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Background The pass rate on the American Board of Internal Medicine (ABIM) nephrology certifying exam has declined and is among the lowest of all internal medicine (IM) subspecialties. In recent years, there have also been fewer applicants for the nephrology fellowship match. Methods This retrospective observational study assessed how changes between 2010 and 2019 in characteristics of 4094 graduates of US ACGME-accredited nephrology fellowship programs taking the ABIM nephrology certifying exam for the first time, and how characteristics of their fellowship programs were associated with exam performance. The primary outcome measure was performance on the nephrology certifying exam. Fellowship program pass rates over the decade were also studied. Results Lower IM certifying exam score, older age, female sex, international medical graduate (IMG) status, and having trained at a smaller nephrology fellowship program were associated with poorer nephrology certifying exam performance. The mean IM certifying exam percentile score among those who subsequently took the nephrology certifying exam decreased from 56.7 (SD, 27.9) to 46.1 (SD, 28.7) from 2010 to 2019. When examining individuals with comparable IM certifying exam performance, IMGs performed less well than United States medical graduates (USMGs) on the nephrology certifying exam. In 2019, only 57% of nephrology fellowship programs had aggregate 3-year certifying exam pass rates ≥80% among their graduates. Conclusions Changes in IM certifying exam performance, certain trainee demographics, and poorer performance among those from smaller fellowship programs explain much of the decline in nephrology certifying exam performance. IM certifying exam performance was the dominant determinant.

ObjectiveTo determine whether internists’ initial specialty certification and the maintenance of that certification (MOC) is associated with lower in-hospital mortality for their patients with acute myocardial infarction (AMI) or congestive heart failure (CHF).DesignRetrospective cohort study of hospitalisations in Pennsylvania, USA, from 2012 to 2017.SettingAll hospitals in Pennsylvania.ParticipantsAll 184 115 hospitalisations for primary diagnoses of AMI or CHF where the attending physician was a self-designated internist.Primary outcome measureIn-hospital mortality.ResultsOf the 2575 physicians, 2238 had initial certification and 820 were eligible for MOC. After controlling for patient demographics and clinical characteristics, hospital-level factors and physicians’ demographic and medical school characteristics, both initial certification and MOC were associated with lower mortality. The adjusted OR for initial certification was 0.835 (95% CI 0.756 to 0.922; pConclusionsInitial certification was associated with lower mortality for AMI or CHF. Moreover, for patients whose physicians had initial certification, an additional advantage was associated with its maintenance.

ObjectiveDiagnostic error is a key healthcare concern and can result in substantial morbidity and mortality. Yet no study has investigated the relationship between adverse outcomes resulting from diagnostic errors and one potentially large contributor to these errors: deficiencies in diagnostic knowledge. Our objective was to measure that associations between diagnostic knowledge and adverse outcomes after visits to primary care physicians that were at risk for diagnostic errors.Setting/participants1410 US general internists who recently took their American Board of Internal Medicine Maintenance of Certification (ABIM-IM-MOC) exam treating 42 407 Medicare beneficiaries who experienced 48 632 ‘index’ outpatient visits for new problems at risk for diagnostic error because the presenting problem (eg, dizziness) was related to prespecified diagnostic error sensitive conditions (eg, stroke).Outcome measures90-day risk of all-cause death, and, for outcome conditions related to the index visits diagnosis, emergency department (ED) visits and hospitalisations.DesignUsing retrospective cohort study design, we related physician performance on ABIM-IM-MOC diagnostic exam questions to patient outcomes during the 90-day period following an index visit at risk for diagnostic error after controlling for practice characteristics, patient sociodemographic and baseline clinical characteristics.ResultsRates of 90-day adverse outcomes per 1000 index visits were 7 for death, 11 for hospitalisations and 14 for ED visits. Being seen by a physician in the top versus bottom third of diagnostic knowledge during an index visit for a new problem at risk for diagnostic error was associated with 2.9 fewer all-cause deaths (95% CI −5.0 to −0.7, p=0.008), 4.1 fewer hospitalisations (95% CI −6.9 to −1.2, p=0.006) and 4.9 fewer ED visits (95% CI −8.1% to −1.6%, p=0.003) per 1000 visits.ConclusionHigher diagnostic knowledge was associated with lower risk of adverse outcomes after visits for problems at heightened risk for diagnostic error.

PURPOSE To examine whether there are group differences in milestone ratings submitted by program directors working with clinical competency committees (CCCs) based on gender for internal medicine (IM) residents and whether women and men rated similarly on milestones perform comparably on subsequent in-training and certification examinations. METHOD This national retrospective study examined end-of-year medical knowledge (MK) and patient care (PC) milestone ratings and IM In-Training Examination (IM-ITE) and IM Certification Examination (IM-CE) scores for 2 cohorts (2014-2017, 2015-2018) of U.S. IM residents at ACGME-accredited programs. It included 20,098/21,440 (94%) residents, with 9,424 women (47%) and 10,674 men (53%). Descriptive statistics and differential prediction techniques using hierarchical linear models were performed. RESULTS For MK milestone ratings in PGY-1, men and women showed no statistical difference at a significance level of .01 (P = .02). In PGY-2 and PGY-3, men received statistically higher average MK ratings than women (P = .002 and P < .001, respectively). In contrast, men and women received equivalent average PC ratings in each PGY (P = .47, P = .72, and P = .80, for PGY-1, PGY-2, and PGY-3, respectively). Men slightly outperformed women with similar MK or PC ratings in PGY-1 and PGY-2 on the IM-ITE by about 1.7 and 1.5 percentage points, respectively, after adjusting for covariates. For PGY-3 ratings, women and men with similar milestone ratings performed equivalently on the IM-CE. CONCLUSIONS Milestone ratings were largely similar for women and men. Generally, women and men with similar MK or PC milestone ratings performed similarly on future examinations. Although there were small differences favoring men on earlier examinations, these differences disappeared by the final training year. It is questionable whether these small differences are educationally or clinically meaningful. The findings suggest fair, unbiased milestone ratings generated by program directors and CCCs assessing residents.

This cohort study examines the association between health care intensity in the region where physicians practice and their ability to practice high-value care, specifically for physicians who relocated after residency., Key Points Question How does the health care environment in a region influence internists’ clinical capabilities, particularly the ability to practice high-value care? Findings This cohort study of 2714 newly certified internists (in 2002) who relocated to a new region after completing residency found that higher intensity of use of health care services in a physician’s destination region was associated with reduced ability to practice appropriately conservative care 1 decade later compared with that ability measured at the end of residency. Meaning The demands of practicing in high-intensity service regions may erode internists’ ability to practice high-value, conservative care., Importance Use of health care services and physician practice patterns have been shown to vary widely across the United States. Although practice patterns—in particular, physicians’ ability to provide high-quality, high-value care—develop during training, the association of a physician’s regional practice environment with that ability is less well understood. Objective To examine the association between health care intensity in the region where physicians practice and their ability to practice high-value care, specifically for physicians whose practice environment changed due to relocation after residency. Design, Setting, and Participants This cohort study included a national sample of 3896 internal medicine physicians who took the 2002 American Board of Internal Medicine initial certification examination followed approximately 1 decade (April 21, 2011, to May 7, 2015) later by the Maintenance of Certification (MOC) examination. At the time of the MOC examination, 2714 of these internists were practicing in a new region. Data were analyzed from March 6, 2016, to May 21, 2018. Exposures Intensity of care in the Dartmouth Atlas hospital referral region (HRR), measured by per-enrollee end-of-life physician visits (primary) and current practice type (secondary). Main Outcomes and Measures The outcome, a physician’s ability to practice high-value care, was assessed using the Appropriately Conservative Management (ACM) score on the MOC examination, measuring performance across all questions for which the correct answer was the most conservative option. The exposure, regional health care intensity, was measured as per-enrollee end-of-life physician visits in the Dartmouth Atlas HRR of the physician’s practice. Results Among the 3860 participating internists included in the analysis (2030 men [52.6%]; mean [SD] age, 45.6 [4.5] years), those who moved to regions in the quintile of highest health care intensity had an ACM score 0.22 SD lower (95% CI, −0.32 to −0.12) than internists who moved to regions in the quintile of lowest intensity, controlling for postresidency ACM scores. This difference reflected scoring in the 44th compared with the 53rd percentile of all examinees. This association was mildly attenuated (0.18 SD less; 95% CI, −0.28 to −0.09) after adjustment for physician and practice characteristics. Conclusions and Relevance This study found that practice patterns of internists who relocate after residency training appear to migrate toward norms of the new region. The demands of practicing in high-intensity regions may erode the ability to practice high-value conservative care.

To evaluate validity evidence for internal medicine milestone ratings across programs for three resident cohorts by quantifying "not assessable" ratings; reporting mean longitudinal milestone ratings for individual residents; and correlating medical knowledge ratings across training years with certification examination scores to determine predictive validity of milestone ratings for certification outcomes.This retrospective study examined milestone ratings for postgraduate year (PGY) 1-3 residents in U.S. internal medicine residency programs. Data sources included milestone ratings, program characteristics, and certification examination scores.Among 35,217 participants, there was a decreased percentage with "not assessable" ratings across years: 1,566 (22.5%) PGY1s in 2013-2014 versus 1,219 (16.6%) in 2015-2016 (P = .01), and 342 (5.1%) PGY3s in 2013-2014 versus 177 (2.6%) in 2015-2016 (P = .04). For individual residents with three years of ratings, mean milestone ratings increased from around 3 (behaviors of an early learner or advancing resident) in PGY1 (ranging from a mean of 2.73 to 3.19 across subcompetencies) to around 4 (ready for unsupervised practice) in PGY3 (mean of 4.00 to 4.22 across subcompetencies, P.001 for all subcompetencies). For each increase of 0.5 units in two medical knowledge (MK1, MK2) subcompetency ratings, the difference in examination scores for PGY3s was 19.5 points for MK1 (P.001) and 19.0 for MK2 (P.001).These findings provide evidence of validity of the milestones by showing how training programs have applied them over time and how milestones predict other training outcomes.

Purpose To investigate how changing to or from solo practice settings relates to maintenance of certification (MOC) exam performance. Method The authors conducted a retrospective analysis of exam pass/fail outcomes for 7,112 physicians who successfully completed their initial MOC cycle from 2000 to 2004. Initial physician MOC practice characteristics records, demographic information, and exam performance were linked with exam pass/fail outcomes from their second MOC cycle from 2006 to 2014 (5,215 physicians after attrition). Exam pass/fail outcomes for physicians' second MOC cycle were compared among four groups: those who remained in group practice across both MOC cycles, those who changed from group to solo practice, those who changed from solo to group practice, and those who remained in solo practice across both MOC cycles. Results Physicians who changed from solo to group practice performed significantly better than those who remained in solo practice (odds ratio [OR] = 1.67; 95% confidence interval [CI] = 1.11, 2.51; P = .027). Conversely, physicians changing from group to solo practice performed significantly worse than physicians staying in group practice (OR = 0.60; 95% CI = 0.45, 0.80; P = .002). Meanwhile, physicians who changed from solo to group practice performed similarly to physicians remaining in group practice (OR = 0.95; 95% CI = 0.67, 1.35; P = 0.76). Conclusions Changes in solo/group practice status were associated with second-cycle MOC exam performance. This study provides evidence that the context in which a physician practices may have an impact on their MOC exam performance.

Background and objectives Medical specialty and subspecialty fellowship programs administer subject-specific in-training examinations to provide feedback about level of medical knowledge to fellows preparing for subsequent board certification. This study evaluated the association between the American Society of Nephrology In-Training Examination and the American Board of Internal Medicine Nephrology Certification Examination in terms of scores and passing status. Design, setting, participants, & measurements The study included 1684 nephrology fellows who completed the American Society of Nephrology In-Training Examination in their second year of fellowship training between 2009 and 2014. Regression analysis examined the association between In-Training Examination and first-time Nephrology Certification Examination scores as well as passing status relative to other standardized assessments. Results This cohort included primarily men (62%) and international medical school graduates (62%), and fellows had an average age of 32 years old at the time of first completing the Nephrology Certification Examination. An overwhelming majority (89%) passed the Nephrology Certification on their first attempt. In-Training Examination scores showed the strongest association with first-time Nephrology Certification Examination scores, accounting for approximately 50% of the total explained variance in the model. Each SD increase in In-Training Examination scores was associated with a difference of 30 U (95% confidence interval, 27 to 33) in certification performance. In-Training Examination scores also were significantly associated with passing status on the Nephrology Certification Examination on the first attempt (odds ratio, 3.46 per SD difference in the In-Training Examination; 95% confidence interval, 2.68 to 4.54). An In-Training Examination threshold of 375, approximately 1 SD below the mean, yielded a positive predictive value of 0.92 and a negative predictive value of 0.50. Conclusions American Society of Nephrology In-Training Examination performance is significantly associated with American Board of Internal Medicine Nephrology Certification Examination score and passing status.

Breast cancer is a leading cause of death in the United States. Continuing medical education programs such as the American Board of Internal Medicine's Maintenance of Certification (MOC) program can increase early detection of cancers by educating physicians about the benefits of screening. Did the imposition of American Board of Internal Medicine's MOC requirement affect guideline-compliant mammography screening?To address this question, we took advantage of a natural experiment that occurred when one group of general internists was required to complete MOC by 2001 because they initially certified in 1991 (MOC required) and another group was grandfathered out of this requirement because they initially certified in 1989 (MOC grandfathers). To measure associations with the MOC requirement, we compared mammography screening in the 2 years before and the 3 years after the 2001 MOC requirement among beneficiaries treated by the MOC-required physicians and compared this difference with the same difference in mammography screening among a control group of beneficiaries treated by the MOC-grandfathered physicians.We found that the MOC requirement was associated with a regression adjusted 2.8% increase (p .001) in annual screening and 1.7% increase (p .001) in biennial screening. When we limited the sample to beneficiaries with no screening at baseline (1999 and 2000), these figures increased to 8.5% (p = .02) and 6.4% (p = .01), respectively.The MOC requirement was associated with an improvement in guideline-compliant mammography screening with the most pronounced improvements among women who were the least adherent at baseline and therefore might have benefited the most from screening.

The American College of Cardiology In-Training Exam (ACC-ITE) is incorporated into most U.S. training programs, but its relationship to performance on the American Board of Internal Medicine Cardiovascular Disease (ABIM CVD) Certification Examination is unknown. ACC-ITE scores from third-year fellows from 2011 to 2014 (n = 1,918) were examined. Covariates for regression analyses included sex, age, medical school country, U.S. Medical Licensing Examination Step, and ABIM Internal Medicine Certification Examination scores. A secondary analysis examined fellows (n = 511) who took the ACC-ITE in the first and third years. ACC-ITE scores were the strongest predictor of ABIM CVD scores (p < 0.0001), and the most significant predictor of passing (p < 0.0001). The change in ACC-ITE scores from first to third year was a strong predictor of the ABIM CVD score (p < 0.001). The ACC-ITE is strongly associated with performance on the ABIM CVD Certification Examination.

PURPOSE As part of the American Board of Internal Medicine's (ABIM's) continuing effort to update its Maintenance of Certification (MOC) program, a content validity tool was used to conduct structured reviews of MOC exam blueprints (i.e., test specification tables) by the physician community. Results from the Cardiovascular Disease MOC blueprint review are presented to illustrate the process ABIM conducted for several internal medicine disciplines. METHOD Ratings of topic frequency and importance were collected from cardiologists in 2016 using a three-point scale (low, medium, high). The web-based survey instrument presented 188 blueprint topic descriptions, each combined with five patient-related tasks (e.g., diagnosis, treatment). Descriptive statistics and chi-square analysis were employed. RESULTS Responses from 441 review participants were analyzed. Frequency and importance ratings were aggregated as a composite statistic representing clinical relevance, and exam assembly criteria were modified to select questions, or items, addressing clinically relevant content only. Specifically, ≥ 88% of exam items now address high-importance topics, including ≤ 15% on topics that are also low frequency; and ≤ 12% of exam items now address medium-importance topics, including ≤ 3% on topics that are also low frequency. The updated blueprint has been published for test takers and provides enhanced information on content that would and would not be tested in subsequent examinations. It is linked to more detailed feedback that examinees receive on items answered incorrectly. CONCLUSIONS The blueprint review garnered valuable feedback from the physician community and provided new evidence for the content validity of the Cardiovascular Disease MOC exam.

The Accreditation Council for Graduate Medical Education's Next Accreditation System requires training programs to demonstrate that fellows are achieving competence in medical knowledge (MK), as part of a global assessment of clinical competency. Passing American Board of Internal Medicine (ABIM) certification examinations is recognized as a metric of MK competency. This study examines several in-training MK assessment approaches and their ability to predict performance on the ABIM Hematology or Medical Oncology Certification Examinations. Results of a Hematology In-Service Examination (ISE) and an Oncology In-Training Examination (ITE), program director (PD) ratings, demographic variables, United States Medical Licensing Examination (USMLE), and ABIM Internal Medicine (IM) Certification Examination were compared. Stepwise multiple regression and logistic regression analyses evaluated these assessment approaches as predictors of performance on the Hematology or Medical Oncology Certification Examinations. Hematology ISE scores were the strongest predictor of Hematology Certification Examination scores (β = 0.41) (passing odds ratio [OR], 1.012; 95 % confidence interval [CI], 1.008-1.015), and the Oncology ITE scores were the strongest predictor of Medical Oncology Certification Examination scores (β = 0.45) (passing OR, 1.013; 95 % CI, 1.011-1.016). PD rating of MK was the weakest predictor of Medical Oncology Certification Examination scores (β = 0.07) and was not significantly predictive of Hematology Certification Examination scores. Hematology and Oncology ITEs are better predictors of certification examination performance than PD ratings of MK, reinforcing the effectiveness of ITEs for competency-based assessment of MK.

Objective The American College of Rheumatology (ACR) Adult Rheumatology In-Training Examination (ITE) is a feedback tool designed to identify strengths and weaknesses in the content knowledge of individual fellows-in-training and the training program curricula. We determined whether scores on the ACR ITE, as well as scores on other major standardized medical examinations and competency-based ratings, could be used to predict performance on the American Board of Internal Medicine (ABIM) Rheumatology Certification Examination. Methods Between 2008 and 2012, 629 second-year fellows took the ACR ITE. Bivariate correlation analyses of assessment scores and multiple linear regression analyses were used to determine whether ABIM Rheumatology Certification Examination scores could be predicted on the basis of ACR ITE scores, United States Medical Licensing Examination scores, ABIM Internal Medicine Certification Examination scores, fellowship directors’ ratings of overall clinical competency, and demographic variables. Logistic regression was used to evaluate whether these assessments were predictive of a passing outcome on the Rheumatology Certification Examination. Results In the initial linear model, the strongest predictors of the Rheumatology Certification Examination score were the second-year fellows’ ACR ITE scores (β = 0.438) and ABIM Internal Medicine Certification Examination scores (β = 0.273). Using a stepwise model, the strongest predictors of higher scores on the Rheumatology Certification Examination were second-year fellows’ ACR ITE scores (β = 0.449) and ABIM Internal Medicine Certification Examination scores (β = 0.276). Based on the findings of logistic regression analysis, ACR ITE performance was predictive of a pass/fail outcome on the Rheumatology Certification Examination (odds ratio 1.016 [95% confidence interval 1.011–1.021]). Conclusion The predictive value of the ACR ITE score with regard to predicting performance on the Rheumatology Certification Examination supports use of the Adult Rheumatology ITE as a valid feedback tool during fellowship training.

Patients with osteoporosis can sustain fractures following falls or other minimal trauma. This risk of fracture can be reduced through appropriate diagnostic testing, pharmacologic therapy, and other readily measured standards of care. Our aim was to develop a credible clinical performance assessment to measure physicians’ quality of osteoporosis care, and determine reasonable performance standards for both competent and excellent care. This was a retrospective cohort study. Three hundred and eighty one general internists and subspecialists with time-limited board certification were included in the study. Performance rates on eight evidence-based measures were obtained from the American Board of Internal Medicine (ABIM) Osteoporosis Practice Improvement Module® (PIM), a web-based tool that uses medical chart reviews to help physicians assess and improve care. We applied a patented methodology, using an adaptation of the Angoff standard-setting method and the Dunn-Rankin method, with an expert panel skilled in osteoporosis care to form a composite and establish standards for both competent and excellent care. Physician and practice characteristics, including a practice infrastructure score based on the Physician Practice Connections Readiness Survey (PPC-RS), were used to examine the validity of the inferences made from the composite scores. The mean composite score was 67.54 out of 100 maximum points with a reliability of 0.92. The standard for competent care was 46.87, and for excellent care it was 83.58. Both standards had high classification accuracies (0.95). Sixteen percent of physicians performed below the competent care standard, while 22 % met the excellent care standard. Specialists scored higher than generalists, and better practice infrastructure was associated with higher composite scores, providing some validity evidence. We developed a rigorous methodology for assessing physicians’ osteoporosis care. Clinical performance feedback relative to absolute standards of care provides physicians with a meaningful approach to self-evaluation to improve patient care.

Background: Clinical reasoning is essential for the practice of medicine. Dual process theory conceptualizes reasoning as falling into two general categories: nonanalytic reasoning (pattern recognition) and analytic reasoning (active comparing and contrasting of alternatives). The debate continues regarding how expert performance develops and how individuals make the best use of analytic and nonanalytic processes. Several investigators have identified the unexpected finding that intermediates tend to perform better on licensing examination items than experts, which has been termed the “intermediate effect.” Purpose: We explored differences between faculty and residents on multiple-choice questions (MCQs) using dual process measures (both reading and answering times) to inform this ongoing debate. Method: Faculty (board-certified internists; experts) and residents (internal medicine interns; intermediates) answered live licensing examination MCQs (U.S. Medical Licensing Examination Step 2 Clinical Knowledge and American Board of Internal Medicine Certifying Examination) while being timed. We conducted repeated analysis of variance to compare the 2 groups on average reading time, answering time, and accuracy on various types of items. Results: Faculty and residents did not differ significantly in reading time [F (1, 35) = 0.01, p = 0.93], answering time [F (1, 35) = 0.60, p = 0.44], or accuracy [F (1, 35) = 0.24, p = 0.63] regardless of easy or hard items. Discussion: Dual process theory was not evidenced in this study. However, this lack of difference between faculty and residents may have been affected by the small sample size of participants and MCQs may not reflect how physicians made decisions in actual practice setting.

Background The Infectious Diseases Society of America In-Training Examination (IDSA ITE) is a feedback tool used to help fellows track their knowledge acquisition during fellowship training. We determined whether the scores on the IDSA ITE and from other major medical knowledge assessments predict performance on the American Board of Internal Medicine (ABIM) Infectious Disease Certification Examination. Methods The sample was 1021 second-year fellows who took the IDSA ITE and ABIM Infectious Disease Certification Examination from 2008 to 2012. Multiple regression analysis was used to determine if ABIM Infectious Disease Certification Examination scores were predicted by IDSA ITE scores, prior United States Medical Licensing Examination (USMLE) scores, ABIM Internal Medicine Certification Examination scores, fellowship director ratings of medical knowledge, and demographic variables. Logistic regression was used to evaluate if these same assessments predicted a passing outcome on the certification examination. Results IDSA ITE scores were the strongest predictor of ABIM Infectious Disease Certification Examination scores (β = .319), followed by prior ABIM Internal Medicine Certification Examination scores (β = .258), USMLE Step 1 scores (β = .202), USMLE Step 3 scores (β = .130), and fellowship directors' medical knowledge ratings (β = .063). IDSA ITE scores were also a significant predictor of passing the Infectious Disease Certification Examination (odds ratio, 1.017 [95% confidence interval, 1.013-1.021]). Conclusions The significant relationship between the IDSA ITE score and performance on the ABIM Infectious Disease Certification Examination supports the use of the ITE as a valid feedback tool in fellowship training.

Importance Success on the internal medicine (IM) examination is a central requirement of the American Board of Internal Medicine’s (ABIM’s) Maintenance of Certification program (MOC). Therefore, it is important to understand the degree to which this examination reflects conditions seen in practice, one dimension of content validity, which focuses on the match between content in the discipline and the topics on the examination questions. Objective To assess whether the frequency of questions on IM-MOC examinations were concordant with the frequency of conditions seen in practice. Design, Setting, and Participants The 2010-2013 IM-MOC examinations were used to calculate the percentage of questions for 186 medical condition categories from the examination blueprint, which balances examination content by considering importance and frequency of conditions seen in practice. Nationally representative estimates of conditions seen in practice by general internists were estimated from the primary diagnosis for 13 832 office visits (2010-2013 National Ambulatory Medical Care Surveys) and 108 472 hospital stays (2010 National Hospital Discharge Survey). Exposures Prevalence of conditions included on the IM-MOC examination questions. Main Outcomes and Measures The outcome measure was the concordance between the percentages of IM-MOC examination questions and the percentages of conditions seen in practice during either office visits or hospital stays for each of 186 condition categories (eg, diabetes mellitus, ischemic heart disease, liver disease). The concordance thresholds were 0.5 SD of the weighted mean percentages of the applicable 186 conditions seen in practice (0.74% for office visits; 0.51% for hospital stays). If the absolute differences between the percentages of examination questions and the percentages of office visit conditions or hospital stay conditions seen were less than the applicable concordance threshold, then the condition category was judged to be concordant. Results During the 2010-2013 IM-MOC examination periods, 3600 questions (180 questions per examination form) were administered and 3461 questions (96.1%) were mapped into the 186 study conditions (mean, 18.6 questions per condition). Comparison of the percentages of 186 categories of medical conditions seen in 13 832 office visits and 108 472 hospital stays with the percentages of 3461 questions on IM-MOC examinations revealed that 2389 examination questions (69.0%; 95% CI, 67.5%-70.6% involving 158 conditions) were categorized as concordant. For concordance between questions and office visits only, 2010 questions (58.08%; 95% CI, 56.43%-59.72% of all examination questions) involving 145 conditions were categorized as concordant. For concordance between questions and hospital stays only, 1456 questions (42.07%; 95% CI, 40.42%-43.71% of all examination questions) involving 122 conditions were categorized as concordant. Conclusions and Relevance Among questions on IM-MOC examinations from 2010-2013, 69% were concordant with conditions seen in general internal medicine practices, although some areas of discordance were identified.

In 1995, the American Board of Internal Medicine (ABIM) formalized an integrated residency curriculum including both clinical and research training (the Research Pathway), designed to develop careers of physician-scientists. Individuals who completed Pathway training between 1995 and 2007 were surveyed to determine the extent to which graduates established research-oriented careers.In 2012, the authors used a Web-based, 56-question, multiple-choice electronic survey of 813 participants in Research Pathway programs who completed their residency training between the years of 1995 and 2007. Survey questions addressed source and type of funding, research productivity, and job title/content. Descriptive and inferential analyses were performed.Forty-seven percent of solicited Pathway graduates participated in the survey. Ninety-seven percent of the respondents completed Pathway training. Ninety-one percent reported some research effort, with a group average of 58.6% of total professional effort spent in research. Seventy-two percent currently hold positions in academic medicine; 8.6% in the biomedical industry; and 2.1% in government medical service. Over 85% reported extramural research funding, with 81.4% receiving research support from federal sources. Among the variables positively correlated with the highest level of research engagement were previous graduate-level research training, any first-author publications arising from the Pathway research experience, and the receipt of extramural career development funding supporting the Pathway research.On the basis of a very high level of active research engagement reported by 385 ABIM Research Pathway graduates, this special research training track appears to be effectively meeting its goal of training biomedical scientists.

Purpose This study extends available evidence about the relationship between scores on the Step 2 Clinical Skills (CS) component of the United States Medical Licensing Examination and subsequent performance in residency. It focuses on the relationship between Step 2 CS communication and interpersonal skills scores and communication skills ratings that residency directors assign to residents in their first postgraduate year of internal medicine training. It represents the first large-scale evaluation of the extent to which Step 2 CS communication and interpersonal skills scores can be extrapolated to examinee performance in supervised practice. Method Hierarchical linear modeling techniques were used to examine the relationships among examinee characteristics, residency program characteristics, and residency-director-provided ratings. The sample comprised 6,306 examinees from 238 internal medicine residency programs who completed Step 2 CS for the first time in 2005 and received ratings during their first year of internal medicine residency training. Results Although the relationship is modest, Step 2 CS communication and interpersonal skills scores predict communication skills ratings for first-year internal medicine residents after accounting for other factors. Conclusions The results of this study make a reasonable case that Step 2 CS communication and interpersonal skills scores provide useful information for predicting the level of communication skill that examinees will display in their first year of internal medicine residency training. This finding demonstrates some level of extrapolation from the testing context to behavior in supervised practice, thus providing validity-related evidence for using Step 2 CS communication and interpersonal skills scores in high-stakes decisions.

Educators in internal medicine are concerned that reducing clinical training from three years to two could negatively affect physicians' ability to provide good patient care. Physician-scientists already follow a short-track research pathway that shortens clinical training to two years. The authors examine whether this shortened training affects ability.The authors use a national sample of 101,031 physicians who took their first internal medicine certification examination between 1993 and 2008 and trained in either a traditional or research pathway. They collected data, including demographics, exam information, and maintenance of certification (MOC) return rates. They used regression models to assess the relationship between training pathway and MOC exam scores and eventual certification status, adjusting for physician characteristics.In this study, research pathway training did not adversely impact internal medicine certification status. Although the scores of physicians who followed the research pathway were slightly lower, the effect size was small. In a subset of research pathway physicians, 63% remained in academic medicine and 37% continued to spend a substantial portion of time in medical research 10 years later.Different training pathways can lead to similar achievements in clinical judgment. The educational model, competency-based rather than time-dependent, that works for research pathway physicians could be extended to other talented trainees who would benefit by customizing training to meet career goals.

High-quality assessment of resident performance is needed to guide individual residents' development and ensure their preparedness to provide patient care. To facilitate this aim, reporting milestones are now required across all internal medicine (IM) residency programs.To describe initial milestone ratings for the population of IM residents by IM residency programs.Cross-sectional study.IM residency programs.All IM residents whose residency program directors submitted milestone data at the end of the 2013-2014 academic year.Ratings addressed 6 competencies and 22 subcompetencies. A rating of "not assessable" indicated insufficient information to evaluate the given subcompetency. Descriptive statistics were calculated to describe ratings across competencies and training years.Data were available for all 21 774 U.S. IM residents from all 383 programs. Overall, 2889 residents (1621 in postgraduate year 1 [PGY-1], 902 in PGY-2, and 366 in PGY-3) had at least 1 subcompetency rated as not assessable. Summaries of average ratings by competency and training year showed higher ratings for PGY-3 residents in all competencies. Overall ratings for each of the 6 individual competencies showed that fewer than 1% of third-year residents were rated as "unsatisfactory" or "conditional on improvement." However, when subcompetency milestone ratings were used, 861 residents (12.8%) who successfully completed training had at least 1 competency with all corresponding subcompetencies graded below the threshold of "readiness for unsupervised practice."Data were derived from a point in time in the first reporting period in which milestones were used.The initial milestone-based evaluations of IM residents nationally suggest that documenting developmental progression of competency is possible over training years. Subcompetencies may identify areas in which residents might benefit from additional feedback and experience. Future work is needed to explore how milestones are used to support residents' development and enhance residency curricula.None.

Maintenance of certification examination performance is associated with quality of care. We aimed to examine relationships between electronic medical knowledge resource use, practice characteristics and examination scores among physicians recertifying in internal medicine.We conducted a cross-sectional study of 3,958 United States physicians who took the Internal Medicine Maintenance of Certification Examination (IM-MOCE) between January 1, 2006 and December 31, 2008, and who held individual licenses to one or both of two large electronic knowledge resource programs. We examined associations between physicians' IM-MOCE scores and their days of electronic resource use, practice type (private practice, residency teaching clinic, inpatient, nursing home), practice model (single or multi-specialty), sex, age, and medical school location.In the 365 days prior to the IM-MOCE, physicians used electronic resources on a mean (SD, range) of 20.3 (36.5, 0-265) days. In multivariate analyses, the number of days of resource use was independently associated with increased IM-MOCE scores (0.07-point increase per day of use, p = 0.02). Increased age was associated with decreased IM-MOCE scores (1.8-point decrease per year of age, p 0.001). Relative to physicians working in private practice settings, physicians working in residency teaching clinics and hospital inpatient practices had higher IM-MOCE scores by 29.1 and 20.0 points, respectively (both p 0.001).Frequent use of electronic resources was associated with modestly enhanced IM-MOCE performance. Physicians involved in residency education clinics and hospital inpatient practices had higher IM-MOCE scores than physicians working in private practice settings.

PURPOSE Good clinical judgment is important to providing high-quality patient care. Keeping current in one's field is challenged by rapid advances in health care and demanding practices. Understanding the collective factors that influence a practicing physician's clinical judgment could help medical educators design improvement programs that target specific audiences. METHOD Data from two medical specialty boards, the American Board of Internal Medicine and American Board of Surgery, were used. Multiple regression analyses were conducted relating first-attempt performance on the maintenance of certification (MOC) exam with physician age, amount of continuing medical education (CME) undertaken, number of physicians in the practice, medical school type, and prior exam performance. Data were based on demographics and exam scores of 18,447 general internists and 4,961 general surgeons who took the MOC exam for the first time between 2003 and 2007. RESULTS Similar findings were obtained for general internists and surgeons. Younger physicians, those with higher scores on initial certification, physicians in group not solo practice, and U.S. medical graduates were significantly more likely to pass the MOC exam (P

Assessing physicians' clinical performance using statistically sound, evidence-based measures is challenging. Little research has focused on methodological approaches to setting performance standards to which physicians are being held accountable.Determine if a rigorous approach for setting an objective, credible standard of minimally-acceptable performance could be used for practicing physicians caring for diabetic patients.Retrospective cohort study.Nine hundred and fifty-seven physicians from the United States with time-limited certification in internal medicine or a subspecialty.The ABIM Diabetes Practice Improvement Module was used to collect data on ten clinical and two patient experience measures. A panel of eight internists/subspecialists representing essential perspectives of clinical practice applied an adaptation of the Angoff method to judge how physicians who provide minimally-acceptable care would perform on individual measures to establish performance thresholds. Panelists then rated each measure's relative importance and the Dunn-Rankin method was applied to establish scoring weights for the composite measure. Physician characteristics were used to support the standard-setting outcome.Physicians abstracted 20,131 patient charts and 18,974 patient surveys were completed. The panel established reasonable performance thresholds and importance weights, yielding a standard of 48.51 (out of 100 possible points) on the composite measure with high classification accuracy (0.98). The 38 (4%) outlier physicians who did not meet the standard had lower ratings of overall clinical competence and professional behavior/attitude from former residency program directors (p = 0.01 and p = 0.006, respectively), lower Internal Medicine certification and maintenance of certification examination scores (p = 0.005 and p0.001, respectively), and primarily worked as solo practitioners (p = 0.02).The standard-setting method yielded a credible, defensible performance standard for diabetes care based on informed judgment that resulted in a reasonable, reproducible outcome. Our method represents one approach to identifying outlier physicians for intervention to protect patients.

Whether patient care is improved by physicians maintaining their American Board of Internal Medicine certification is not known. This study compared how often physicians who had maintained certific...

Purpose The U.S. health care system is not prepared to meet the needs of the increasing population of older adults. Few physicians become geriatricians, but most will care for older adults. The authors assessed the quality of care for older adults in residency clinics and physician practices. Method Using the American Board of Internal Medicine's Care of the Vulnerable Elderly practice improvement module, researchers studied the quality of care provided to older adults in 52 internal and family medicine residency clinic sites and by a motivated group of 144 practicing physicians from 2006 to 2008. They also studied the characteristics of the practice systems in the clinics and offices and the relationship between specific elements of practice systems and the quality of care. Results Patients seen by residents were younger, had fewer chronic conditions, and were less likely to receive recommended care. Residency clinic systems were less likely to have elements designed to support care for older adults. Even when present, there was little correlation with care provided. Practicing physicians were more likely to provide recommended processes of care, and system elements in their practices were more likely to function well and correlate with delivery of key processes of care, but much room for improvement remains. Conclusions Practice system elements designed to support care for older adults perform differently in residency clinics than in practicing physicians' offices. Significant gaps in the quality of care for older adults exist and are much more pronounced in the residency clinic setting.

To add to the small body of validity research addressing whether scores from performance assessments of clinical skills are related to performance in supervised patient settings, the authors examined relationships between United States Medical Licensing Examination (USMLE) Step 2 Clinical Skills (CS) data gathering and data interpretation scores and subsequent performance in history taking and physical examination in internal medicine residency training.The sample included 6,306 examinees from 238 internal medicine residency programs who completed Step 2 CS for the first time in 2005 and whose performance ratings from their first year of residency training were available. Hierarchical linear modeling techniques were used to examine the relationships among Step 2 CS data gathering and data interpretation scores and history-taking and physical examination ratings.Step 2 CS data interpretation scores were positively related to both history-taking and physical examination ratings. Step 2 CS data gathering scores were not related to either history-taking or physical examination ratings after other USMLE scores were taken into account.Step 2 CS data interpretation scores provide useful information for predicting subsequent performance in history taking and physical examination in supervised practice and thus provide validity evidence for their intended use as an indication of readiness to enter supervised practice. The results show that there is less evidence to support the usefulness of Step 2 CS data gathering scores. This study provides important information for practitioners interested in Step 2 CS specifically or in performance assessments of medical students' clinical skills more generally.

Importance In 1990, the American Board of Internal Medicine (ABIM) ended lifelong certification by initiating a 10-year Maintenance of Certification (MOC) program that first took effect in 2000. Despite the importance of this change, there has been limited research examining associations between the MOC requirement and patient outcomes. Objective To measure associations between the original ABIM MOC requirement and outcomes of care. Design, Setting, and Participants Quasi-experimental comparison between outcomes for Medicare beneficiaries treated in 2001 by 2 groups of ABIM-certified internal medicine physicians (general internists). One group (n = 956), initially certified in 1991, was required to fulfill the MOC program in 2001 (MOC-required) and treated 84 215 beneficiaries in the sample; the other group (n = 974), initially certified in 1989, was grandfathered out of the MOC requirement (MOC-grandfathered) and treated 69 830 similar beneficiaries in the sample. We compared differences in outcomes for the beneficiary cohort treated by the MOC-required general internists before (1999-2000) and after (2002-2005) they were required to complete MOC, using the beneficiary cohort treated by the MOC-grandfathered general internists as the control. Main Outcomes and Measures Quality measures were ambulatory care–sensitive hospitalizations (ACSHs), measured using prevention quality indicators. Ambulatory care–sensitive hospitalizations are hospitalizations triggered by conditions thought to be potentially preventable through better access to and quality of outpatient care. Other outcomes included health care cost measures (adjusted to 2013 dollars). Results Annual incidence of ACSHs (per 1000 beneficiaries) increased from the pre-MOC period (37.9 for MOC-required beneficiaries vs 37.0 for MOC-grandfathered beneficiaries) to the post-MOC period (61.8 for MOC-required beneficiaries vs 61.4 for MOC-grandfathered beneficiaries) for both cohorts, as did annual per-beneficiary health care costs (pre-MOC period, $5157 for MOC-required beneficiaries vs $5133 for MOC-grandfathered beneficiaries; post-MOC period, $7633 for MOC-required beneficiaries vs $7793 for MOC-grandfathered beneficiaries). The MOC requirement was not statistically associated with cohort differences in the growth of the annual ACSH rate (per 1000 beneficiaries, 0.1 [95% CI, −1.7 to 1.9];P = .92), but was associated with a cohort difference in the annual, per-beneficiary cost growth of −$167 (95% CI, −$270.5 to −$63.5;P = .002; 2.5% of overall mean cost). Conclusion and Relevance Imposition of the MOC requirement was not associated with a difference in the increase in ACSHs but was associated with a small reduction in the growth differences of costs for a cohort of Medicare beneficiaries.

PURPOSE Experienced clinicians derive many diagnoses intuitively, because most new problems they see closely resemble problems they've seen before. The majority of these diagnoses, but not all, will be correct. This study determined whether further reflection regarding initial diagnoses improves diagnostic accuracy during a high-stakes board exam, a model for studying clinical decision making. METHOD Keystroke response data were used from 500 residents who took the 2010 American Board of Internal Medicine (ABIM) Internal Medicine Certification Examination. Data included time to initial response on each question, whether the answer was correct, and whether or not the resident changed her or his initial response. The focus was on 80 diagnosis questions that comprised realistic clinical vignettes with multiple-choice single-best answers. Cognitive skill (ability) was measured using overall exam scores. Case complexity was determined using item difficulty (proportion of examinees that correctly answered the question). A hierarchical generalized linear model was used to assess the relationship between time spent on initial responses and the probability of correctly answering the questions. RESULTS On average, residents changed their responses on 12% of all diagnosis questions (or 9.6 questions out of 80). Changing an answer from incorrect to correct was almost twice as likely as changing an answer from correct to incorrect. The relationship between response time and accuracy was complex. CONCLUSIONS Further reflection appears to be beneficial to diagnostic accuracy, especially for more complex cases.

Background Electronic resources are increasingly used in medical practice. Their use during high-stakes certification examinations has been advocated by many experts, but whether doing so would affect the capacity to differentiate between high and low abilities is unknown. Objective To determine the effect of electronic resources on examination performance characteristics. Design Randomized controlled trial. Setting Medical certification program. Participants 825 physicians initially certified by the American Board of Internal Medicine (ABIM) who passed the Internal Medicine Certification examination or sat for the Internal Medicine Maintenance of Certification (IM-MOC) examination in 2012 to 2015. Intervention Participants were randomly assigned to 1 of 4 conditions: closed book using typical or additional time, or open book (that is, UpToDate [Wolters Kluwer]) using typical or additional time. All participants took the same modified version of the IM-MOC examination. Measurements Primary outcomes included item difficulty (how easy or difficult the question was), item discrimination (how well the question differentiated between high and low abilities), and average question response time. Secondary outcomes included examination dimensionality (that is, the number of factors measured) and test-taking strategy. Item response theory was used to calculate question characteristics. Analysis of variance compared differences among conditions. Results Closed-book conditions took significantly less time than open-book conditions (mean, 79.2 seconds [95% CI, 78.5 to 79.9 seconds] vs. 110.3 seconds [CI, 109.2 to 111.4 seconds] per question). Mean discrimination was statistically significantly higher for open-book conditions (0.34 [CI, 0.32 to 0.35] vs. 0.39 [CI, 0.37 to 0.41] per question). A strong single dimension showed that the examination measured the same factor with or without the resource. Limitation Only 1 electronic resource was evaluated. Conclusion Inclusion of an electronic resource with time constraints did not adversely affect test performance and did not change the specific skill or factor targeted by the examination. Further study on the effect of resource inclusion on other examinations is warranted. Primary Funding Source ABIM Foundation.

Growing concern about rising costs and potential harms of medical care has stimulated interest in assessing physicians' ability to minimize the provision of unnecessary care.To assess whether graduates of residency programs characterized by low-intensity practice patterns are more capable of managing patients' care conservatively, when appropriate, and whether graduates of these programs are less capable of providing appropriately aggressive care.Cross-sectional comparison of 6639 first-time takers of the 2007 American Board of Internal Medicine certifying examination, aggregated by residency program (n = 357).Intensity of practice, measured using the End-of-Life Visit Index, which is the mean number of physician visits within the last 6 months of life among Medicare beneficiaries 65 years and older in the residency program's hospital referral region.The mean score by program on the Appropriately Conservative Management (ACM) (and Appropriately Aggressive Management [AAM]) subscales, comprising all American Board of Internal Medicine certifying examination questions for which the correct response represented the least (or most, respectively) aggressive management strategy. Mean scores on the remainder of the examination were used to stratify programs into 4 knowledge tiers. Data were analyzed by linear regression of ACM (or AAM) scores on the End-of-Life Visit Index, stratified by knowledge tier.Within each knowledge tier, the lower the intensity of health care practice in the hospital referral region, the better residency program graduates scored on the ACM subscale (P .001 for the linear trend in each tier). In knowledge tier 4 (poorest), for example, graduates of programs in the lowest-intensity regions had a mean ACM score in the 38th percentile compared with the 22nd percentile for programs in the highest-intensity regions; in tier 2, ACM scores ranged from the 75th to the 48th percentile in regions from lowest to highest intensity. Graduates of programs in low-intensity regions tended, more weakly, to score better on the AAM subscale (in 3 of 4 knowledge tiers).Regardless of overall medical knowledge, internists trained at programs in hospital referral regions with lower-intensity medical practice are more likely to recognize when conservative management is appropriate. These internists remain capable of choosing an aggressive approach when indicated.

PURPOSE One way to ensure quality of health care in the United States is through maintenance of certification (MOC). In this study, the authors explored whether participation in the internal medicine MOC program varies by physician-level characteristics, professional activities, and the size and location of the practice. They also sought to determine which component of MOC was incomplete for physicians who participated but did not complete the program. METHOD The authors used a theoretical realist approach to understand whether participation in the American Board of Internal Medicine MOC program varies according to physician and practice characteristics. The data came from a study sample that consisted of all physicians whose original certification was granted in internal medicine from 1990 through 1999; the study was conducted in 2013. Chi-square tests of independence and a multinomial logistic regression were conducted to determine which physician-level characteristics, professional activities, and practice characteristics were significantly associated with MOC participation. RESULTS Results showed that physicians who completed MOC tended to have higher certification exam scores; were younger; were U.S. medical graduates; practiced as subspecialists and in the Midwest; spent more time in patient care, teaching, or administration; worked in nonsolo practices; or were employed in counties with less than 20% of persons in poverty. CONCLUSIONS As certifying boards evaluate their programs, they need to continuously improve their features to assure the public that physicians maintaining certification are providing high-quality patient care.

Supplemental Digital Content is available in the text., Purpose To determine whether the 2003 Accreditation Council for Graduate Medical Education (ACGME) duty hours reform affected medical knowledge as reflected by written board scores for internal medicine (IM) residents. Method The authors conducted a retrospective cohort analysis of postgraduate year 1 (PGY-1) Internal Medicine residents who started training before and after the 2003 duty hour reform using a merged data set of American Board of Internal Medicine (ABIM) Board examination and the National Board of Medical Examiners (NMBE) United States Medical Licensing Examination (USMLE) Step 2 Clinical Knowledge test scores. Specifically, using four regression models, the authors compared IM residents beginning PGY-1 training in 2000 and completing training unexposed to the 2003 duty hours reform (PGY-1 2000 cohort, n = 5,475) to PGY-1 cohorts starting in 2001 through 2005 (n = 28,008), all with some exposure to the reform. Results The mean ABIM board score for the unexposed PGY-1 2000 cohort (n = 5,475) was 491, SD = 85. Adjusting for demographics, program, and USMLE Step 2 exam score, the mean differences (95% CI) in ABIM board scores between the PGY-1 2001, 2002, 2003, 2004 and 2005 cohorts minus the PGY-1 2000 cohort were −5.43 (−7.63, −3.23), −3.44 (−5.65, −1.24), 2.58 (0.36, 4.79), 11.10 (8.88, 13.33) and 11.28 (8.98, 13.58) points respectively. None of these differences exceeded one-fifth of an SD in ABIM board scores. Conclusions The duty hours reforms of 2003 did not meaningfully affect medical knowledge as measured by scores on the ABIM board examinations.

Importance US internal medicine residency programs are now required to rate residents using milestones. Evidence of validity of milestone ratings is needed. Objective To compare ratings of internal medicine residents using the pre-2015 resident annual evaluation summary (RAES), a nondevelopmental rating scale, with developmental milestone ratings. Design, Setting, and Participants Cross-sectional study of US internal medicine residency programs in the 2013-2014 academic year, including 21 284 internal medicine residents (7048 postgraduate-year 1 [PGY-1], 7233 PGY-2, and 7003 PGY-3). Exposures Program director ratings on the RAES and milestone ratings. Main Outcomes and Measures Correlations of RAES and milestone ratings by training year; correlations of medical knowledge ratings with American Board of Internal Medicine (ABIM) certification examination scores; rating of unprofessional behavior using the 2 systems. Results Corresponding RAES ratings and milestone ratings showed progressively higher correlations across training years, ranging among competencies from 0.31 (95% CI, 0.29 to 0.33) to 0.35 (95% CI, 0.33 to 0.37) for PGY-1 residents to 0.43 (95% CI, 0.41 to 0.45) to 0.52 (95% CI, 0.50 to 0.54) for PGY-3 residents (all P values P values P P P P Conclusions and Relevance Among US internal medicine residents in the 2013-2014 academic year, milestone-based ratings correlated with RAES ratings but with a greater difference across training years. Both rating systems for medical knowledge correlated with ABIM certification examination scores. Milestone ratings may better detect problems with professionalism. These preliminary findings may inform establishment of the validity of milestone-based assessment.

There is limited understanding of how clinical reasoning is developed, maintained, and objectively assessed. Using the theoretical lens of deliberate practice, we explored physicians' views on clinical reasoning. We compared responses from internists (faculty) and internal medicine interns, to identify potential qualitative and/or quantitative differences in how clinical reasoning is developed and maintained.Participants' free-text comments regarding how clinical reasoning is developed, maintained, and objectively assessed were analyzed. Three investigators coded responses using a constant-comparative, grounded theory approach. We also compared the frequencies of each theme between the 2 groups.Twenty-two faculty and 17 interns participated in this study. Faculty and intern themes for how clinical reasoning is developed, maintained, and objectively assessed were similar, but quantitative and qualitative differences emerged. Interrater reliability of themes was high (overall kappa: 0.92; range: 0.88-0.98). Only experts (faculty) mentioned the value of teaching for development and maintenance of clinical reasoning. Interns focused on knowledge acquisition activities and use of online resources. Experts and intern participants both struggled with how to best measure clinical reasoning; direct observation was rarely mentioned as a strategy.Consistent with our theoretical expectations, we found quantitative and qualitative differences in participants' responses, which have implications for teaching and assessment of clinical reasoning. By capturing the types of activities and their relative frequencies within and between these groups, this work adds to the deliberate practice literature.

To learn whether there are differences among certified and self-designated cardiologists, internists, and family practitioners in terms of the mortality of their patients with acute myocardial infarction (AMI).Data on all patients admitted with AMI were collected for calendar year 1993 by the Pennsylvania Health Care Cost Containment Council and analyzed. Certified and self-designated family practitioners, internists, and cardiologists (n = 4,546) were compared with respect to the characteristics of their patients' illnesses. In addition, a regression model was fitted in which mortality was the dependent measure and the independent variables were the probability of death, hospital characteristics (location and the availability of advanced cardiac care), and physician characteristics (patient volume, years since graduation from medical school, specialty, and certification status).On average, cardiologists treated more patients than did generalists, and their patients were less severely ill. In the regression analysis, all variables were statistically significant except the availability of advanced cardiac care. Holding all other variables constant, treatment by a certified physician was associated with a 15% reduction in mortality among patients with AMI.Less patient mortality was associated with treatment by physicians who were cardiologists, cared for larger numbers of AMI patients, were closer to their graduation from medical school, and were certified.

Introduction: Board certification has evolved from a “point-in-time” event to a process of periodic learning and reevaluation of medical competence through maintenance of certification (MOC). To better understand MOC participation, the transtheoretical model (TTM) was used to describe physicians' perceptions of MOC as a sequence of attitudinal changes. Method: Data were from a survey of internal medicine (IM) physicians' attitudes toward periodic reevaluation through MOC. An overall importance or decisional balance score was computed for each physician by summing his or her ratings across the 10 quality measures. The decisional balance score was used to classify physicians according to their acceptance of MOC, aligned with the 3 early TTM stages-of-change groups—precontemplation (PC), contemplation (C), and preparation (P)—where PC was least accepting and P was most accepting. Effect sizes assessed whether differences in attitudes toward reevaluation via MOC were of sufficient magnitude to support the TTM principles. Results: The difference in degree of acceptance of MOC between the P group and the PC and C groups was significant (p < 0.001), but the effect size was lower than predicted by the “strong” principle. Resistance to MOC for the PC and C groups was significantly greater than the P group (p < 0.001) and supported the “weak” principle. Physicians' beliefs about how often they should demonstrate performance on quality measures aligned well with the American Board of Internal Medicine's MOC requirements, with the P group believing in more frequent assessments than the PC and C groups (p < 0.001). Conclusions: Results show that physicians in the Preparation stage had overcome resistance to MOC as predicted by the “weak” principle of the TTM, but their attitude scores about the benefits of MOC were below what was expected by theory. This suggests that the structure of MOC may have made it easier for physicians to overcome barriers to MOC participation but may have lacked adequate resources to promote the benefits of participating in the process. More effort is needed to understand the specific benefits of MOC for reevaluating competencies, how to engage physicians and other stakeholders in the design of MOC, and how to communicate the rationale and evidence to those who are less accepting of MOC.

Contains fulltext : 125473.pdf (Publisher’s version ) (Open Access) Burnout is prevalent in residency training and practice and is linked to medical error and suboptimal patient care. However, little is known about how burnout affects clinical reasoning, which is essential to safe and effective care. The aim of this study was to examine how burnout modulates brain activity during clinical reasoning in physicians. Using functional Magnetic Resonance Imaging (fMRI), brain activity was assessed in internal medicine residents (n = 10) and board-certified internists (faculty, n = 17) from the Uniformed Services University (USUHS) while they answered and reflected upon United States Medical Licensing Examination and American Board of Internal Medicine multiple-choice questions. Participants also completed a validated two-item burnout scale, which includes an item assessing emotional exhaustion and an item assessing depersonalization. Whole brain covariate analysis was used to examine blood-oxygen-level-dependent (BOLD) signal during answering and reflecting upon clinical problems with respect to burnout scores. Higher depersonalization scores were associated with less BOLD signal in the right dorsolateral prefrontal cortex and middle frontal gyrus during reflecting on clinical problems and less BOLD signal in the bilateral precuneus while answering clinical problems in residents. Higher emotional exhaustion scores were associated with more right posterior cingulate cortex and middle frontal gyrus BOLD signal in residents. Examination of faculty revealed no significant influence of burnout on brain activity. Residents appear to be more susceptible to burnout effects on clinical reasoning, which may indicate that residents may need both cognitive and emotional support to improve quality of life and to optimize performance and learning. These results inform our understanding of mental stress, cognitive control as well as cognitive load theory.

To study relationships between clinical skill measures assessed at the beginning of general internists' careers and their career outcomes and practice characteristics.General Internist Community Tracking Study Physician Survey respondents (2000-2001, 2004-2005) linked with residency program evaluations and American Board of Internal Medicine board certification examination score records; n = 2,331.Cross-sectional regressions of career outcome and practice characteristic measures on board examination scores/success, residency evaluations interacted with residency type, and potential confounding variables.Failure to achieve board certification was associated with $27,206 (18 percent, p.05) less income and 14.9 percent more minority patients relative to physicians scoring in the bottom quartile on their initial examination who eventually became certified (p.01). Other skill measures were not associated with income. Scoring in the top rather than bottom quartile on the board certification examination was associated with 9 percent increased likelihood of reporting high career satisfaction (p.05). Among physicians trained in community hospital residency programs, lower evaluations were associated with 14.5 percent higher share of minority patients (p.05). Both skill measures were associated with practice type.There are associations between early career skill measures and career outcomes. In addition, minority patients are more likely to be treated by physicians with lower early career clinical skills measures than nonminority patients.

PURPOSE: To examine the association between physicians' cognitive skills and their performance on a composite measure of diabetes care that included process, outcome, and patient experience measures. METHOD: The sample was 676 physicians from the United States with time-limited certification in general internal medicine between 2005 and 2009. Scores from the American Board of Internal Medicine (ABIM) internal medicine maintenance of certification (MOC) examination were used to measure practicing physicians' cognitive skills (scores reflect fund of medical knowledge, diagnostic acumen, and clinical judgment). Practice performance was assessed using a diabetes composite measure aggregated from clinical and patient experience measures obtained from the ABIM Diabetes Practice Improvement Module. RESULTS: Using multiple regression analyses and controlling for physician and patient characteristics, MOC examination scores were significantly associated with the diabetes composite scores (β = .22, P < .001). The association was particularly stronger with intermediate outcomes than with process and patient experience measures. Performance in the endocrine disease content domain of the examination was more strongly associated with the diabetes composite scores (β = .19, P < .001) than the performance in other medical content domains (β = .06-.14). CONCLUSIONS: Physicians' cognitive skills significantly relate to their performance on a comprehensive composite measure for diabetes care. Although significant, the modest association suggests that there are unique aspects of physician competence captured by each assessment alone and that both must be considered when assessing a physician's ability to provide high-quality care.

Expanded abstract Citation Prasad M, Holmboe ES, Lipner RS, Hess BJ, Christie JD, Bellamy SL, Rubenfeld GD, Kahn JM. Clinical Protocols and Trainee Knowledge About Mechanical Ventilation. JAMA. 2011; 306(9):935-941. PubMed PMID: 21900133 This is available on http://www.pubmed.gov Background Clinical protocols are associated with improved patient outcomes; however, they may negatively affect medical education by removing trainees from clinical decision making. Methods Objective: To study the relationship between critical care training with mechanical ventilation protocols and subsequent knowledge about ventilator management. Design: A retrospective cohort equivalence study linking a national survey of mechanical ventilation protocol availability with knowledge about mechanical ventilation. Exposure to protocols was defined as high intensity if an intensive care unit had 2 or more protocols for at least 3 years and as low intensity if 0 or 1 protocol. Setting: Accredited US pulmonary and critical care fellowship programs. Subjects: First-time examinees of the American Board of Internal Medicine (ABIM) Critical Care Medicine Certification Examination in 2008 and 2009. Intervention: N/A Outcomes: Knowledge, measured by performance on examination questions specific to mechanical ventilation management, calculated as a mechanical ventilation score using item response theory. The score is standardized to a mean (SD) of 500 (100), and a clinically important difference is defined as 25. Variables included in adjusted analyses were birth country, residency training country, and overall first-attempt score on the ABIM Internal Medicine Certification Examination. Results The 90 of 129 programs (70%) responded to the survey. Seventy seven programs (86%) had protocols for ventilation liberation, 66 (73%) for sedation management, and 54 (60%) for lung-protective ventilation at the time of the survey. Eighty eight (98%) of these programs had trainees who completed the ABIM Critical Care Medicine Certification Examination, totaling 553 examinees. Of these 88 programs, 27 (31%) had 0 protocols, 19 (22%) had 1 protocol, 24 (27%) had 2 protocols, and 18 (20%) had 3 protocols for at least 3 years. 42 programs (48%) were classified as high intensity and 46 (52%) as low intensity, with 304 trainees (55%) and 249 trainees (45%), respectively. In bi-variable analysis, no difference in mean scores was observed in high-intensity (497; 95% CI, 486-507) vs low-intensity programs (497; 95% CI, 485-509). Mean difference was 0 (95% CI, -16 to 16), with a positive value indicating a higher score in the high-intensity group. In multivariable analyses, no association of training was observed in a high-intensity program with mechanical ventilation score (adjusted mean difference, -5.36; 95% CI, -20.7 to 10.0). Conclusions Among first-time ABIM Critical Care Medicine Certification Examination examinees, training in a high-intensity ventilator protocol environment compared with a low-intensity environment was not associated with worse performance on examination questions about mechanical ventilation management.

Much research has been devoted to addressing challenges in achieving reliable assessments of physicians’ clinical performance but less work has focused on whether valid and accurate classification decisions are feasible. This study used 957 physicians certified in internal medicine (IM) or a subspecialty, who completed the American Board of Internal Medicine (ABIM) Diabetes Practice Improvement Module (PIM). Ten clinical and two patient-experience measures were aggregated into a composite measure. The composite measure score was highly reliable (r = .91) and classification accuracy was high across the entire score scale (>0.90), which indicated that it is possible to differentiate high-performing and low-performing physicians. Physicians certified in endocrinology and those who scored higher on their IM certification examination had higher composite scores, providing some validity evidence. In summary, it is feasible to create a psychometrically robust composite measure of physicians’ clinical performance, specifically for the quality of care they provide to patients with diabetes.

A shortage of primary care physicians is expected, due in part to decreasing numbers of physicians entering general internal medicine (GIM). Practicing general internists may contribute to the shortage by leaving internal medicine (IM) for other careers in and out of medicine. To better understand mid-career attrition in IM. Mail survey to a national sample of internists originally certified by the American Board of Internal Medicine in GIM or an IM subspecialty during the years 1990 to 1995. Self-reported current status as working in IM, working in another medical or non-medical field, not currently working but plan to return, or retired; and career satisfaction. Nine percent of all internists in the 1990–1995 certification cohorts and a significantly larger proportion of general internists (17%) than IM subspecialists [(4%) P

Background The relationship between physicians' cognitive skill and the delivery of evidence-based processes of care is not well characterized.Therefore, we set out to determine associations between general internists' performance on the American Board of Internal Medicine maintenance of certification examination and the receipt of important processes of care by Medicare patients. Methods Physicians were grouped into quartiles based on their performance on the American Board of Internal Medicine examination. Hierarchical generalized linear models examined associations between examination scores and the receipt of processes of care by Medicare patients. The main outcome measures were the associations between diabetes care, using a composite measure of hemoglobin A 1c , and lipid testing and retinal screening, mammography, and lipid testing in patients with cardiovascular disease and the physician's performance on the American Board of Internal Medicine examination, adjusted for the number of Medicare patients with diabetes and cardiovascular disease in a physician's practice panel; frequency of visits; patient comorbidity, age, and ethnicity; and physician training history and type of practice. Results Physicians scoring in the top quartile were more likely to perform processes of care for diabetes (composite measure odds ratio [OR], 1.17; 95% confidence interval [CI], 1.07-1.27) and mammography screening (OR, 1.14; 95% CI, 1.08-1.21) than physicians in the lowest physician quartile, even after adjustment for multiple factors. There was no significant difference among the groups in lipid testing of patients with cardiovascular disease (OR, 1.00; 95% CI, 0.91-1.10). Conclusion Our findings suggest that physician cognitive skills, as measured by a maintenance of certification examination, are associated with higher rates of processes of care for Medicare patients.

Few studies have systematically and rigorously examined the quality of care provided in educational practice sites.The objectives of this study were to (1) describe the patient population cared for by trainees in internal medicine residency clinics; (2) assess the quality of preventive cardiology care provided to these patients; (3) characterize the practice-based systems that currently exist in internal medicine residency clinics; and (4) examine the relationships between quality, practice-based systems, and features of the program: size, type of program, and presence of an electronic medical record.This is a cross-sectional observational study.This study was conducted in 15 Internal Medicine residency programs (23 sites) throughout the USA.The participants included site champions at residency programs and 709 residents.Abstracted charts provided data about patient demographics, coronary heart disease risk factors, processes of care, and clinical outcomes. Patients completed surveys regarding satisfaction. Site teams completed a practice systems survey.Chart abstraction of 4,783 patients showed substantial variability across sites. On average, patients had between 3 and 4 of the 9 potential risk factors for coronary heart disease, and approximately 21% had at least 1 important barrier of care. Patients received an average of 57% (range, 30-77%) of the appropriate interventions. Reported satisfaction with care was high. Sites with an electronic medical record showed better overall information management (81% vs 27%) and better modes of communication (79% vs 43%).This study has provided insight into the current state of practice in residency sites including aspects of the practice environment and quality of preventive cardiology care delivered. Substantial heterogeneity among the training sites exists. Continuous measurement of the quality of care provided and a better understanding of the training environment in which this care is delivered are important goals for delivering high quality patient care.