INDICATORS OF THE EDUCATIONAL-EFFECTIVENESS OF SUBSPECIALTY TRAINING-PROGRAMS IN INTERNAL-MEDICINE

Purpose. To identify markers within the subspecialty educational process in internal medicine that are associated with greater improvements in knowledge and skill. Method. Candidates for the 1991 cardiovascular disease examination of the American Board of Internal Medicine (ABIM) were matched to the fellowship programs they attended, and their performances on the internal medicine examination of the ABIM, demographic data, and performances on the cardiovascular disease examination were averaged within each program. Information on the programs themselves was also available. The variables were divided according to whether they controlled for input to the training programs, were indicators of educational process, or served as the outcome measure. Analyses were restricted to the 140 programs for which complete information was available and that had four or more candidates who took the cardiovascular examination (97 programs were excluded). Results. The multiple correlation between all measures and scores on the cardiovascular disease examination was .80. Forty-five percent of the explained variance is attributable to previous performance on the internal medicine examination alone. The remaining 55% is shared by the educational indicators and the input measure or explained by the indicators alone. Among the indicators, location of medical school, length of fellowship training, ratings of overall clinical competence, fellow-to-faculty ratio, and number of subspecialities in the same institution made small contributions on their own. Program size, university affiliation, and period of approval by the residency review committee contributed little. Conclusion. The data are clear that indicators of educational process such as fellow-to-faculty ratio, longer periods of training, and performance during fellowship can generate greater gains in knowledge and judgment than would be expected if fellows merely built on their abilities at the time of entry to training. Such indicators may be useful if changes in health care delivery require reducing the numbers of specialty and subspecialty training positions.