Designed to serve as a benchmark of a resident physician’s progress and to help with preparation for board certification, in-service training exams are a milestone on the calendar across all levels of residency training.
How much weight do these exams carry? And how should you prepare? Insight from a long-time residency faculty member and recently graduated resident shed some light on those questions.
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A benchmark for the boards
While the exams vary in several ways by physician specialty, their fundamental purpose remains the same: to prepare residents for board certification. Each year, exam content covers similar topics, so the expectation is that as residents progress from PGY-1 to PGY-2 and further, their score will rise with each exam.
The exams offer a data point for programs and residents to identify knowledge gaps and areas for development. Though dates are specialty dependent, in-service exams are frequently administered in the second half of an academic year.
It is important to note that in-service exams are not the only measure of one’s progress, according to John Andrews, MD, the AMA’s vice president of graduate medical education innovation.
“In-training exams prepare you to pass your boards,” said Dr. Andrews, a former pediatrics residency program director. “How they relate to how effective you are in practice is an open question.”
A literature review of research conducted on the utility of in-service exams, published in the Journal of Graduate Medical Education, found that there is a moderate to strong correlation between in-service exam performance and board exam performance.
“That the predictive value for passing the board examination is stronger than the predictive value for failing calls into question the ‘common wisdom’ that [in-service exam] scores can be used to identify ‘at risk’ residents,” the paper’s authors wrote. “The graduate medical education community should continue to exercise caution and restraint in using [in-service exam] scores for moderate to high-stakes decisions.”
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What are the stakes?
The importance of in-service exams varies widely by specialty and residency program. For primary care specialties such as pediatrics and internal medicine, the exams are used as formative tools to guide learning. In surgical specialties, the stakes can be higher—scores may be used as a marker to help determine whether a resident should advance to the next training year and can be a consideration for fellowship applicants in competitive subspecialty fields.
“It should be clear within the confines of your training program how that in-training exam is being used,” Dr. Andrews said. “For some residents, it’s very important that they prepare for that in-training exam because it directly impacts their progression in their training, whereas in other disciplines, it’s simply a feedback loop to let you know how you’re doing and doesn’t have any practical bearing on your progression.”
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How to prepare
The amount of time and energy a resident dedicates toward studying for an in-service exam should directly correlate to the stakes of their exam on a programmatic and specialty level. There are many specialty-specific resources to help study. Often, previous board exams are available and can work as a valuable resource.
During her psychiatry residency, Avani Patel, MD, MHA, was able to ease into the process of in-service exam prep because both her program and specialty weren’t emphasizing scores. As she got closer to taking the boards, during her third and fourth years of training, she put more energy into the process.
“I set the bar really low for myself intern year, but I was surprised at how much knowledge I had learned along the way,” said Dr. Patel, an AMA member. “By the time I got to my final year, I blew it out of the water, which was great.”
In her later years of residency, Dr. Patel did more question banks and practice tests.
“I continued to do more background research,” she said. “I did flash cards with some of the history and things that were less interesting to me. I found that my scores got better because I started recognizing the patterns more.”
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A tool for growth
While it’s certainly important to understand and meet any specialty- or program-specific benchmarks for exam performance, a disappointing score doesn’t have to derail your training.
“A single poor performance on an in-service exam isn’t an ominous sign, but it’s just a clue that you need to do some work to prepare yourself to take exams down the line,” Dr. Andrews said.
“When we got reports on the in-training exam in pediatrics, there was a content analysis,” Andrews said. “If someone performed poorly in endocrinology, it indicated a gap in preparation.”
As residents grew closer to the completion of their training and board certification, if scores remained low, Dr. Andrews would often advise them to enroll in a board-exam preparation course.
“The ultimate goal is to pass your boards when you finish your residency,” Dr. Andrews said. “These exams give you feedback to help you do that, but they’re not a marker of your clinical ability.”Dr. Patel agreed that the exams are merely a single data point.
“Medicine has so many other layers,” she said. “Exams primarily measure knowledge, but they don’t capture the full picture of what makes a good physician.”
