You failed the written boards: What to do now

I graduated this July and took the QE (written general surgery boards) on July 19th. I got my results today and I failed. Not only did I fail but my score placed me in the 5th percentile. Needless to say I'm disappointed. You hear stories about CE (oral exam) failure but never about QE failure. I never blew the ABSITE out of the water (50, 29, 20, 34, 38), but I never would have expected to perform so poorly. Rather than search for blame I'd like to form an effective strategy so that I pass the second time around.

I am sorry to hear of your misfortune. I can’t imagine how you must be feeling.

In your time as a PD did you have a resident or residents fail the QE? Several residents failed the QE. The most notable was a guy who never got below the 60th percentile on the ABSITE. To this day, I cannot understand how that happened.

What became of these people? You will be happy to learn that nearly everyone eventually passed. Patients never ask you how many times it took you to pass the boards. They don’t know about that sort of thing. As far as I know, failing the boards on the first attempt has no long term ramifications except for your program which is judged by the percentage of residents who pass the boards on their first attempt.

Any advice on how to avoid another failure? In order to help you answer the last question I will tell you that I went through SESAP 15 once. I listened to the audio as well. I stuck to high yield sources and UpToDate to supplement SESAP. I avoided reading any formal textbooks but I did read Cameron front to back during residency.

I have found that everyone learns in different ways. There is no single path to success.

One thing you said caught my attention. “I avoided reading any formal textbooks…” I think that would be a good place to start. You need to get a basic full-sized surgery textbook and read it carefully all the way through. I would advise you to take notes, make flashcards, or whatever else you think might help you to remember important points. Cameron is a great book but in my opinion it is more suited to studying for the oral boards because it is more clinically focused.

SESAP is geared more toward surgeons doing recertifying exams and is probably not worth spending time on for the QE.

Many of my residents used books of practice questions which may help, but only after you have done a lot of reading.


After you have studied your textbook and are feeling fairly comfortable, you should think about taking an intensive review course a few weeks before the exam. That may help solidify your knowledge. Taking a review course without studying beforehand probably won’t work because it is so much information over a short period of time that you will not be able to retain it all.

Study hard because the last thing you need is to fail the QE again. That would put tremendous pressure on the third attempt. You don’t want to be in that position.

I hope this helps. Good luck.

Review courses and board exams

Four years ago, I wrote a post called "Hints for new residents." Among my 15 tips was this: "Read, read, read. This isn't like school. You can't cram for your boards. You can’t learn 4 or 5 years’ worth of material in a one-week review course. You have to learn it as you go along."

Just published online in the journal Surgery is a paper entitled "Review courses for the American Board of Surgery certifying examination do not provide an advantage" by four officials from the board.

They surveyed new surgeons who took the certifying (oral) exam, 1067 for the first time and 329 who had previously failed the test, during the time period from October 2012 through June 2013. The overall response rate was 90%.

The pass rate for first-time takers was significantly better than that of repeaters, 82.1% and 72.6% respectively, p < 0.001; 77.9% of all examinees took a review course—76.1% were first-time takers compared to 84.6% of those repeating the exam, p = 0.002.

Why aren't all board recertification exams oral?

A loyal reader, who agrees with me that we may be teaching and testing medical students and residents the wrong way, asks why aren't all board recertification examinations given orally. She correctly asserts that oral examinations are better because they assess how people think rather than how much they have memorized.

Here's why it would be difficult to do.

The initial surgery board exam is given in two parts. First a written exam must be passed. Those who pass it are tested orally at one of four or five different times and locations within the following year. Oral exams are quite labor intensive.

Each candidate is examined by three pairs of surgeons, consisting of a senior examiner who is a member of the board itself and a surgeon from the local area. Each session lasts 30 minutes per pair for a total of 90 minutes. Multiply that by 1300+ examinees per year.

I had the privilege of serving as an examiner on one occasion. It's very stressful because one wants to be fair but also not let incompetent surgeons become certified. It's also much harder to standardize oral exams. Scenarios used in the exam are chosen by the board each year, but the individual examiners may have different approaches to the way the questions are asked and answered. For a number of surgical diagnoses, there may be more than one correct way to handle a problem, which makes creating a written exam difficult too.

About 1800 to 2000 general surgeons take the recertifying exams every year. To give each one of them a 90 minute oral exam would be very expensive and time consuming. It would be hard to find practicing surgeons willing to give up so much time to be examiners.

Many surgeons and other specialists are complaining about the cost of maintaining board certification. Taking a written recertification exam now involves going to a testing center and sitting in front of a computer. Many such centers exist, and traveling to them is much less complicated than going to one of the four or five cities where the oral examinations are held every year.

I do not see any way that recertification exams can ever be even partially oral. Until someone finds a way to make computer-based exams more clinically oriented, the ability to memorize facts will remain the basis for all recertification testing. 

There are other issues such as how to deal with surgeons who have specialized in a narrow area of surgery for many years, which is becoming more prevalent with so many graduates of residencies taking fellowships.

I addressed the other maintenance of certification components in a post last year. The concept of maintenance of certification is noble, but the execution is not working for those subjected to the process.

If anyone has a better idea, please comment.

Is Maintenance of Physician Board Certification a Sham?

Over the last few years, medical specialty boards have begun to compel physicians to maintain board certification by a number of means. This is an extension of recertification requirements which have been in existence since the mid-1970s.

Here is what the American Board of Surgery (ABS) mandates for Maintenance of Certification (MOC) every three years except where noted:

1. You must have an unrestricted medical license, hospital privileges in surgery, and references from the chief of surgery and the chair of the credentials committee of your hospital. It’s hard to argue with the need to have a license and practice in a hospital. However, if a surgeon had real quality issues, shouldn’t they have come to light before the end of a three-year cycle of MOC?

2. You must document 90 hours of CME credit, 60 of which must include some sort of Q & A testing which must be passed with an average score of at least 75%. I have previously blogged about the inadequacy of most CME programs. Even CMEs that require testing are often laughably simple. The American Board of Internal Medicine offers (for a price) open-book and Internet-based courses. Regarding self-assessed CMEs, the ABS website states, “[t]here is no required minimum number of questions and repeated attempts are permitted.”

3. You must successfully complete a written recertification examination every 10 years. Surely that must be an effective measure? Maybe not. For the last five years, the pass rate for recertification in general surgery is 94% or greater. The American Board of Internal Medicine (ABIM) recert exams must be a little tougher or those who take it may not be as smart as surgeons. The pass rates for the ABIM recert exams have been 88% to 92% for the last four years with similar rates for all of the medical subspecialties.

4. You must participate in a national, regional or local outcomes registry or quality assessment program. Participation in a national outcomes registry sounds great, but none of the available registries have policing powers and many rely on individual surgeon input to track outcomes. As mentioned in the critique of the first requirement, quality issues are far more likely to be discovered at the local level than by a registry that collects data submitted by the surgeon herself.

As if all of the above issues are not enough, how about this for a hot potato from the ABS? “Periodic communication skills assessment based on patient feedback may also be required in the future.” I can’t wait to see how that information is going to be collected. By what criteria will communication skills be judged? And what will happen to someone deemed a poor communicator?

I suppose the boards are doing all of this to forestall government or other regulatory bodies stepping in. Meanwhile, let’s everyone play along.

None of the MOC requirements address another issue, which is fitness for practice. A December 10^th article in the Washington Post on aging physicians notes that some hospitals are setting age limits at which doctors are required to have physical and mental evaluations in order to maintain staff privileges. That’s great but not for just the elderly; every doctor needs to have period fitness testing.

Right now, all you have to do to stay on the staff of most hospitals is have a colleague attest to the fact that you are in good health, hardly a rigorous standard.

I’ve known a few physicians well under the age of 65 who could have used a checkup from the neck up.

To answer my own question, maintenance of certification is a sham.