Summary of findings
Here, we conducted a cross-sectional analysis to explore the effect of the ENAM score on the ENARM based on data from 28872 applicants between 2019 and 2023. Our major findings are as follows: 1) 6 out of 10 applicants pass the exam (pass rate ≥ 11), reducing to 3 out of 10 in the groups who did not take the ENAM and applied in the captive modality; 2) there was an overconcentration of candidates in Lima and specialties like pediatrics, obstetric-gynecology, and surgery; 3) the performance of applicants per specialty varies, with the lowest score seen in Family Medicine, and the highest on Cardiology; and 4) there was a strong association between the ENAM score and the ENARM, influenced by receiving honors, and this relationship persists when adjusting for the year, setting of application, modality, and application specialty.
Strengths and limitations
Although the study has several strengths, such as the large sample size, the statistical analysis, and the consistency with previous studies, it is not free of limitations. Due to its cross-sectional nature, establishing causal relationships is outside the capabilities of this study. Some variables, such as socioeconomic status, psychological factors, or educational resources, were unavailable due to reliance on secondary data. Moreover, while we converted the ENARM scores into pass/fail, this does not reflect the standard setting. Hence, it is important to interpret the number of passing applicants carefully.
Interpretation of findings
The hypothetical pass rate shows that 4 out of 10 applicants may fail the ENARM. This is in accordance with a study that reported that 4 out of 10 trainees failed the ENAM [13]. Additionally, 2 out of 10 who did not take the ENAM and applied in a captive modality passed the ENARM. This may be explained because this subgroup of doctors probably has over 10 years since graduation, and there is a wealth of evidence on knowledge decline. This is in accordance with prior research on Mexican medical education, where more years since graduation were associated with lower scores in their examination [5]. While this suggests the need for continuous training, this also points towards the quality of Peruvian medical education.
Previous academic achievement has been widely described as the principal constituent of future academic achievement [9, 17]. Our findings are aligned with this maxim and in accordance with research conducted in the US, where Step 1 and Step 2 CK scores were associated with resident performance [18–20]. This relationship underscores the impact of behavior on academic performance, as described by Aristoteles: "We are what we repeatedly do. Excellence, then, is not an act, but habit.'
While we provided evidence on academic factors, it is important to understand this as a multidimensional phenomenon that has yet to be understood [9]. It would be useful to categorize factors as modifiable and not modifiable [18]. Hence, research to identify these factors is needed. For example, research conducted in other examinations found a positive association with using retrieval-practice software such as Anki flashcards or question banks [22]. In other studies, test anxiety was associated with lower performances in large-scale examinations [23]. Hence, future studies must explore other factors that composite the ENARM score through different lenses.
Peru's capital concentrates most applicants, reflecting the lack of opportunities in other cities. Several problems arise from this finding. As residency programs have been associated with better patient care [24, 25], the overconcentration of programs in Lima is detrimental to other cities and may hinder the quality of care. This may also promote migration, leading to a lack of social support during residency training and affecting resident's well-being [26]. This may lead to attrition [27], which is a problem non-reported in Peru. Hence, this points out the need to redistribute residency spots across the Peruvian country.
Most applicants choose surgery, pediatrics, and obstetric-gynecology. These findings align with the literature [17, 18]. However, our study reveals disparities in specialty selection. This is exemplified by the low number of applicants in some specialties like Internal Medicine or Family Medicine. It may be explained because some specialties are perceived as low prestige and less resolutive for Peruvian medical practitioners [19]. In the case of Family Medicine, this represents a problem for Peru's primary healthcare. For example, there are roughly 1 family doctor per 30,000 inhabitants [28], when the recommended is 1 per 3,000. Hence, a major shortage of family doctors is critical in a country that urgently needs to increase its primary care workforce [29].
There were major differences in applicants' profiles. This was obvious when comparing Cardiology, Plastic Surgery, and Dermatology versus Family and Community Medicine. Based on the median score per specialty, our findings suggest that "high achievers" tend to choose prestigious specialties. This is in accordance with findings from the USMLE Step 1 and Step 2 CK, where one study showed that those who matched in dermatology had the highest scores while family medicine applicants had the lowest [6]. Similarly to the above, this supports the hypothesis on how medical practitioners perceived some specialties [30]. Hence, as top performers may decide based on intellectual challenge, these specialties are deemed not eligible. Moreover, this may indicate the existence of power dynamics between medical specialties and that some may be perceived as a never-ending consultation process due to a lack of resolution capacity in the Peruvian healthcare system.
Implications and Future Research
To our knowledge, this is the first study to evaluate the Peruvian National Residency Examination. Moreover, it reveals several problems in Peruvian medical education. The most proximal is using the proposed model to predict ENARM performance and identify applicants at risk of not matching. Moreover, to expand on other variables not measured in this model, we suggest employing the framework described in previous work and exploring the effect of psychological, institutional, and sociodemographic variables [9].
Our findings revealed problems in Peruvian medical education. First, those who did not match often returned to the Peruvian healthcare system. However, who did not match? Maybe, the 4 out of 10 applicants who would fail the ENARM, or the 7–8 out of 10 who graduated after 2008 and did not take ENAM, or those who applied through the captive modality. While we acknowledge that failing the ENARM does not reflect the quality of care, current evidence suggests that USMLE scores are associated with in-hospital mortality, length-of-stay, or adverse events [31–33]. Extrapolating these to our context, this leaves a major question: Who is taking care of our patients? In light of no licensing examination in Peru, this represents evidence of the need to implement one urgently.
Another problem highlighted was the centralization of medical education, similarly to undergraduate training [34], Lima concentrates more than half of residency spots, which may explain why over half of the medical doctors are concentrated in the capital [34]. Moreover, if regulatory bodies or decision-makers do not consider this centralization of medical training, a collapse in the clinical fields is imminent. Hence, this study is our ode to reimagining medical education.