Relationships Between the ACGME Resident and Faculty Surveys and Program Pass Rates on the ABIM Internal Medicine Certification Examination

PURPOSE

The Accreditation Council for Graduate Medical Education (ACGME) has surveyed residents since 2003, and faculty since 2012. Surveys are designed to assess program functioning and specify areas for improvement. The purpose of this study was to assess the association of the ACGME's resident and faculty surveys with residency-program-specific performance on the American Board of Internal Medicine (ABIM) certification exam.

METHOD

Data were available from residents and faculty in 375 U.S. ACGME-accredited internal medicine programs from the 2012-2013, 2013-2014, and 2014-2015 academic years. Analysis of variance and correlations were used to examine the relationship between noncompliance with ACGME program requirements as assessed by the resident and faculty surveys, and ABIM program pass rates.

RESULTS

Noncompliance reported on the resident and faculty surveys was highest for programs not meeting the ACGME program requirement of an 80% pass rate on the ABIM certification examination. This relationship was significant for overall noncompliance, both within the resident (P < .001) and faculty (P < .05) surveys, for many areas within the two surveys (correlations ranged between -.07 and -.25, and P values ranged between .20 and < .001), and for the highest levels of noncompliance across areas of the resident (P < .001) and faculty (P < .04) surveys.

CONCLUSIONS

ACGME resident and faculty surveys were significantly associated with ABIM program pass rates, supporting the importance of these surveys within the ACGME's Next Accreditation System.

Use of pharmacogenetic and clinical factors to predict the therapeutic dose of warfarin

Initiation of warfarin therapy using trial-and-error dosing is problematic. Our goal was to develop and validate a pharmacogenetic algorithm. In the derivation cohort of 1,015 participants, the independent predictors of therapeutic dose were: VKORC1 polymorphism -1639/3673 G>A (-28% per allele), body surface area (BSA) (+11% per 0.25 m(2)), CYP2C9(*)3 (-33% per allele), CYP2C9(*)2 (-19% per allele), age (-7% per decade), target international normalized ratio (INR) (+11% per 0.5 unit increase), amiodarone use (-22%), smoker status (+10%), race (-9%), and current thrombosis (+7%). This pharmacogenetic equation explained 53-54% of the variability in the warfarin dose in the derivation and validation (N= 292) cohorts. For comparison, a clinical equation explained only 17-22% of the dose variability (P < 0.001). In the validation cohort, we prospectively used the pharmacogenetic-dosing algorithm in patients initiating warfarin therapy, two of whom had a major hemorrhage. To facilitate use of these pharmacogenetic and clinical algorithms, we developed a nonprofit website, http://www.WarfarinDosing.org.

Self-assessment of practice performance: development of the ABIM Practice Improvement Module (PIM)

BACKGROUND

Quality measurement and improvement in practice are requirements for Maintenance of Certification by the American Board of Medical Specialties boards and a component of many pay for performance programs.

OBJECTIVE

To describe the development of the American Board of Internal Medicine (ABIM) Practice Improvement Module (PIM) and the average performance of ABIM diplomates who have completed the Preventive Cardiology PIM.

DESIGN

Observational study of self-administered practice quality improvement.

SETTING

Office practices through the United States.

PARTICIPANTS

A total of 179 cardiologists and general internists completing requirements for ABIM Maintenance of Certification from 2004 through 2005.

MEASUREMENTS

Physicians self-audited at least 25 charts to obtain performance measures, patient demographics, and coronary heart disease risk factors. At least 25 patients completed surveys regarding their experience of care in the physician's practice. Physicians completed a self-assessment survey detailing the presence of various practice systems.

RESULTS

The mean rate for systolic blood pressure control was 48%, for diastolic blood pressure 84%, and for low-density lipoprotein (LDL) cholesterol at goal 65%. Of patients 61% rated the quality of care as excellent and 58% rated the practices excellent at encouraging questions and answering them clearly. More than 85% of patients reported "no problem" obtaining a prescription refill, scheduling an appointment, reaching someone in the practice with a question, or obtaining lab results. Targets for improvement were increasing the rates for LDL cholesterol or systolic blood pressure at goal, improving patients' physical activity, patient education, and accuracy of risk assessment. Improvement strategies included implementing chart forms, patient education, or care management processes.

LIMITATIONS

Patients and charts were selected by physicians reporting their performance for the purpose of MOC.

CONCLUSIONS

The Preventive Cardiology PIM successfully provides a self-assessment of practice performance and provides guidance in helping physicians initiate a cycle of quality improvement in their practices.

Quantitation of human immunodeficiency virus type 1 RNA in plasma by using blood dried on filter paper

We compared whole blood dried on filter paper to the standard assay with frozen cell-free plasma for use in the quantitation of the human immunodeficiency virus RNA load in blood. RNA values from filter paper, corrected for the hematocrit, gave results comparable to those of the standard assay in terms of sensitivity and reproducibility.

Quantitation of human immunodeficiency virus type 1 RNA in cell free seminal plasma: comparison of NASBA with Amplicor reverse transcription-PCR amplification and correlation with quantitative culture

Human immunodeficiency virus type 1 (HIV-1) is transmitted by infected males in semen. However, the inoculum required for infection is unknown. The ability to collect such information will rely on the availability of reliable quantitative assays of HIV-1 in semen. We examined the comparative performance of NASBA and Amplicor Monitor RT-PCR in quantifying HIV-1 RNA in cell free seminal plasma from seropositive men and correlated the results obtained with viral titres measured by a seminal cell quantitative microculture (QMC) assay. Of samples analysed, 68% and 56% by both NASBA and RT-PCR contained measurable HIV-1 RNA, respectively. Amplification inhibition frequently affected RT-PCR but not NASBA. Excluding samples with complete RT-PCR inhibition, there was 90% qualitative concordance and a strong positive correlation (r = 0.86) of RNA levels measured by the two methods. Comparison of the concentration of HIV-1 RNA in seminal plasma samples, as measured by NASBA, with QMC viral titres indicated that RNA levels probably reflect the infectiousness of whole semen. NASBA is a reliable technique for quantitating HIV-1 RNA in seminal plasma and should become a valuable tool in the study of factors that influence the sexual transmission of HIV.

Primary Ki-1 (anaplastic large cell) lymphoma of the brain and spinal cord

The authors report a case of primary Ki-1 lymphoma of the brain. The patient was a 4 1/2-year-old black girl who presented with a 4- and 5-day history of headaches, nausea, vomiting, neck stiffness, and difficulty in walking. Computed tomography (CT) scan of the brain showed two discrete densities in the left occipital lobe and in the brain stem. Magnetic resonance imaging (MRI) showed multiple densities scattered over the brain surface and brain stem. Microscopically, the tumor was an anaplastic neoplasm that diffusely infiltrated brain parenchyma. The neoplastic cells were large with amphophilic cytoplasm, large nuclei with irregular nuclear contours and prominent nucleoli. A high mitotic rate including atypical mitotic figures was noted. Immunohistochemical stains showed diffuse strong positivity for CD30 and moderate focal staining for epithelial membrane antigen. Leukocyte common antigen, cytokeratin, neuron specific enolase, monocyte/macrophage and B- and T-marker stains were negative. The histology was characteristic for Ki-1 large cell lymphoma. Cytologic examination of cerebrospinal fluid (CSF) demonstrated similar neoplastic cells. This is one of the first reports of this variant in the pediatric population.

Does feedback on examination performance help directors of internal medicine residencies evaluate the medical knowledge of their residents against national norms?

BACKGROUND

As part of the admission process to the American Board of Internal Medicine's certifying examination in internal medicine, training program directors evaluate residents in several components of clinical competence, including medical knowledge. Research suggested that these ratings had different meanings across programs. A report comparing certifying examination performance and ratings of medical knowledge at the program and national levels was developed and sent to program directors after the 1988 through 1992 examinations. The present study investigated whether feedback helped program directors identify where their residents ranked nationally.

METHOD

Subjects were first-time takers of the 1986 through 1992 certifying examinations in internal medicine who took the examination in the year they completed training and who received ratings of 4 through 9 in medical knowledge. All subjects were from programs contributing examinees in all seven study years and that received feedback in 1988 through 1991. Year-by-year distributions of program mean percentages of examinees receiving each rating of medical knowledge (4 through 9) were generated. Program means for equated examination scores and ratings of medical knowledge were computed for each year. Correlations between program mean scores and ratings were also computed.

RESULTS

The distributions of the ratings were stable across the study years. Mean scores declined while mean ratings were unchanged. At the same time, correlations between scores and ratings increased. The biggest one-year change was from 1989 to 1990 (.49 to .57).

CONCLUSION

Since equated scores are directly comparable, declining mean scores but unchanged mean ratings suggest that the standards applied by program directors drifted downward. The increasing correlations suggest that program directors improved in their abilities to evaluate residents relative to a common standard. It is not clear what effect the feedback had on program directors' evaluations. It is encouraging, however, to see a higher level of agreement among program directors on the meaning of the ratings.

Clinical furcation diagnoses and interradicular bone defects

The purpose of the present study was to assess associations between clinical depth of involved furcations and their bony defect depth. Twelve patients with moderate to advanced periodontitis in molars were recruited for clinical evaluation of furcation involvement by 6 dentists. Two groups of 3 dentists were assigned to the right or left half of the dentition. All dentists assessed the clinical depth of involvement of the furcations using the Ramfjord index (2 mm) in patients 1 through 6, and using the Hamp index (3 mm) in patients 7 through 12. Diagnoses were made with calibrated and uncalibrated Nabers 2 probes. After the clinical assessments the patients received full mouth scaling and root planing. After reevaluation the molars were surgically exposed. During surgery the depth of the bony furcation defects was assessed using horizontal probing and impressions. Clinically assessed depth of furcation involvement was then compared with the surgical measurements. A total of 1,180 clinical furcation diagnoses were available, of which 426 could be surgically evaluated using both the straight probe and the impressions. These evaluations were done in a total of 72 furcations using probe and impressions. For the Ramfjord index, 5% of the clinical degree 1, 40% of the degree 2, and 43% of the degree 3 readings were overestimations. For the Hamp index, 7% of degree 1, 24% of degree 2, and 0% of degree 3 readings were overestimations. These clinical diagnoses were overestimations. Forty-three percent of surgical degree 3 involvements were not recognized when using the Ramfjord index, and 27% when using the Hamp Index. These results suggest that furcation diagnosis is of limited validity.

Genomic organization of human surfactant protein D (SP-D). SP-D is encoded on chromosome 10q22.2-23.1

Surfactant protein D (SP-D) is a member of the family of mammalian C-type lectins. SP-D is secreted into the pulmonary airspaces by lung epithelial cells and is believed to contribute to the lung's defense against inhaled microorganisms. We have previously characterized cDNAs specific for human SP-D (hSP-D). We now describe the partial characterization of genomic clones for hSP-D and present evidence for an SP-D gene with coding sequences spanning > 11 kilobases on the long arm of chromosome 10. Genomic sequencing demonstrated that the signal peptide/amino-terminal domain, the carbohydrate recognition domain, and the linking sequence between the collagen domain, and carbohydrate recognition domain are each encoded by a single exon, as for surfactant protein A and the mannose-binding protein C. However, sequencing also demonstrated a unique intron-exon structure for the collagen domain which is encoded on five exons, including four tandem exons of 117 bp. The latter exons show marked conservation in the predicted distribution of hydrophilic amino acids, consistent with tandem replication of this collagen gene sequence during evolution. Segregation analysis of HindIII digests of genomic DNA using specific cDNA probes demonstrated selective hybridization of radiolabeled hSP-D cDNA to chromosome 10- and 10q-containing human/hamster somatic hybrids. The presence of SP-D gene sequences was confirmed by DNA amplification using oligomers specific for sequences within the collagen domain of the hSP-D gene. Fluorescence in situ hybridization of metaphase chromosomes using genomic probes gave selective labeling of 10q22.2-23.1. We speculate that SP-D is encoded at a locus on 10q that includes the genes for surfactant protein A.

Human surfactant protein D: SP-D contains a C-type lectin carbohydrate recognition domain

Lung surfactant protein D (SP-D) shows calcium-dependent binding to specific saccharides, and is similar in domain structure to certain members of the calcium-dependent (C-type) lectin family. Using a degenerate oligomeric probe corresponding to a conserved peptide sequence derived from the amino-terminus of the putative carbohydrate binding domain of rat and bovine SP-D, we screened a human lung cDNA library and isolated a 1.4-kb cDNA for the human protein. The relationship of the cDNA to SP-D was established by several techniques including amino-terminal microsequencing of SP-D-derived peptides, and immunoprecipitation of translation products of transcribed mRNA with monospecific antibodies to SP-D. In addition, antibodies to a synthetic peptide derived from a predicted unique epitope within the carbohydrate recognition domain of SP-D specifically reacted with SP-D. DNA sequencing demonstrated a noncollagenous carboxy-terminal domain that is highly homologous with the carboxy-terminal globular domain of previously described C-type lectins. This domain contains all of the so-called "invariant residues," including four conserved cysteine residues, and shows high homology with the mannose-binding subfamily of C-type lectins. Sequencing also demonstrated an amino-terminal collagenous domain that contains an uninterrupted sequence of 59 Gly-X-Y triplets and that also contains the only identified consensus for asparagine-linked oligosaccharides. The studies demonstrate that SP-D is a member of the C-type lectin family, and confirm predicted structural similarities to conglutinin, SP-D, and the serum mannose binding proteins.

Clinical nursing research priorities: a Delphi study

Using the delphi technique, a group of clinical nurse specialists was surveyed regarding delineation of clinical nursing research priorities. Upon completion of the four-round survey, the results suggested that the top priorities for nursing research are: (1) factors which influence longevity in clinical nursing practice, (2) patient care delivery systems as related to nurse satisfaction, and (3) indicators of quality nursing care.

Dermal penetration of avermectin B1a in the rhesus monkey

Forearms of rhesus monkeys were treated with [3H]avermectin B1a in three different vehicles and concentrations so that the penetration of avermectin B1a through skin could be determined. In order to simulate exposure of farm workers, such as mixer-loaders, applicators, and harvesters, to this pesticide, avermectin B1a was applied to the forearms of the monkeys as an emulsifiable concentrate (300 micrograms/monkey), a diluted emulsifiable concentrate (4.5 micrograms/monkey), and as a suspension in water (216 micrograms/monkey). After 1 or 10 hr of exposure, the treatment area was washed. The levels of radioactivity were determined in the urine, feces, plasma, and wash. On the basis of the amounts of radioactivity excreted in the urine and feces and the levels of radioactivity in the plasma after dermal application compared to those found after intravenous administration of the compound, less than 1% of the doses was absorbed. These data indicate that avermectin B1a would not readily penetrate the skin of farm workers exposed to it. Therefore, the hazard to farm workers exposed to this compound would be substantially mitigated.

[TRH stimulation test in the diagnosis of hyperthyreosis]

After a review concerning the present knowledge on the hypothalamic peptide releasing hormones, the response of TSH to intravenous administration of TRH in man (Thyreotrophin Releasing Hormone Stimulation Test) is discussed, with regard to clinical endocrinology. Personal investigations with the TRH test were carried out in 3 groups of conditions correlated with thyroid hyperfunction: 1) suspected hyperthyroidism with equivocal routine tests (9 subjects); 2) autonomous thyroid decompensated adenoma, with or without clinical hyperthyroidism (5 subjects); 3) thyrotoxicosis (Graves' disease) in remission phase after pharmacological or surgical treatment (10 subjects). In these conditions the test provided useful diagnostic information for appropriate therapeutical decisions.