- Email: [email protected]
Recent trends in internal medicine education: A brief update
European Journal of Internal Medicine 25 (2014) 221–223
Contents lists available at ScienceDirect
European Journal of Internal Medicine journal homepage: www.elsevier.com/locate/ejim
Reflections in Internal Medicine
Recent trends in internal medicine education: A brief update Michael T. Flannery ⁎ 12901 Bruce B Downs Blvd., MDC Box 19 Room L1041, Tampa, FL 33612, United States
a r t i c l e
i n f o
Article history: Received 18 November 2013 Received in revised form 21 January 2014 Accepted 28 January 2014 Available online 20 February 2014 Keywords: Internal medicine American Board of Internal Medicine (ABIM) Accredited Council for Graduate Medical Information (ACGME) National Registry of Matching Programs (NRMP)
a b s t r a c t This perspective attempts to bring graduate medical offices, residency programs and medical students interested in categorical internal medicine (CIM) a brief update on the American Board of Internal Medicine (ABIM), Accreditation Council for Graduate Medical Education (ACGME) and the National Registry for Medical Programs (NRMP) changes for the past 3–5 years in the United States (US). The US model for certification and recertification may serve as a homogenous example for other countries. This model will be described so that there is an understanding of the importance of such changes in the American system and its effect on resident education. This is critical knowledge for both teachers and learners in internal medicine in preparation for a lifetime career and requirements for certification/credentialing for both programs and their residents/fellows. Data from the review indicate a small increase in the number of applicants but a concordant decrease in ABIM initial certification exams. Programs should well be aware of the new focus on outcomes via the Next Accreditation System (NAS) being put forth by the ACGME. © 2014 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.
1. Introduction to the US model for medical student/resident education Though the American system has conformity through legislation across its 50 states, it can appear quite complicated to students, residents and physicians from other countries. Starting at the medical student level, each student must complete the 4-year requirements for their school which must be accredited by the Liaison Committee for Medical Education (LCME) so that all schools meet the same LCME's educational requirements. In addition to the school's requirements, each medical student must take and pass two National Board of Medical Examiners (NBME) examinations over their 4 years. The first exam is taken and must be passed after year one and focuses on the first year of medical education i.e. basic sciences and the second exam is taken and must be passed in the fourth year and focus more on the student's clinical education. Next, each student must register with the National Registry for Medical Programs (NRMP) early in their fourth year no matter what residency he or she chooses to go into. In this system, programs rank students who interviewed with them and students separately rank their programs based on interest in attending that program. The NRMP then matches the students with the program in the spring of their fourth year. Previous to 3 years ago, students who did not match for whatever reason had to call programs with open spots hoping to obtain a residency position somewhere. Over the past 3 years the NRMP now uses a backup system (Supplemental Offer and Acceptance Program or
⁎ Tel.: +1 813 974 6443; fax: +1 813 905 9794. E-mail addresses: mfl[email protected], mfl[email protected].
SOAP) for unmatched students to match with programs with open positions. This has resulted in a far more organized approach for unmatched students and programs that are unfilled after the initial match. During whatever residency the students enter, they must take and pass a third national board exam (NBME) typically in their first year or two of residency. The NBME does allow students or residents to retake the exam if they fail. Once residents complete the requirements for their residency; they take a written certification exam for their discipline. For instance, after completing 3 years of residency in internal medicine, whether going into a subspecialty or directly into practice, each resident must take and pass the American Board of Internal Medicine's computerized certification exam. This computerized exam in internal medicine consists of approximately 220 questions given over 1 day at a local supervised testing center. We are advised that approximately 20 questions are new questions that are being statistically evaluated for future use and these questions will not be held against the resident in the final testing. Applicants may view a “blueprint” of the content questions from the ABIM website [1]. In order to be allowed to take the exam, their program director must fill out a competency based form for the ABIM. This focuses on the six major competencies: medical knowledge, patient care, interpersonal skills and communication, systems based practice, practice based improvement and professionalism. Residents are used to these competency evaluations and they are done after they complete every 30-day rotation and are reviewed directly with the program director every 6 months. Currently, these are ranked from a low of zero to a numerical high of 9. On the final rating, a deficiency represents any number three or less for which the ABIM will not let the resident sit for the exam. Results are usually available within 6 weeks of completion. Residents who fail the examination
0953-6205/$ – see front matter © 2014 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.ejim.2014.01.020
222
M.T. Flannery / European Journal of Internal Medicine 25 (2014) 221–223
after three attempts must complete a continuous medical education process as specified by the ABIM. Some residencies, particularly surgical disciplines and radiology, have boards that require a passed written examination and then an oral examination at a local center. In addition to initial certification, beginning in 1990, anyone certified after that date must undergo recertification after 10 years. That process has changed over the past 23 years to now include a requirement of 1) taking updated evidence-based take home tests on the web or mailed, typically 3 exams, which must be passed; 2) doing a practice improvement model (PIM) in your practice for which you can pick several diagnosis to choose from such as diabetes, hypertension, asthma etc. (you must involve at least 25 patients in your PIM who provide survey feedback directly to the ABIM) and subsequently report the outcomes, good or bad, of your PIM); and 3) take a local computerized 180-question (1-day) recertification exam for which you must pass as well. Once these requirements are met in internal medicine, you are given another 10 years of certification. Physicians initially certified after 1990 will most likely have to recertify 4–5 times in their practice lifetime. To not be board certified tremendously limits practice options as insurance companies, clinics and hospitals require certification. Those initially certified before 1990 are grandfathered in, something which much debated in the US. Practically all residencies must be accredited by the Accreditation Council on Graduate Medical Education (ACGME). The ACGME sets forth common program requirements developed by a national committee of excellence for that discipline. Many of the ACGME policies, such as work hour restrictions to 80 h per week, are set forth or encouraged by the US Congress based on evidence based data from the literature. Programs would be visited by an ACGME expert and based on meeting these requirements and direct feedback from current residents a certification would be given anywhere from probation to up to 6 years accreditation before another visit. Beginning in July 2014, the ACGME is moving to a “New Accreditation System” (NAS) that involves an annual review of a program's board passage rates, faculty and resident surveys (administered by email anonymously each spring with a required 70% response rate), procedure logs, an electronic report from each program director on each resident's competencies such as patient care, medical knowledge, professionalism, etc. The NAS, therefore, will now focus on the program's outcomes on an annual basis with periodic visitation every 10 years which conforms to other American education models. Another important component of NAS is a Clinical Learning Environment Review (CLER) visit approximately every 18 months to one of the program's affiliated hospitals. For instance, my program has three affiliated hospitals that will be visited over time. The focus of CLER is to meet with many stakeholders for each program such as the hospitals administrators, nursing, technologists and residents and attendings for that program over a period of a few days. Such meetings discuss patient safety, transitions of care, resident fatigue mitigation, quality improvement etc. Basically, questioning would focus on anything that would affect resident functioning and quality patient care. A final report would be given to the institutional head administrator (Designated Institutional Official or DIO) of graduate medical education (GME) for that system. The local GME office is directly responsible for every accredited program in its institutional network. Overall, in addition to program/hospital visits there is an institutional visit for overall accreditation. If the institution goes on probation for poor outcomes, then each accredited program (no matter what its individual status is) goes on probation as well. Therefore, there is significant work and planning in cooperation with the hospitals involved to ensure ACGME requirements are met so that a maximum status of 10 years of accreditation may be obtained before the next visit (Self Study Visit or SSV).
in 2012. This parallels the pass rate in 2000 of 86% before the upward trend of 6 years through 2007. The opposite is true for recertification examination that began in 2000. In 2000, the first time pass rate for recertification ranged from 68% in cardiac electrophysiology to 89% in pulmonary disease. By 2012, recertification first time pass rates varied from 80% in internal medicine to 98% in pulmonary disease. Therefore, while certification pass rates have declined roughly 10% points over the past 10 years, recertification first time pass rates have increased 5–10% points during the same time period. It is certainly reasonable to assume that recertification candidates having seen initial pass rates are preparing more thoroughly for their written component of the recertification process. The resident review committee for internal medicine announced, in 2012, that they were aware of the declining pass rates on initial certification during a review of the next accreditation system at the accredited council of graduate medical education meeting. No reasoning or hypothesis was specified for such a decline. The most likely reason is that the ABIM is returning to the average pass rate in the early 1990s given that there has been no decrease in students interested in internal medicine to date with the lower pass rates. The percentage breakdown of residents (US, AOA and IMG) has changed very little for internal medicine programs during this timeframe. One would suspect that such a decline was purposeful beginning in 2008 with a low of 84% first time certification pass rate in 2011. Many programs utilize some type of board preparation in addition to larger review sessions available across the country. The American Board of Internal Medicine website (www.abim.org/about/ examInfo/blueprint.aspx) has a board tutorial for review which can significantly guide initial certifiers; however, it is unknown how much this is utilized by candidates. There are a number of review papers that look at predictors in passing the certification or recertification exam [2–4]. 3. Accreditation Council for Graduate Medical Education [5] Internal medicine is one of the seven of the Phase I Next Accreditation System (NAS) programs along with pediatrics, emergency medicine, general surgery, orthopedic surgery, neurosurgery and urology. These programs were required to utilize the NAS as of July 2013. The focus of NAS is on outcomes such as board passage rate, scholarly activity, faculty/resident annual surveys, milestone (competency) development/usage and clinical learning environment review site visits (CLER visit). An obvious problem for internal medicine residency programs is the 80/80 rule. Eighty percent of the residents must take the examination over 3 years and 80% must pass. Certainly, the number of programs with b80% 3-year rolling pass rate will increase given the overall decrease in first time exam pass rates. Repeating the examination or waiting a year or so is associated with significant decrease in exam pass rates. While this is not usually listed as one of the common citations for core internal medicine residency program, it certainly may become a common citation with the current average pass rates. Phase II programs milestones (competencies) will be released in early 2014 and will be required by July of that year. Such milestones will be utilized by the clinical competency committee for each program, in addition to other outcomes measures such as evaluations, surveys, core/procedure logs etc. Similar to other large accreditation systems, self study visits will be scheduled every 10 years if there are significant problems. This will eliminate program information forms and allows for a more meaningful discussion of the program's outcomes. Whether these changes result in improved outcomes in program oversight remains to be seen. However, the focus on outcomes corresponds to what a program must focus on in its annual program review. 4. National Registry for Matching Programs [6]
2. American Board of Internal Medicine [1] Current certification rates demonstrate a decrease in performance with first time pass rates declining from a pass of 94% in 2007 to 85%
In the 2013 National Residency Matching Program (NRMP) 99.4% (highest in 30 years) of the 6277 positions in categorical internal medicine (CIM) often were filled. Fourteen programs, out of 393 programs,
M.T. Flannery / European Journal of Internal Medicine 25 (2014) 221–223
went unfilled. In 2013, 49.9% (lowest in 30 years) of the internal medicine positions were filled by US seniors. This was down from a high of 57.4% US seniors in 2011. For CIM programs, osteopathic graduates represented 6.6% of the matched applicants, 13.8% were US internal medicine IMGs and 27.2% were non-US IMGs. Over the past 5 years, the number of positions in CIM has risen with an annual growth rate of approximately 3–6%. This seems to correlate with the interest in jobs as hospitalists which allows shift work, something favored by residents. The number of US and all the independent applicants has also increased over the past 5 years, US 11.8%, US IMGs 50.3% and osteopathic 33%. For CIM, 2.5% of US applicants and 41.7% of independent applicants went unmatched. The average number of ranked applicants per position, needed to fill all positions within CIM, was 5.7 down from 6.4 in 2012 but similar to 5.6 in 2009. In 2013, 12 CIM programs participated in the Supplemented Offer and Acceptance Program (SOAP) with 31 positions offered. Ten of the 11 programs filled 29 of their positions. This was down from the 17 programs offering 40 positions in 2012. US seniors accepted the majority of SOAP positions overall in (68.7%) 2013. At the conclusion of SOAP overall, 93.5% of the positions had been filled. Diversity in internal medicine is typically hailed as a positive aspect for programs as various minds come together with many backgrounds and different perspectives on the clinical exposures they have encountered. It will be important not only to continue the increase in internal medicine positions but also to focus on program diversity as one on internal medicine's strengths. 5. Summary While this update has demonstrated a near 10% point decrease in initial board certification for internal medicine, there are ways to enhance preparation, utilizing internal program board reviews as well as adjunct review materials and the ABIM's board tutorial gives appropriate guidance and support to successfully pass their certification exam on the first try. Programs and candidates must be aware of the 80% 3-year rolling requirement to avoid non-certification and program citation. Internal medicine programs must cautiously approach the Next Accreditation System and its internal focus on outcomes and positive dialogue. For those programs that follow the ACGME guidelines, the majority will have positive self study visits with good feedback to improve the residents' clinical and educational experience. Indeed, the ACGME expects that with the NAS model 75% of programs will receive accreditation with/without commendation [5]. The NAS will offer programs the opportunity, in concept, to think and act more creatively regarding their program in conjunction with key stakeholders such as the hospital's chief medical officers (CMO), designated institutional official (DIO), program directors/program coordinators, fellows and residents. Beta testing with the Clinical Learning Environment Review
223
(CLER) has demonstrated good feedback for the DIOs with feasible suggestions from the visiting team. Time will tell whether the NAS will be an improvement compared to our former methods of accreditation. Focusing on quality program outcomes is a good first start. Finally, the NRMP data continue to show increasing numbers of candidates interested in internal medicine or one of its many subspecialties for a career choice. The data also highlight the significant diversity of applicants from US seniors, osteopathic, US IMGs and non-US IMGs. Such diversity both in residents and clinically has a very positive effect on the strength of a given program. Maintaining this diversity in the setting of increased competition will be crucial for programs to balance. Close monitoring of yearly data from the ABIM, ACGME and NRMP is essential for program educators and residents/fellows to follow trends that may affect their program outcomes; something the ACGME will be monitoring as well. Funding None. Learning points • Given a 10% decrease in initial internal medicine board certification exams, programs must better prepare their residents in order to meet the 80% 3 year rolling pass rate requirement. • The new accreditation system of the Accreditation Council for Graduate Medical Education will focus on program outcomes and involvement of hospital partners. • The National Registry for Matching Programs yearly data continues to show an increase in the number and diversity of internal medicine applicants. Conflict of interests The authors state that they have no conflicts of interest. References [1] ABIM.org. [accessed 11–18–13]. [2] Babbott SF, Beasley BW, Hinchey KT, Blotzer JW, Holmboe ES. The predictive validity of the internal medicine in-training examination. Am J Med 2007;120:735–40. [3] Reed DA, West CP, Holmboe ES, Halvorsen A, Lipner RS, Jacobs C, et al. Relationship of electronic medical knowledge resource use and practice characteristics with internal medicine maintenance of certification examination scores. J Gen Intern Med 2012;8:917–23. [4] Brateanu A, Changhong Y, Kattan MW, Olender J, Nielsen C. A nomogram to predict the probability of passing the American Board of Internal Medicine Examination. Med Educ Online 2012;17:1–7. [5] ACGME.org. [accessed 11–18–13]. [6] NRMP.org/data/resultsanddata2013.pdf. [accessed 11–18–13].
Contents lists available at ScienceDirect
European Journal of Internal Medicine journal homepage: www.elsevier.com/locate/ejim
Reflections in Internal Medicine
Recent trends in internal medicine education: A brief update Michael T. Flannery ⁎ 12901 Bruce B Downs Blvd., MDC Box 19 Room L1041, Tampa, FL 33612, United States
a r t i c l e
i n f o
Article history: Received 18 November 2013 Received in revised form 21 January 2014 Accepted 28 January 2014 Available online 20 February 2014 Keywords: Internal medicine American Board of Internal Medicine (ABIM) Accredited Council for Graduate Medical Information (ACGME) National Registry of Matching Programs (NRMP)
a b s t r a c t This perspective attempts to bring graduate medical offices, residency programs and medical students interested in categorical internal medicine (CIM) a brief update on the American Board of Internal Medicine (ABIM), Accreditation Council for Graduate Medical Education (ACGME) and the National Registry for Medical Programs (NRMP) changes for the past 3–5 years in the United States (US). The US model for certification and recertification may serve as a homogenous example for other countries. This model will be described so that there is an understanding of the importance of such changes in the American system and its effect on resident education. This is critical knowledge for both teachers and learners in internal medicine in preparation for a lifetime career and requirements for certification/credentialing for both programs and their residents/fellows. Data from the review indicate a small increase in the number of applicants but a concordant decrease in ABIM initial certification exams. Programs should well be aware of the new focus on outcomes via the Next Accreditation System (NAS) being put forth by the ACGME. © 2014 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.
1. Introduction to the US model for medical student/resident education Though the American system has conformity through legislation across its 50 states, it can appear quite complicated to students, residents and physicians from other countries. Starting at the medical student level, each student must complete the 4-year requirements for their school which must be accredited by the Liaison Committee for Medical Education (LCME) so that all schools meet the same LCME's educational requirements. In addition to the school's requirements, each medical student must take and pass two National Board of Medical Examiners (NBME) examinations over their 4 years. The first exam is taken and must be passed after year one and focuses on the first year of medical education i.e. basic sciences and the second exam is taken and must be passed in the fourth year and focus more on the student's clinical education. Next, each student must register with the National Registry for Medical Programs (NRMP) early in their fourth year no matter what residency he or she chooses to go into. In this system, programs rank students who interviewed with them and students separately rank their programs based on interest in attending that program. The NRMP then matches the students with the program in the spring of their fourth year. Previous to 3 years ago, students who did not match for whatever reason had to call programs with open spots hoping to obtain a residency position somewhere. Over the past 3 years the NRMP now uses a backup system (Supplemental Offer and Acceptance Program or
⁎ Tel.: +1 813 974 6443; fax: +1 813 905 9794. E-mail addresses: mfl[email protected], mfl[email protected].
SOAP) for unmatched students to match with programs with open positions. This has resulted in a far more organized approach for unmatched students and programs that are unfilled after the initial match. During whatever residency the students enter, they must take and pass a third national board exam (NBME) typically in their first year or two of residency. The NBME does allow students or residents to retake the exam if they fail. Once residents complete the requirements for their residency; they take a written certification exam for their discipline. For instance, after completing 3 years of residency in internal medicine, whether going into a subspecialty or directly into practice, each resident must take and pass the American Board of Internal Medicine's computerized certification exam. This computerized exam in internal medicine consists of approximately 220 questions given over 1 day at a local supervised testing center. We are advised that approximately 20 questions are new questions that are being statistically evaluated for future use and these questions will not be held against the resident in the final testing. Applicants may view a “blueprint” of the content questions from the ABIM website [1]. In order to be allowed to take the exam, their program director must fill out a competency based form for the ABIM. This focuses on the six major competencies: medical knowledge, patient care, interpersonal skills and communication, systems based practice, practice based improvement and professionalism. Residents are used to these competency evaluations and they are done after they complete every 30-day rotation and are reviewed directly with the program director every 6 months. Currently, these are ranked from a low of zero to a numerical high of 9. On the final rating, a deficiency represents any number three or less for which the ABIM will not let the resident sit for the exam. Results are usually available within 6 weeks of completion. Residents who fail the examination
0953-6205/$ – see front matter © 2014 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.ejim.2014.01.020
222
M.T. Flannery / European Journal of Internal Medicine 25 (2014) 221–223
after three attempts must complete a continuous medical education process as specified by the ABIM. Some residencies, particularly surgical disciplines and radiology, have boards that require a passed written examination and then an oral examination at a local center. In addition to initial certification, beginning in 1990, anyone certified after that date must undergo recertification after 10 years. That process has changed over the past 23 years to now include a requirement of 1) taking updated evidence-based take home tests on the web or mailed, typically 3 exams, which must be passed; 2) doing a practice improvement model (PIM) in your practice for which you can pick several diagnosis to choose from such as diabetes, hypertension, asthma etc. (you must involve at least 25 patients in your PIM who provide survey feedback directly to the ABIM) and subsequently report the outcomes, good or bad, of your PIM); and 3) take a local computerized 180-question (1-day) recertification exam for which you must pass as well. Once these requirements are met in internal medicine, you are given another 10 years of certification. Physicians initially certified after 1990 will most likely have to recertify 4–5 times in their practice lifetime. To not be board certified tremendously limits practice options as insurance companies, clinics and hospitals require certification. Those initially certified before 1990 are grandfathered in, something which much debated in the US. Practically all residencies must be accredited by the Accreditation Council on Graduate Medical Education (ACGME). The ACGME sets forth common program requirements developed by a national committee of excellence for that discipline. Many of the ACGME policies, such as work hour restrictions to 80 h per week, are set forth or encouraged by the US Congress based on evidence based data from the literature. Programs would be visited by an ACGME expert and based on meeting these requirements and direct feedback from current residents a certification would be given anywhere from probation to up to 6 years accreditation before another visit. Beginning in July 2014, the ACGME is moving to a “New Accreditation System” (NAS) that involves an annual review of a program's board passage rates, faculty and resident surveys (administered by email anonymously each spring with a required 70% response rate), procedure logs, an electronic report from each program director on each resident's competencies such as patient care, medical knowledge, professionalism, etc. The NAS, therefore, will now focus on the program's outcomes on an annual basis with periodic visitation every 10 years which conforms to other American education models. Another important component of NAS is a Clinical Learning Environment Review (CLER) visit approximately every 18 months to one of the program's affiliated hospitals. For instance, my program has three affiliated hospitals that will be visited over time. The focus of CLER is to meet with many stakeholders for each program such as the hospitals administrators, nursing, technologists and residents and attendings for that program over a period of a few days. Such meetings discuss patient safety, transitions of care, resident fatigue mitigation, quality improvement etc. Basically, questioning would focus on anything that would affect resident functioning and quality patient care. A final report would be given to the institutional head administrator (Designated Institutional Official or DIO) of graduate medical education (GME) for that system. The local GME office is directly responsible for every accredited program in its institutional network. Overall, in addition to program/hospital visits there is an institutional visit for overall accreditation. If the institution goes on probation for poor outcomes, then each accredited program (no matter what its individual status is) goes on probation as well. Therefore, there is significant work and planning in cooperation with the hospitals involved to ensure ACGME requirements are met so that a maximum status of 10 years of accreditation may be obtained before the next visit (Self Study Visit or SSV).
in 2012. This parallels the pass rate in 2000 of 86% before the upward trend of 6 years through 2007. The opposite is true for recertification examination that began in 2000. In 2000, the first time pass rate for recertification ranged from 68% in cardiac electrophysiology to 89% in pulmonary disease. By 2012, recertification first time pass rates varied from 80% in internal medicine to 98% in pulmonary disease. Therefore, while certification pass rates have declined roughly 10% points over the past 10 years, recertification first time pass rates have increased 5–10% points during the same time period. It is certainly reasonable to assume that recertification candidates having seen initial pass rates are preparing more thoroughly for their written component of the recertification process. The resident review committee for internal medicine announced, in 2012, that they were aware of the declining pass rates on initial certification during a review of the next accreditation system at the accredited council of graduate medical education meeting. No reasoning or hypothesis was specified for such a decline. The most likely reason is that the ABIM is returning to the average pass rate in the early 1990s given that there has been no decrease in students interested in internal medicine to date with the lower pass rates. The percentage breakdown of residents (US, AOA and IMG) has changed very little for internal medicine programs during this timeframe. One would suspect that such a decline was purposeful beginning in 2008 with a low of 84% first time certification pass rate in 2011. Many programs utilize some type of board preparation in addition to larger review sessions available across the country. The American Board of Internal Medicine website (www.abim.org/about/ examInfo/blueprint.aspx) has a board tutorial for review which can significantly guide initial certifiers; however, it is unknown how much this is utilized by candidates. There are a number of review papers that look at predictors in passing the certification or recertification exam [2–4]. 3. Accreditation Council for Graduate Medical Education [5] Internal medicine is one of the seven of the Phase I Next Accreditation System (NAS) programs along with pediatrics, emergency medicine, general surgery, orthopedic surgery, neurosurgery and urology. These programs were required to utilize the NAS as of July 2013. The focus of NAS is on outcomes such as board passage rate, scholarly activity, faculty/resident annual surveys, milestone (competency) development/usage and clinical learning environment review site visits (CLER visit). An obvious problem for internal medicine residency programs is the 80/80 rule. Eighty percent of the residents must take the examination over 3 years and 80% must pass. Certainly, the number of programs with b80% 3-year rolling pass rate will increase given the overall decrease in first time exam pass rates. Repeating the examination or waiting a year or so is associated with significant decrease in exam pass rates. While this is not usually listed as one of the common citations for core internal medicine residency program, it certainly may become a common citation with the current average pass rates. Phase II programs milestones (competencies) will be released in early 2014 and will be required by July of that year. Such milestones will be utilized by the clinical competency committee for each program, in addition to other outcomes measures such as evaluations, surveys, core/procedure logs etc. Similar to other large accreditation systems, self study visits will be scheduled every 10 years if there are significant problems. This will eliminate program information forms and allows for a more meaningful discussion of the program's outcomes. Whether these changes result in improved outcomes in program oversight remains to be seen. However, the focus on outcomes corresponds to what a program must focus on in its annual program review. 4. National Registry for Matching Programs [6]
2. American Board of Internal Medicine [1] Current certification rates demonstrate a decrease in performance with first time pass rates declining from a pass of 94% in 2007 to 85%
In the 2013 National Residency Matching Program (NRMP) 99.4% (highest in 30 years) of the 6277 positions in categorical internal medicine (CIM) often were filled. Fourteen programs, out of 393 programs,
M.T. Flannery / European Journal of Internal Medicine 25 (2014) 221–223
went unfilled. In 2013, 49.9% (lowest in 30 years) of the internal medicine positions were filled by US seniors. This was down from a high of 57.4% US seniors in 2011. For CIM programs, osteopathic graduates represented 6.6% of the matched applicants, 13.8% were US internal medicine IMGs and 27.2% were non-US IMGs. Over the past 5 years, the number of positions in CIM has risen with an annual growth rate of approximately 3–6%. This seems to correlate with the interest in jobs as hospitalists which allows shift work, something favored by residents. The number of US and all the independent applicants has also increased over the past 5 years, US 11.8%, US IMGs 50.3% and osteopathic 33%. For CIM, 2.5% of US applicants and 41.7% of independent applicants went unmatched. The average number of ranked applicants per position, needed to fill all positions within CIM, was 5.7 down from 6.4 in 2012 but similar to 5.6 in 2009. In 2013, 12 CIM programs participated in the Supplemented Offer and Acceptance Program (SOAP) with 31 positions offered. Ten of the 11 programs filled 29 of their positions. This was down from the 17 programs offering 40 positions in 2012. US seniors accepted the majority of SOAP positions overall in (68.7%) 2013. At the conclusion of SOAP overall, 93.5% of the positions had been filled. Diversity in internal medicine is typically hailed as a positive aspect for programs as various minds come together with many backgrounds and different perspectives on the clinical exposures they have encountered. It will be important not only to continue the increase in internal medicine positions but also to focus on program diversity as one on internal medicine's strengths. 5. Summary While this update has demonstrated a near 10% point decrease in initial board certification for internal medicine, there are ways to enhance preparation, utilizing internal program board reviews as well as adjunct review materials and the ABIM's board tutorial gives appropriate guidance and support to successfully pass their certification exam on the first try. Programs and candidates must be aware of the 80% 3-year rolling requirement to avoid non-certification and program citation. Internal medicine programs must cautiously approach the Next Accreditation System and its internal focus on outcomes and positive dialogue. For those programs that follow the ACGME guidelines, the majority will have positive self study visits with good feedback to improve the residents' clinical and educational experience. Indeed, the ACGME expects that with the NAS model 75% of programs will receive accreditation with/without commendation [5]. The NAS will offer programs the opportunity, in concept, to think and act more creatively regarding their program in conjunction with key stakeholders such as the hospital's chief medical officers (CMO), designated institutional official (DIO), program directors/program coordinators, fellows and residents. Beta testing with the Clinical Learning Environment Review
223
(CLER) has demonstrated good feedback for the DIOs with feasible suggestions from the visiting team. Time will tell whether the NAS will be an improvement compared to our former methods of accreditation. Focusing on quality program outcomes is a good first start. Finally, the NRMP data continue to show increasing numbers of candidates interested in internal medicine or one of its many subspecialties for a career choice. The data also highlight the significant diversity of applicants from US seniors, osteopathic, US IMGs and non-US IMGs. Such diversity both in residents and clinically has a very positive effect on the strength of a given program. Maintaining this diversity in the setting of increased competition will be crucial for programs to balance. Close monitoring of yearly data from the ABIM, ACGME and NRMP is essential for program educators and residents/fellows to follow trends that may affect their program outcomes; something the ACGME will be monitoring as well. Funding None. Learning points • Given a 10% decrease in initial internal medicine board certification exams, programs must better prepare their residents in order to meet the 80% 3 year rolling pass rate requirement. • The new accreditation system of the Accreditation Council for Graduate Medical Education will focus on program outcomes and involvement of hospital partners. • The National Registry for Matching Programs yearly data continues to show an increase in the number and diversity of internal medicine applicants. Conflict of interests The authors state that they have no conflicts of interest. References [1] ABIM.org. [accessed 11–18–13]. [2] Babbott SF, Beasley BW, Hinchey KT, Blotzer JW, Holmboe ES. The predictive validity of the internal medicine in-training examination. Am J Med 2007;120:735–40. [3] Reed DA, West CP, Holmboe ES, Halvorsen A, Lipner RS, Jacobs C, et al. Relationship of electronic medical knowledge resource use and practice characteristics with internal medicine maintenance of certification examination scores. J Gen Intern Med 2012;8:917–23. [4] Brateanu A, Changhong Y, Kattan MW, Olender J, Nielsen C. A nomogram to predict the probability of passing the American Board of Internal Medicine Examination. Med Educ Online 2012;17:1–7. [5] ACGME.org. [accessed 11–18–13]. [6] NRMP.org/data/resultsanddata2013.pdf. [accessed 11–18–13].