The problems with making oral board recertification universal

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 1,300+ 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 1,800 to 2,000 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.

“Skeptical Scalpel” is a surgeon blogs at his self-titled site, Skeptical Scalpel.

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  • Joel Sherman MD

    All board exams used to include orals. They were given up for many reasons. But the most important reason in my opinion was that the results were erratic. There were examiners in the 60′s who prided themselves on rarely passing anyone (at least in Internal Medicine). You could be asked to explore 3 very clinical pertinent scenarios, or 3 esoteric questions which few knew. They swore that the examiners knew nothing about each candidate, but it was just plain untrue. They knew everything about you. That includes whether you were at Mass General or were just a lowly peon in the hierarchy. In other words they knew whether your job depended on passing or it made little difference as was the case into the ’70s.
    Going back to orals is the worst solution.

    • ninguem

      My sentiments exactly.

      My relatively short academic career before private practice, we had a faculty member not allowed to do oral exams anymore, over behavior like that.

  • Dr. Drake Ramoray

    Some of my endocrine tests take over a week to come back. Oral Endocrine boards. Lol

  • Skeptical Scalpel

    Thanks for the comments. I agree that oral exams will never be used for recertification. They still are used in general surgery and a few other specialties.

  • ninguem

    It’s expensive to run oral exams.

    It’s also easy for bias to creep in.

    Lots of things in medicine can be approached multiple ways. From time to time, you get academics so stuck in their ways, “my way is the only right way to treat this disease, and any other approach is wrong, malpractice, and you are morally suspect for even considering any other approach”.

    This despite abundant evidence that other academic institutions, or other countries, treat the disease in different ways, with equal success.

    From time to time, specialty board administrators get enough complaints to require monitoring, and even exclusion of certain “opinionated” academics so egocentric and narrow-minded that they cannot comprehend another physician of equal skill approaching a disease in any other manner.

    So, I agree, for a bunch of reasons, it is highly unlikely that recertification will be done by oral boards.

    I’m not even sure it’s appropriate for initial certification, let alone recertification.

  • Docsicle

    I wonder if an interactive, computer-based, virtual reality type of testing system could be developed as a hybrid between oral and written tests. Medical computer games have been developed (though not very successful, publicly), and I think this could be used, possibly, for testing.