Assessment in the context of licensure and certification.

Over the past 25 years, three major forces have had a significant influence on licensure and certification: the shift in focus from educational process to educational outcomes, the increasing recognition of the need for learning and assessment throughout a physician's career, and the changes in technology and psychometrics that have opened new vistas for assessment. These forces have led to significant changes in assessment for licensure and certification. To respond to these forces, licensure and certification programs have improved the ways in which their examinations are constructed, scored, and delivered. In particular, we note the introduction of adaptive testing; automated item creation, scoring, and test assembly; assessment engineering; and data forensics. Licensure and certification programs have also expanded their repertoire of assessments with the rapid development and adoption of simulation and workplace-based assessment. Finally, they have invested in research intended to validate their programs in four ways: (a) the acceptability of the program to stakeholders, (b) the extent to which stakeholders are encouraged to learn and improve, (c) the extent to which there is a relationship between performance in the programs and external measures, and (d) the extent to which there is a relationship between performance as measured by the assessment and performance in practice. Over the past 25 years, changes in licensure and certification have been driven by the educational outcomes movement, the need for lifelong learning, and advances in technology and psychometrics. Over the next 25 years, we expect these forces to continue to exert pressure for change which will lead to additional improvement and expansion in examination processes, methods of assessment, and validation research.

The subspecialization rate of third year internal medicine residents from 1992 through 1998.

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