Certification and specialization: do they matter in the outcome of acute myocardial infarction?

PURPOSE: 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). METHOD: 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). RESULTS: 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. CONCLUSIONS: 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.

Recertification in internal medicine: a program of continuous professional development. Task Force on Recertification.

In 2000, the American Board of Internal Medicine (ABIM) introduced a second-generation recertification process that builds on the current knowledge-centered program by adding assessments of clinical and communication skills, clinical performance, and medical outcomes. The three-part process, called a program of continuous professional development, includes innovative self-evaluation exercises, documentation of essential knowledge, and confirmation of satisfactory qualifications and professional and community good standing. The program introduces the principles of continuous quality improvement; deemphasizes the summary nature of the traditional secure examination; and is designed to be a more continuous, less saltatory process for maintaining clinical competence. With the continuous professional development program, ABIM believes that it has taken a substantial step toward creating a recertification process that meets its goal of being valuable, doable, tolerable, and affordable" while maintaining the high standards expected of an accountable profession.

Examiner differences in the mini-CEX.

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

Future roles and training of internal medicine subspecialists. American Board of Internal Medicine Task Force on Subspecialty Internal Medicine.

While fellowship training programs are being reduced in size to better conform to societal needs, the training of subspecialist basic scientists and clinical investigators must be protected to ensure continued discovery and the scholarly application of knowledge to patient care. Fewer subspecialist clinicians must be appropriately trained to serve as consultants, as principal care providers, and as scholarly leaders and educators in their subspecialties. This article describes the recommendations of the American Board of Internal Medicine for subspecialty training. To encourage physicians to choose careers as investigators, overlapping but different training paths are delineated for subspecialist clinicians and investigators. More didactic coursework is recommended for both paths. To maximize the contribution of fewer subspecialists, it is essential to provide rigorous training that is appropriately relevant and realistically matched with career opportunities.

The mini-CEX (clinical evaluation exercise): a preliminary investigation.

OBJECTIVE: To gather preliminary data on the mini-CEX (clinical evaluation exercise), a device for assessing the clinical skills of residents. DESIGN: Evaluation of residents by faculty members using the mini-CEX. SETTING: 5 internal medicine training programs in Pennsylvania. PARTICIPANTS: 388 mini-CEX encounters involving 88 residents and 97 evaluators. MEASUREMENTS: A mini-CEX encounter consists of a single faculty member observing a resident while that resident conducts a focused history and physical examination in any of several settings. After asking the resident for a diagnosis and treatment plan, the faculty member rates the resident and provides educational feedback. The encounters are intended to be short (about 20 minutes) and to occur as a routine part of training so that each resident can be evaluated on several occasions by different faculty members. RESULTS: The encounters occurred in both inpatient and ambulatory settings and were longer than anticipated (median duration, 25 minutes). Residents saw either new or follow-up patients who collectively presented with a broad range of clinical problems. The median evaluator assessed two residents and was generally satisfied with the mini-CEX format; residents were even more satisfied with the format. The reproducibility of the mini-CEX is higher than that of the traditional CEX, and its measurement characteristics are similar to those of other test formats, such as standardized patients and standardized oral examinations. CONCLUSIONS: The mini-CEX assesses residents in a much broader range of clinical situations than the traditional CEX, has better reproducibility, and offers residents greater opportunity for observation and feedback by more than one faculty member and with more than one patient. On the other hand, the mini-CEX may be more difficult to administer because multiple encounters must be scheduled for each resident. Exclusive use of the mini-CEX also prevents residents from being observed while doing a complete history and physical examination. Given the promising results and measurement characteristics of the mini-CEX, however, the American Board of Internal Medicine encourages the use of this method in conjunction with or as an alternative to the traditional CEX.

Certification in internal medicine: 1989-1992.

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

A core component of the certification examination in internal medicine.

OBJECTIVE: 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.

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

OBJECTIVE: 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.