The SC test is a simple and direct approach to testing organization and use of knowledge. It has the strong advantage for a testing method of being relatively easy to construct and use and to be machine-scorable. It can be either paper- or computer-based and can be used in undergraduate, postgraduate, or continuing medical education.

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.

Context.-Clinical competence is a determinant of the quality of care delivered, and may be associated with use of health care resources by primary care physicians. Clinical competence is assumed to be assessed by licensing examinations, yet there is a paucity of information on whether scores achieved predict subsequent practice. Objective.-To determine if licensing examination scores were associated with selected aspects of quality of care and resource use in initial primary care practice. Design.-Prospective cohort study of recently licensed family physicians, followed up for the first 18 months of practice. Setting.-The Québec health care system. Participants.-A total of 614 family physicians who passed the licensing examination between 1991 and 1993 and entered fee-for-service practice in Québec. Main Outcome Measures.-All patients seen by physicians were identified by the universal health insurance board and all health services provided to these patients were retrieved for the 18 months prior to (baseline) and after (follow-up) the physicians' entry into practice. Medical service and prescription claims files were used to measure rates of resource use (specialty consultation, symptom-relief prescribing compared with disease-specific prescribing) and quality of care (inappropriate prescribing, mammography screening). Baseline data were used to adjust for differences in practice population. Results.-Study physicians saw a total of 1 116 389 patients, of whom 113 535 (10.2%) were elderly and 83 391 (7.5%) were women aged 50 to 69 years. Physicians with higher licensing examination scores referred more of their patients for consultation (3.8/1000 patients per SD increase in score; 95% confidence interval [CI], 1.2-7.0; P = .005), prescribed to elderly patients fewer inappropriate medications (−2.7/1000 patients per SD increase in score; 95% CI, −4.8 to −0.7; P = .009) and more disease-specific medications relative to symptom-relief medications (3.9/1000 patients per SD increase in score; 95% CI, 0.3 to 7.4; P = .03), and referred more women aged 50 to 69 years (6.6/1000 patients per SD increase in score; 95% CI, 1.2-11.9; P = .02) for mammography screening. If patients of physicians with the lowest scores had experienced the same rates of consultation, prescribing, and screening as patients of physicians with the highest scores, an additional 3027 patients would have been referred, 179 fewer elderly patients would have been prescribed symptom-relief medication, 912 more elderly patients would have been prescribed disease-specific medication, 189 fewer patients would have received inappropriate medication, and 121 more women would have received mammography screening. Conclusions.-Licensing examination scores are significant predictors of consultation, prescribing, and mammography screening rates in initial primary care practice.

The authors assumed that the richness of knowledge organization, as indicated by SC test scores, would predict part of the performance on the measures of clinical reasoning (SAMP and SOO), but would predict less well performance on the OSCE which measures both clinical skills and clinical reasoning. Data found in the study are coherent with this hypothesis. This is evidence in favour of the construct validity of the SC test. It also indicates that, in the context of certification assessment, if a candidate has shown good organization of clinical knowledge at an early point in training, it can be expected that he/she will show good organization at subsequent measurements of this kind of knowledge. This appears to be true even if the later measures bear on a wider clinical domain.

Objective To assess whether the transition from a traditional curriculum to a community oriented problem based learning curriculum at Sherbrooke University is associated with the expected improvements in preventive care and continuity of care without a decline in diagnosis and management of disease. Design Historical cohort comparison study. Setting Sherbrooke University and three traditional medical schools in Quebec, Canada. Participants 751 doctors from four graduation cohorts ; three before the transition to community based problem based learning (n = 600) and one after the transition (n = 151). Outcome measures Annual performance in preventive care (mammography screening rate), continuity of care, diagnosis (difference in prescribing rates for specific diseases and relief of symptoms), and management (prescribing rate for contraindicated drugs) assessed using provincial health databases for the first 4-7 years of practice. Results After transition to a community oriented problem based learning curriculum, graduates of Sherbrooke University showed a statistically significant improvement in mammography screening rates (55 more women screened per 1000, 95% confidence interval 10.6 to 99.3) and continuity of care (3.3% more visits coordinated by the doctor, 0.9% to 5.8%) compared with graduates of a traditional medical curriculum. Indicators of diagnostic and management performance did not show the hypothesised decline. Sherbrooke graduates showed a significant fourfold increase in disease specific prescribing rates compared with prescribing for symptom relief after the transition. Conclusion Transition to a community oriented problem based learning curriculum was associated with significant improvements in preventive care and continuity of care and an improvement in indicators of diagnostic performance.