Declining Performance on the Qualifying Examination: Modeling of a Potential Inflection Point in Emergency Medicine

Objectives To investigate longitudinal trends in the American Board of Emergency Medicine (ABEM) Qualifying Examination (QE) performance, identify statistically significant inflection points in pass rates, and determine factors associated with the recent decline observed in 2022. Methods This was a retrospective, observational study conducted in 2 phases. Phase 1 analyzed all QE attempts from 1980 to 2024 ( n = 83,254) to identify changepoints using segmented regression and Bayes factor comparisons. Phase 2 focused on QE attempts surrounding the most recent changepoint from 2016 to 2024 ( n = 23,784) and used multilevel nonlinear piecewise growth models to examine the association between physician characteristics and QE pass rates before and after the 2022 changepoint. Results Three statistically significant changepoints were identified: 1988, 2003, and 2022. Although increases in pass rates were noted in 1988 and 2003, 2022 was marked by a decline in pass rates with a steeper drop post-2022 (slope from 2016 to 2022=−0.17 vs slope 2022 to 2024=−0.67). From 2016 to 2022, MD graduates had a lesser decline in performance compared with non-MD peers. After 2022, those trained during the COVID pandemic also experienced a lesser decline. Conclusion ABEM QE pass rates experienced 3 major inflection points since 1980, with the most recent occurring in 2022 and representing a meaningful decline. Physician-level characteristics, particularly medical school degree type and COVID-era training, were significantly associated with this trend.