosing family medicine were more likely to be board certified (aOR 1.13; 95% CI, 1.01–1.26).
Conclusion
Demographic and educational factors were associated with board certification among US medical graduates in every specialty category examined; findings varied among specialty categories.
doi:10.1001/jama.2011.1099
PMCID: PMC3217584  PMID: 21900136
11.  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
12.  Accreditation council for graduate medical education (ACGME) annual anesthesiology residency and fellowship program review: a "report card" model for continuous improvement 
BMC Medical Education  2010;10:13.
Background
The Accreditation Council for Graduate Medical Education (ACGME) requires an annual evaluation of all ACGME-accredited residency and fellowship programs to assess program quality. The results of this evaluation must be used to improve the program. This manuscript describes a metric to be used in conducting ACGME-mandated annual program review of ACGME-accredited anesthesiology residencies and fellowships.
Methods
A variety of metrics to assess anesthesiology residency and fellowship programs are identified by the authors through literature review and considered for use in constructing a program "report card."
Results
Metrics used to assess program quality include success in achieving American Board of Anesthesiology (ABA) certification, performance on the annual ABA/American Society of Anesthesiology In-Training Examination, performance on mock oral ABA certification examinations, trainee scholarly activities (publications and presentations), accreditation site visit and internal review results, ACGME and alumni survey results, National Resident Matching Program (NRMP) results, exit interview feedback, diversity data and extensive program/rotation/faculty/curriculum evaluations by trainees and faculty. The results are used to construct a "report card" that provides a high-level review of program performance and can be used in a continuous quality improvement process.
Conclusions
An annual program review is required to assess all ACGME-accredited residency and fellowship programs to monitor and improve program quality. We describe an annual review process based on metrics that can be used to focus attention on areas for improvement and track program performance year-to-year. A "report card" format is described as a high-level tool to track educational outcomes.
doi:10.1186/1472-6920-10-13
PMCID: PMC2830223  PMID: 20141641
13.  Associations between subspecialty fellowship interest and knowledge of internal medicine: A hypothesis-generating study of internal medicine residents 
Background
Little is known about whether and how medical knowledge relates to interest in subspecialty fellowship training. The purpose of this study was to examine the relationships between residents' interest in subspecialty fellowship training and their knowledge of internal medicine (IM).
Methods
A questionnaire was emailed to 48 categorical postgraduate-year (PGY) two and three residents at a New York university-affiliated IM residency program in 2007 using the Survey Monkey online survey instrument. Overall and content area-specific percentile scores from the IM in-training examination (IM-ITE) for the same year was used to determine objective knowledge.
Results
Forty-five of 48 residents (response rate was 93.8%) completed the survey. Twenty-two (49%) were PG2 residents and 23(51%) were PGY3 residents. Sixty percent of respondents were male. Six (13%) residents were graduates of U.S. medical schools. Eight (18%) reported formal clinical training prior to starting internal medicine residency in the U.S. Of this latter group, 6 (75%) had training in IM and 6 (75) % reported a training length of 3 years or less. Thirty-seven of 45 (82%) residents had a subspecialty fellowship interest. Residents with a fellowship interest had a greater mean overall objective knowledge percentile score (56.44 vs. 31.67; p = 0.04) as well as greater mean percentile scores in all content areas of IM. The adjusted mean difference was statistically significant (p < 0.02) across three content areas.
Conclusions
More than half of surveyed residents indicated interest in pursuing a subspecialty fellowship. Fellowship interest appears positively associated with general medical knowledge in this study population. Further work is needed to explore motivation and study patterns among internal medicine residents.
doi:10.1186/1472-6920-11-5
PMCID: PMC3038163  PMID: 21281500
14.  Clinical Informatics Board Certification: History, Current Status, and Predicted Impact on the Clinical Informatics Workforce 
Applied Clinical Informatics  2010;1(1):11-18.
Within health and health care, medical informatics and its subspecialties of biomedical, clinical, and public health informatics have emerged as a new discipline with increasing demands for its own work force. Knowledge and skills in medical informatics are widely acknowledged as crucial to future success in patient care, research relating to biomedicine, clinical care, and public health, as well as health policy design. The maturity of the domain and the demand on expertise necessitate standardized training and certification of professionals. The American Medical Informatics Association (AMIA) embarked on a major effort to create professional level education and certification for physicians of various professions and specialties in informatics. This article focuses on the AMIA effort in the professional structure of medical specialization, e.g., the American Board of Medical Specialties (ABMS) and the related Accreditation Council for Graduate Medical Education (ACGME). This report summarizes the current progress to create a recognized sub-certificate of competence in Clinical Informatics and discusses likely near term (three to five year) implications on training, certification, and work force with an emphasis on clinical applied informatics.
doi:10.4338/ACI-2009-11-R-0016
PMCID: PMC3631890  PMID: 23616825
Education; Professional training; Clinical informatics; Training and education requirements; General healthcare providers; Informatics specialists; Strategies for health IT training; Continuing professional development and continuing education
15.  Tracking Residents Through Multiple Residency Programs: A Different Approach for Measuring Residents' Rates of Continuing Graduate Medical Education in ACGME-Accredited Programs 
Background
Increased focus on the number and type of physicians delivering health care in the United States necessitates a better understanding of changes in graduate medical education (GME). Data collected by the Accreditation Council for Graduate Medical Education (ACGME) allow longitudinal tracking of residents, revealing the number and type of residents who continue GME following completion of an initial residency. We examined trends in the percent of graduates pursuing additional clinical education following graduation from ACGME-accredited pipeline specialty programs (specialties leading to initial board certification).
Methods
Using data collected annually by the ACGME, we tracked residents graduating from ACGME-accredited pipeline specialty programs between academic year (AY) 2002–2003 and AY 2006–2007 and those pursuing additional ACGME-accredited training within 2 years. We examined changes in the number of graduates and the percent of graduates continuing GME by specialty, by type of medical school, and overall.
Results
The number of pipeline specialty graduates increased by 1171 (5.3%) between AY 2002–2003 and AY 2006–2007. During the same period, the number of graduates pursuing additional GME increased by 1059 (16.7%). The overall rate of continuing GME increased each year, from 28.5% (6331/22229) in AY 2002–2003 to 31.6% (7390/23400) in AY 2006–2007. Rates differed by specialty and for US medical school graduates (26.4% [3896/14752] in AY 2002–2003 to 31.6% [4718/14941] in AY 2006–2007) versus international medical graduates (35.2% [2118/6023] to 33.8% [2246/6647]).
Conclusion
The number of graduates and the rate of continuing GME increased from AY 2002–2003 to AY 2006–2007. Our findings show a recent increase in the rate of continued training for US medical school graduates compared to international medical graduates. Our results differ from previously reported rates of subspecialization in the literature. Tracking individual residents through residency and fellowship programs provides a better understanding of residents' pathways to practice.
doi:10.4300/JGME-D-10-00105.1
PMCID: PMC3010950  PMID: 22132288
16.  National study of continuity clinic satisfaction in pediatric fellowship training 
Background
A national online survey was conducted to evaluate pediatric subspecialty fellow satisfaction regarding continuity clinic experience.
Methods
An anonymous online survey (SurveyMonkey™) was developed to evaluate demographics of the program, clinic organization, and patient and preceptor characteristics, and to compare fellow satisfaction when fellows were the primary providers with faculty supervision versus attending-run clinics assisted by fellows or a combination of the two models. Pediatric subspecialty fellows in a 3-year Accreditation Council for Graduate Medical Education accredited program in the United States (excluding emergency medicine, neonatology, and critical care) were invited to participate.
Results
There were 644 respondents and nearly half (54%) of these had fellow-run clinics. Eighty-six percent of fellows responded that they would prefer to have their own continuity clinics. Higher satisfaction ratings on maintaining continuity of care, being perceived as the primary provider, and feeling that they had greater autonomy in patient management were associated with being part of a fellow-run clinic experience (all P < 0.001). Additionally, fellow-run clinics were associated with a feeling of increased involvement in designing a treatment plan based on their differential diagnosis (P < 0.001). There were no significant associations with patient or preceptor characteristics.
Conclusion
Fellow-run continuity clinics provide fellows with a greater sense of satisfaction and independence in management plans.
doi:10.2147/AMEP.S51069
PMCID: PMC3791542  PMID: 24101886
resident education/training; workforce; pediatric; patient-provider relationship; pediatric outpatient clinic
17.  Program Requirements for Fellowship Education in the Subspecialty of Clinical Informatics 
The Program Requirements for Fellowship Education identify the knowledge and skills that physicians must master through the course of a training program to be certified in the subspecialty of clinical informatics. They also specify accreditation requirements for clinical informatics training programs. The AMIA Board of Directors approved this document in November 2008.
doi:10.1197/jamia.M3046
PMCID: PMC2649323  PMID: 19074295
18.  Building Faculty Community: Fellowship in Graduate Medical Education Administration 
Introduction
The Department of Graduate Medical Education at Stanford Hospital and Clinics has developed a professional training program for program directors. This paper outlines the goals, structure, and expected outcomes for the one-year Fellowship in Graduate Medical Education Administration program.
Background
The skills necessary for leading a successful Accreditation Council for Graduate Medical Education (ACGME) training program require an increased level of curricular and administrative expertise. To meet the ACGME Outcome Project goals, program directors must demonstrate not only sophisticated understanding of curricular design but also competency-based performance assessment, resource management, and employment law. Few faculty-development efforts adequately address the complexities of educational administration. As part of an institutional-needs assessment, 41% of Stanford program directors indicated that they wanted more training from the Department of Graduate Medical Education.
Intervention
To address this need, the Fellowship in Graduate Medical Education Administration program will provide a curriculum that includes (1) readings and discussions in 9 topic areas, (2) regular mentoring by the director of Graduate Medical Education (GME), (3) completion of a service project that helps improve GME across the institution, and (4) completion of an individual scholarly project that focuses on education.
Results
The first fellow was accepted during the 2008–2009 academic year. Outcomes for the project include presentation of a project at a national meeting, internal workshops geared towards disseminating learning to peer program directors, and the completion of a GME service project. The paper also discusses lessons learned for improving the program.
doi:10.4300/01.01.0024
PMCID: PMC2931184  PMID: 21975722
19.  Use of a Standardized Patient Exercise to Assess Core Competencies During Fellowship Training 
Background
The Accreditation Council for Graduate Medical Education requires fellows in many specialties to demonstrate attainment of 6 core competencies, yet relatively few validated assessment tools currently exist. We present our initial experience with the design and implementation of a standardized patient (SP) exercise during gastroenterology fellowship that facilitates appraisal of all core clinical competencies.
Methods
Fellows evaluated an SP trained to portray an individual referred for evaluation of abnormal liver tests. The encounters were independently graded by the SP and a faculty preceptor for patient care, professionalism, and interpersonal and communication skills using quantitative checklist tools. Trainees' consultation notes were scored using predefined key elements (medical knowledge) and subjected to a coding audit (systems-based practice). Practice-based learning and improvement was addressed via verbal feedback from the SP and self-assessment of the videotaped encounter.
Results
Six trainees completed the exercise. Second-year fellows received significantly higher scores in medical knowledge (55.0 ± 4.2 [standard deviation], P  =  .05) and patient care skills (19.5 ± 0.7, P  =  .04) by a faculty evaluator as compared with first-year trainees (46.2 ± 2.3 and 14.7 ± 1.5, respectively). Scores correlated by Spearman rank (0.82, P  =  .03) with the results of the Gastroenterology Training Examination. Ratings of the fellows by the SP did not differ by level of training, nor did they correlate with faculty scores. Fellows viewed the exercise favorably, with most indicating they would alter their practice based on the experience.
Conclusions
An SP exercise is an efficient and effective tool for assessing core clinical competencies during fellowship training.
doi:10.4300/JGME-D-09-00001.1
PMCID: PMC2931209  PMID: 21975896
20.  Establishing a clinical pharmacology fellowship program for physicians, pharmacists, and pharmacologists: a newly accredited interdisciplinary training program at the Ohio State University 
Studying the effect of drugs on humans, clinical pharmacologists play an essential role in many academic medical and research teams, within the pharmaceutical industry and as members of government regulatory entities. Clinical pharmacology fellowship training programs should be multidisciplinary and adaptable, and should combine didactics, applied learning, independent study, and one-on-one instruction. This article describes a recently developed 2 year clinical pharmacology fellowship program – one of only nine accredited by the American Board of Clinical Pharmacology – that is an integrative, multi faceted, adaptable method for training physicians, pharmacists, and scientists for leadership roles in the pharmaceutical industry, in academia, or with regulatory or accreditation agencies. The purpose of this article is to provide information for academic clinicians and researchers interested in designing a similar program, for professionals in the field of clinical pharmacology who are already affiliated with a fellowship program and may benefit from supplemental information, and for clinical researchers interested in clinical pharmacology who may not be aware that such training opportunities exist. This article provides the details of a recently accredited program, including design, implementation, accreditation, trainee success, and future directions.
doi:10.2147/AMEP.S60986
PMCID: PMC4075108  PMID: 25018660
clinical pharmacology education; clinical pharmacology fellowship
21.  Cultural Competency Training Requirements in Graduate Medical Education 
Background
Cultural competency is an important skill that prepares physicians to care for patients from diverse backgrounds.
Objective
We reviewed Accreditation Council for Graduate Medical Education (ACGME) program requirements and relevant documents from the ACGME website to evaluate competency requirements across specialties.
Methods
The program requirements for each specialty and its subspecialties were reviewed from December 2011 through February 2012. The review focused on the 3 competency domains relevant to culturally competent care: professionalism, interpersonal and communication skills, and patient care. Specialty and subspecialty requirements were assigned a score between 0 and 3 (from least specific to most specific). Given the lack of a standardized cultural competence rating system, the scoring was based on explicit mention of specific keywords.
Results
A majority of program requirements fell into the low- or no-specificity score (1 or 0). This included 21 core specialties (leading to primary board certification) program requirements (78%) and 101 subspecialty program requirements (79%). For all specialties, cultural competency elements did not gravitate toward any particular competency domain. Four of 5 primary care program requirements (pediatrics, obstetrics-gynecology, family medicine, and psychiatry) acquired the high-specificity score of 3, in comparison to only 1 of 22 specialty care program requirements (physical medicine and rehabilitation).
Conclusions
The degree of specificity, as judged by use of keywords in 3 competency domains, in ACGME requirements regarding cultural competency is highly variable across specialties and subspecialties. Greater specificity in requirements is expected to benefit the acquisition of cultural competency in residents, but this has not been empirically tested.
doi:10.4300/JGME-D-12-00085.1
PMCID: PMC3693685  PMID: 24404264
22.  Associations between quality indicators of internal medicine residency training programs 
BMC Medical Education  2011;11:30.
Background
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.
Methods
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.
Results
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.
Conclusions
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.
doi:10.1186/1472-6920-11-30
PMCID: PMC3126786  PMID: 21651768
program quality; Residency Review Committee; American Board of Internal Medicine Certifying Examination
23.  Wound Care Specialization: The Current Status and Future Plans to Move Wound Care into the Medical Community 
Advances in Wound Care  2012;1(5):184-188.
Background
There has been an explosion of basic science results in the field of wound care over the past 20 years. Initially, wound dressings were the only therapeutic option available to the wound practitioner. With advanced basic science knowledge, technical innovation, and the recent participation of pharmaceutical companies, the wound clinician now has an arsenal of dressings, biological tissue replacements, gene therapy, and cell-based treatment options. What has not, however, kept pace with these changes is the education and practical training for those treating nonhealing wounds. The pace of innovation in wound diagnostic tools has also lagged, creating even more pressure on the clinician to use experience, skill, and training to properly diagnose the root cause for the nonhealing wound. As wound healing is not considered a medical specialty, there is no formal training process for physicians, and subsequently, allied health practitioners are often the only ones available to provide care for these complex patients. Wound care training, however, is also not part of any formal curriculum for these healthcare providers as well, creating confusion for patients, payors, regulators, researchers, and product manufacturers.
The Problem
In all other fields of medicine there is a formal process in place for physicians to train, certify, and credential. Medicine is constantly evolving and there have been several new fields of specialty care created over the past two decades that can serve as examples for the wound care field to follow. Without academic-based, clinical residency/fellowship training in wound healing ultimately leading to formal certification, the field will be unable to achieve an appropriate status in the medical establishment. Achieving this goal will impact product innovation, payment, and the sustainability of the field.
Basic/Clinical Science Advances
The enhanced understanding of normal and dysregulated wound healing processes, which have been uncovered by basic scientists, has translated to the bedside through the creation of multiple advanced biological solutions for patients with nonhealing wounds.
Clinical Care Relevance
These advanced wound care therapeutics will require physician involvement in a way not previously seen in wound care. It will no longer be possible to practice wound care “part time” in the near future. The amount of new information and massive base of core knowledge required will mandate a full-time commitment. The increase in patients with this condition because of an aging population, increased numbers of diabetic patients, and the ever growing epidemic of obesity will mandate that all clinicians providing wound care will need to increase their skill sets through formal training. In addition, underserved patient populations are disproportionately affected and their outcomes are comparatively worse, further complicating the problem at a healthcare structural and policy level.
Conclusion
The American College of Wound Healing and Tissue Repair was founded in Illinois as a nonprofit organization whose express function is to organize university-based medical school programs around a common curriculum for physicians who want to specialize in wound healing. Currently, two wound care fellows have graduated from the University of Illinois at Chicago and other programs are under development. The ultimate process will be achieved when certification is accredited by an organization such as the American Board of Medical Specialties. This article outlines the current process in place to achieve this goal within 10 years.
doi:10.1089/wound.2011.0346
PMCID: PMC3839023  PMID: 24527303
24.  Is Fellowship Training Necessary for Neurohospitalists? 
The Neurohospitalist  2011;1(3):125-127.
Neurohospitalists are an emerging subspecialty group in neurology.1 A recent survey of neurohospitalists found 75% of respondents had completed general neurology residency plus additional fellowship training (54% vascular neurology, 13% neurocritical care, and 33% other).2 A limited number of neurohospitalist fellowship positions3,4 are offered in the United States, however, a standardized curriculum or subspecialty certification examination does not currently exist. Given the recent dialogue surrounding the utility of neurohospitalist fellowship training, the purpose of this article is to provide 2 contrasting perspectives on the perceived need for neurohospitalist fellowship training.
doi:10.1177/1941875211408328
PMCID: PMC3726127  PMID: 23983845
neurhospitalist; fellowship; education
25.  COMPETENCY REVALIDATION STUDY OF SPECIALTY PRACTICE IN SPORTS PHYSICAL THERAPY 
Background and Purpose:
Every ten years the American Board of Physical Therapy Specialties conducts a practice analysis to revalidate and revise the description of specialty practice for sports physical therapy (SPT). The primary purpose of this paper is to describe the process and results of the most recent analysis, which defines the competencies that distinguish the subspecialty practice of (SPT). Additionally, the study allowed for the comparison of responses of board certified specialists in SPT to respondents who were not specialists while reflecting on demographic changes and evolving trends since the previous analysis of this physical therapy specialty practice was conducted 10 years ago.
Methods
A survey instrument based on guidelines from the American Board of Physical Therapy Specialties was developed by the Sports Specialty Council (SSC) and a panel of subject matter experts (SME) in SPT to re‐evaluate contemporary practice. The instrument was pilot tested and following revisions, was sent to 1780 physical therapists, 930 of whom were board certified specialists in SPT and 850 of whom were randomly selected members of the Sports Physical Therapy Section (SPTS) who were not board certified specialists in SPT. 414 subjects returned completed surveys for a 23% response rate. 235 of the respondents were known to be board certified sports specialists, 120 did not indicate their specialty status, and 35 were non‐specialists in SPT. All were members of the SPTS of the American Physical Therapy Association. The survey responses were analyzed using descriptive statistics. Univariate comparisons were performed using parametric and nonparametric statistical tests in order to evaluate differences between specialist and non‐specialist item responses.
Results
The survey results were reviewed by the SSC and a panel of SME. Using a defined decision making process, the results were used to determine the competencies that define the specialty practice of SPT. Survey results were also used to develop the SPT specialty board examination blueprint and define the didactic curriculum required of accredited SPT residency programs. A number of significant comparisons between the specialists and non‐specialists were identified.
Conclusion
The competency revalidation process culminated in the publication of the 4th edition of the Sports Physical Therapy Description of Specialty Practice in November of 2013. This document serves to guide the process related to the attainment and maintenance of the board certified clinical specialization in SPT. In anticipation of the continued evolution of this specialty practice, this process will be repeated every 10 years to reassess the characteristics of these providers and the factors they consider critically important and unique to the practice of SPT.
PMCID: PMC4275200  PMID: 25540711
Continued Competence; Practice Validation; Sports Certified Specialist; Sports Physical Therapy Clinical Specialization

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