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Internal medicine board scores and resident duty hour reform.


Silber JH, Small D, Bosk CL, Volpp KG. — University of Pennsylvania

Romano PS. — University of California, Davis

Itani KMF. — Veterans Administration Boston Health Care System and Boston University

Rosen AK. — Boston University

Lipner RS. — American Board of Internal Medicine

Presented: AcademyHealth Annual Research Meeting, June 2012

Research Objective: In July 2003, the Accreditation Council for Graduate Medical Education (ACGME) introduced the 80-hour work week for U.S. residency training. This represented a profound change in resident education through a reduction of the work week, which averaged between 90-120 hours prior to reform to a maximum of 80 hours after reform, and limited the number of consecutive hours that could be worked by a resident to no more than 24 continuous hours, with an additional 6 hours for education and transfer of care. Though motivated by a desire to reduce medical errors, it was also recognized that the new regulations might improve resident quality of life and educational performance. The objective of this study was to determine whether this change affected educational achievement as reflected by written board scores for internal medicine residents.

Study Design: A merged dataset of the American Board of Internal Medicine (ABIM) Internal Medicine Certification Examination and the National Medical Board of Medical Examiners (NMBE) USMLE Step 2 Clinical Knowledge test scores. Using linear regression, the dependent variable was ABIM certification exam score; the independent variables included demographics (age, sex, race, foreign medical school graduate status), plus the Step 2 exam score of each resident and his or her residency program. The coefficient on the variable denoting the year each resident started residency, with year 2000 as the reference group (a cohort unexposed to the reform) provided the estimated effect of reform exposure on ABIM exam performance.

Population Studied: Cohorts of residents starting Post Graduate Year 1 (PGY1) training in 2000 were compared annually to those starting in 2001 through 2005. These residents came from 418 residency programs with a mean of 13.6 trainees per program taking the ABIM certification exam each year.

Principal Findings: A total of 33,483 residents took the Step 2 and the ABIM certification exams over the 6 annual PGY1 cohorts. Adjusting for demographics, program and Step 2 exam score, the model predicted nearly half of the variation in ABIM certification exam scores (R2 = 0.44). The mean ABIM certification exam score for the unexposed cohort that completed residency before the reform, the PGY1 2000 cohort, was 491 (SD = 85). The adjusted mean differences in scores between PGY1 cohorts starting in 2001, 2002, 2003, 2004 and 2005 versus 2000 were only -5.8 (95% CI = -8.1, -3.6), -3.7 (-6.1, -1.2), 2.6 (0.4, 4.8), 11.2 (8.9, 13.4) and 11.4 (9.1, 13.7) points respectively (none exceeding a fifth of a standard deviation).

Conclusions: The introduction of the duty hour reforms of 2003 did not appear to meaningfully affect educational achievement for the subsequent internal medicine specialty board examinations.

Implications for Policy, Delivery or Practice: The 2003 duty hour reforms had little effect on board scores. For internal medicine residents, it appears that the reduced time learning in the hospital was counterbalanced by other improved or more effective learning behaviors. Whether these results apply to other specialty residents' board scores, or whether these results will remain stable after the newest ACGME regulatory change in 2011, remains to be determined.

For more information about this presentation, please contact Research@abim.org