Blog | Thursday, May 17, 2012

Board exams don't resemble real practice and waste my time


I took the day off today. I'm taking my recertification exam tomorrow, and I like to go into these things well-rested. I got up with PalKid, made her breakfast, had a leisurely cup of coffee and enjoyed a ride to school with a loquacious second-grader. I violated one of my primary rules for before-the-test days and did a little studying at the coffee shop. It's still hard for me to take this exam terribly seriously. I was reminded of this when I dropped by my office to get a little work done, work that bore little resemblance to what I will encounter on the board exams.

Internists trained after the 1980s are required to re-certify every 10 years. It's not a stretch to say that most internists find the process time-consuming, expensive, and largely irrelevant. As medical knowledge has expanded, the practice of medicine has become very subspecialized. There is little need for me to know the current regimen for the treatment of multiple myeloma. It's enough to know how to diagnose it and to know some of the consequences of treatment. I don't manage kidney dialysis, so the ins and outs are, to me, not terribly useful. I'm not a brain surgeon (just ask anyone) so I don't really need to know the best surgical approach for a pituitary macroadenoma.

The recertification process takes at least a year or so. One of the more useful aspects is the requirement that I do "learning modules," sets of questions that help me review important topics (but that are explicitly labeled as being NOT board review questions, wink-wink). Of course, I could do those modules in the course of my yearly continuing medical education. The most onerous bit is the "practice improvement module." I chose diabetes, a condition familiar to my practice.

It required my patients to fill out surveys, for me to enter data from a couple of a dozen charts, go through several other bits, re-review my charts, and at the end of the month or so it took, time was taken away from my life and I learned something I already knew: It's hard to take care of diabetics when they are real people. Not every patient can reach the standards we've set, nor should they, depending on their circumstances.

Tomorrow I show up at a testing facility with two forms of photo ID and must submit to "palm vein biometric analysis." Then I have to leave everything outside the room: my two forms of photo ID, my wristwatch, my wallet, any pens or pencils, and God-knows what else. Probably my belt and shoe laces. No scratch paper for me! (Apparently they provide some sort of small dry-erase board or something to jot ideas on.)

Is this expensive, humiliating, time-consuming effort useful? Who knows? There aren't many useful outcomes measures in the literature. It's not clearly known whether the current process makes better doctors. It is clear, to those of us in daily practice, that the process was not designed by practicing internists, at least not those who work full-time in the busy primary care environment. It also fails to recognize the technology available to modern physicians. We no longer rely exclusively on our memory when evaluating patients. We have quick and easy access to web-based references and to our colleagues. The board exams reflect our ability to recall rote knowledge, something most of us are quite good at, but it encourages behavior that is not good for our patients. Our access to information helps our patients, keeps us from making mistakes based on faulty memory.

I'm not terribly concerned. I do well on standardized exams, but I realize that this little talent has little to do with my daily practice.

It's pretty embarrassing that we allow our colleagues to put us through this. The exam is the least offensive bit. The entire process is a drain on the limited time and resources of a primary care physician. The process could be simplified by having docs do question sets at home, with access to reference sources, the way we actually work in real life. Throw a dozen of those at me and I'll probably learn more medicine in two months than I have in two years of my current recertification process.

(Here's an example of more realistic questions you'll never see.)

Did I mention that we get a TSA-style wanding?

Peter A. Lipson, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. After graduating from Rush Medical College in Chicago, he completed his internal medicine residency at Northwestern Memorial Hospital. This post first appeared at his blog, White Coat Underground. The blog, which has been around in various forms since 2007, offers "musings on the intersection of science, medicine, and culture." His writing focuses on the difference between science-based medicine and "everything else," but also speaks to the day-to-day practice of medicine, fatherhood, and whatever else migrates from his head to his keyboard.