Graduate medical education (GME) could explore several forward-thinking processes to enhance the journey of medical trainees. These processes could focus on selecting applicants for residency, fostering their development to excel as trainees, and preparing them to graduate as competent, certified physicians capable of independently practicing their specialties.
As objective numerical scores from the United States Medical Licensing Examination (USMLE) become a thing of the past, it may be time to consider developing specialty-specific knowledge assessments modeled after the “Anesthesia Knowledge Test (AKT).” For instance, an “Internal Medicine Knowledge Test (IMKT)” could be created for internal medicine, and similar tests could be developed for other specialties. These assessments could be administered and scored within the Electronic Residency Application Service (ERAS) portal when applicants attend their first interviews for a given specialty. The scores could then be automatically uploaded to the ERAS system, eliminating the need for applicants to retake the tests during subsequent interviews in the given specialty within the same ERAS cycle.
The purpose of these specialty-specific test scores could be to help predict whether interviewed applicants, if ranked and matched, are likely to succeed as certified trainees (CTs) during their residency. Herein, the evolution of CTs might involve the American Board of Medical Specialties (ABMS) transitioning from traditional in-training examinations to preemptive board-certification examinations conducted during residency. This shift would allow residents to achieve initial board certification before graduating, streamlining their progression into independent practice.
In the future, applicants who fail to match in any program during the ERAS season could be offered the opportunity to participate in a post-season “interviewship” at programs that had included them in their National Resident Matching Program (NRMP) rank order lists. These weeklong extended “interviewships” could provide applicants with an additional chance to demonstrate their potential, potentially improving their NRMP rankings in the next ERAS cycle compared to applicants who have not undergone such an experience at that program.
If the assessment during the “interviewship” were kept strictly for internal use, programs could decide not to provide letters of recommendation for external purposes. While some may question whether this process introduces bias—favoring previous “interviewship” participants in future ERAS cycles—any such bias might still be less pronounced than offering “interviewships” to applicants who have never previously interviewed at the program in any ERAS season. This approach could create a structured pathway for unmatched applicants to strengthen their future candidacy by gaining valuable program-specific feedback.
In line with the earlier proposal to abolish in-training examinations due to their limited effectiveness in remediating trainees, initial board-certification examinations could be integrated into the residency training period, similar to how the USMLE is embedded within medical school education. This shift would allow uncertified trainees (UCTs) to transition into certified trainees (CTs) during their residency, ultimately becoming certified graduates (CGs) upon completing their training.
However, UCTs who fail to achieve CT-status during their training period could be required to extend their training by an additional 6–12 months. In cases where further progression to CT-status is not feasible, such individuals could be required to exit their programs as uncertified graduates (UCGs), with a mandate to practice under a UCG-specific credential. This futuristic approach could ensure certifiable competency while providing structured pathways for remediation or alternative career options.
Extending training periods beyond 12 months solely for the purpose of achieving certification during residency may become economically unsustainable for both physicians and health care systems, unless both parties agree and concur to terminate the training altogether. Ironically, discontinuing the training of difficult-to-certify trainees could exacerbate the shortage of physician specialists, particularly in specialties with more complex certification processes.
When addressing this challenge, ABMS would need to evolve toward simplified, single-stage examination systems designed to enhance and accelerate certification rates. This could include the development of comprehensive, formal preparation tools, enabling UCTs to master officially sourced ABMS educational materials. Residency programs could then focus on achieving near-perfect certification rates by allowing UCTs multiple attempts during their training period at certification examinations available year-round just like the USMLE. This approach could streamline the path to certification while maintaining rigorous standards and ensuring a steady supply of board-certified physician specialists.
Deepak Gupta is an anesthesiologist. Sarwan Kumar is an internal medicine physician.
