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Why Board Exams are Dated


In an era where knowledge is at our fingertips, board exams have become less practical for clinicians.

Due to take my boards next month, I spent last week at a 3.5 day intensive board review course. It was like taking three years of residency over the span of three days. While exhausting, the course was a good review of information I already knew along with a few surprises and reminders. Now that I've been in practice for 15 years (and am taking my third board exam), I have a different perspective than I did the first two times through the process. What I need to memorize for the test and what I need to know to practice are more clearly defined than they were when I was a newer physician.

My notes from the course are reflective of this. I took two sets of parallel notes – the things I need to know between now and April 13 (when I take the boards) and the things I need to know well beyond April 13. On the board exam, most geriatric problems can be solved by identifying the previously undiagnosed hypothyroidism or stopping polypharmacy. Medications for dementia don't work that well, so they have limited applicability to many patients with dementia. In the real world, it's never as simple as hypothyroidism. Polypharmacy is a true culprit in many medical mishaps, and is difficult to challenge in our current medical climate in which there's a pill for every ill.

For the boards, counseling about diet and exercise is a viable treatment approach. While at my clinic, I tried this with a patient with morbid obesity and two patients who are still consuming regular soda despite having uncontrolled diabetes. Fellow physicians can imagine how these conversations went. True lifestyle change is difficult for anyone and unfortunately only works well for those few patients that are able to adopt significant change. I wish it were different as I do believe in food as medicine and the importance of exercise and sleep.

On the boards, medications can be judged on their actual effectiveness. In the real world, they are evaluated on a complex formulation of effectiveness, cost, side effects, number of doses per day, and what your patient's neighbor's cousin heard about the medication on Dr. Oz. Many medications are beyond the reach of the average American's deductible. Similarly, I can memorize indications for testing and screening, but when my patient can't afford it, the information becomes useless.

I appreciate the need to make sure physicians maintain knowledge and competence. However, I do not believe a board exam is the way to do that, particularly in an era when so much knowledge is available at our fingertips. What benefit is there in memorizing something that changes over time with advancing scientific study and is easily accessible to anyone with fingers and a keyboard? Where is the assessment of critical thinking that is so important when you have to weigh affordable third and fourth options because the first and second are not accessible to your patient's insurance coverage?

I hope by the next time I take a board exam there's less emphasis on memorization and obscure medical conditions, and more assessment focused on therapy, approaches, creativity, ingenuity, compromise, and prioritization.

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