Harry R. Kimball

Certifying examination performance and patient outcomes following acute myocardial infarction

Objectiveu2002 To establish whether successful certifying examination performances of doctors are associated with their patients’ mortality and length of stay following acute myocardial infarction.

Examiner Differences in the Mini-Cex

Objective: The objective of this study was to analyze whether faculty ratings of residents, using the mini-CEX oral exam format, differed in stringency or were influenced by the clinical setting. It also sought to learn whether the examiners were satisfied with the format.Method: A mini-CEX encounter consisted of a single faculty member observing a resident conduct a focused history and physical examination in an inpatient, outpatient, or emergency room setting. After asking the resident for a diagnosis and treatment plan, the faculty member rated the resident and provided educational feedback. The encounters were intended to be short and occur as a routine part of the training, so each resident would be evaluated on many occasions by different faculty.Sample: Sixty-four attending physicians evaluated residents from five internal medicine training programs; data were analyzed for 355 mini-CEX encounters involving 88 residents.Results: There were not large differences among the examiners in their ratings. Moreover, there were not great differences among the ratings in terms of the training program with which the examiner was associated, the setting of the mini-CEX, or the nature of the patient. The examiners were generally satisfied with the format and their level of satisfaction was correlated with the residents perceptions of the format.Conclusion: The mini-CEX adapts itself to a broad range of clinical situations, and these results show that it should produce roughly comparable scores over examiners and settings. This makes it a worthwhile device for evaluation at the local level.

The relevance to clinical practice of the certifying examination in internal medicine

AbstractObjective: To determine the relevance of the initial certifying examination to the practice of internal medicine and the suitability of items used in initial certification for recertification.n Design: Using a matrix-sampling approach, items from the 1991 Certifying Examination were assigned to two sets of judges: directors of the American Board of Internal Medicine (ABIM) and practicing general internists. Each judge rated the relevance of items on a five-point scale.n Participants: 54 current or former directors of the ABIM and 72 practicing general internists; practitioners were nominated by directors and their ratings were included if they spent > 80% of their time in direct patient care.n Results: The directors’ mean rating of all 576 items was 3.98 (SD=0.62); the practitioners’ mean rating was 4.11 (SD=0.82). The directors assigned to 27 items ratings of less than 3 and the practitioners assigned to 42 items ratings of less than 3; seven of these items received low ratings from both groups. There were differences in the two groups’ ratings of the relevance of various medical content categories, but the mean rating of core items was higher than that of noncore items and the mean rating of items testing clinical judgment was higher than that of items testing knowledge or synthesis.n Conclusions: These findings suggest that the initial certifying examination is relevant to clinical practice and that many of the examination items are suitable for use in recertification. Differences in perception appear to exist between practitioners and directors, and the use of practitioner ratings is likely to be a routine part of judging the suitability of items for Board examinations in the future.

Training the Future Internal Medicine Subspecialist

The past two decades have witnessed a dramatic explosion in the creation of new scientific knowledge and technology that have combined to provide astonishing advances in the care of patients. The avalanche of discoveries in the cross-cutting disciplines of immunology, molecular biology, genetics, and the information sciences have added further to the knowledge that must be incorporated into the training of the contemporary medical subspecialist. With the exception of cardiovascular disease, however, trainees have not been afforded additional time in standard subspecialty fellowships to assimilate this greater knowledge base or to acquire experience for excellence as a clinician and consultant. The cardiologists recognized this problem in 1986 when the 17th Bethesda Conference concluded that training be extended to a minimum of 3 years with additional emphasis on the need for meaningful research experience.l The American Board of Internal Medicine (ABIM) responded to this consensus recommendation by adopting a 3-year training requirement for certification in cardiovascular disease. However, the length of formal training in other subspecialties has remained at 2 years since the late 1960s although many training programs-generally concentrated in academic settings-have offered extended training on an elective basis. Analysis of data from the National Study for Internal Medicine Manpower (NaSIMM) indicates that the majority of internal medicine subspecialty programs (65%) offer training beyond 2 years and the majority of current second-year fellows (60%) train for

The Subspecialization Rate of Third Year Internal Medicine Residents From 1992 Through 1998

Background: The appropriateness of U.S. physician workforce size and the proportion of generalists versus specialists have long been debated. Difficulty collecting reliable data and varying methodologies complicate clear analysis of workforce questions. Purpose: This work examines the rate at which internists subspecialized during the 1990s. It also compares two approaches for estimating subspecialization rates: (a) following resident classes longitudinally (cohort approach), and (b) comparing 1st year fellowship (F-1) class size to the previous years 3rd-year resident (R-3) class size (F-1/R-3). Methods: Data were collected through the American Board of Internal Medicines tracking program. Physicians completing their R-3 year in 1992 through 1998 were the participants. The proportion of each R-3 group that eventually entered subspecialty training was examined. Demographic data for those entering subspecialty training and those who did not were compared. Subspecialization rate estimates for the cohort and F-1/R-3 approaches were also compared. Results: The number of internists increased, whereas the number entering subspecialty training declined. Men were more likely to enter a subspecialty than women. International medical school graduates were more likely to enter a subspecialty than U.S. medical school graduates. University-based residency program trainees were more likely to enter a subspecialty than community hospital program trainees. Those entering subspecialty training tended to be younger and score higher on the internal medicine certification examination than those who did not. Almost identical estimates where produced by the cohort and F-1/R-3 approaches. Conclusions: There was a downward trend in the rate at which internists entered subspecialty training during the 1990s. The two methodologies examined produced similar results.

Certification in internal medicine: 1989-1992

AbstractObjective: To determine whether changes in the demographic/educational mix of those entering internal medicine from 1986 to 1989 were associated with differences among them at the time of certification.n Participants: Included in the study were all candidates for the 1989 to 1992 American Board of Internal Medicine certifying examinations in internal medicine.n Measurements: Demographic information and medical school, residency training, and examination experience were available for each candidate. Data defining quality, size, and number of subspecialties were available for internal medicine training programs.n Results: From 1990 to 1992, the total number of men and women candidates increased as did the numbers of foreign-citizen non-U.S. medical school graduates and osteopathic medical school graduates; the number of U.S. medical school graduates remained nearly constant and the number of U.S.-citizen graduates of non-U.S. medical schools declined. The pass rates for all groups of first-time examination takers decreased, while the ratings of program directors remained relatively constant. Program quality, size, and number of subspecialty programs had modest positive relationships with examination performance.n Conclusions: Changes in the characteristics of those entering internal medicine from 1986 to 1989 were associated with declines in performance at the time of certification. These declines occurred in all content areas of the test and were apparent regardless of program quality. These data identify some of the challenges internal medicine faces in the years ahead.

A core component of the certification examination in internal medicine

AbstractObjective: To develop and test the psychometric characteristics of an examination of core content in internal medicine.n Design: A cross-sectional pilot test comparing the core examination with the 1988 certifying examination and two pretest examinations.n Setting: The 1988 certifying examination of the American Board of Internal Medicine.n Participants: A random sample of 2,975 candidates from 8,968 candidates who took the 1988 certifying examination were given the core examination; similarly drawn samples were each given one of two pretests of traditional questions.n Interventions: A framework for developing an examination of core internal medicine questions was designed and used to develop a 92-question core test with an absolute pass/fail standard.n Results: Candidates answered 74% of core internal medicine questions, compared with 64%, 52%, and 53% of traditional questions on the 1988 certifying examination and the two pretests. The discriminating ability of the core internal medicine examination was lower than that of the certifying examination (r-values were 0.28 and 0.34, respectively). The pass rate was 83% for the core internal medicine examination and 57% for the certifying examination; 27% passed the core examination and failed the certifying examination; 1% passed the certifying examination and failed the core examination.n Conclusion: Core internal medicine questions were easier than but almost as discriminating as traditional questions of the certifying examination. A small percentage of candidates passed the certifying examination but failed the core examination.

Recertification and the american board of family practice

drug and transfusion reactions are included on our revised summary. The process of summary at discharge is a key moment for identifying these events. While lacking perfect sensitivity and specificity, this mechanism has successfully identified more than 300 adverse drug reactions in a two-year period. 4 4. Computerized databases. Transforming the free-text summary into a computerized database offers great patientcare, institutional, and epidemiologic potentials. Our computerized discharge summaries are automatically printed whenever a patient registers in the emergency room. Gabrieli 5 has designed a dictionary that can process text from discharge summaries to create indexed databases. The etiiciencies of this existing source of clinical epidemiologic data should not be overlooked. GORDON SCHIFF, MD, Section of General Medicine, Department o f Medicine, Cook County Hospital, Chicago, IL 60612.9985