Workforce Reform, International Medical Graduates, and the In-Training Examination

The Internal Medicine In-Training Examination (ITE) is a self-assessment resource intended for use midway through the medical residency (the winter of postgraduate year 2 [PGY-2]). It is taken each year by almost all PGY-2 residents in the United States and by most PGY-1 and PGY-3 residents as well. Psychometric analysis shows that the examination is highly reliable [1], and it is predictive of subsequent performance on the certifying examination of the American Board of Internal Medicine [2, 3].

Although only a surrogate for clinical ability or performance, the results of highly reliable standardized examinations are among the few readily available measures of these qualities. They are therefore widely used and will continue to be used in this way until other tools are developed for the direct assessment of clinical competence [4].

The two largest groups of examinees, approximately equal in size, are residents who have graduated from medical schools in the United States and foreign-born physicians who have graduated from schools outside of the United States and Canada (international medical graduates [IMGs]). The large numbers of persons in these groups who take examinations have permitted statistically valid comparisons. (Other groups-graduates of schools of osteopathic medicine, graduates of Canadian medical schools, and native-born U.S. citizens who have graduated from medical schools abroad-are smaller and have not been included in published analyses.)

During the past 3 years, a trend in the performance of U.S. graduates and IMGs on the ITE has become increasingly apparent. The scores of IMGs at all three levels of residency are …