Resident elective selection is dependent on numerous factors including career preference, subspecialty interest, real or perceived quality of subspecialty education, opportunity to secure faculty recommendation letters, desire to improve knowledge in the subspecialty, auditioning for fellowship opportunities, guidance of an advisor or program director, and even such things as ease of the schedule or rigorousness of the rotation.
Although analysis of the data from 2008 suggested a positive association between exposure to the pulmonary and rheumatology electives and improved ABIM-CE scores, analysis of subspecialty elective exposures for all years combined failed to demonstrate a statistically significant positive relationship between specific elective exposures and ABIM-CE scores. It is possible that the sample size in this study was too small to demonstrate differences in outcomes simply because the residency program studied has relatively high numbers of elective exposures and high overall pass rates on the ABIM-CE. Another factor which may have contributed to lack of association between elective exposure and ABIM-CE performance in this study is that while all major electives in our program have a formal curriculum, there is wide variation in the structure, goals and objectives of the individual electives. Some electives include both inpatient and outpatient experiences, while others focus on only one or the other. The elective experience may vary dependent on the teaching experience of the attending physician. Finally, electives vary as to inclusion of pre- and post-testing, required reading lists, and subspecialty conference exposures. Prior studies have shown that formalized elective curricula [11, 12] or inclusion of elective specific multiple-choice testing program  improves resident performance on standardized tests of medical knowledge.
In our study participation in the cardiology elective was associated with worse performance on the ABIM-CE. This finding may reflect the nature of this elective as a more service driven elective, with a focus on repetitive, protocol driven, hospital-based experience and fewer one-on-one resident-attending interactions. Investigation of the characteristics of specific electives, such as the inpatient and outpatient focus, inclusion of reading lists, subspecialty conferences and pre- and post-testing these relationships was outside the scope of this study, but merits further investigation in a larger prospective study.
Our study did not demonstrate a statistically significant relationship between repeated elective exposures in a single specialty and ABIM-CE performance, suggesting that repeated exposure to a particular subspecialty may not offer additional improvement in medical knowledge. Although the population size limited the statistical significance of this finding, the data suggests that there may be a “threshold” number of elective exposures associated with improved ABIM-CE scores, but above which further elective experiences do not further improve ABIM-CE performance. This observation is helpful to program directors planning schedules and supports recommendations to move residency education from a structure and process based “time dependent” system towards a more competency based program where the major outcome is knowledge acquisition driven by the learner and assessed using multiple outcome measures .
While there is an increasing push towards self-directed learning and autonomy in selection of electives it is well recognized that residents themselves are not always good judges of their own medical knowledge . As in prior studies , our data showed strong correlation between the program director medical knowledge score and the ABIM-CE score, reinforcing the continued predictive value of program director evaluations, and supporting use of these evaluations in guiding residents throughout residency.
An unexpected finding of this study was the statistically significant negative association between female gender and ABIM-CE performance in this program. In the United States the number of women applying to medical school is increasing . Women now make up more than 50% of matriculating medical students, and 25% of practicing physicians . A similar negative association between female gender and ABIM-CE performance was reported in a larger study evaluating internal medicine residents’ performance on the IM-ITE and correlating this with quality of life, burnout and educational debt . Our findings suggest that female residents may experience barriers to education during residency that impact ABIM-CE performance, an observation that merits further investigation.
Our study has some limitations that warrant further discussion. The study was conducted in a single, university-based residency program with an ABIM-CE mean pass rate above the national average. It may therefore have been underpowered to show a difference in ABIM-CE score with subspecialty elective exposure. Residents in our program are permitted numerous subspecialty electives throughout the three years of training, and this may have contributed to the absence of detectable difference for high enrollment electives (such as infectious diseases). Furthermore, the observed results may not be widely applicable to training programs with fewer subspecialty elective opportunities.
It should also be noted that we studied only subspecialty exposures and did not assess reasons for elective selection or avoidance. There may be a selection bias in that residents who were interested in a subspecialty may be more likely to study in that subspecialty. Additionally, in our program, residents with poor subspecialty performance on the annual IM-ITE are counseled to participate in an elective in that subspecialty. Family and economic issues may further confound the relationship between ABIM-CE performance and elective exposures. Residents who become parents during residency may time their elective exposures to dovetail with their parental leave, and sleep deprivation and other stresses may thus impact their elective experience. Educational debt may be another confounder in the relationship with ABIM-CE performance. Prior studies have shown that educational debt is associated with lower mean IM-ITE scores . In many internal medicine residencies, the somewhat lighter call schedule during electives affords residents an opportunity to take on additional “moonlighting” shifts. During the time period of this study our institution had a moonlighting policy in place, which permitted residents with high satisfactory evaluations to moonlight while on elective. This may have resulted in residents with higher educational debt taking more electives, or selecting electives with lighter duties possibly skewing the associations between elective exposures and ABIM-CE performance.
The data from Table 1 show that mean delta-SPS scores declined over the five years under study, while the number of electives taken increased. In addition to the confounders discussed above, ACGME limitations on duty hours may play a role in these observations. The ACGME changed duty hour requirements in July 2003 and July 2011, so all cohorts in the current study fell under the auspices of the 2003 requirements including: a) 80-hour limits on the resident work week; b) 30-hour limit on overnight/continuous duty shifts; c) one day in seven (averaged) free of all duties; d) no more frequent than every third night overnight call, and e) “adequate” rest periods. Since data is not available for residents taking the ABIM-CE prior to 2005 it is not possible to compare the cohort under study with a historical cohort prior to the implementation of the 2003 ACGME duty hour requirements. A further change in ACGME duty hours was implemented in 2011, so it would be interesting to see if this trend towards declining ABIM-CE performance persists in future cohorts.
We did make an attempt to investigate the effect of timing of subspecialty elective exposure on IM-ITE scores in order to compare scores before and after an elective as well as to help measure knowledge retention throughout residency. However, although residents in our program are expected to participate in this annual exam; some residents were unable to complete the exam in each of the three years of residency because of personal issues or scheduling conflicts. Due to the paucity of data we could not evaluate impact of elective exposure over time in our cohort, but this would be important to study in a larger or prospective cohort.
Residency education is continuously evolving and adapting to the learning environment. With the advent of the Next Accreditation System (NAS)  there will be an emphasis on the responsibility of the sponsoring institution to ensure quality of the learning environment. With this in mind it is important for residency programs to evalute the impact of elective exposures on outcomes and to identify innovations that improve the quality of these exposures.