I am relieved and proud to report that I passed my boards: I am officially a diplomate of the American Board of Obstetrics and Gynecology. While the oddly formal “diplomate” is a term in common use with physicians, I didn’t understand what “diplomate” and its sister phrase “board-certified physician” meant until I undertook my own board preparation.
The Medical College Admission Test (MCAT) is a memorably stressful element of applying to medical school. On the AAMC website the MCAT is described as “a standardized, multiple-choice examination designed to assess the examinee’s problem solving, critical thinking, and knowledge of science concepts and principles prerequisite to the study of medicine.” This test’s objectives are clearly stated, and we all understand that our MCAT score can determine whether or not we get admitted to medical school.
Once admitted, matriculated and on our happy ways, the standardized testing continued. First came the multi-step United States Medical Licensing Exam (USMLE). According to the USMLE website, “The USMLE assesses a physician’s ability to apply knowledge, concepts, and principles, and to demonstrate fundamental patient-centered skills, that are important in health and disease and that constitute the basis of safe and effective patient care. Each of the three steps of the USMLE complements the others; no step can stand alone in the assessment of readiness for medical licensure.”
Despite being described as a test to assess “patient-centered skills,” and the claim that “no step can stand alone,” it’s widely understood that the first two steps are to assess residency applications, with step 1 typically being weighted the most. I contend that the excessive weighing of step 1 in residency applications has effectively “hijacked” the test.
Most residents have annual standardized in-service exams; obstetrics and gynecology residents take the Council on Resident Education in Obstetrics and Gynecology (CREOG) exam. The CREOG website states, “The CREOG In-Training Examination provides a quantitative assessment of individual residents’ cognitive knowledge in obstetrics and gynecology. The goal is to provide performance assessment of individual residents and the program as a whole. Annual statistical analyses demonstrate the examination’s continuing validity as an educational evaluation instrument.”
CREOG scores are solely reported to the resident and their respective programs. The scores are not used to assess fellowship or employment applications, but I believe they are truly representative of a resident’s knowledge base. Although I always thought that this exam unfortunately came at the worst time possible, I have come to believe that this was the most useful standardized test in my medical career because it told me what I knew, what I needed to study and what I could do to improve for next year’s exam — and ultimately OB/GYN licensure tests.
On my last day of residency, I took the American Board of Obstetrics and Gynecology (ABOG) written examination. Although technically I am not required to become a board-certified physician, it incredibly difficult to secure a job or hospital privileges without this qualification. The ABOG is a relatively short written exam focused on the application of basic knowledge to clinical problems. Like the USMLE, the ABOG is a “competency” exam, but unlike the step tests, it is only pass/fail and exam takers are not told their scores. I think this is important because this exam is designed to catch those physicians who may need remediation or may be unsafe.
The ultimate step in achieving board certification in obstetrics and gynecology is the dreaded oral exam. This exam requires the preparation of case-lists, thousands of pages of reading, hundreds of hours of studying, and ultimately a grueling three-hour oral exam in Dallas. I found it simply exhausting.
Dr. Paul Teirstein suggests in his recent NEJM article, “Boarded to Death — Why Maintenance of Certification is Bad for Doctors and Patients,” that our methods of assessing physician competency might be flawed. The article states that “the ABIM [American Board of Internal Medicine] describes its tests as using ‘psychometrics’ leading to ’high reliability and reproducibility,’ but no clear correlation between these test results and patient outcomes has been documented. Furthermore, many physicians believe that closed-book tests are no longer relevant, since physicians can now easily turn to online resources, as well as their colleagues, while caring for patients.”
This leads me to wonder if we physicians are being over-tested, incorrectly tested, inappropriately tested, or just simply continuously tested, causing us to neglect skills other than studying and test preparation.
With that said, I plan to follow every rule and regulation associated with maintenance my new board certification. Qualifying for this certification required one MCAT, four USMLE steps, four CREOG exams, one ABOG written examination and one ABOG oral examination. After eleven exams in eleven years, why would I want to risk it all? Also, keep in mind that I still have two more board exams to go since I am in an accredited fellowship. After that, I have to take an exam every six years as part of the maintenance of certification process.
I suppose I have to accept that the testing will never end.
Brian Levine is an obstetrician-gynecologist. This article originally appeared in The American Resident Project.