Keeping Score of the Scores: Additional Perspectives on the Decline of Family Medicine ITE Scores

To the Editor: We were intrigued by the article entitled “The Decline in Family Medicine In-Training Examination Scores: What We Know and Why It Matters” by Newton et al, which elaborated on the significant decline in Family Medicine (FM) resident in-training examination (ITE) scores.¹ The authors did an excellent job addressing many of the potential causes and implications of this issue. It was noteworthy to see that the decline in ITE did not differentiate across variables such as gender, international medical graduate status, underrepresented minorities in medicine (URiM) status, baseline USMLE score, or osteopathic physician status.¹

We appreciate the authors’ spotlight on the COVID-19 pandemic and its toll on resident experiential and didactic learning and the consequent declining FM ITE scores. Though harder to measure, it may be helpful to consider the attitudes and/or “mastery mindset” of residents as another possible factor in this decline.² The article draws attention to the importance of delineating the significance of ITEs. If the ITE is considered a “low-stakes” examination compared with the American Board of Family Medicine Certification (ABFM) examination, residents may be content with declining ITE scores when their probability of passing their FM boards are greater than 95%. Some are driven as a sense of personal pride, but others may feel that a strong passing score is good enough, and that a 90^th percentile is no better than a 60^th percentile. We all know that a great clinician is far more than high scores on a standardized examination. With the USMLE and many medical schools using a pass/fail criterion instead of numeric or letter grades, maybe we have de-emphasized scores so much that our trainees do not push themselves for that highest possible score. Is it, perhaps, time to reassess the intent of the ITE? If the intent for the ITE is to be a low-stakes, formative assessment of residents’ knowledge and possibly less of a predictor of future performance on board passage rate, the declining scores may reflect a timely de-emphasis on the high-stakes, high-pressure nature of standardized exams and their impact on the well-being of trainees.³

The authors emphasized the importance of the traditional role of didactics and alternative clinical experiences as “critical to learning” and improving resident scores.¹ In the published study “The Association Between Family Medicine Residents' Mindsets and In-Training Examination Scores” there was, surprisingly, a negative or inverse relationship between ITE performance and the mastery mindset scores of second year residents.² This may be due to the increased focus on clinical and experiential learning. Though residencies often support resident learning with immediate feedback and guidance clinically, explicit training on self-directed learning and using the ITE examination as a tool for self-study would be extremely valuable.² Self-directed study is imperative as a lifelong learner. Furthermore, social media has taken a newfound role in medical education and is often readily available to our resident learners who have learning styles and preferences influenced not only by cultural background but pop culture.⁴ Perhaps, residencies can use ABFM’s resources and online learning modalities to assist learners in an innovative, interactive, and personalized way.¹

In conclusion, we would like to express gratitude to the authors for bringing this topic to the forefront for undergraduate and graduate FM educators. It is our hope that we can find innovative and effective tools and techniques to improve resident education and ITE and ABFM Board performance for FM residents. This exploration should foster discovery of resourceful ways to meet the new Quintuple Aim for Health Care Improvement (population health, improved patient care experience, reduced cost, provider well-being, and health equity advancement) in graduate medical education and beyond.⁵