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Design and Participants: This retrospective cohort analysis examined the relationships between internal medicine milestone ratings and the American Board of Internal Medicine’s initial certification examination score with hospital outcomes among Medicare fee-for-service beneficiaries treated by newly trained internists practicing as hospitalists. Outcomes included 7-day mortality and readmission rates, 30-day mortality and readmission rates, length of stay, and subspecialist consultation frequency. Analyses accounted for hospital fixed effects and adjusted for patient characteristics, physician years of experience, and year. Multivariate linear regression was used.
Results: Analyzed hospitalists (N=6,898) finished training between 2016 and 2018. Among 455,120 hospitalizations, patients were aged median 79 years (IQR=73-86); 57% female; and 1.9% Asian, 9.8% Black, 4.6% Hispanic, and 82% White. Seven-day mortality and readmission rates were 3.5% (95% CI=3.4%-3.6%) and 5.6% (5.5%-5.6%), and 30-day mortality and readmission rates were 8.8% (8.7%-8.9%) and 17% (16.5%-16.7%). Length of stay and number of specialty consultations were mean 3.6 days (3.6-3.6) and 1.0 (1.0-1.0). High vs low overall or knowledge milestone core competency ratings were associated with no significant outcome measures. For example, high vs low overall core competency ratings were associated with a nonsignificant 2.7% increase in 7-day mortality (−5.2% to 11%). However, top vs bottom examination quartile was associated with a 8.0% reduction in 7-day mortality (−13% to −3.1%) and 9.3% reduction in 7-day readmission (−13 to −5.7%). For 30-day mortality, this association was −3.5% (−6.7% to −0.4%). Top vs bottom examination quartile was associated with 2.4% more consultations (0.8%-3.9%) but was not associated with length of stay or 30-day readmission.
Commentary: Certification examinations and milestone ratings are the two primary methods for assessing physician graduates of US training programs, including hospice and palliative medicine (HPM) fellowships. The association between examination scores and physician quality needs further study within HPM, including graduates from eligible non–internal medicine specialties and for those grandfathered into the specialty. If certification exam scores are found to reflect HPM physician care quality, HPM fellowships should further incorporate the areas of clinical competency deficit into curriculum design, including the development and potential use of self-assessment (in-training) examinations. Further study is needed for HPM-certified clinicians given the breadth of training backgrounds and the variable clinical experiences during a 1-year fellowship at US training sites.
Bottom Line: Among new US internal medicine residency–trained hospitalists, certification examination scores—but not residency milestone ratings—were associated with better clinical outcomes; HPM-specific outcomes require further study.
Reviewer: Yuya Hagiwara, MD MACM, University of Iowa, Carver College of Medicine, Iowa City, IA
References:
1. Beckman JJ, Speicher MR. Characteristics of ACGME Residency Programs that Select Osteopathic Medical Graduates. J Grad Med Educ. 2020:435-440.
2. Holmboe ES, Yamazaki K, Edgar L, et al. Reflections on the first 2 years of milestone implementation. J Grad Med Educ. 2015;7(3):506-511. doi:10.4300/JGME-07-03-43.
3. Iobst W, Aagaard E, Bazari H, et al. Internal medicine milestones. J Grad Med Educ. 2013;5(1 Suppl 1):14-23. doi:10.4300/JGME-05-01s1-03.
Source: Gray BM, Vandergrift JL, Stevens JP, Lipner RS, McDonald FS, Landon BE. Associations of internal medicine residency milestone ratings and certification examination scores with patient outcomes. JAMA. 2024;332(4):300-309. doi:10.1001/jama.2024.5268.
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