Improving medical specialty selection with pre-training examinations

Considering that the United States Medical Licensing Examination (USMLE) primarily evaluates candidates’ general medical knowledge, there is a growing need to introduce specialty-specific pre-training examinations (PTEs). This is because the USMLE’s focus on overall medical knowledge may not accurately predict the performance of applicants in their specialty-specific in-training examinations (ITEs). The introduction of PTEs could serve as a more reliable indicator of applicants’ commitment and aptitude for their chosen specialties. These PTE scores could then be used as a valuable metric for ranking candidates in the Match process.

In the context of the evolving landscape of graduate medical education (GME), incorporating PTEs might lead to a fundamental shift in prioritizing medical knowledge within the six core competencies. It has the potential to position specialty-specific expertise as a primary core competency, potentially influencing the ranking of interviewed applicants in the future. This shift towards specialty-specific PTEs could be pivotal in determining the future direction of GME and the relative importance of medical knowledge within each specialty.

Paradoxically, in an era marked by an ongoing and severe shortage of physicians, the traditional requirement of post-GME knowledge-based board certification examinations may not be an absolute necessity. This shortage often permits board-eligible physicians to practice for an extended period before eventually achieving full board certification.

Furthermore, the PTE scores have the potential to assist interviewers in mitigating unintended discrimination when inadvertently ranking applicants during The Match based solely on the widely recognized nationwide rankings of their medical schools. This is because the PTE scores of interviewed applicants can provide a more comprehensive view, allowing interviewers to look beyond the perceived prestige of their medical institutions.

The underlying rationale for the introduction of future-oriented PTEs can be succinctly stated. The selection of candidates for GME residencies remains inherently uncertain, leading to intricate and often irreversible remediation processes when evaluation by the core competencies persists, even as they evolve into milestones and, subsequently, into entrustable professional activities (EPAs). In essence, it is observed that nearly all matched applicants eventually graduate, regardless of their varying ITE scores during GME residency. Furthermore, they go on to practice their respective specialties, irrespective of their diverse board certification outcomes post-GME graduation.

Deepak Gupta is an anesthesiologist. Sarwan Kumar is an internal medicine physician.

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