Why Are So Many Younger Doctors Failing Their Boards?

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 s/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 H. Schumann, MD is a general internist and medical educator at the University of Oklahoma School of Community Medicine in Tulsa, OK . He is also author of the blog,GlassHospital (@GlassHospital), where this post originally appeared.

23 replies »

  1. Well, they clearly lowered the standards in your case. You used “affect” when you should have used “effect.” Downstream is one word, not two.

  2. The answer is that practicing physicians don’t have the time to devote six months to memorizing useless facts that they never use in their day-to-day practice. When was the last time an IM doctor prescribed a chemotherapy regimen? The answer is NEVER because it is out of the scope of their job and would be considered malpractice. The ABIM exam is littered with such insanity, so doctors who never have and never will practice the way the exam requires are forced to spend months memorizing things that they will immediately forget so that they can fill their brains with useful medical knowledge. There are sub-specialty questions all over the exam in every field from hemo-onc to cards to radiology. They are USELESS.

  3. Yes, a very good point. The Bar Exam is required to legally practice law and be licensed in a given state. The ABIM is not legally required to be licensed or practice medicine in any state. That is what the USMLE 1-3 are for. The ABIM has become a money-making scam where hospitals and employers require physicians to be board certified even though there is good evidence that it makes no difference in terms of practice patterns, patient outcomes, etc.

  4. It never ceases to amaze me that smart people who work in an evidence-based field still manage to come to conclusions based on absolutely no evidence at all. Blaming “study habits” is a hypothesis at this point and not a proven fact. Arguing against that hypothesis is the fact that re-cert failure rates are on the rise as well and those people aren’t “millennials.” The real argument needs to be whether or not the ABIM exams are actually weeding out “bad” doctors or whether they are just more BS for already over-burdened physicians. With EMR almost ubiquitous, why aren’t we simply monitoring care practices and then sending those who don’t follow best practices to CME courses that target specific deficiencies? The questions on the ABIM IM exam are ludicrous, asking things about specific chemotherapy regiments that NO IM doctor will EVER prescribe. It isn’t a test of practice quality, it is a test of:
    A. How much time do you have to study.
    B. How much money can you spend on prep materials.
    C. How well you memorize keywords and trigger facts so that you can answer a question right even if you don’t know the first thing about the process, procedure, disease, or treatment being tested.

    The test is a failure in every sense of the word, but doctors just go along with it because they are so used to being tested. Doctors need a union so that they can fight things like this that have no impact on patient care other than to take away precious time from physicians that could be spent elsewhere.

  5. So many well developed comments about a flawed process. Unfortunately, the whole system is being controlled by IT geeks that are also physicians and IT specialists. This brings a whole plethora of new methods for qualifying tests and particular questions. Bottom Line: From the start they left out the most important test of this new system before going live. That is test it to break it. We are dealing with the aftermath of their having failed to do this test. The test taking physicians are the guinea pigs that should have come before going live.

    Lastly, a plea. I have to take this thing myself this year, even though in most other areas of medicine I should have been grandfathered in as my initial board had no reference what soever to a limitation.
    Help me find the best board prep course. Please.

    Thank you.

  6. If a school faculty had a high failure rate in his class, he will be warned by the school and subsequently fired. When would you realize that Board Certifications are overrated? This is a disguise under which an evil business model runs. Make Boards fair, nondiscriminatory, ethical and moral and true TESTS of knowledge, skills and competency and not just a moneymaking conglomerate!!!

  7. An easy analogy is to say that the board exam is for a doctor what the bar exam is for a lawyer.

    This totally absurd. Doctors practice medicine because they have passed their curriculum examination and Licensing examination. They do not practice medicine just because they have Board Certification. Attorney’s Board is totally different. ABIM and ABOphthalmology exam concepts and focus have been very very different. ABIM is creating a megamachine business model to test and retest and keep “them coming back.” An ideal Board should pass majority of candidates due to sufficient knowledge, skills and competency. If a Board does not pass enough candidates, there may be problem with questions, wording and tricky scenarios.


  8. この設計はオオワシ!あなたは確かに面白がっ楽しま読者を維持する方法を知っている。仕事あなたのウィットとあなたのビデオの間に、私はほとんど自分のブログ(!よく、ほとんど…笑)ワンダフルを開始するために移動されました。私は本当に|あなたが言っていた、そしてあなたがそれを提示する方法、それよりも何楽しん愛さ。あまりにもクール!

  9. I’d like to know: why are so many doctors who passed the initial ABIM certifying exam 10 years ago now failing the RE-certifying exam? The pass rate of the initial certifying exam has remained in the 84-88% range the last 5 years while the pass rate for the recertifying exam went from the 84-90% range from 2009-2012 to 78% in 2013? And it didn’t get better in 2014 so far– the overall pass rate on the spring recertfying exam was 65%. Look it up.

    If we’re supposed to believe that medical education and training is so inadequate that our latest graduates are unprepared, what is the explanation for the graduates of 10 years past not being able to pass the recertifying exam?

    Don’t you think it just MIGHT be because the ABIM is intentionally making the exam more difficult? And if you want to know why they would do that– don’t you think it would be to push through their MOC narrative that nobody asked for or cared about or thinks is anything more than money into the pockets of the ABMS and its other corporations?

  10. Ils reposent sur un concept d’ordinateurs portables proches des netbooks (léger et économique) animé par le système d’exploitation Chrome OS qui organise toutes ses fonctionnalités autour du cloud (donc du web), notamment en ligne sur où il est en précommande depuis le 15 juin.48%) et Altice (24, La réorganisation de lentreprise intervenue en mai dernier sest inscrite dans cette logique. et se rend indispensable pour jongler avec les différents formats vidéos et audio (MPEG-1, VLC Media Player est un élément important de FreePlayer,01 pour Windows?Le système de jeu est simple, la sortie grand public du photophone Lumia 1020 et son capteur de 41 mégapixels. malgré quelques divergences dans leurs estimations respectives.

  11. “Focus exams closer to real practice.” Brilliant.
    ‘Beware Nostalgiaitis Imperfecta’. Again, brilliant.

    There is, however, a missing educational component that we discovered in corporate America. We called these the Critical Success Factors for Learning.”

    Technology dependency is still dependency.

  12. @Tnfalpha:

    Re: your points:

    Re: 1 – Eric Holmboe (renowned medical educator and internist) just wrote on his twitter account: ‘Beware Nostalgiaitis Imperfecta’. Genius.

    Re 2- Love the point of view you and Dr. Hersh have stated: “Focus exams closer to real practice.”

    There are probably a bunch more factors, and we can likely innovate faster than what we have done in the past. Technology is exponential, and we have not grown even linearly. 😀

    I wrote a longer reply at this site – http://t.co/CuvwWXHsAF – in defense of my fellow GenY/Millennial folks 😀


  13. This “Gilding the lily” as you call it raises the question of what is the motive for having this exam in the first place? Essentially, it seems like justification for our high salaries. If we have to pass a really hard exam, then we are worth the $200k. No one seems to be asking if IM physicians really need to know all the stuff on the exam to be competent physicians. Is someone a better doctor because they can name – off the top of their head – the drug used to treat a pregnant woman with syphilis who happens to be allergic to penicillin? Frankly, I’d prefer my doctor to take the 15 seconds it takes to google that than try to remember it from their med school training.

    ABIM of course would say the exam isn’t harder. Unfortunately, they have an incentive to justify these high salaries, and having less people pass increases that cache. We should do a couple things:
    1. stop criticizing young trainees because they’re “different” than the old guard – they’re less empathetic, they’re less dedicated, they’re chronic googlers. Seriously, you’re just revealing your age and grumpyness. Hey kids, get off my lawn! Yawn.
    2. Focus exams closer to real practice like what Dr. Hersh suggested above. People whined when kids could use calculators for math and science exams; now they are considered an accurate reflection of the skills kids need when they’re outside the classroom. I know medicine is about 50 years behind any educational or operations management innovations, but lets try cutting that down to, say, 10 and we’ll be in much better shape

  14. I agree this development is a concern, but before we ascribe blame to health IT, Gen Y/millenial laziness, or anything else, can we see some data supporting the assignment of blame? Let’s not let this finding be a Rorschach test for everything each of us does not like about medicine, healthcare, or society.

    In the meantime, however, I have a more fundamental question: Is an exam like the ABIM the best indicator of how a physician best applies his or her knowledge to the optimal care of patients? In other words, when it comes to applying knowledge to real patients, does it matter whether the knowledge resides in the physician’s head or is easily accessible on a computer? Do we want performance on this test to be the standard by which we judge the competence of physicians? I thought we were getting away from that approach.

    Instead, why don’t we test physicians by some sort of vignette process, whereby they are presented with a case, armed with their brain, their computer, and anything else they want to use? Then we can see who orders the right tests, prescribes the right treatment, etc.?

  15. The American Board of Pediatrics has an even lower pass rate than the ABIM, it has been hovering around 70-75% for the past 20 years.

  16. Interesting post- I did hear the question banks did need to get refreshed after a board review cheating scandal a few years ago…

    infusing new questions into the pool (esp if they did not have time to test the questions) could make the test harder…just a thought. it does not likely explain everything, but its just something to consider.

    i wonder if ACP – ITE exam scores have been going down at this same time – that may speak to something that is more intrinsic to residents or their training – as opposed to something specific with the test.

  17. Or perhaps the exam is harder.

    What did you expect the ABIM to say?

  18. @Genius – dare I say, that was…genius.

    I agree re Topol – these health IT guys go on about the benefits of technology and are removed from real practice.

    And working in a VA, the issue of ‘it’s in there’ takes on a whole new meaning. Home organizer Barbara Hemphill has an expression she uses to explain the importance of getting rid of paper – ‘if you have it but can’t find it, it’s the same as not being there’.

    And to the article and Bubba’s points – there are only so many hours in the day. Add societal and millenial ADD, plus the availability of Google, and you get a real laziness-piecemeal thinking-lack of hours to learn what is needed trifecta.

    And this only adds to the ordering a pile of tests-stuck with our face in the keyboard-going through the industrial factory line of patients issues that current practitioners are already dealing with. Not sure how we bring some of the humanity, laying of hands, and broad knowledge back to the care of people.

  19. They are being dumbed down by the HIT devices they are forced to use. I see this every minute of every day.

    Nurses have become stupid (but good clickers), interns know nothing (thye use their smarties to look up), students think the computer is the patient, and folks like Topol [pontificate about HIT innovations but never examine or manage patients in the clinic.

    Even former ONCHIT Chief Blumenthal settled a med mal case in which the results were in the computer but no one saw them.