Taking Leave During Residency: Types of Absences and Subsequent Delays and Variations in Physical Medicine and Rehabilitation Medical Board Pass Rates

BACKGROUND

Past investigations into specialty board pass rates highlight the importance of continuous education during residency training and limited delays in taking the board examinations.1,2 However, the lives of residents often require a complex management of both personal and professional growth. Medical education leaders must play an active role in fostering an environment where trainees can thrive through structured changes in policy.

In July 2021, the American Board of Medical Specialties mandated a leave policy for member boards with residency programs that lasted 2 or more years. While the exact framing of the leave policy was left to the discretion of the member boards, residents must be allowed “a minimum of 6 weeks of time away from training for purposes of parental, caregiver and medical leave at least once during training, without exhausting all other allowed time away from training and without extending training.”3

A recent review found that all applicable boards adhered to the American Board of Medical Specialties leave mandate, but the policies themselves were inconsistent across specialties.4 The American Board of Physical Medicine and Rehabilitation (ABPMR) already allowed 6 wks of leave each year in 2018 and in 2021 added an additional four consecutive weeks of parental, caregiver, and medical leave for eligible resident and fellows without extending training.4,5 Although the changes in ABPMR’s leave policy are progressive, questions remain about the reasons why physical medicine and rehabilitation (PM&R) residents take a leave of absence (LOA) during residency, as well as subsequent impact on specialty board pass rates.

The identification of reasons why PM&R residents take an LOA can better inform the changing policies related to certain types of leave, allow improved guidance to residency program directors, as well as help destigmatize the need for taking a leave during training. It is difficult to envision an accreditation process which is—per the ABPMR vision statement—dynamic, reliable, and valid, without understanding the dynamics of this population of candidates for certification.

The goals of the current investigation were to (1) describe the characteristics of PM&R residents who take a significant LOA during their PM&R residency, (2) compare differences in part I and part II performance, and (3) determine prevalence of delays in taking the part I and part II examinations based on LOA.

METHODS

Research team members conducted a retrospective analysis of deidentified information from the ABPMR physician database. Inclusion criteria were physicians who completed a PM&R residency training program between 1998 and 2020. Residents who had their training extended for 7 days or more with a documented reason were categorized as individuals who took an extended LOA.

Data of Interest

Demographic data on residents who took an extended LOA included age, sex, geographic training location, and type of medical degree. First-time candidate data for part I and part II board examination performance were pulled for all residents in the study period. The ABPMR board examinations have demonstrated validity6,7 and are designed to test knowledge (part I)8 and its application to patient care (part II).9 Last, information on reasons for an LOA was reviewed and coded into categories for analysis.

Analyses

Basic count and percentage were used to determine participant characteristics and delays in completing the part I and part II examinations. A Wald χ2 test determined whether the reason for the LOA influenced board pass rates. Odds ratios for passing the board examinations were calculated for each unique reason for taking an LOA compared with residents who did not take an LOA. All analyses were conducted through SPSS Version 28 (Armonk, NY).

The Mayo Clinic Institutional Review Board determined this study did not meet the criteria for human subject research and thus did not require further institutional review board review.

RESULTS

Between 1998 and 2020, 10,803 physicians completed their residency training in PM&R. Of those graduates, 643 (6.0%) residents extended their training seven or more days; the range of extended leave was 7–1296 days.

Participant Characteristics

Most participants who took an LOA during their residency identified as female (n = 434, 67%), were between 25 and 34 yrs old at the start of residency (n = 509, 79%), and had medical doctor degrees (n = 494, 77%; Table 1). There was adequate representation in the sample from all regions of the United States. Upon review, four categories surfaced on the reason why residents took an LOA during residency: academic concerns/remediation (n = 108), parental (n = 191), personal health (n = 73), and personal unidentified (n = 271).

TABLE 1 - Participant characteristics Demographics Reason for Leave of Absence No Leave of Absence (n = 10160) Academic/Remediation (n = 108) Parental (n = 191) Personal Health (n = 73) Personal Unspecified (n = 271) Total (N = 643) n (% Within Column) Sex  Male 6407 (63%) 77 (71%) 6 (3%) 27 (37%) 88 (33%) 198 (31%)  Female 3568 (35%) 29 (27%) 184 (96%) 45 (62%) 176 (65%) 434 (67%)  Nonbinary 7 (0.1%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%)  Prefer not to answer 175 (2%) 2 (2%) 1 (1%) 1 (1%) 7 (3%) 11 (2%) Age at the beginning of residency  20–24 29 (1%) 0 (0%) 0 (0%) 0 (0%) 2 (1%) 2 (1%)  25–29 5951 (59%) 24 (22%) 116 (61%) 30 (41%) 112 (41%) 282 (44%)  30–34 2745 (27%) 44 (41%) 58 (30%) 24 (33%) 101 (37%) 227 (35%)  35–39 874 (9%) 20 (19%) 16 (8%) 11 (15%) 30 (11%) 77 (12%)  40–44 367 (4%) 9 (8%) 1 (1%) 4 (6%) 16 (6%) 30 (5%)  45–49 113 (1%) 6 (6%) 0 (0%) 0 (0%) 7 (3%) 13 (2%)  >50 39 (1%) 1 (1%) 0 (0%) 1 (1%) 0 (0%) 2 (1%) Degree  MD 7470 (74%) 90 (83%) 145 (76%) 49 (67%) 210 (78%) 494 (77%)  DO 2574 (25%) 17 (16%) 44 (23%) 24 (33%) 57 (21%) 142 (22%)  MBBS 116 (1%) 1 (1%) 2 (1%) 0 (0%) 4 (2%) 7 (1%) Region of residency  Northeast 3474 (34%) 35 (32%) 37 (19%) 20 (27%) 77 (28%) 169 (26%)  Midwest 2568 (25%) 25 (23%) 69 (36%) 22 (30%) 78 (29%) 194 (30%)  South 2746 (27%) 32 (30%) 54 (28%) 23 (32%) 74 (27%) 183 (28%)  West 1213 (12%) 14 (13%) 27 (14%) 8 (11%) 39 (14%) 88 (14%)
Comparison of Board Pass Rates Based on Reason for Leave

The reason for taking an LOA significantly influenced the part I examination pass/fail result (Wald = 21.75, df = 4, P < 0.001; Table 2). The odds ratios indicated that physicians who took a parental LOA did not have a significantly different part I pass rate than physicians who did not take an LOA (P = 0.79). Physicians who took a personal LOA because of health concerns did not have a significantly different part I pass rate than physicians without an LOA (P = 0.12). Physicians who took an LOA for unspecified personal reasons or had an LOA because of academic or remediation reasons had a lower part I pass rate than physicians who did not take an LOA (P < 0.05 and P < 0.001, respectively).

TABLE 2 - Comparison of pass rates based on reason for leave Board Exam Pass Rate Reason for Leave of Absence No Leave of Absence Academic/Remediation Parental Personal Health Personal Unspecified Part I examination  Part 1, n 7870 77 160 58 221  Pass rate 91.8% 79.2% 91.3% 86.2% 87.3%  Odds ratio Reference 0.34 (0.19–0.59) a 0.93 (0.53–1.61) 0.56 (0.26–1.18) 0.61 (0.41–0.92) b Part II examination  Part 1, n 7775 76 160 58 220  Pass rate 86.6% 67.5% 94.4% 82.8% 81.4%  Odds ratio Reference 0.30 (0.19–0.50) a 2.36 (1.20–4.64) b 0.68 (0.34–1.34) 0.63 (0.45–0.90) b

Similarly, the reason for LOA significantly influenced the part II examination pass/fail result (Wald = 36.60, df = 4, P < 0.001; Table 2). Contrary to the part I examination results, the odds ratio indicated that physicians who took a parental LOA had a significantly higher pass rate than physicians who did not take an LOA (P < 0.05). Physicians who took a personal LOA because of health concerns did not have a significantly different pass rate than physicians without an LOA (P = 0.26). Physicians who took an LOA for unspecified personal reasons or had an LOA because of academic/remediation reasons had a lower pass rate than physicians who did not take an LOA (P < 0.05 and P < 0.001, respectively).

Delays in Taking Board Examination Based on Reason for Leave and Subsequent Pass Rates

Residents who did not take an LOA during training had significantly lower odds of passing both the part I and part II examinations if they delayed taking the test (P < 0.001). Most physicians who took an LOA during residency had no delay in taking the part I examination (n = 380, 74%) nor the part II examination (n = 281, 54%).

There were no significant differences in pass rates for residents who took a parental or personal health leave while delaying the part I examination compared with those with the same leave but no delay (Table 3). Residents who took parental leave had the highest percentage of no delays and highest pass rates for both part I (n = 129, 81% no delay; 91.5% pass rate) and part II (n = 99, 62% no delay; 93.9% pass rate) examinations compared with other reasons for leave (Table 3). Participants who took an LOA had a greater percentage of delays for the part II examination compared with part I.

TABLE 3 - Examination delays based on reason for leave, subsequent pass rates, and odds of passing Part I Examination Part II Examination Delay Taking Board Exam Reason for Leave No Delay 1 yr >2 yrs No Delay 1 yr >2 yrs No leave of absence   n (%) 7515 (95%) 264 (3%) 91 (1%) 6576 (81%) 788 (10%) 450 (6%)  Pass rate % 92.9% 75.4% 48.4% 89.3% 78.9% 62.3%  Odds ratio Reference 0.23 (.17–0.31) a 0.07 (0.05–0.11) a Reference 0.50 (0.41–0.61) a 0.22 (0.18–0.27) a Academic/remediation   n (%) 49 (64%) 20 (26%) 8 (10%) 32 (42%) 24 (31%) 21 (27%)  Pass rate % 85.7% 80.0% 37.5% 75.0% 75.0% 47.6%  Odds ratio Reference 0.67 (0.17–02.59) 0.10 (0.02–0.52) b Reference 1.00 (0.30–3.40) 0.33 (0.10–1.09) Parental   n (%) 129 (81%) 28 (18%) 3 (1%) 99 (62%) 48 (30%) 13 (8%)  Pass rate % 91.5% 89.3% 100.0% 93.9% 95.8% 92.3%  Odds ratio Reference 0.78 (0.20–2.99) n/a Reference 1.48 (0.29–7.64) 0.77 (0.09–6.99) Personal health   n (%) 34 (59%) 21 (36%) 3 (5%) 26 (45%) 22 (38%) 10 (17%)  Pass rate % 91.2% 90.5% 0.0% 84.6% 81.8% 80.0%  Odds ratio Reference 0.92 (0.14–6.01) n/a Reference 0.82 (0.18–3.74) 0.73 (0.11–4.77) Personal unspecified   n (%) 168 (76%) 44 (20%) 9 (4%) 124 (56%) 66 (30%) 31 (14%)  Pass rate % 91.1% 81.8% 44.4% 84.7% 83.3% 64.5%  Odds ratio Reference 0.44 (0.17–1.12) 0.08 (0.02–0.32) a Reference 0.91 (0.40–2.04) 0.36 (0.15–0.89) c

a P < 0.001.

b P < 0.01.

c P < 0.05.


DISCUSSION

Reasons for an extended LOA varied for PM&R residents. Of the four identified reasons for an LOA, residents who took parental leave did not have adverse outcomes on part I examinations and were more likely to pass than those who did not take an LOA for part II examinations. However, residents who took an LOA for unspecified personal reasons or because of academic/remediation concerns had lower pass rates on both part I and part II examinations. Residents who took a medical LOA had no difference in pass rates for either part I or part II examination compared with those who did not take an LOA. Of those residents who did take parental LOA, the majority did not delay in taking board examinations. The ABPMR extends eligibility for part I into the month of the examination to accommodate residents needing to extend residency by several weeks.

With the current findings, program directors can better understand how the reason for an LOA can have varying influence on specialty board examination pass rates. Hesitance toward extended parental LOA because of fears about board pass rates may be unwarranted. Of the 9740 active PM&R physicians in the United States in 2019, 35.8% (n = 3486) identified as female.10 Almost all of the PM&R residents who took a parental LOA were female in the current study. There is opportunity to recruit and retain trainees through supportive parental LOA policies, especially considering the underrepresentation of women in PM&R.

Along with the American Board of Medical Specialties mandate in 2021, the Accreditation Council of Graduate Medical Education will require accredited residency and fellowship programs to “provide residents/fellows with at least the equivalent of 100 percent of their salary for the first six weeks of the first approved medical, parents, or caregiver leave(s) of absence taken” starting July 1, 2022.11 Paid leave will help alleviate any financial strains that residents will face with medical, parental, and caregiver leave, as well as allow focused attention on their responsibilities during the leave period.12

Although parental and medical leave did not negatively affect board pass rates, residents taking an LOA because of academic/remediation concerns had lower part I and part II examination pass rates. Early detection and intervention with struggling residents should be explored by residency programs to mitigate concerns. The annual Self-Assessment Examination for Residents during PM&R residency has been reported as an early detection tool for performance on board examinations.13,14 However, such in-training assessments during residency are meant to be a formative assessment of clinical knowledge that provide feedback to residents.15 Systematic review suggests that in-training examinations can help identify those who will do well on the specialty board examinations, but the assessment may not adequately identify those who will perform poorly on their board examinations,15 suggesting that additional variables may affect board examination performance. One strategy to provide academic support during residency is a structured board review course for at-risk residents.16 Review activities, such as curated weekly assigned reading by faculty, are found to increase first-time board examination pass rates.17

Physicians delaying specialty board examinations, especially delays of more than 2 yrs, have been found to have lower examination pass rates than those without delays.2,18,19 However, such studies often do not separate out the reason for delay as a source of variation in pass rates, as the current study demonstrated. Within a PM&R resident sample, there was variation in board certification pass rates for delays based on the reason for an extended leave from residency training. Parental and personal health reasons for leave did not affect board pass rates for part I or part II based on whether they delayed taking the examination or not. Future studies on certification examination pass rates based on delays in testing should factor in the reason for an extended delay.

The current study population focused on PM&R, which has a unique work context compared with other specialties. Similar studies of LOA, specialty board pass rates, and delays in board examinations in other medical specialties may help inform decisions that are ideally consistent across medical boards. In addition, a significant portion of LOAs could not be identified and were labeled in a separate category, “personal unspecified.” Further investigation is needed into the personal reasons for LOA, as well as the experiences and processes related to taking an LOA during training. Such insight can help program directors determine how to best support those who need to take an LOA during training.

CONCLUSIONS

There were four main reasons for extended LOA during PM&R residency: medical, parental, academic/remediation, and unspecified personal reasons. Residents who took an extended LOA during their PM&R training for medical or parental reasons had similar or better odds of passing their part I and part II examinations to peers who did not extend their training. However, residents who took leave because of academic/remediation concerns did have poorer odds of passing their board examinations. There was limited delay in part I examinations compared with part II examinations. Further investigation is needed to identify national and program-level processes and approaches to best support residents who need to take medical and parental leaves during training.

REFERENCES 1. Driscoll SW, Geis CC, Raddatz MM, et al.: Predictors of performance on the American Board of Physical Medicine and Rehabilitation maintenance of certification examination. PM R 2018;10:1361–5 2. Robinson LR, Driscoll S, Sabharwal S, et al.: Does delay in taking the American Board of Physical Medicine and Rehabilitation certification examinations affect passing rates?Am J Phys Med Rehabil 2016;95:725–9 3. American Board of Medical Specialties policies on parental, caregiver and medical leave during training. Available at: https://www.abms.org/policies/parental-leave/. Accessed January 28, 2022 4. Magudia K, Campbell SR, Rangel EL, et al.: Medical specialty board Parental, caregiver, and medical leave policy updates after 2021 American Board of Medical Specialties mandate. JAMA 2021;326:1867–70 5. ABPMR New family leave policy for residents and fellows. Available at: https://www.abpmr.org/NewsCenter/Detail/family-leave-policy. Accessed January 28, 2022 6. Raddatz MM, Robinson LR: Demonstrating construct validity of the American Board of Physical Medicine and Rehabilitation part I examination: an analysis of dimensionality. PM R 2017;9:985–9 7. Chiodo A, Raddatz M, Driscoll SW, et al.: Should there be a part II ABPMR examination?: a psychometric inquiry. PM R 2019;11:1115–20 8. ABPMR Part I. Available at: https://www.abpmr.org/Primary/PartI. Accessed January 28, 2022 9. ABPMR Part II. Available at: https://www.abpmr.org/Primary/PartII#. Accessed January 28, 2022 11. Accreditation Council for Graduate Medical Education ACGME Institutional Requirements. Posted September 26, 2021. Available at: https://www.acgme.org/globalassets/pfassets/programrequirements/800_institutionalrequirements_2022.pdf. Accessed February 10, 2022 12. Ortiz Worthington R, Feld LD, Volerman A: Supporting new physicians and new parents: a call to create a standard parental leave policy for residents. Acad Med 2019;94:1654–7 13. Massagli TL, Gittler MS, Raddatz MM, et al.: Does the physical medicine and rehabilitation self-assessment examination for residents predict the chances of passing the part 1 board certification examination?PM R 2017;9:154–8 14. Moroz A, Bang H: Predicting performance on the American Board of Physical Medicine and Rehabilitation written examination using resident self-assessment examination scores. J Grad Med Educ 2016;8:50–6 15. McCrary HC, Colbert-Getz JM, Poss WB, et al.: A systematic review of the relationship between in-training examination scores and specialty board examination scores. J Grad Med Educ 2020;13:43–57 16. Aeder L, Fogel J, Schaeffer H: Pediatric board review course for residents “at risk”. Clin Pediatr (Phila) 2010;49:450–6 17. de Virgilio C, Chan T, Kaji A, et al.: Weekly assigned reading and examinations during residency, ABSITE performance, and improved pass rates on the American Board of Surgery examinations. J Surg Educ 2008;65:499–503 18. Malangoni MA, Jones AT, Rubright J, et al.: Delay in taking the American Board of Surgery qualifying examination affects examination performance. Surgery 2012;152:738–43 19. Marco CA, Counselman FL, Korte RC, et al.: Delaying the American Board of Emergency Medicine qualifying examination is associated with poorer performance. Acad Emerg Med 2014;21:688–93

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