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1.  Charting the Road to Competence: Developmental Milestones for Internal Medicine Residency Training 
Background
The Accreditation Council for Graduate Medical Education (ACGME) Outcome Project requires that residency program directors objectively document that their residents achieve competence in 6 general dimensions of practice.
Intervention
In November 2007, the American Board of Internal Medicine (ABIM) and the ACGME initiated the development of milestones for internal medicine residency training. ABIM and ACGME convened a 33-member milestones task force made up of program directors, experts in evaluation and quality, and representatives of internal medicine stakeholder organizations. This article reports on the development process and the resulting list of proposed milestones for each ACGME competency.
Outcomes
The task force adopted the Dreyfus model of skill acquisition as a framework the internal medicine milestones, and calibrated the milestones with the expectation that residents achieve, at a minimum, the “competency” level in the 5-step progression by the completion of residency. The task force also developed general recommendations for strategies to evaluate the milestones.
Discussion
The milestones resulting from this effort will promote competency-based resident education in internal medicine, and will allow program directors to track the progress of residents and inform decisions regarding promotion and readiness for independent practice. In addition, the milestones may guide curriculum development, suggest specific assessment strategies, provide benchmarks for resident self-directed assessment-seeking, and assist remediation by facilitating identification of specific deficits. Finally, by making explicit the profession's expectations for graduates and providing a degree of national standardization in evaluation, the milestones may improve public accountability for residency training.
doi:10.4300/01.01.0003
PMCID: PMC2931179  PMID: 21975701
2.  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
3.  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
4.  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
5.  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
6.  Teaching Internal Medicine Residents Quality Improvement Techniques using the ABIM’s Practice Improvement Modules 
Summary
Introduction/aim
Standard curricula to teach Internal Medicine residents about quality assessment and improvement, important components of the Accreditation Council for Graduate Medical Education core competencies practiced-based learning and improvement (PBLI) and systems-based practice (SBP), have not been easily accessible.
Program description
Using the American Board of Internal Medicine’s (ABIM) Clinical Preventative Services Practice Improvement Module (CPS PIM), we have incorporated a longitudinal quality assessment and improvement curriculum (QAIC) into the 2 required 1-month ambulatory rotations during the postgraduate year 2. During the first block, residents complete the PIM chart reviews, patient, and system surveys. The second block includes resident reflection using PIM data and the group performing a small test of change using the Plan–Do–Study–Act (PDSA) cycle in the resident continuity clinic.
Program Evaluation
To date, 3 resident quality improvement (QI) projects have been undertaken as a result of QAIC, each making significant improvements in the residents’ continuity clinic. Resident confidence levels in QI skills (e.g., writing an aim statement [71% to 96%, P < .01] and using a PDSA cycle [9% to 89%, P < .001]) improved significantly.
Discussion
The ABIM CPS PIM can be used by Internal Medicine residency programs to introduce QI concepts into their residents’ outpatient practice through encouraging practice-based learning and improvement and systems-based practice.
doi:10.1007/s11606-008-0549-5
PMCID: PMC2517947  PMID: 18449612
Internal Medicine residents; quality improvement; practiced-based learning and improvement; systems-based practice; practice improvement module
7.  Predicting Pass Rates on the American Board of Internal Medicine Certifying Examination 
Our objective was to determine the ability of the internal medicine In-Training Examination (ITE) to predict pass or fail outcomes on the American Board of Internal Medicine (ABIM) certifying examination and to develop an externally validated predictive model and a simple equation that can be used by residency directors to provide probability feedback for their residency programs. We collected a study sample of 155 internal medicine residents from the three Virginia internal medicine programs and a validation sample of 64 internal medicine residents from a residency program outside Virginia. Scores from both samples were collected across three class cohorts. The Kolmogorov-Smirnov z test indicated no statistically significant difference between the distribution of scores for the two samples (z = 1.284, p = .074). Results of the logistic model yielded a statistically significant prediction of ABIM pass or fail performance from ITE scores (Wald = 35.49, SE = 0.036, df = 1, p < .005) and overall correct classifications for the study sample and validation sample at 79% and 75%, respectively. The ITE is a useful tool in assessing the likelihood of a resident's passing or failing the ABIM certifying examination but is less predictive for residents who received ITE scores between 49 and 66.
doi:10.1046/j.1525-1497.1998.00122.x
PMCID: PMC1496976  PMID: 9669571
certifying examination; in-training examination; education; predictions; residents
8.  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
9.  Trends in American Board of Psychiatry and Neurology specialties and neurologic subspecialties 
Neurology  2010;75(12):1110-1117.
Objective: To review the current status and recent trends in the American Board of Psychiatry and Neurology (ABPN) specialties and neurologic subspecialties and discuss the implications of those trends for subspecialty viability.
Methods: Data on numbers of residency and fellowship programs and graduates and ABPN certification candidates and diplomates were drawn from several sources, including ABPN records, Web sites of the Accreditation Council for Graduate Medical Education and the American Medical Association, and the annual medical education issues of the Journal of the American Medical Association.
Results: About four-fifths of neurology graduates pursue fellowship training. While most recent neurology and child neurology graduates attempt to become certified by the ABPN, many clinical neurophysiologists elect not to do so. There appears to have been little interest in establishing fellowships in neurodevelopmental disabilities. The pass rate for fellowship graduates is equivalent to that for the “grandfathers” in clinical neurophysiology. Lower percentages of clinical neurophysiologists than specialists participate in maintenance of certification, and maintenance of certification pass rates are high.
Conclusion: The initial enthusiastic interest in training and certification in some of the ABPN neurologic subspecialties appears to have slowed, and the long-term viability of those subspecialties will depend upon the answers to a number of complicated social, economic, and political questions in the new health care era.
doi:10.1212/WNL.0b013e3181f39a41
PMCID: PMC3463033  PMID: 20855855
ABMS = American Board of Medical Specialties; ABPN = American Board of Psychiatry and Neurology; ACGME = Accreditation Council for Graduate Medical Education; MOC = maintenance of certification; RRC-N = Residency Review Committee in Neurology.
10.  Ambulatory Morning Report 
We assessed the ability of a novel ambulatory morning report format to expose internal medicine residents to the breadth of topics covered by the American Board of Internal Medicine (ABIM) exam. Cases were selected by the Ambulatory Assistant Chief Residents and recorded in a logbook to limit duplication. We conducted a retrospective review of 406 cases discussed from July 1998 to July 2000 and cataloged each according to the primary content area. The percentage of cases in each area accurately reflected that covered by the ABIM exam, with little redundancy or over-selection of esoteric diseases. Our data suggest that a general medicine clinic is capable of exposing house staff to the wide breadth of internal medicine topics previously thought to be unique to subspecialty clinics.
doi:10.1046/j.1525-1497.2002.10202.x
PMCID: PMC1495020  PMID: 11929507
postgraduate education; ambulatory care; internal medicine residency; morning report
11.  Patients’ assessment of professionalism and communication skills of medical graduates 
BMC Medical Education  2014;14:28.
Background
Professionalism and communication skills constitute important components of the integral formation of physicians which has repercussion on the quality of health care and medical education. The objective of this study was to assess medical graduates’ professionalism and communication skills from the patients’ perspective and to examine its association with patients’ socio-demographic variables.
Methods
This is a hospital based cross-sectional study. It involved 315 patients and 105 medical graduates selected by convenient sampling method. A modified and validated version of the American Board of Internal Medicine’s (ABIM) Patient Assessment survey questionnaire was used for data collection through a face to face interview. Data processing and analysis were performed using the Statistical Package for Social Science (SPSS) 16.0. Mean, frequency distribution, and percentage of the variables were calculated. A non-parametric Kruskal Wallis test was applied to verify whether the patients’ assessment was influenced by variables such as age, gender, education, at a level of significance, p ≤ 0.05.
Results
Female patients constituted 46% of the sample, whereas males constituted 54%. The mean age was 36 ± 16. Patients’ scoring of the graduate’s skills ranged from 3.29 to 3.83 with a mean of 3.64 on a five-point Likert scale. Items assessing the “patient involvement in decision-making” were assigned the minimum mean values, while items dealing with “establishing adequate communication with patient” assigned the maximum mean values. Patients, who were older than 45 years, gave higher scores than younger ones (p < 0.001). Patients with higher education reported much lower scores than those with lower education (p = 0.003). Patients’ gender did not show any statistically significant influence on the rating level.
Conclusion
Generally patients rated the medical graduates’ professionalism and communication skills at a good level. Patients’ age and educational level were significantly associated with the rating level.
doi:10.1186/1472-6920-14-28
PMCID: PMC3923249  PMID: 24517316
12.  Description of a Developmental Criterion-Referenced Assessment for Promoting Competence in Internal Medicine Residents 
Rationale
End-of- rotation global evaluations can be subjective, produce inflated grades, lack interrater reliability, and offer information that lacks value. This article outlines the generation of a unique developmental criterion-referenced assessment that applies adult learning theory and the learner, manager, teacher model, and represents an innovative application to the American Board of Internal Medicine (ABIM) 9-point scale.
Intervention
We describe the process used by Southern Illinois University School of Medicine to develop rotation-specific, criterion-based evaluation anchors that evolved into an effective faculty development exercise.
Results
The intervention gave faculty a clearer understanding of the 6 Accreditation Council for Graduate Medical Education competencies, each rotation's educational goals, and how rotation design affects meaningful work-based assessment. We also describe easily attainable successes in evaluation design and pitfalls that other institutions may be able to avoid. Shifting the evaluation emphasis on the residents' development of competence has made the expectations of rotation faculty more transparent, has facilitated conversations between program director and residents, and has improved the specificity of the tool for feedback. Our findings showed the new approach reduced grade inflation compared with the ABIM end-of-rotation global evaluation form.
Discussion
We offer the new developmental criterion-referenced assessment as a unique application of the competences to the ABIM 9-point scale as a transferable model for improving the validity and reliability of resident evaluations across graduate medical education programs.
doi:10.4300/01.01.0012
PMCID: PMC2931180  PMID: 21975710
13.  Medicine in the 21st Century: Recommended Essential Geriatrics Competencies for Internal Medicine and Family Medicine Residents 
Background
Physician workforce projections by the Institute of Medicine require enhanced training in geriatrics for all primary care and subspecialty physicians. Defining essential geriatrics competencies for internal medicine and family medicine residents would improve training for primary care and subspecialty physicians. The objectives of this study were to (1) define essential geriatrics competencies common to internal medicine and family medicine residents that build on established national geriatrics competencies for medical students, are feasible within current residency programs, are assessable, and address the Accreditation Council for Graduate Medical Education competencies; and (2) involve key stakeholder organizations in their development and implementation.
Methods
Initial candidate competencies were defined through small group meetings and a survey of more than 100 experts, followed by detailed item review by 26 program directors and residency clinical educators from key professional organizations. Throughout, an 8-member working group made revisions to maintain consistency and compatibility among the competencies. Support and participation by key stakeholder organizations were secured throughout the project.
Results
The process identified 26 competencies in 7 domains: Medication Management; Cognitive, Affective, and Behavioral Health; Complex or Chronic Illness(es) in Older Adults; Palliative and End-of-Life Care; Hospital Patient Safety; Transitions of Care; and Ambulatory Care. The competencies map directly onto the medical student geriatric competencies and the 6 Accreditation Council for Graduate Medical Education Competencies.
Conclusions
Through a consensus-building process that included leadership and members of key stakeholder organizations, a concise set of essential geriatrics competencies for internal medicine and family medicine residencies has been developed. These competencies are well aligned with concerns for residency training raised in a recent Medicare Payment Advisory Commission report to Congress. Work is underway through stakeholder organizations to disseminate and assess the competencies among internal medicine and family medicine residency programs.
doi:10.4300/JGME-D-10-00065.1
PMCID: PMC2951777  PMID: 21976086
14.  The Impact of ACGME Work-Hour Reforms on the Operative Experience of Fellows in Surgical Subspecialty Programs 
Background
In July 2003, the Accreditation Council for Graduate Medical Education (ACGME) introduced a set of regulations that mandated a reduction in the number of hours that medical residents can work. These requirements have generated controversy among medical educators, with some expressing concern that reducing resident hours may limit clinical exposure and competency, particularly in surgical specialties.
Objective
This study examines the impact of duty hour restrictions on resident operative experience in residents in 2 surgical subspecialties since the implementation of the ACGME duty hour limits.
Method
We examined operative log data for vascular surgery and pediatric surgery, using the academic year immediately preceding the duty hour restrictions, 2002 to 2003, as a baseline for comparison to subsequent academic years through 2006 to 2007 for vascular surgery and 2007 to 2008 for pediatric surgery.
Results
Graduating fellows in pediatric surgery showed no change in their total operative volume following duty hour restrictions. The pediatric-defined category of neonate procedures showed an increase following duty hour restrictions. Graduating fellows in vascular surgery showed an increase in total major procedures as surgeon. The vascular-defined categories of endovascular-diagnostic, endovascular-therapeutic, and endovascular-graft procedures also increased.
Conclusions
The reduction of duty hours has not resulted in a decrease in operative volume as some have predicted. Operative volume in pediatric surgery remained mainly unchanged, whereas operative volume in vascular surgery increased. We explore possible explanations for the observed findings.
doi:10.4300/JGME-D-10-00174.1
PMCID: PMC3186271  PMID: 22379533
15.  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
16.  'Correction:'Peer chart audits: A tool to meet Accreditation Council on Graduate Medical Education (ACGME) competency in practice-based learning and improvement 
Background
The Accreditation Council on Graduate Medical Education (ACGME) supports chart audit as a method to track competency in Practice-Based Learning and Improvement. We examined whether peer chart audits performed by internal medicine residents were associated with improved documentation of foot care in patients with diabetes mellitus.
Methods
A retrospective electronic chart review was performed on 347 patients with diabetes mellitus cared for by internal medicine residents in a university-based continuity clinic from May 2003 to September 2004. Residents abstracted information pertaining to documentation of foot examinations (neurological, vascular, and skin) from the charts of patients followed by their physician peers. No formal feedback or education was provided.
Results
Significant improvement in the documentation of foot exams was observed over the course of the study. The percentage of patients receiving neurological, vascular, and skin exams increased by 20% (from 13% to 33%) (p = 0.001), 26% (from 45% to 71%) (p < 0.001), and 18% (51%–72%) (p = 0.005), respectively. Similarly, the proportion of patients receiving a well-documented exam which includes all three components – neurological, vascular and skin foot exam – increased over time (6% to 24%, p < 0.001).
Conclusion
Peer chart audits performed by residents in the absence of formal feedback were associated with improved documentation of the foot exam in patients with diabetes mellitus. Although this study suggests that peer chart audits may be an effective tool to improve practice-based learning and documentation of foot care in diabetic patients, evaluating the actual performance of clinical care was beyond the scope of this study and would be better addressed by a randomized controlled trial.
doi:10.1186/1748-5908-2-24
PMCID: PMC1959518  PMID: 17662124
17.  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
18.  A tool for self-assessment of communication skills and professionalism in residents 
Background
Effective communication skills and professionalism are critical for physicians in order to provide optimum care and achieve better health outcomes. The aims of this study were to evaluate residents' self-assessment of their communication skills and professionalism in dealing with patients, and to evaluate the psychometric properties of a self-assessment questionnaire.
Methods
A modified version of the American Board of Internal Medicine's (ABIM) Patient Assessment survey was completed by 130 residents in 23 surgical and non-surgical training programs affiliated with a single medical school. Descriptive, regression and factor analyses were performed. Internal consistency, inter-item gamma scores, and discriminative validity of the questionnaire were determined.
Results
Factor analysis suggested two groups of items: one group relating to developing interpersonal relationships with patients and one group relating to conveying medical information to patients. Cronbach's alpha (0.86) indicated internal consistency. Males rated themselves higher than females in items related to explaining things to patients. When compared to graduates of U.S. medical schools, graduates of medical schools outside the U.S. rated themselves higher in items related to listening to the patient, yet lower in using understandable language. Surgical residents rated themselves higher than non-surgical residents in explaining options to patients.
Conclusion
This appears to be an internally consistent and reliable tool for residents' self-assessment of communication skills and professionalism. Some demographic differences in self-perceived communication skills were noted.
doi:10.1186/1472-6920-9-1
PMCID: PMC2631014  PMID: 19133146
19.  Pediatric Residents' Learning Styles and Temperaments and Their Relationships to Standardized Test Scores 
Background
Board certification is an important professional qualification and a prerequisite for credentialing, and the Accreditation Council for Graduate Medical Education (ACGME) assesses board certification rates as a component of residency program effectiveness. To date, research has shown that preresidency measures, including National Board of Medical Examiners scores, Alpha Omega Alpha Honor Medical Society membership, or medical school grades poorly predict postresidency board examination scores. However, learning styles and temperament have been identified as factors that 5 affect test-taking performance. The purpose of this study is to characterize the learning styles and temperaments of pediatric residents and to evaluate their relationships to yearly in-service and postresidency board examination scores.
Methods
This cross-sectional study analyzed the learning styles and temperaments of current and past pediatric residents by administration of 3 validated tools: the Kolb Learning Style Inventory, the Keirsey Temperament Sorter, and the Felder-Silverman Learning Style test. These results were compared with known, normative, general and medical population data and evaluated for correlation to in-service examination and postresidency board examination scores.
Results
The predominant learning style for pediatric residents was converging 44% (33 of 75 residents) and the predominant temperament was guardian 61% (34 of 56 residents). The learning style and temperament distribution of the residents was significantly different from published population data (P  =  .002 and .04, respectively). Learning styles, with one exception, were found to be unrelated to standardized test scores.
Conclusions
The predominant learning style and temperament of pediatric residents is significantly different than that of the populations of general and medical trainees. However, learning styles and temperament do not predict outcomes on standardized in-service and board examinations in pediatric residents.
doi:10.4300/JGME-D-10-00147.1
PMCID: PMC3244328  PMID: 23205211
20.  Board review course effect on resident in-training examination 
Background
The in-training examination is a national and yearly exam administered by the American Board of Emergency Medicine to all emergency medicine residents in the USA. The purpose of the examination is to evaluate a resident’s progress toward obtaining the fundamental knowledge to practice independent emergency medicine.
Aims
The purpose of this study was to determine the effects of a 40 hour board review lecture course on the resident in-training examination in emergency medicine.
Methods
A 40 hour board review lecture course was designed and implemented during the weekly 5 hour long resident conferences during the 8 weeks preceding the in-training examination date in 2006. Attendance was mandatory at the Accreditation Council for Graduate Medical Education (ACGME) standard of 70% or greater. A positive result was considered to be a 10% increase or greater in the resident’s individual national class percentile ranking among their national peers for their class year for the emergency medicine in-training examination. A resident was excluded from the study if there was no 2005 in-training examination score for self-comparison. The 95% confidence intervals (CI) were used to analyze the results.
Results
Of 16 residents, 1 (6.25%; 95% CI: 0–18%) showed a positive result of increasing their national class percentile ranking by 10% or greater. For the PGY2, one of the eight had a positive result (12.5%; 95% CI: 0–35.4%). For PGY3, no resident (0%; 95% CI: 0–35.4%) had a positive result.
Conclusions
A 40 hour board review lecture course has no positive effect on improving a resident’s in-training examination score.
doi:10.1007/s12245-008-0068-5
PMCID: PMC2657258  PMID: 19384650
In-training examination; Board review; Emergency medicine resident
21.  Maintenance of certification in Internal Medicine: participation rates and patient outcomes 
The clinical practice of internal medicine continues to evolve with the addition of new information and new technology. Most internists in practice will have erosion of their knowledge after they complete training unless life-long learning occurs. The American Board of Internal Medicine (ABIM) began to issue time-limited certification in 1990 and asserts that the Maintenance of Certification (MOC) program promotes the professional development of internists. However, the available medical literature does not provide strong support for the assumption that internists with certification or recertification have better patient outcomes. This relationship between recertification and patient outcomes needs more study. In addition, the participation in the Maintenance of Certification program by internists with lifetime certifications has been low, and recertification by leaders in internal medicine has also been relatively low. Some physicians in practice have concerns about the relevance of the program and the cost. Our review suggests that the ABIM needs to review its current Maintenance of Certification program and make changes to enhance its clinical relevance and educational value. We suggest that professional development should be based on focused reviews of the current literature, which is immediately relevant to clinical practice, and that recertification could be based on completion of modules and more frequent, less onerous testing.
doi:10.3402/jchimp.v2i4.19753
PMCID: PMC3715151  PMID: 23882382
certification; recertification; internal medicine; patient outcomes; mortality
22.  An Assessment of Patient-Based and Practice Infrastructure–Based Measures of the Patient-Centered Medical Home: Do We Need to Ask the Patient? 
Health Services Research  2011;47(1 Pt 1):4-21.
Objective
To examine the importance of patient-based measures and practice infrastructure measures of the patient-centered medical home (PCMH).
Data Sources
A total of 3,671 patient surveys of 202 physicians completing the American Board of Internal Medicine (ABIM) 2006 Comprehensive Care Practice Improvement Module and 14,457 patient chart reviews from 592 physicians completing ABIM's 2007 Diabetes and Hypertension Practice Improvement Module.
Methodology
We estimated the association of patient-centered care and practice infrastructure measures with patient rating of physician quality. We then estimated the association of practice infrastructure and patient rating of care quality with blood pressure (BP) control.
Results
Patient-centered care measures dominated practice infrastructure as predictors of patient rating of physician quality. Having all patient-centered care measures in place versus none was associated with an absolute 75.2 percent increase in the likelihood of receiving a top rating. Both patient rating of care quality and practice infrastructure predicted BP control. Receiving a rating of excellent on care quality from all patients was associated with an absolute 4.2 percent improvement in BP control. For reaching the maximum practice-infrastructure score, this figure was 4.5 percent.
Conclusion
Assessment of physician practices for PCMH qualification should consider both patient based patient-centered care measures and practice infrastructure measures.
doi:10.1111/j.1475-6773.2011.01302.x
PMCID: PMC3447253  PMID: 22092245
Patient-centered care; practice infrastructure; medical home; blood pressure control
23.  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
24.  Resident Research and Scholarly Activity in Internal Medicine Residency Training Programs 
OBJECTIVES
1) To describe how internal medicine residency programs fulfill the Accreditation Council for Graduate Medical Education (ACGME) scholarly activity training requirement including the current context of resident scholarly work, and 2) to compare findings between university and nonuniversity programs.
DESIGN
Cross-sectional mailed survey.
SETTING
ACGME-accredited internal medicine residency programs.
PARTICIPANTS
Internal medicine residency program directors.
MEASUREMENTS
Data were collected on 1) interpretation of the scholarly activity requirement, 2) support for resident scholarship, 3) scholarly activities of residents, 4) attitudes toward resident research, and 5) program characteristics. University and nonuniversity programs were compared.
MAIN RESULTS
The response rate was 78%. Most residents completed a topic review with presentation (median, 100%) to fulfill the requirement. Residents at nonuniversity programs were more likely to complete case reports (median, 40% vs 25%; P =.04) and present at local or regional meetings (median, 25% vs 20%; P =.01), and were just as likely to conduct hypothesis-driven research (median, 20% vs 20%; P =.75) and present nationally (median, 10% vs 5%; P =.10) as residents at university programs. Nonuniversity programs were more likely to report lack of faculty mentors (61% vs 31%; P <.001) and resident interest (55% vs 40%; P =.01) as major barriers to resident scholarship. Programs support resident scholarship through research curricula (47%), funding (46%), and protected time (32%).
CONCLUSIONS
Internal medicine residents complete a variety of projects to fulfill the scholarly activity requirement. Nonuniversity programs are doing as much as university programs in meeting the requirement and supporting resident scholarship despite reporting significant barriers.
doi:10.1111/j.1525-1497.2005.40270.x
PMCID: PMC1490049  PMID: 15836549
ACGME; resident research; medical education; national survey
25.  Duty Hour Recommendations and Implications for Meeting the ACGME Core Competencies: Views of Residency Directors 
Mayo Clinic Proceedings  2011;86(3):185-191.
OBJECTIVE: To describe the views of residency program directors regarding the effect of the 2010 duty hour recommendations on the 6 core competencies of graduate medical education.
METHODS: US residency program directors in internal medicine, pediatrics, and general surgery were e-mailed a survey from July 8 through July 20, 2010, after the 2010 Accreditation Council for Graduate Medical Education (ACGME) duty hour recommendations were published. Directors were asked to rate the implications of the new recommendations for the 6 ACGME core competencies as well as for continuity of inpatient care and resident fatigue.
RESULTS: Of 719 eligible program directors, 464 (65%) responded. Most program directors believe that the new ACGME recommendations will decrease residents' continuity with hospitalized patients (404/464 [87%]) and will not change (303/464 [65%]) or will increase (26/464 [6%]) resident fatigue. Additionally, most program directors (249-363/464 [53%-78%]) believe that the new duty hour restrictions will decrease residents' ability to develop competency in 5 of the 6 core areas. Surgery directors were more likely than internal medicine directors to believe that the ACGME recommendations will decrease residents' competency in patient care (odds ratio [OR], 3.9; 95% confidence interval [CI], 2.5-6.3), medical knowledge (OR, 1.9; 95% CI, 1.2-3.2), practice-based learning and improvement (OR, 2.7; 95% CI, 1.7-4.4), interpersonal and communication skills (OR, 1.9; 95% CI, 1.2-3.0), and professionalism (OR, 2.5; 95% CI, 1.5-4.0).
CONCLUSION: Residency program directors' reactions to ACGME duty hour recommendations demonstrate a marked degree of concern about educating a competent generation of future physicians in the face of increasing duty hour standards and regulation.
The reactions of residency program directors to the ACGME duty hour recommendations demonstrate a marked degree of concern about educating a competent generation of future physicians in the face of increasing duty hour standards and regulation.
doi:10.4065/mcp.2010.0635
PMCID: PMC3046937  PMID: 21307391

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