Old Hands Help Nurture Next Generation of Endocrinologists

As physicians, we continually present ourselves for assessments, often in the form of high-stakes testing. Some tests serve as rites of passage, providing us with anecdotes that we draw upon to amuse others at parties or convey to young'uns the travails that we eliminated for them.

One area of controversy in our contemporary environment has been the testing to validate our suitability for practice as we age. Physicians eligible for Medicare are common; we total about 300,000, and the 2016 US census found that 30% of physicians are aged 60 years or older.

Some institutions have initated cognitive screening of practicing physicians, usually at age 70 years.

Too many of these assessments either classify us (IQ tests, Iowa Tests of Basic Skills), or weed us out (SATs, MCATs, National Medical Board and recertification exams), when the real purpose of testing should be to enhance our capacity, in addition to sometimes protecting the public.

Had I not retired in 2018, this would be the year and season to roll the dice one more time for my third specialty recertification exam.

Knowing this task would arrive, my last few years of patient care would have included some appointments with myself to tackle periodic American Board of Internal Medicine (ABIM) learning modules. I found this to be a mostly decent program that enhanced knowledge without posing a threat to future activites. The questions made it something of a scavenger hunt through the World Wide Web of exotic endocrinology that rarely appeared in my exam room to find which of the multiple choice options best answered each question. Eventually, I would get a summary of why each choice should be preferred or rejected.

Did perfomance on these modules portend performance at the high-stakes exam to come? I don't know, but it was always a relief when one of the antecedent module's questions became a gift and appeared in the high-stakes exam.

To make high-stakes, one-time testing less of a knowledge casino for our younger colleagues first acquiring their knowledge and demonstrating their skills, many fellowship programs, including endocrinology, have incorporated periodic assessments under simulated conditions. The results of this intervention, with some particulars unique to US training programs, were recently reported in the Journal of the Endocrine Society.

Although the subject content of the specialty In-Training Exam approximates what candidates will later see when they sit for the ABIM specialty certification tests, it merges the educational and performance goals of our programs amid an experience that is less intimidating than a single exam that establishes or denies a needed credential. The Endocrine Society developed this educational tool with many unique features designed to standardize a learning environment in which training programs can differ considerably and offer feedback at different stages of program participation.

Much of the secrecy that the ABIM requires to keep questions confidential for subsequent use has been sacrified by the Endocrine Society, which now has to create a new set of questions for each exam — a considerable effort. Scores are not just reported by how many answers the test-takers got right, but which ones showed strengths or need for remediation. When program directors were polled in anticipation of this program's design, they showed a clear preference for moving their trainees' learning forward over its possible predictive value for the ABIM exam itself.

On analysis over 3 years, however, performance on the In-Training Exam turned out to be a reliable predictor — indeed the best predictor — of likelihood of achieving board certification via the ABIM examination. A score of 75% on the Endocrine Society exam yielded a 97% likelihood of passing the ABIM exam. Even a much lower score of 55% left the fellow with a 70% chance of passing the ABIM exam.

Success with the In-Training Exam provided the strongest evidence of ABIM exam success, but it was not the only correlate. Those who passed the ABIM Internal Medicine Certification on the first try had an advantage with the ABIM Endocrinology exam, as did younger test-takers compared with older test-takers. Although gender and country of medical school did not reach P < .05 significance, the P values of .15 and .20, respectively, still suggest a slight advantage to males and to graduates of American medical schools.

Although studies have a purpose (this one being to judge the predictive value of an exam in a friendly environment for a desired result later in a setting that is still a rite of passage), the data collected and presented also offer insights into the people we welcome into the fraternity of endocrinologists.

Our current fellows are about 70% female, and 50% attended school outside the United States, perhaps with a gap between completing an internal medicine residency and entering fellowship, with a mean age of about 35 years. They seem to be diligent and capable, with 93% passing their internal medicine certification on the first attempt and 89% achieving this for their endocrine boards. In a brief but accurate summary, these present as the very people you would like to nurture as your professional descendants.

That means treating them right, something the Endocrine Society and its program directors seem to have dedicated themselves to doing. In this era when physicians have legitimate reasons to write on social media forums about the impersonalization of our electronic environment — with administrators prioritizing metrics over skills, a culture that makes us "providers" despite our distinctive training, and assorted assaults on our professional stature — there are senior endocrinologists who have the backs of the upcoming generation.

We still have to take our high-stakes exams, but this In-Training Exam program may do much to alleviate some of the undue anxiety that dogs many of us for months until the scores arrive. It helps to know in advance that our worries are probably greatly exaggerated.

Richard M. Plotzker, MD, is a retired endocrinologist from the Department of Medicine, Mercy Hospital of Philadelphia.

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