Guide
What is the truth?
Source: Yimaitong Author: Daju This article is authorized by the author to be published by Yimaitong, please do not reprint without authorization.
There has always been a debate about whether a person who can take the exam means that he is more capable. Some people think that this is certainly the case, otherwise why are there so many talented people in elite schools, while ordinary schools are relatively low-key. However, some people feel that this is not the case, and there are many people with "high scores and low ability" and "low scores and high energy" in real life.
So what is the truth?
近段时间，JAMA发表一篇题为Associations of Internal Medicine Residency Milestone Ratings and Certification Examination Scores With Patient Outcomes 的论文，认为患者预后与医师考试成绩有关。
Examination ability = ability to see a doctor? They studied 6,898 physicians
The competency of U.S. internal medicine residents is assessed through milestone ratings and certification exams from the American Board of Internal Medicine (ABIM).
The Internal Medicine Milestone Rating is centered around 6 core competencies and is assessed through specific subcompetencies (Patient Care, Medical Knowledge, Practice-Based Learning and Improvement, System-Based Practice, Interpersonal and Communication Skills, and Professionalism) and is designed to provide comprehensive feedback on residency training effectiveness.
ABIM's certification exam is administered shortly after the completion of residency training and is designed to assess clinical judgment derived from medical knowledge. In contrast to the milestone ratings, the certification exam does not incorporate direct observations of residents caring for patients. However, the exam questions were designed by committees of different groups of practicing physicians to reflect actual clinical scenarios in which physicians are asked to make judgments about patient care.
Although it is important to assess the ability of newly trained physicians to practice independently, few studies have evaluated the relationship between internal medicine milestone ratings or ABIM's initial internal medicine certification exam scores and patient outcomes.
To explore this association, the study included 6,898 internal medicine residents who completed their third year of training between 2017 and 2019 with valid milestone ratings and ABIM initial internal medicine certification exam scores.
The evaluation indicators were 7-day mortality after admission and 7-day readmission rate after discharge. This period was chosen because it is more reflective of the process of care that occurs during hospitalization rather than the overall burden of disease or social determinants. In addition, 30-day mortality and readmission rates, length of hospital stay, and specialist consultation rates were also included in the observational indicators.
The independent variables are the quartile of the certification exam score and the milestone rating, including the overall core competency rating index, which is equal to the average of the milestone sub-competency ratings at the end of the residency period, which is divided into low, medium, high, and knowledge core competency indicators.
In terms of statistical analysis, the study design used pseudo-random assignment of patients and residents within the hospital and fully considered hospital-level quality differences by estimating correlation with independent multivariate linear regression for each outcome, including hospital fixed effects, which effectively compared outcomes between physicians within the same hospital.
Physician test scores may be associated with 7-day mortality and readmission rates in hospitalized patients
The results showed that among 455,120 hospitalized patients, the 7-day mortality and readmission rates were 3.5% (95% confidence interval, 3.4%-3.6%) and 5.6% (95% confidence interval, 5.5%-5.6%), respectively, and the 30-day mortality and readmission rates were 8.8% (95% confidence range, 8.7%-8.9%) and 16.6% (95% CI, 16.5%-16.7%), respectively. The mean length of hospital stay and the number of specialist consultations were 3.6 days (95% confidence interval, 3.6–3.6 days) and 1.01 days (95% confidence interval, 1.00–1.03), respectively. High or low ratings for overall or knowledge milestone core competencies are independent of the outcome indicators assessed. For example, a high or low overall core competency rating was not associated with a 2.7% increase in seven-day mortality (95% CI, -5.2% to 10.6%; P=.51）。 In contrast, the ABIM internal medicine certification exam was associated with inpatient outcomes, with a significant 8.0% reduction in 7-day mortality compared to the top quarter and bottom one-quarter of test scores (95% CI, −13.0% to −3.1%; P=0.002), the 7-day readmission rate was significantly reduced by 9.3% (95% CI, −13.0% to −5.7%; P<.001）。 For 30-day mortality, the correlation was -3.5% (95% CI -6.7% to -0.4%; P=0.03）。 Consultation rates were 2.4% higher (95% CI, 0.8%-3.9%; P<.003), but was not associated with length of hospital stay or 30-day readmission rate.
Thus, among newly trained residents, certification exam scores, rather than residency milestone ratings, were associated with improved outcomes for hospitalized patients.
The study also observed an important mismatch between ABIM Internal Medicine Certification Exam scores and core competency rating indicators. For example, in the category with the lowest overall core competency ratings, about two-thirds of physicians were not in the lowest quartile (64.3%) of internal medicine certification exam scores, while 15.3% were in the highest quartile.
The study also showed that higher test scores were associated with an increased frequency of specialist consultations, suggesting that high-achieving residents were able to make greater use of specialized care because they had a clear understanding of their own abilities and were therefore able to make better judgments when using specialist adjuvant therapy.
As the saying goes: "Knowing is knowing, not knowing is not knowing, and knowing is also knowing", the wisdom of our ancestors has also taught us clinicians a lesson, ask for more advice when encountering problems, and ask for more consultation if you don't know, which can not only improve yourself but also benefit patients.
Thus, among newly trained residents, certification test scores were associated with improved outcomes in hospitalized patients, suggesting that the formal inclusion of standardized tests in inpatient ratings may improve the effectiveness of residency outcomes. From this point of view, it is not unfounded for me and my top students to disagree with those students who did not pass the final examination of regular training but stayed in the hospital affiliated to the school.
Envious! People who are good at everything
Writing this, the author can't help but think of some sad memories when I was in school. When I was in graduate school, my mentor was a perfectionist, but she liked my sister so much that the rest of us were bubbling with sourness, but we couldn't do anything about it. When I was first unfamiliar with it, I just thought that my sister was the first in the master's examination, the first in the doctoral examination, and the 580 in the doctor's qualification examination. She may not be able to do it clinically. As a result, when we went to the clinical department for rotation, each department had a legend left by the senior sister.
I studied gastroscopy in the gastroscopy room for 3 months, but I did a stumbling job, just when I was about to regain my confidence and continue to stumble, the teacher said: "Your XX senior sister has studied for 2 months, the mirror is very smooth, and the report is very accurate, smart people really learn everything fast." "Ah...... The confidence I had so hard to hold up collapsed in an instant.
Just when you think that people are only more talented in medicine, it turns out that people can also play guitar, piano, and the kind that can perform in formal settings. So, don't use high scores and low grades as an excuse for bad performance, and admit that people with high scores do have stronger learning ability and clearer self-awareness.
Interaction at the end of the article: Do you think doctors who can take the exam have stronger clinical ability? Welcome to leave a message in the comment area~
Editor-in-charge|Yiyi Atay
Cover image source: Visual China
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