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Abstract Background The administration of performance assessments during the coronavirus disease of 2019 (COVID-19) pandemic posed many challenges, especially for examinations employed as part of certification and licensure. The National Assessment Collaboration (NAC) Examination, an Objective Structured Clinical Examination (OSCE), was modified during the pandemic. The purpose of this study was to gather evidence to support the reliability and validity of the modified NAC Examination. Methods The modified NAC Examination was delivered to 2,433 candidates in 2020 and 2021. Cronbach’s alpha, decision consistency, and accuracy values were calculated. Validity evidence includes comparisons of scores and sub-scores for demographic groups: gender (male vs. female), type of International Medical Graduate (IMG) (Canadians Studying Abroad (CSA) vs. non-CSA), postgraduate training (PGT) (no PGT vs. PGT), and language of examination (English vs. French). Criterion relationships were summarized using correlations within and between the NAC Examination and the Medical Council of Canada Qualifying Examination (MCCQE) Part I scores. Results Reliability estimates were consistent with other OSCEs similar in length and previous NAC Examination administrations. Both total score and sub-score differences for gender were statistically significant. Total score differences by type of IMG and PGT were not statistically significant, but sub-score differences were statistically significant. Administration language was not statistically significant for either the total scores or sub-scores. Correlations were all statistically significant with some relationships being small or moderate (0.20 to 0.40) or large (> 0.40). Conclusions The NAC Examination yields reliable total scores and pass/fail decisions. Expected differences in total scores and sub-scores for defined groups were consistent with previous literature, and internal relationships amongst NAC Examination sub-scores and their external relationships with the MCCQE Part I supported both discriminant and criterion-related validity arguments. Modifications to OSCEs to address health restrictions can be implemented without compromising the overall quality of the assessment. This study outlines some of the validity and reliability analyses for OSCEs that required modifications due to COVID.

Abstract Background There is considerable variation among physicians in inappropriate antibiotic prescribing, which is hypothesized to be attributable to diagnostic uncertainty and ineffective communication. The objective of this study was to evaluate whether clinical and communication skills are associated with antibiotic prescribing for upper respiratory infections and sinusitis. Methods A cohort study of 2,526 international medical graduates and 48,394 U.S. Medicare patients diagnosed by study physicians with an upper respiratory infection or sinusitis between July 2014 and November 2015 was conducted. Clinical and communication skills were measured by scores achieved on the Clinical Skills Assessment examination administered by the Educational Commission for Foreign Medical Graduates (ECFMG) as a requirement for entry into U.S residency programs. Medicare Part D data were used to determine whether patients were dispensed an antibiotic following an outpatient evaluation and management visit with the study physician. Physician age, sex, specialty and practice region were retrieved from the ECFMG databased and American Medical Association (AMA) Masterfile. Multivariate GEE logistic regression was used to evaluate the association between clinical and communication skills and antibiotic prescribing, adjusting for other physician and patient characteristics. Results Physicians prescribed an antibiotic in 71.1% of encounters in which a patient was diagnosed with sinusitis, and 50.5% of encounters for upper respiratory infections. Better interpersonal skills scores were associated with a significant reduction in the odds of antibiotic prescribing (OR per score decile 0.93, 95% CI 0.87–0.99), while greater proficiency in clinical skills and English proficiency were not. Female physicians, those practicing internal medicine compared to family medicine, those with citizenship from the US compared to all other countries, and those practicing in southern of the US were also more likely to prescribe potentially unnecessary antibiotics. Conclusions Based on this study, physicians with better interpersonal skills are less likely to prescribe antibiotics for acute sinusitis and upper respiratory infections. Future research should examine whether tailored interpersonal skills training to help physicians manage patient expectations for antibiotics could reduce unnecessary antibiotic prescribing.

Abstract Background Although lipid-lowering drugs are not recommended for primary prevention in patients 75+, prevalence of use is high and there is unexplained variation in prescribing between physicians. The objective of this study was to determine if physician communication ability and clinical competence are associated with prescribing lipid-lowering drugs for primary and secondary prevention. Methods We used a cohort of 4,501 international medical graduates, 161,214 U.S. Medicare patients with hyperlipidemia (primary prevention) and 49,780 patients with a history of cardiovascular disease (secondary prevention) not treated with lipid-lowering therapy who were seen by study physicians in ambulatory care. Clinical competence and communication ability were measured by the ECFMG clinical assessment examination. Physician citizenship, age, gender, specialty and patient characteristics were also measured. The outcome was an incident prescription of lipid-lowering drug, evaluated using multivariable GEE logistic regression models for primary and secondary prevention for patients 75+ and 65-74. Results Patients 75+ were less likely than those 65-74 to receive lipid-lowering drugs for primary (OR 0.62, 95% CI 0.59-0.66) and secondary (OR 0.70, 95% CI 0.63-0.78) prevention. For every 20% increase in clinical competence score, the odds of prescribing therapy for primary prevention to patients 75+ increased by 24% (95% CI 1.02-1.5). Communication ability had the opposite effect, reducing the odds of prescribing for primary prevention by 11% per 20% score increase (95% CI 0.8-0.99) for both age groups. Physicians who were citizens of countries with higher proportions of Hispanic (South/Central America) or Asian (Asia/Oceania) people were more likely to prescribe treatment for primary prevention, and internal medicine specialists were more likely to treat for secondary prevention than primary care physicians. Conclusion Clinical competence, communication ability and physician citizenship are associated with lipid-lowering drug prescribing for primary prevention in patients aged 75+.

The purpose of medical licensing examinations is to protect the public from practitioners who do not have adequate knowledge, skills, and abilities to provide acceptable patient care, and therefore evaluating the validity of these examinations is a matter of accountability. Our objective was to discuss the Medical Council of Canada's Qualifying Examinations (MCCQEs) Part I (QE1) and Part II (QE2) in terms of how well they reflect future performance in practice. We examined the supposition that satisfactory performance on the MCCQEs are important determinants of practice performance and, ultimately, patient outcomes. We examined the literature before the implementation of the QE2 (pre-1992), post QE2 but prior to the implementation of the new Blueprint (1992-2018), and post Blueprint (2018-present). The literature suggests that MCCQE performance is predictive of future physician behaviours, that the relationship between examination performance and outcomes did not attenuate with practice experience, and that associations between examination performance and outcomes made sense clinically. While the evidence suggests the MCC qualifying examinations measure the intended constructs and are predictive of future performance, the validity argument is never complete. As new competency requirements emerge, we will need to develop valid and reliable mechanisms for determining practice readiness in these areas.

Objective To determine whether internists’ initial specialty certification and the maintenance of that certification (MOC) is associated with lower in-hospital mortality for their patients with acute myocardial infarction (AMI) or congestive heart failure (CHF).Design Retrospective cohort study of hospitalisations in Pennsylvania, USA, from 2012 to 2017.Setting All hospitals in Pennsylvania.Participants All 184 115 hospitalisations for primary diagnoses of AMI or CHF where the attending physician was a self-designated internist.Primary outcome measure In-hospital mortality.Results Of the 2575 physicians, 2238 had initial certification and 820 were eligible for MOC. After controlling for patient demographics and clinical characteristics, hospital-level factors and physicians’ demographic and medical school characteristics, both initial certification and MOC were associated with lower mortality. The adjusted OR for initial certification was 0.835 (95% CI 0.756 to 0.922; p

Abstract Objective Breaking bad news (BBN) is particularly difficult in perinatology. Previous research has shown that BBN skills can be learned and improved when taught and practiced. This project evaluated whether a structured training session would enhance perinatology residents’ skills in BBN. Methods This was a randomized controlled intervention study with year 1 to 4 Perinatology residents from a medical school in Brazil, during the 2014/15 school year. A total of 61 out of 100 (61%) eligible residents volunteered to a structured training program involving communicating a perinatal loss to a simulated patient (SP) portraying the mother followed by the SP’s immediatefeedback,bothvideo recorded. Later, residents were randomly assigned to BBN training based on a setting, perception, invitation, knowledge, emotion and summary (SPIKES) strategy with video reviews (intervention) or no training (control group). All residents returned for a second simulation with the same SP blinded to the intervention and portraying a similar case. Residents’ performances were then evaluated by the SP with a checklist. The statistical analysis included a repeated measures analysis of covariance (RM-ANCOVA). Complementarily, the residents provided their perceptions about the simulation with feedback activities. Results Fifty-eight residents completed the program. The simulations lasted on average 12 minutes, feedback 5 minutes and SPIKES training between 1h and 2h30m. There was no significant difference in the residents’ performances according to the SPs’ evaluations (p = 0.55). The participants rated the simulation with feedback exercises highly. These educational activities might have offset SPIKES training impact. Conclusion The SPIKES training did not significantly impact the residents’ performance. The residents endorsed the simulation with feedback as a useful training modality. Further research is needed to determine which modality is more effective.

BACKGROUND:Migration of physicians has been a cause for global concern. In China, reforms of the higher education and healthcare systems have led to a shortage of postgraduate training positions relative to the number of medical graduates. Medical graduates opt for non-clinical roles or move abroad to pursue further training and practice opportunities. The impact of this physician migration is not known. This study quantifies where Chinese migrant physicians to the U.S. were educated, where they went to practice, and how these trends have changed over time. METHODS:We combined data on physician characteristics from the 2008 and 2017 American Medical Association Physician Masterfiles with demographic information from the Educational Commission for Foreign Medical Graduates. Using a repeated cross-sectional approach, we reviewed the available data, including citizenship at entry to medical school, medical school attended, practice specialty, and practice location. RESULTS:The number of Chinese-educated physicians (CEPs) to the United States (US) has increased over the past 10 years, from 3,878 in 2008 to 5,355 in 2017 (+38.1%). The majority held Chinese citizenship at entry to medical school (98.4% vs 97.1%) with the remainder being citizens of other East Asian nations. Of the Chinese citizens identified in 2008, 913 (19.3%) attended medical school outside of China; in 2017, 376 (6.7%) attended medical school outside of China, representing a decrease of 58.8%. Overall, in 2017, four Chinese medical schools provided 32.1% of all Chinese-educated physicians in the US. Over 50% of the CEPs were practicing in Internal Medicine, Anatomic/ Clinical Pathology, Anesthesiology, Family Medicine or Neurology. Compared with all IMGs, CEPs are more likely to be Anatomic/ Clinical Pathologists and Anesthesiologists. CEPs were concentrated in several states, including New York, California and Massachusetts. In 2017, a lower proportion of CEPs in the US healthcare workforce were in residency training, compared to 2008 (13.2% vs 22.8%). CONCLUSIONS:Unlike trends from some other South Asian countries, the number of CEPs in the US has increased over the past 10 years. Migration trends may vary depending on citizenship and country of medical school training. The majority of Chinese-educated graduates come to the US from relatively few medical schools. Fewer CEPs currently in residency training might indicate lower success rates in securing GME training in the US.