Reported Pediatrics Milestones (Mostly) Measure Program, Not Learner Performance.

PURPOSE: Semiannually, U.S. pediatrics residency programs report resident milestone levels to the Accreditation Council for Graduate Medical Education (ACGME). The Pediatrics Milestones Assessment Collaborative (PMAC, consisting of the National Board of Medical Examiners, American Board of Pediatrics, and Association of Pediatric Program Directors) developed workplace-based assessments of 2 inferences: readiness to serve as an intern with a supervisor present (D1) and readiness to care for patients with a supervisor nearby in the pediatric inpatient setting (D2). The authors compared learner and program variance in PMAC scores with ACGME milestones. METHOD: The authors examined sources of variance in PMAC scores and milestones between November 2015 and May 2017 of 181 interns at 8 U.S. pediatrics residency programs using random effects models with program, competency, learner, and program × competency components. RESULTS: Program-related milestone variance was substantial (54% D1, 68% D2), both in comparison to learner milestone variance (22% D1, 14% D2) and program variance in the PMAC scores (12% D1, 10% D2). In contrast, learner variance represented 44% (D1) or 26% (D2) of variance in PMAC scores. Within programs, PMAC scores were positively correlated with milestones for all but one competency. CONCLUSIONS: PMAC assessments provided scores with little program-specific variance and were more sensitive to differences in learners within programs compared with milestones. Milestones reflected greater differences by program than by learner. This may represent program-based differences in intern performance or in use of milestones as a reporting scale. Comparing individual learner milestones without adjusting for programs is problematic.

Evaluating Validity Evidence for USMLE Step 2 Clinical Skills Data Gathering and Data Interpretation Scores: Does Performance Predict History-Taking and Physical Examination Ratings for First-Year Internal Medicine Residents?

PURPOSE: To add to the small body of validity research addressing whether scores from performance assessments of clinical skills are related to performance in supervised patient settings, the authors examined relationships between United States Medical Licensing Examination (USMLE) Step 2 Clinical Skills (CS) data gathering and data interpretation scores and subsequent performance in history taking and physical examination in internal medicine residency training. METHOD: The sample included 6,306 examinees from 238 internal medicine residency programs who completed Step 2 CS for the first time in 2005 and whose performance ratings from their first year of residency training were available. Hierarchical linear modeling techniques were used to examine the relationships among Step 2 CS data gathering and data interpretation scores and history-taking and physical examination ratings. RESULTS: Step 2 CS data interpretation scores were positively related to both history-taking and physical examination ratings. Step 2 CS data gathering scores were not related to either history-taking or physical examination ratings after other USMLE scores were taken into account. CONCLUSIONS: Step 2 CS data interpretation scores provide useful information for predicting subsequent performance in history taking and physical examination in supervised practice and thus provide validity evidence for their intended use as an indication of readiness to enter supervised practice. The results show that there is less evidence to support the usefulness of Step 2 CS data gathering scores. This study provides important information for practitioners interested in Step 2 CS specifically or in performance assessments of medical students' clinical skills more generally.

The relationship between communication scores from the USMLE Step 2 Clinical Skills examination and communication ratings for first-year internal medicine residents.

PURPOSE: This study extends available evidence about the relationship between scores on the Step 2 Clinical Skills (CS) component of the United States Medical Licensing Examination and subsequent performance in residency. It focuses on the relationship between Step 2 CS communication and interpersonal skills scores and communication skills ratings that residency directors assign to residents in their first postgraduate year of internal medicine training. It represents the first large-scale evaluation of the extent to which Step 2 CS communication and interpersonal skills scores can be extrapolated to examinee performance in supervised practice. METHOD: Hierarchical linear modeling techniques were used to examine the relationships among examinee characteristics, residency program characteristics, and residency-director-provided ratings. The sample comprised 6,306 examinees from 238 internal medicine residency programs who completed Step 2 CS for the first time in 2005 and received ratings during their first year of internal medicine residency training. RESULTS: Although the relationship is modest, Step 2 CS communication and interpersonal skills scores predict communication skills ratings for first-year internal medicine residents after accounting for other factors. CONCLUSIONS: The results of this study make a reasonable case that Step 2 CS communication and interpersonal skills scores provide useful information for predicting the level of communication skill that examinees will display in their first year of internal medicine residency training. This finding demonstrates some level of extrapolation from the testing context to behavior in supervised practice, thus providing validity-related evidence for using Step 2 CS communication and interpersonal skills scores in high-stakes decisions.

What new residents do during their initial months of training.

BACKGROUND: Studies completed over the past decade suggest the presence of a gap between what students learn during medical school and their clinical responsibilities as first-year residents. The purpose of this survey was to verify on a large scale the responsibilities of residents during their initial months of training. METHOD: Practice analysis surveys were mailed in September 2009 to 1,104 residency programs for distribution to an estimated 8,793 first-year residents. Surveys were returned by 3,003 residents from 672 programs; 2,523 surveys met inclusion criteria and were analyzed. RESULTS: New residents performed a wide range of activities, from routine but important communications (obtain informed consent) to complex procedures (thoracentesis), often without the attending physician present or otherwise involved. CONCLUSIONS: Medical school curricula and the content of competence assessments prior to residency should consider more thorough coverage of the complex knowledge and skills required early in residency.

Validity evidence for USMLE examination cut scores: results of a large-scale survey.

PURPOSE: This research examined the credibility of the cut scores used to make pass/fail decisions on United States Medical Licensing Examination (USMLE) Step 1, Step 2 Clinical Knowledge, and Step 3. METHOD: Approximately 15,000 members of nine constituency groups were asked their opinions about (1) current initial and ultimate fail rates and (2) the highest acceptable, lowest acceptable, and optimal initial and ultimate fail rates. RESULTS: Initial fail rates were generally viewed as appropriate; more variability was associated with ultimate fail rates. Actual fail rates for each examination across recent years fell within the range that respondents considered acceptable. CONCLUSIONS: Results provide important evidence to support the appropriateness of the cut scores used to make classification decisions for USMLE examinations. This evidence is viewed as part of the overall validity argument for decisions based on USMLE scores.

Gathering evidence of external validity for the Foundations of Medicine examination: a collaboration between the National Board of Medical Examiners and the University of Minho.

BACKGROUND: To gather evidence of external validity for the Foundations of Medicine (FOM) examination by assessing the relationship between its subscores and local grades for a sample of Portuguese medical students. METHOD: Correlations were computed between six FOM subscores and nine Minho University grades for a sample of 90 medical students. A canonical correlation analysis was run between FOM and Minho measures. RESULTS: Moderate correlations were noted between FOM subscores and Minho grades, ranging from -0.02 to 0.53. One canonical correlation was statistically significant. The FOM variate accounted for 44% of variance in FOM subscores and 22% of variance in Minho end-of-year grades. The Minho canonical variate accounted for 34% of variance in Minho grades and 17% of the FOM subscore variances. CONCLUSIONS: The FOM examination seems to supplement local assessments by targeting constructs not currently measured. Therefore, it may contribute to a more comprehensive assessment of basic and clinical sciences knowledge.