Rethinking the Initial Board Certification Exam

Abstract

Each year, over 30,000 physicians take a certification exam that costs thousands of dollars, requires countless hours of preparation, and has little evidence of effectively evaluating physicians [1]. This exam is described as voluntary but is typically required for physicians to practice in their specialty at hospitals and to be credentialed by insurance companies. Recently, there have been major changes to United States Medical Licensing Examinations (USMLE) and maintenance of certification (MOC) exams; however, similar discussions have not transpired for initial board certification exams. We argue that a single high-stakes multiple-choice-based exam at the culmination of residency training is an outdated method of evaluation for board certification. Furthermore, recent changes to the MOC process which include module-based learning and open-book questions can inform a new way forward for the initial board certification process. Small studies demonstrate a correlation with performance on USMLE exams and board certification exams, but there is a paucity of evidence demonstrating standardized multiplechoice examinations predict effective physicians [2]. One retrospective study with data from over 10 years ago showed USMLE Step 2 scores had an inverse relationship with patient mortality for foreign medical graduates, and another article from almost 20 years ago described a minor correlation between primary care indices and Canadian licensing exams [3, 4]. A more recent comprehensive review suggested there was no correlation between USMLE scores and important clinical skills [5].While one paper linked board certification in general with higher physician performance scores using the RAND claims-based quality assessment tool, to our knowledge, no studies have linked certification or USMLE licensing exam performance to the quality of patient care. [6] Ideally, nearly all physicians that complete all four USMLE Step exams and an Accreditation Council for Graduate Medical Education (ACGME) accredited residency should pass a board certification exam. In reality, greater percentages of candidates fail board certification exams than USMLE exams, exposing discord between the two licensures and challenging the validity of board certification exams. While USMLE exam failure rates since 2014 remained steady between 2 and 6%, initial board certification exam failure rates have higher variance. For pediatrics, it ranged from 9 to 19%, internal medicine 9–13%, and general surgery 6–21% [7–10]. After years of investment in the training of specialist physicians, the relatively higher failure rates of board exams raise questions about the training and certification process. While some of this discord may be explained by the variation of training among residency programs, all ACGME-accredited residencies should theoretically prepare diplomates for board certification. Inconsistency in pass rates and decreasing pass rates across specialties are poor markers of initial board certification exams as an educational outcome measure. Failing initial board certification examinations does not come without a price. Physicians are severely restricted in their employment options and failed exams have been reported as contributing factors to physician suicide, although this has not been validated in peer-reviewed literature [11]. In the context of what has been described as an epidemic of medical student and physician burnout, depression, and suicide, the stress that certification exams places on candidates cannot be taken lightly, especially with the lack of evidence of improved patient-centered outcomes in physicians who have completed board certification exams. Board certification exams do have some advantages. One high-stakes examination is exactly that one exam. Board examination bodies and those advocating for these exams point to the studies mentioned above as markers of the predictive value of written medical examinations and that * David Greenky [email protected]