The End Product

It seems a little bit cruel so close to the holidays, but last week, pediatricians across the country were confronting their biggest fear. Did I pass the Boards?

The Initial General Certifying Exam for Pediatrics is one of the hardest (if not the hardest) certification exams to take. The bar is set such that only about 75% of individuals taking the exam actually pass. Supposedly most other branches of medicine are in the 90’s. Unfortunately, that is a significant amount of pediatricians who are not going to have ‘Happy Holidays’.

The day of reckoning came last Wednesday. As someone who spends most of his time around residents, I was privy to the celebrations of a handful of recent graduates whether in person or via technology. It started unexpectedly with a phone call from a graduate I keep in touch with and continued when I mistakenly called the Chief Residents’ office. Being close to the rejoicing of these recent graduates brought me back to that day 4 years ago when I was to receive my thumbs up or thumbs down vote from Caesar.

The hardest part is not knowing exactly when the email notification is going to arrive. you just know that it will be “sometime in mid to late December”. So when it finally does show up, your heart immediately starts racing due to lack of mental preparedness. Then comes the moment of truth. You get to the website and prepare to log in. And you prepare. Then prepare a little more. Take a deep breath and prepare just one more time. Okay nowwellholdonnotquiteyetokayhowabout NOW! Even thought I felt pretty good about the test, there was something about the finality of seeing the result which was nerve-wracking, which is a similar story to that which I have heard from others as well.

When I finally screwed up the courage to click on the button to view my fate, I was excited by the results and quickly shut the browser down. Only, I immediately regretted this decision because I doubted my own eyes and wanted to dwell on the words on the screen for a longer amount of time. So I went to log back in. Only….. nothing. Nothing happened. The website was frozen. Wait, how could this be? Did I get the ‘Passed’ message in error? I NEED TO KNOW!

I started to reach out to some of my classmates to see if they passed in order to dispel my nervous energy. Only it turned out most of my class was not nearly as lucky as I was. Not that they didn’t pass, but they didn’t even get to see their results like I did. The website was shut down for technical reasons and would not be able to be revived for at least a month. Everyone was going to have to wait for a postcard to come in the mail another 3 weeks from now. Talk about excruciating pain. But in the end, my eyes did not fail me and I truly was a Board-certified Pediatrician. But what did that mean? Was I really any different than earlier in the day when I was not yet known to be Board-certified?

The process of being certified and accredited by an independent agency is a necessary evil. To give the public at-large piece of mind, it is important to make sure that doctors, who see and treat people when they are at their weakest and most vulnerable position, are held to a minimum standard. But focusing on a test of knowledge to be the sole voice proclaiming whether or not a new graduate is “good enough” is by no means ideal.

Case in point, one of the best doctors I know did not pass the boards on the first try. When the focus is solely on a one-time performance, this can happen. Especially when it ignores many other skills that a medical professional (especially a top-notch pediatrician) brings to the clinical encounter including communication skills, empathy, and critical thinking skills. Supposedly, these are some of the skills that the USMLE Step 2 CS are trying to verify in medical students. I did not have the experience of taking this test (I was in the last class that did not have to take CS), but reviews have been mixed (at best) as to whether it truly meets its objective.

This highlights the main issue for medical education. We don’t have any objective measures with which we can measure whether a trainee is ready to move on to independent practicing. Most everyone has in mind what a graduating resident should “look like”, but this is just an overall impression with a lot of subjective measurements. This is an issue on multiple levels.

When there is a resident that people think is struggling, without an objective standard to meet, it is difficult to know exactly where the “finish line” is and how best to help the struggling resident get there. Too often, the resident languishes in a “no man’s land” because both teacher and learner have become lost and there is no map to guide the way.

With the new work hour rules that took effect coming in to this year, it is going to be very hard to know whether or not the changes that a program has made were beneficial. If we can’t completely measure what the previous graduates were like, how can we then compare whether the upcoming graduates are up to par and if more adjustments need to be made? Without a direction to head towards, are we as educators merely foundering blindly in the dark?

The next generation of scholarship needs to focus on figuring out what the End Product should look like. And while the best part of medicine is that none of us are ever a truly finished product, there need to be better sign posts along the way. Luckily, there are people working on this in many of the specialties. The so-called Milestones will be coming at some point and while invariably they will not be perfect, they should be an excellent step not only for the practice of medicine but also for ushering in a new age of medical education.

For now, we will continue to utilize the one objective measure that we have, a score on a test. But deep down inside, I know that we can do better. Until that time, I will just have to rely on the method I have always relied on, the picture I have in my mind of the ideal doctor.


About ironsalsa

I'm just a man who likes to hear himself talk, yet pretends he can't stand himself.
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