by Carol A. Westbrook
The single most important skill you need to practice medicine is the ability to pass multiple-choice exams. Most people saw their last standardized test when college or grad school ended. No so for us doctors– exam taking continues until retirement. The process begins with the high SAT score required for entry into a good college, then a high MCAT to get into medical school. In medical school we complete Steps 1 and 2 of the USMLE (US Medical Licensing Exam) and in residency, Step 3. After residency come the Specialty Boards (e.g. Internal Medicine, Surgery, etc.), then the Subspecialty Boards (e.g. Cardiology, Oncology). It continues with re-certification exams in your specialty every 10 years. It does not end until retirement.
So here I am, in my 60's, having to sit for an exam in order to renew my credentials as a Medical Oncologist. If you haven't taken a standardized test within the last decade you will be surprised to find how things have changed. There is no paper, no filling out circles with No.2 pencils, and no exam booklets. The questions are read on a computer screen, and answered by point-and-click with a mouse. The exams are given at a testing center in a strip mall, where other test-takers may be fireman, manicurists, or hairdressers taking their state licensing exams. After passing triple security (two ID's and a palm print scan) you enter the exam room, where you will be directed to a workstation containing only a computer on an otherwise empty desk. No purses, wallets, watches, pens, cell phones, or calculators are allowed into the room. It is dead silent, and anonymous. Nonetheless, you quickly adapt to the computerized routine, and the exam itself is remarkably similar to any other multiple-choice exam. As always, there are a series of single questions and 4 answers, of which only one is right, including the notorious “all of the above” or “none of the above.”
Scoring well on a multiple-choice exam requires certain skills. You do need at least a passing familiarity with the material, of course, but just as important is a feel for the psychology of the exam–are they trying to trip me up on this question? Is there a hidden trick? Does the exam phrasing suggest a certain emphasis? Also required is precise reading of the question, and facility with English grammar (beware of the double negative!). The most important skill for the test-taker, though, is the ability to “cram”. By cramming, I mean the ability to review and retain a large amount of detailed information for a few days prior to the test.
I'll admit, my ability to cram is not what it used to be. I could never compete with a young, newly-minted doctor fresh out of a training program. Sure, I attended a review course, and I crammed for weeks prior to the test, but I'll admit I was a bit anxious about going into this exam. Perhaps multiple-choice exams are one way of weeding out doctors with memory loss or Alzheimer's disease? On the other hand, I have been treating patients with cancer for almost thirty years and am confident in my competence. I, like other specialists, have kept up with the latest advances and completed my required continuing education in order to provide our patients with the best possible care. I am left asking, what is the purpose of taking a multiple-choice, “Maintenance of Certification” exam?
The questionnaire given at the post-test evaluation asked if the exam accurately represented clinical practice. My answer was a resounding, “strongly disagree”. I don't feel a multiple-choice exam tests anything except one's ability to take such an exam. This exam has little to do with my clinical skills or medical knowledge.
A skilled physician is not someone who can recall a lot of factual knowledge. Rather, it s someone who has the ability and experience to obtain relevant clinical information, and then utilize the universe of medical knowledge to make the best treatment decisions possible, keeping the patient's special needs in mind.
Here is the reality check. When I see a patient with a particularly difficult clinical problem, I don't guess which is better, A, B, C or D. I look it up! I call the pathologist and discuss the biopsy. Or I consult a variety of approved sources which are available to me instantly, online, and frequently updated by specialists. I check the published guidelines and find out what is appropriate and, more importantly, what is likely to be covered by insurance — or what is not. I network with other physicians, or present the case at one of our weekly conference. At times I contact one of the “uber-specialists,” in a nearby university whose practice is limited to only one type of cancer. Ironically, these sub-specialized university professors who write the exams would be unlikely to pass a general oncology exam themselves because their practice is so limited!
In this day and age of instant online access to the world's knowledge, and ready social networking, a multiple-choice exam which relies on factual memory seems and outdated, almost anachronistic way to ascertain a physician's competence. They persist because they are easy to write and easy to score, in spite of their irrelevance.
If I could rewrite the medical oncology certification exams, I would permit the physician to have open use of any online resources. In my dream exam, the doctor would be able to use these resources to provide an answer that reflects current knowledge, that insurance would reimburse, put the treatment orders correctly into the electronic chart, and the complete the answer before the 15-minute clinic visit is over. Now that is a realistic scenario!
Post-script: Yes, I did pass the exam and won't have to take it again for 10 years.