The letter from Pivalizza et al. confirms that residency programs do respond rapidly to changes in certification requirements.1 The program directors at this relatively large residency program suggest that both attrition of residents earlier in their training and changes to the curriculum could impact the conclusions about knowledge acquisition in the study by Zhou et al.2 The letter suggests that these factors, especially attrition of residents who likely had lower in-training examination scores, may have contributed to higher in-training examination scores in clinical anesthesia year 2, potentially tainting the “acceleration of knowledge” argument.2 Information about the training outcomes of residents who do not successfully pass their BASIC exam, either on initial or further attempts, could help alleviate the concerns regarding the representativeness of the resident cohort.
The more important question that this letter, the original article by Zhou et al.,2 and the editorial1 all allude to is, “What measures would confirm that the changes in examination resulted in increased knowledge acquisition?” As noted in our editorial, if certification requirements stay the same, the ultimate outcome measure would be that a cohort of graduates would be more successful in their first attempt following the move to administering BASIC and ADVANCED examinations.1 Ideally, this cohort would need to include and account for those residents who entered training but were not allowed to take the ADVANCED examination because they were unsuccessful in passing the BASIC examination.
The letter by Pivalizza et al. also highlights an additional implied outcome that will result from a change in the certification requirements. The first certification requirement now occurs early in training; residents who do not pass the BASIC examination would be more likely to leave (or be dismissed from) training prior to completing residency. The remaining residents who have passed their BASIC examination are more likely to be successful in their initial attempt to pass the ADVANCED certification examination, leading to a greater proportion of residents successful on their first attempt to become certified. From a patient safety perspective, this may be a desirable long-term outcome, because a prior investigation by Zhou et al. indicated that anesthesiologists who obtained their certification on the first attempt had a lower likelihood of having an action against their medical license than those who required more than one attempt.3 Under previous certification rules, the initial certification examination occurred after residents had successfully completed their training. Prior to the change in certification, residents who did not successfully pass their written examination could enter practice and potentially never achieve certification.
Residency programs and program directors are likely to be the first to identify the desirable as well as the unintended consequences of changes in certification. It is hoped that additional investigations from residency programs will follow the letter by Pivalizza et al. and provide information about how the introduction of the BASIC examination impacts training, certification, and patient safety outcomes.
The authors declare no competing interests.