Tuesday, April 15, 2014

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.


Anonymous said...

The written exam is esp. puzzling in the age of Google. If I am uncertain whether Rocephin (for example) is indicated for a post-op infection, it takes a minute on my phone to find out.

I think anesthesiologists are required a session with a simulator for recert, but that would be tough to do with most specialties.

I don't see an answer, but I also don't see throwing up our hands and just assume every doc is competant unless thrown out by tje state board.

Skeptical Scalpel said...

There must be a better way. Most docs complain that the recert exam doesn't test them on what they actually do. The tests tend to lean toward zebras instead of horses. The good news is that in surgery at least, the pass rates are quite high, running at about 95%. Here's a link to the stats http://www.absurgery.org/default.jsp?statgeneral

Anonymous said...

Dosn't a pass rate of 95% mean the process is useless?

Skeptical Scalpel said...

You said that, not me. But I agree. You might say it's for show although it could be that surgeons really study hard for the exam.

Anonymous said...

Well for starters, why in the name of 2014 are people still needing to fly out to these places for certs? Why can't these interviews be done over the web? That would certainly cut out time and expense. What are we paying for in terms of $$ amounts for those recerts just for the exams alone? 3 years ago I paid $250 for one IT exam. What about the $200 goes to the pocket of the doctor doing the exam? Maybe $50 for the licensing group? That way there aren't people making a boatload of $$ off of others' misery. Yes it is misery. I know when I was doing certs with 4-5 different groups the money was just stupid. Then the work would pay for the first one only.

As for simulators check out this today from Medscape: http://www.medscape.com/viewarticle/821463, "Skills acquired by simulation-based training seem to be transferable to the operative setting for laparoscopic cholecystectomy and endoscopy. Future research will strengthen these conclusions by evaluating predetermined competency levels on the same simulators and using objective validated global rating scales to measure operative performance.". What about the uses of that?

Skeptical Scalpel said...

Anon, I'm not sure what you mean by an "IT exam." As a local oral board examiner for three days, I received no pay. I am not sure what the board members got, but it may have been their travel expenses. Maybe the oral exams could be done via Skype. It's worth a try.

I suppose simulators could be used for board exams, but I don't see how that would cut costs.

artiger said...

I wouldn't hold my breath. The boards have a good gig going here, and they aren't going to let someone pull up the track in front of the gravy train anytime soon.

Skeptical Scalpel said...

Artiger, I agree. It's not going to change unless it would be to get worse.

You should see what the American Board of Internal Medicine is doing to its constituents in the area of maintenance of certification. It's much worse than surgery.

Anonymous said...

Hi Skep Iam from India who is looking to join a Medical school pls give your opinion on spartan, St George and Trinity. My ambition is to become a General Surgeon

Skeptical Scalpel said...

All I can say is that Spartan and Trinity are far less widely known that St. George's.

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