Declining board exam pass rates: Blame millennial doctors?

An interesting conversation recently took place among residency program directors in my field of internal medicine.

At issue was the declining pass rate of first-time test takers of the ABIM Certification Exam.

It’s a mouthful to say, but the ABIM exam is the ultimate accolade for internists. One is only eligible to take the exam after having successfully completed a three-year residency training period (the part that includes “internship,” right after medical school).

An easy analogy is to say that the board exam is for a doctor what the bar exam is for a lawyer. The difference is that a doctor can still practice if he does not pass — they might be excluded from certain jobs or hospital staffs, but certification, while important, is a bit of gilding the lily. (Licensure to practice comes from a different set of exams.)

There’s no doubt it’s a hard test. I was tremendously relieved to have passed it on my first try. Over the last few years, the pass rate for first time takers has fallen from ~90% to a low of 84%.

It may not seem significant, but for 7300 annual test takers, the difference in pass rates affects about 365 people — or one additional non-passing doctor for every day of the year.

In any event, we program directors have taken note. And the falling pass rate has raised questions:

  • Has the test increased in difficulty? No, says the ABIM.
  • Are the study habits of millennials not up to the level of baby boomers and Gen X’ers? Now you may be on to something.

One concern that has a ring of truth to it is that young doctors have become great “looker-uppers,” and have lost the sense of what it’s like to actually read and study medicine. While doctors enter the profession with a commitment to lifelong learning, some of us fear that the young folk only go far enough to commit to lifelong Googling.

Another key point. In today’s era of restricted work hours, something has to give. Too often, when residents must complete the same amount of work in a limited amount of time, what’s sacrificed is the didactic portion of the education: the stuff we do by running through case after case, discussing subtleties and action plans. When time is limited, the work’s simply gotta get done.

There’s even a term that describes this phenomenon: work compression.

John Schumann is an internal medicine physician who blogs at GlassHospital.

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  • buzzkillerjsmith

    I’m not sure why the pass rate has declined. Could it be that IM is now getting poorer med students in because of the lousy pay and working conditions?

    The JAMA work compression article is interesting and almost comical. Same amount of work and less time to do it. This does not seem like a big improvement to me.

    Years ago we residents did a lot of “scut work,” drawing labs and running them to the lab, trying to track down X-ray films, calling and trying to schedule diagnostic procedures. The VA was famous for the scut work. Any residents out there to tell us whether it’s the same now?

  • ninguem

    “…..One concern that has a ring of truth to it is that young doctors have become great “looker-uppers,” and have lost the sense of what it’s like to actually read and study medicine. While doctors enter the profession with a commitment to lifelong learning, some of us fear that the young folk only go far enough to commit to lifelong Googling…..”

    A legitimate question is, does it make a difference? Is it important to memorize something that’s not something life-or-death that you have to know by heart, immediately, Maybe the doctor and patient are better off if the doctor double-checks. Maybe doctors of a previous generation memorized things that no longer need to be memorized in the age of Google. Maybe, in times past, it was more important to memorize something that might take an hour to look up, when nowadays it can be referenced in seconds.

  • drgh

    It sure is a good distraction from the “Dr. Wachter reflects after completing his term at the ABIM” article.

  • Marian P

    I passed my boards in 1981 and voluntarily re-certified in 2,000 and 2010. I studied the MKSAP each time and took all the practice exams. However, when I did the ABIM modules, I used resources like UpToDate and MD Consult to find the answers quickly (permitted by the ABIM, these are not closed-book). Frankly, I resented the many hours it took me to memorize things for the test as this isn’t how I practice anymore. Medicine changes rapidly, and being a good doctor means a commitment to lifelong learning and constantly looking things up, not regurgitating a bunch of memorized stuff that gets outdated very quickly. Some things never change: excellent assessment skills, taking a good history, performing a careful exam. But as to which tests to order and what drugs to use you’d better be looking it up or consulting an expert, because things change. I think maybe the exam needs to change: give the examinees internet access and see how quickly they can get to the right answer. That’s a lot like real life. Maybe the millennials are just using their brains more efficiently.

    • Elvish

      “”I think maybe the exam needs to change: give the examinees internet access and see how quickly they can get to the right answer.”"
      Why don`t we do the same thing to the USMLE ? You are going to forget half the stuff the moment you walk out of test centre.

      3 years and a change of medical school( not six nor four), 3 years of residency, without an internship, ACGME duty hours and finally an open book, nay, an open “internet” for board certification and people, naively, think that the US has the best medical training in the world.

      What a joke !

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      “But as to which tests to order and what drugs to use you’d better be
      looking it up or consulting an expert, because things change.”

      How does one become an expert if everybody is looking things up on the Internet? Aren’t you supposed to be that expert?

      • Guest

        But medicine and the recommendations for appropriate treatment are constantly changing. I think it’s great that docs have a resource at their fingertips that will keep them constantly abreast of the most current treatment. I see older docs I work with doing out of date, archaic treatments simply because that’s what they’re comfortable with.

        • http://onhealthtech.blogspot.com Margalit Gur-Arie

          Yes, it’s good that resources are more readily available, but shouldn’t one keep up with the latest and greatest research on an ongoing basis and internalize it, instead of keeping up with nothing and trusting that they can always look it up if and when the need arises? Isn’t there a certain level of knowledge that must be committed to memory in order to enable intelligent observation and synthesis of findings?

    • azmd

      I dunno. I teach my residents that there is a certain body of knowledge that they just need to know off the top of their heads. In the first place, because no matter how quickly you can look something up, it’s always faster to just know it. In the second place, there are going to be things you need to know in emergencies when there’s no time to look things up, and in the third place, patients are always going to ask you questions and trust me, they will be underwhelmed to hear you say “I don’t know, but I know where to look it up.”

      Of course it’s important to be up to date, that’s why you need to keep up with the literature, and a certain amount of looking things up to check is always going to be necessary.

      But I do think it’s important not to get too far into the mind set that what we do is look things up. Anybody can do that.

      • Marian P

        Agree there is a base of knowledge everyone should have. Common problems, managing chronic disease, and recognizing potential emergencies would be in that category, for example. But having taken three ABIM exams ( geriatrics, Hospice and Palliative Care, and IM) in the last three years, there was an awful lot of minutia, especially on the IM exam, or problems that would not be appropriate for the generalist to handle, in my opinion. And I am fortunate enough to have a retentive mind and have excellent test taking skills. I passed by a comfortable margin, but I am not sure failing means you are not competent.

        • azmd

          Oh, well. I am not disagreeing that written boards can be overly picky and not a good reflection of one’s clinical abilities. I am just saying we should be careful about saying that we can look most things up. So can our patients.

      • Noni

        Agree, but written boards in any specialty are not known for testing on practical and important knowledge!

      • rbthe4th2

        I, and other friends, have not been underwhelmed by a doc who says I don’t know. We’ve actually told hospital admins and the like, that it shows strength of character to admit the truth and persue other options because the patient is worth it. That’s what they telegraph to us.
        Quite honestly, I’ve had risk managers about drop when they hear stuff like this. They should be happy because this means the doc has patient interests at heart first, and is very probably less likely to get sued than someone else. A doc who has the intestinal fortitude to research, when you present with vague symptoms that aren’t immediately leading to a cookie cutter dx, give me that doc ANY day.
        Yes, they can look things up, and so can I. Its about working together for the patients’ health. I don’t expect Hawkeye Pierce for every doc. It just would be nice not to get Frank Burns too much. LOL.
        Btw AZMD thanks for a few of your comments. Some of the items I’d like to respond to are closed but I do appreciate your candor and effort.

      • http://warmsocks.wordpress.com/ WarmSocks

        Once my family physician said, “I don’t know. I’ll have to do some research and get back to you.” At my follow-up two weeks later, he had the answer. I wasn’t underwhelmed. I appreciated him taking the time to find the answer.

        Another time he said, “I don’t know; let me see what I can find out,” and left me there in the exam room while he found my answer. Again, I wasn’t underwhelmed.

        HOWEVER those were the exceptions. Usually he can answer questions off the top of his head. As long as a doctor has a good grasp of the basics, I don’t think patients mind if unusual situations require a little bit of research.

    • Suzi Q 38

      I refer to “Up To Date” when seeking information about any given medical condition. Those doctors have researched it all for you.

  • Sunny S

    “[I do not] carry such information in my mind since it is readily available in books. …The value of a college education is not the learning of many facts but the training of the mind to think.” – Einstein

    He may not have been speaking of medicine, but it’s still applicable.

  • EmilyAnon

    A patient gets a list of in-network doctors from their insurance company. Let’s say there are 4 names, with only one that says board certified. Not knowing anything about these doctors (and not a reader of doctor participating forums) which one do you think they will choose. It may be unfortunate but BC is kind of a status symbol of excellence in the eyes of most patients, whether true or not. In this case what else is there to guide a patient in making what they hope is the best choice?

  • mw4165

    The bigger issue is WHY 90% pass rate was considered normal. When you look at other board certifications/Bar pass rates, they tend to hover around 60% for first time test takers. Maybe MDs have it too easy and “Passing the Boards” really is meaningless relative to other doctoral level professions.

    • Laura Davies

      As psychiatrists, our 1st time pass (for the written portion, which makes you eligible for the oral portion), is approximately 66%. the oral portion is lower. This is with 4 years of residency (or 6 for us child psychiatrists).

  • M.Miller

    I agree with mw4165. I can’t think of any other profession where a 1st time certification/licensure pass rate of 90% would be normal or 84% would be a concern. Most feel that the exam is too easy if 1st pass is at 90% and make the test harder. In many professions, not passing means not working. Shouldn’t “gilding the lily” be more of a challenge, not less?

  • bc

    It’s true anybody can look anything up in this day and age. The difference is in how that information is interpreted. A trained physician has a large body of experience and knowledge to draw upon while being fluent in medical terminology to succinctly and accurately come to a conclusion. The same can not always be said about a patient looking up their medical symptoms/conditions.