Lynn O. Langdon

Future Roles and Training of Internal Medicine Subspecialists

At a retreat in January 1993, the executive committee of the American Board of Internal Medicine concluded that it is more important than ever for subspecialists to be highly trained, both clinically and in clinical and basic research, since fewer subspecialists are likely to be supported by the future health care system. Accordingly, a task force primarily composed of the chairs of the subspecialty boards considered ways to enhance training to better prepare internal medicine subspecialists for their future roles. In developing their recommendations, the task force kept in mind the need for the roles of subspecialists to be compatible with and complementary to those of general internists to provide excellent, coordinated, and integrated health care. In June 1995, these recommendations were unanimously adopted as policy by the American Board of Internal Medicine, which comprises both subspecialists and general internists. The potential for federal budget cuts and economic upheaval in the health care market to dramatically reduce the financing available for subspecialty training is of grave concern [1]. The benefits of high-quality graduate medical education are realized by all segments of society. Its costs at all levels should be broadly borne, and health insurers, including managed care plans, should not be allowed to opt out of financing this education. But the primary interest of the American Board of Internal Medicine is the quality of training of internists; ways to finance graduate medical education are beyond the Boards purview. The Board supports the view that too many subspecialists are being trained [2]. The Board also anticipates that funds for excellent training of fewer subspecialists will continue to be available. Although training fewer subspecialists will reduce educational costs, it will also create stress and tension in a system that, until now, has depended on subspecialist fellows to provide much-needed service. These are realities that must be dealt with, but they must not undermine public commitment to highquality training for physicians. In return, the medical profession must take seriously its obligation to use educational resources as efficiently and effectively as possible. To maximize the contribution of fewer subspecialists, rigorous training that is appropriate, relevant, and realistically matched with career opportunities is essential. Subspecialists have made major and unique contributions to health care by advancing medical knowledge and technology and promoting excellence in the management of complex illnesses. Although discussions about the physician workforce have focused primarily on the clinical contribution of specialists, planning for the future must include continued investment in knowledge that results from subspecialty basic and clinical research. Subspecialists are needed as both investigators and clinicians. All subspecialists must have a comprehensive knowledge base and broad experience in the clinical practice of their subspecialties. However, diversity of the future roles for subspecialists, coupled with new demands and diminishing resources for training, led the Board to recommend different but overlapping training pathways for the subspecialist investigator and the subspecialist clinician (Table 1). Table 1. Career Paths of the Subspecialist Clinician and Subspecialist Investigator Because there is an oversupply of subspecialist clinicians [3-5], the total number of subspecialty fellowship positions should be reduced, and the proportion of investigator trainees should be increased. Nevertheless, it remains important to train subspecialist clinicians to prevent future gaps in the supply stream, to provide for the needs of patients with complex medical illnesses, and to maintain the number of subspecialist clinical faculty to serve as teachers and role models. Each subspecialty training program should have the necessary resources to provide high-quality training in both the clinical and investigative paths. However, occasionally concentrating resources in fewer programs may be the most effective way to provide excellent training for a cadre of subspecialist basic scientists and clinical investigators. Consortia comprising several institutions may be useful models for aiding future subspecialty training, allowing geographic pooling of training resources to provide a coordinated approach to training participants for various subspecialty careers. While recommendations for specific subspecialty training pathways were being formulated, it became clear that each pathway would be enhanced by additional didactic learning and formal coursework that might lead to a separate degree in some cases. Didactic topics for each training pathway are described in more detail later in this article, but examples include the subspecialist basic scientist with a graduate degree in molecular biology and the clinical investigator with a degree in clinical epidemiology. The curricula for the didactic components of training, many of which are not as extensive as that for a separate degree program, are independent of the clinical content of training. In other words, a common body of knowledge is required of investigators and clinicians, regardless of their medical discipline. Therefore, cross crossdivisional crossdivisional divisional modular units of instruction should be considered as an efficient way to extend training opportunities throughout departments of medicine. Many of these educational components would be equally appropriate for internal medicine residents and subspecialty fellows, furthering the potential efficiency of these components. The Role and Training of the Subspecialist Investigator Scientific inquiry and innovation are hallmarks of the subspecialist research investigator. The range of research done by subspecialists is wide and varied. The Board anticipates that the career pathways of subspecialist investigators will evolve in two directions, toward basic patient-oriented research and toward applied patient-oriented research [6]. Although the training for each of these two investigative pathways includes several unique components, both require a long and rigorous curriculum. Subspecialties are part of the continuum of internal medicine. Subspecialty training must begin, as it does now, with a solid foundation in internal medicine. Thus, the Board recommends that the training pathway for all subspecialist investigators consist of a coordinated curriculum that includes at least 2 years of internal medicine training, at least 1 or 2 years of clinical subspecialty training (depending on the subspecialty), and at least 3 years of research training under the supervision of the subspecialty program director. The Task Force on the Curriculum of Internal Medicine of the Federated Council of Internal Medicine is expected to issue a final report in 1996. The Board encourages the identification of a core internal medicine curriculum that includes aspects of internal medicine training that are essential to subspecialty investigators. For some trainees, individual programs may require additional protected time for research activities. Training should also include documented continuity experience in the internal medicine ambulatory setting and formal coursework in research methods. The Board will consider subspecialist basic scientists and clinical investigators with 7 years of training to be eligible to apply for certification in internal medicine and cardiology, gastroenterology, or two subspecialties (such as hematology and oncology). Certification of investigators in other single subspecialties will require at least 6 years of training. The Subspecialist Basic Scientist Continuous improvement in health care is founded on basic research. The contribution of the physician-scientist who expands the frontiers of biomedical knowledge through hypothesis-testing in the laboratory remains essential to future improvement in health care. Health care benefits can be obtained in the short term by leveraging the existing knowledge base, but long-term advances would be jeopardized if knowledge ceased to expand. It is also crucial that subspecialist physician-scientists maintain an intellectual exchange with their investigator-colleagues in preclinical departments. Yet, according to the Association of Subspecialty Professors, fewer than 2% of all physicians are biomedical scientists, and they recently have been steadily disappearing. According to Neilson and colleagues [7], the common denominator that marks a young physician-scientist successful is having had the best training possible Training of the subspecialist basic scientist requires a rigorous and varied curriculum. In addition to training in internal medicine and the clinical subspecialty, the basic scientist needs an in-depth understanding of basic science and biostatistics, study design, and legal and ethical principles, as well as substantial laboratory experience. Formal course work in basic laboratory techniques, computer technology, evaluation of experimental data, biostatistics, and grant and manuscript writing should be included. Duration of research experience during training is well accepted as a predictor of the success of an investigator. Although some argue that 2 years should be the minimum [8], the Board endorses the recommendations of the National Research Council and others who recommend at least 3 years [9]. This stringent requirement makes the total training period required for certification in the subspecialty 1 year longer for an investigator than for a clinician. Although it can be argued that longer training discourages young physicians from considering careers as investigators, the alternative is worse. Insufficiently trained investigators will not be successful in competing for research funds. The Subspecialist Clinical Investigator A recent report from the Institute of Medicine predicted that the shortage of c

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. 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. 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. 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. 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.

A Comparison of Video and Print Formats in the Assessment of Skill in Interpreting Cardiovascular Motion Studies

The purpose of the present study is to see if print and video formats of cardiovascular motion studies measured interpretive abilities in the same way. Participants in centers randomly assigned either Form A or B of echocardiograms saw one print and one video subtest. Participants in centers randomly assigned ventriculogram/arteriogram Form A or B saw four subtests: one print and one video for each type of study. Analyses revealed that the video subtests were easier than the print subtests, the print subtests were slightly more reproducible than the video subtests, the disattenuated correlations between print and video subtests of the same type of study were nearly perfect, and with multiple-choice question scores, experience and candidate descriptors were moderate. Given the equivalence of the formats, this study supports the use of the print format in national examinations. But, if resources are available, a video examination could be developed with reasonable psychometric characteristics for local use.

The certification process in adolescent medicine

The first and second certifying examinations in adolescent medicine were administered jointly by the American Board of Pediatrics (ABP) and the American Board of Internal Medicine (ABIM) on November 15, 1994, to 295 candidates, and on November 18, 1997, to 197 candidates including 170 who were taking the examination for the first time. This report describes the certification process and the characteristics of those taking the first and second examinations in adolescent medicine. The purposes of certification in adolescent medicine, consistent with the purposes of specialty boards, are to improve the quality of patient care during the second decade of life, expand and improve training to include a comprehensive and scientifically based approach to the care of young people as they enter adulthood, and stimulate faculty development and research for the problems of the adolescent population (1). Certification addresses these goals by establishing rigorous standards for training, verifying the knowledge base of candidates through a written examination, and requiring periodic recertification. This certification program recognizes a growing number of physicians with expertise in the medical problems of adolescents and the emergence in the past 30 years of a body of knowledge about the health problems, the effects of rapid biologic and psychologic change, and the interaction of biologic, psychologic, social, and environmental forces that characterize this unique developmental period (2).

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. Design: A cross-sectional pilot test comparing the core examination with the 1988 certifying examination and two pretest examinations. Setting: The 1988 certifying examination of the American Board of Internal Medicine. 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. 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. 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. 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.

An adaptation of item modeling for developing test‐item banks

An adaptation of item modeling, an item‐writing procedure, is described. As with related methods, the procedure includes dividing the stem of an item into discrete elements of information and then altering the elements to create new items. In this adaptation, writers were instructed to change the elements so that each incorrect option in the original item becomes the correct answer to a new item. Another part of the process, an innovation that increases the number of items generated, is to change the question asked of examinees (e.g., from diagnosis to treatment) for each item and write new response options. Two novice item writers applied modeling to patient‐based, one‐best‐answer items. They found the procedure easy to use and intuitive. From 13 items, they produced 209 modeled items in 24 at‐home hours, plus 12 hr of meeting time. A consultant evaluated a subset of items and estimated that approximately half the items were of sufficient quality to appear on a subspecialty certifying examination. Though...

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