Association Between Licensure Examination Scores and Practice in Primary Care

CONTEXT: Standards for licensure are designed to provide assurance to the public of a physician's competence to practice. However, there has been little assessment of the relationship between examination scores and subsequent practice performance. OBJECTIVE: To determine if there is a sustained relationship between certification examination scores and practice performance and if licensing examinations taken at the end of medical school are predictive of future practice in primary care. DESIGN, SETTING, AND PARTICIPANTS: A total of 912 family physicians, who passed the Québec family medicine certification examination (QLEX) between 1990 and 1993 and entered practice. Linked databases were used to assess physicians' practice performance for 3.4 million patients in the universal health care system in Québec, Canada. Patients were seen during the follow-up period for the first 4 years (1993 cohort of physicians) to 7 years (1990 cohort of physicians) of practice from July 1 of the certification examination to December 31, 1996. MAIN OUTCOME MEASURES: Mammography screening rate, continuity of care index, disease-specific and symptom-relief prescribing rate, contraindicated prescribing rate, and consultation rate. RESULTS: Physicians achieving higher scores on both examinations had higher rates (rate increase per SD increase in score per 1000 persons per year) of mammography screening (beta for QLEX, 16.8 95% confidence interval [CI, 8.7-24.9]; beta for Medical Council of Canada Qualifying Examination MCCQE, 17.4 95% CI, 10.6-24.1) and consultation (beta for QLEX, 4.9 95% CI, 2.1-7.8; beta for MCCQE, 2.9 95% CI, 0.4-5.4). Higher subscores in diagnosis were predictive of higher rates in the difference between disease-specific and symptom-relief prescribing (beta for QLEX, 3.9 95% CI, 0.9-7.0; beta for MCCQE, 3.8 95% CI, 0.3-7.3). Higher scores of drug knowledge were predictive of a lower rate (relative risk per SD increase in score) of contraindicated prescribing for MCCQE (relative risk, 0.88; 95% CI, 0.77-1.00). Relationships between examination scores and practice performance were sustained through the first 4 to 7 years in practice. CONCLUSION: Scores achieved on certification examinations and licensure examinations taken at the end of medical school show a sustained relationship, over 4 to 7 years, with indices of preventive care and acute and chronic disease management in primary care practice.