ABR clinical boards: Why the hell are we memorizing these numbers?

[ProtonElectronNeutron]

Studying for clinical boards feels like trying to remember the phone numbers of all my contacts. What the hell!! Why can’t we focus on the concepts or even which treatment was better?

---

Members don't see this ad.

 

[RadOncDoc21]

Studying for clinical boards feels like trying to remember the phone numbers of all my contacts. What the hell!! Why can’t we focus on the concepts or even which treatment was better?

So that during tumor boards, you can sound smarter than the 10 other rad oncs kissing the rings of the med oncs.

 

[elementaryschooleconomics]

Studying for clinical boards feels like trying to remember the phone numbers of all my contacts. What the hell!! Why can’t we focus on the concepts or even which treatment was better?

It really is bizarre. I love all these practice questions asking me to know the PFS differences in the arms of trials started in the 1980s.

It just feels like hazing, and I feel a deep sense of relief when I get a question which is like, a picture with an arrow pointing to a structure, and I can answer it because I've been contouring that anatomical site for the past 4 years.

Alright, back to memorizing the rate of Grade 3+ GI toxicity in that one retroperitoneal sarcoma trial...

 

[elementaryschooleconomics]

Also, in the interest of being totally honest: I would much rather memorize the rates of Grade 3+ GI toxicity THAN EVER LOOK AT ANYTHING THAT HAS TO DO WITH THE ABR RADBIO/PHYSICS EXAMS EVER AGAIN.

It's not even close.

 

[SubserviantToABR]

Studying for clinical boards feels like trying to remember the phone numbers of all my contacts. What the hell!! Why can’t we focus on the concepts or even which treatment was better?

Don't be disrespectful. You owe our founders who have elevated your status in the house of medicine.

Reference: The American Board of Radiology Initial Certification in Radiation Oncology: Moving Forward Through Collaboration

 

[ProtonElectronNeutron]

Don't be disrespectful. You owe our founders who have elevated your status in the house of medicine.

Reference: The American Board of Radiology Initial Certification in Radiation Oncology: Moving Forward Through Collaboration
View attachment 333236

Such a pity!

 

[deleted1098629]

Studying for clinical boards feels like trying to remember the phone numbers of all my contacts. What the hell!! Why can’t we focus on the concepts or even which treatment was better?

Because your examiners are the most unimaginative people in all of medicine. Hence why the field is suffering.

Back in the olden days I remember we had a visiting professor who was considered one of the giants of radiation oncology. I had just started my job as an attending. One of my colleagues asked this person a question about the futility of radiation in a certain cancer quoting a number that he approximated. The visiting professor snapped back and said something along the lines of: It's not X%! It's actually Y.Z%! You should know your data better!

As if conceptualizing something as 30% instead of 28.9% will make you a better radiation oncologist. I can't remember the actual numbers but the whole incident was hilarious. When I look back on it. In the moment I almost micturated my pants!

 

[elementaryschooleconomics]

Because your examiners are the most unimaginative people in all of medicine. Hence why the field is suffering.

Back in the olden days I remember we had a visiting professor who was considered one of the giants of radiation oncology. I had just started my job as an attending. One of my colleagues asked this person a question about the futility of radiation in a certain cancer quoting a number that he approximated. The visiting professor snapped back and said something along the lines of: It's not X%! It's actually Y.Z%! You should know your data better!

As if conceptualizing something as 30% instead of 28.9% will make you a better radiation oncologist. I can't remember the actual numbers but the whole incident was hilarious. When I look back on it. In the moment I almost micturated my pants!

Man, I have experienced so many variations of this scenario.

The intellectual masturbation of the Old Guard of Radiation Oncology is very real and very detrimental. It reminds me of grad school, when I'd be watching someone present their dissertation work and were very anxious/unconfident. How did they disguise that fact? Bedazzle us with BS. Just throw an absolute fire hose of obscure facts and details and trivia to hide that you don't believe in yourself and what you're doing.

People - or specialties - confident in themselves and what they bring to the table don't need to hide behind trivia.

 

[thecarbonionangle]

Worst boards of any specialty
Terrible leadership
Bad job market
Declining pay and utilization
Just be happy you get A job

‘Tis a great time to be a rad onc

 

[deleted941485]

Man, I have experienced so many variations of this scenario.

The intellectual masturbation of the Old Guard of Radiation Oncology is very real and very detrimental. It reminds me of grad school, when I'd be watching someone present their dissertation work and were very anxious/unconfident. How did they disguise that fact? Bedazzle us with BS. Just throw an absolute fire hose of obscure facts and details and trivia to hide that you don't believe in yourself and what you're doing.

People - or specialties - confident in themselves and what they bring to the table don't need to hide behind trivia.

I have yet to see literature citations in an ortho spine consult.

 

[deleted1098629]

I have yet to see literature citations in an ortho spine consult.

Bone broken?
Bone pressing on stuff?
I fix bone!

Gotta love our ortho colleagues. I do enjoy it when they're on call instead of their cousins for spine

 

[thecarbonionangle]

I always liked dealing with ortho spine over neurosurgery.

 

[Mandelin Rain]

Here’s a secret.

If it seems like it’d be low, confidently say 15-25%.
if it seems like it’d be high, confidently say 75-85%.

You have now memorized 75-85% of rad onc stats.

 

[elementaryschooleconomics]

Here’s a secret.

If it seems like it’d be low, confidently say 15-25%.
if it seems like it’d be high, confidently say 75-85%.

You have now memorized 75-85% of rad onc stats.

Something else I've noticed:

If the comparison is "treatment" vs "treatment + XRT":

1) The toxicity in question will double (35% with treatment vs 70% with XRT)
2) The effect (usually recurrence or something) will halve (20% with treatment vs 10% with XRT)

OS benefit in studies where XRT has an overall survival benefit? 5%

Incidence of nodal involvement? 10-15%

#radonc

 

[RadOncDoc21]

Something else I've noticed:

If the comparison is "treatment" vs "treatment + XRT":

1) The toxicity in question will double (35% with treatment vs 70% with XRT)
2) The effect (usually recurrence or something) will halve (20% with treatment vs 10% with XRT)

OS benefit in studies where XRT has an overall survival benefit? 5%

Incidence of nodal involvement? 10-15%

#radonc

Any meta-analysis is 5% OS.

If there is a choice between up front RT vs a new unproven immunotherapy drug, choose new immunotherapy drug despite there being no survival benefit and select the lowest number.

If anything involves the use of radiation, chances are there is an ongoing trial trying to eliminate it or shorten the course to five fractions or less despite there being a survival benefit and select the most reasonable answer.

If the answer is radiation alone, check again and select the highest number!

 

[ramsesthenice]

Just put in your time and take your lumps. Remember that the pass rate is exceptionally high for clinical writtens. I agree with everything that has been said above as far as estimates for practical knowledge. Just prepare yourself, there are going to be a lot of bull**** questions on your exam. I had one in particular that was beyond absurd and a great example of how not to write a question. The fact I remember it years later says something. But as an educator it was just so egregious it stuck with me. They specifically asked for pathologic responses to chemoradiation for a particular disease and the options were 9, 15, 25, and 50%. The problem? There are 2 major trials and in one the answer is 9 and in the other it was 15. So....??? This is my beef with asking for specific numbers from specific trials. They make for easy and objective written questions for the exam writer but to some extent they imply a certain amount of "correctness" to the exact number. In practice you will tell your patients 10-15%. Period.

Here is what you should be shooting for on test day. You should be highly confident on 50% of the questions. You should be 50/50 on about 30% of the questions (like the one above). There will probably be 15% or so that are just beyond the pale. Old school attendings I know still describe this as an "easy" exam which is "nothing like in service exams." I can only speak for my exam but it sure felt almost exactly like taking an in service exam and the questions were not vetted that much better.

 

[elementaryschooleconomics]

Just put in your time and take your lumps.

This is my beef with asking for specific numbers from specific trials. They make for easy and objective written questions for the exam writer but to some extent they imply a certain amount of "correctness" to the exact number.

I think this is the problem right here (not that I disagree with you in any way).

I have heard variations of these two statements from many faculty over the years:

1) "Just do it, it's how you earn your seat at the table"

2) "The way the exams are written are done so because asking trivia is easy to write, not because they demonstrate your aptitude as a physician"

These statements are always followed up with essentially throwing hands up in the air, saying no one will do anything about it, that by the time someone gets to a point in their career that they CAN do something about it, they no longer want to or even if they do, they don't have the time because they will not be adequately reimbursed either financially or with prestige.

The other point that's often left unsaid: if you took these exams 30+ years ago, as many of our leaders did, the amount of general knowledge required was nowhere near what we need to have today. Examples of this have been published:

Changes in Length and Complexity of Clinical Practice Guidelines in Oncology, 1996-2019

This cross-sectional study calculates the increase in clinical cancer knowledge represented in the National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines from 1996 to 2019.

jamanetwork.com

"Between 1996 and 2019, the mean (SD) page count of NCCN Guidelines increased from 26 (4.2) to 198 (30.0) pages, a 762% absolute increase overall and a mean increase of 7.5 pages annually (Figure 1). Mean (SD) references cited increased from 28 (16.8) to 856 (146.3), a 3057% increase overall and a mean increase of 36 references annually (Figure 2). Similar increases were seen across all cancer types studied. The mean (SD) number of decision paths increased from 30 (8.5) to 111 (49.5), a 370% absolute increase. Trends in page count and references cited were best fit by exponential regression (R2 = 0.99 for both). Using the best-fit models, projections for mean page count and references cited in 2025 would be 355 pages and 1954 references per disease site guideline."

At what point will this break down? We need to seriously consider moving towards testing candidates in a way that is more reflective of real-world practice if the ABR wants to achieve its goal of "certifying minimally competent physicians who can practice medicine safely".

These pedantic quests we're asked to complete are of increasingly questionable value to us, and to society.

 

[thecarbonionangle]

Some boards are moving to that model, where you can look up on up to date and even guidelines. Basically just making sure you know where to look and you would reach the “right” answer on your own.

 

[Gfunk6]

Here’s a secret.

If it seems like it’d be low, confidently say 15-25%.
if it seems like it’d be high, confidently say 75-85%.

You have now memorized 75-85% of rad onc stats.

While this is a good hard and fast rule, the problem is that the answer choices don't really help. For instance if the correct answer is low risk, the choices are usually:

A) 15.1%
B) 15.2%
C) 15.3%
D) 15.4%
E) 15.5%

 

[ramsesthenice]

I think this is the problem right here (not that I disagree with you in any way).

I have heard variations of these two statements from many faculty over the years:

1) "Just do it, it's how you earn your seat at the table"

2) "The way the exams are written are done so because asking trivia is easy to write, not because they demonstrate your aptitude as a physician"

These statements are always followed up with essentially throwing hands up in the air, saying no one will do anything about it, that by the time someone gets to a point in their career that they CAN do something about it, they no longer want to or even if they do, they don't have the time because they will not be adequately reimbursed either financially or with prestige.

The other point that's often left unsaid: if you took these exams 30+ years ago, as many of our leaders did, the amount of general knowledge required was nowhere near what we need to have today. Examples of this have been published:

Changes in Length and Complexity of Clinical Practice Guidelines in Oncology, 1996-2019

This cross-sectional study calculates the increase in clinical cancer knowledge represented in the National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines from 1996 to 2019.

jamanetwork.com

"Between 1996 and 2019, the mean (SD) page count of NCCN Guidelines increased from 26 (4.2) to 198 (30.0) pages, a 762% absolute increase overall and a mean increase of 7.5 pages annually (Figure 1). Mean (SD) references cited increased from 28 (16.8) to 856 (146.3), a 3057% increase overall and a mean increase of 36 references annually (Figure 2). Similar increases were seen across all cancer types studied. The mean (SD) number of decision paths increased from 30 (8.5) to 111 (49.5), a 370% absolute increase. Trends in page count and references cited were best fit by exponential regression (R2 = 0.99 for both). Using the best-fit models, projections for mean page count and references cited in 2025 would be 355 pages and 1954 references per disease site guideline."

At what point will this break down? We need to seriously consider moving towards testing candidates in a way that is more reflective of real-world practice if the ABR wants to achieve its goal of "certifying minimally competent physicians who can practice medicine safely".

These pedantic quests we're asked to complete are of increasingly questionable value to us, and to society.

We have such an exam. It’s called the oral exam. The format can be intimidating but most of the examiners are very reasonable and keep it to real world scenarios. Why are we still doing both? That is a great question. We should either fix the written and dump the orals or just dump the written exam in my opinion.

 

[RadOncMegatron]

Don't be disrespectful. You owe our founders who have elevated your status in the house of medicine.

Reference: The American Board of Radiology Initial Certification in Radiation Oncology: Moving Forward Through Collaboration
View attachment 333236

I do IN THEORY like that we are tested heavily, like tradiational Ph.D. programs. We can confidently let patients and our peers know that our process is very rigorous. I feel we truly earn our post-doctorate certification, by mastering not only the big concepts, but minutiae as well. As specialists. I don't think it's out of bounds to know the minutiae of our own craft.

With that said, our recognition, was from the caliber of folks coming in, not our in house testing requirements. Rarely, if EVER, have I heard a med onc or surgeon say "OMG you guys do orals? You are so smart dude/dudette." Surgeons, still do orals and med onc eh...

I think the written can be scrapped and some of that put into the oral exam. I'd hate to have rad bio and physics incorporated into the orals, so keep that exam as a necessary evil.

 

[medgator]

One written exam, one oral exam, boom, done

 

[deleted1098629]

One written exam, one oral exam, boom, done

This will happen, in 5 years or so.

-Many programs have picked candidates who did not perform well on the USMLEs for this incoming class.


-Step 1 has changed to pass/fail. Programs just lost their best indicator of how well a resident will do on a poorly worded MCQ test.

Then they'll fix the exam, I think

 

[medgator]

This will happen, in 5 years or so.

-Many programs have picked candidates who did not perform well on the USMLEs for this incoming class.


-Step 1 has changed to pass/fail. Programs just lost their best indicator of how well a resident will do on a poorly worded MCQ test.

Then they'll fix the exam, I think

They will turn it from MC to matching and probably include more picture questions

 

[ramsesthenice]

This will happen, in 5 years or so.

-Many programs have picked candidates who did not perform well on the USMLEs for this incoming class.


-Step 1 has changed to pass/fail. Programs just lost their best indicator of how well a resident will do on a poorly worded MCQ test.

Then they'll fix the exam, I think

It depends on who you mean by they. The exam is administered by the ABR who don't administer these exams for free. Does the pass rate mean anything to them? What would their incentive to change be?

 

[elementaryschooleconomics]

It depends on who you mean by they. The exam is administered by the ABR who don't administer these exams for free. Does the pass rate mean anything to them? What would their incentive to change be?

I would imagine senior leadership of individual programs. The ACGME requires an average first-time pass rate of 60% averaged over 5 years I believe. In RadOnc programs with 1-3 residents a year, that's a slim margin of error.

Instead of letting the market correct itself and programs not meeting this metric being forced to shut down, I can absolutely believe interested stakeholders would lobby to change the exams (rather than making the harder choices of providing adequate education or closing down).

 

[udrag14]

While this is a good hard and fast rule, the problem is that the answer choices don't really help. For instance if the correct answer is low risk, the choices are usually:

A) 15.1%
B) 15.2%
C) 15.3%
D) 15.4%
E) 15.5%

It wasn't that close when I took the clinical exam. The trials were random on the test, but it was obvious if you read the trial.

 

[ramsesthenice]

I would imagine senior leadership of individual programs. The ACGME requires an average first-time pass rate of 60% averaged over 5 years I believe. In RadOnc programs with 1-3 residents a year, that's a slim margin of error.

Instead of letting the market correct itself and programs not meeting this metric being forced to shut down, I can absolutely believe interested stakeholders would lobby to change the exams (rather than making the harder choices of providing adequate education or closing down).

So in this scenario the ABR could

A) cede control

or

B) manipulate the scoring criteria to meet a predetermined pass rate.

You should ask someone from the class of 2019 which of those 2 scenarios seems more likely.

PS: please don’t. No need to open those wounds again.

 

[medgator]

 

[RTOGsaveRadonc]

Because of the dinosaurs running this field. It’s not like any advancement in medicine wasn’t based on some* sort of trial, you have people that studied when google wasn’t a thing or you couldn’t look this stuff up in a second trying to get you to memorize completely useless information.

“Let me cite the percentages of that study for rate control vs rhythm control” —-everybody else : yea ..no

it sums up the ingenuity and lack of innovation better than anything else. It’s the perfect receipt to how you take the cream of the crop in all of medicine and completely eff your field

 

[ramsesthenice]

For all of you still in training just wait until you start doing your OLA questions. They are a true breath of fresh air and in my opinion much closer to what boards exams should look like. It is clearly possible to make written examinations that are simultaneously data-driven and real world applicable. While it is great for those of us on this end of things now, it does make it all the more frustrating that they won't make similar changes to the clinical writtens.

 

[Lamount]

Studying for clinical boards feels like trying to remember the phone numbers of all my contacts. What the hell!! Why can’t we focus on the concepts or even which treatment was better?

I think the logic goes something like this...

'I had to do, so now you have to do it... if they don't make you do it, then why did they make me do it?'

 

[gmsquid]

Its been a few years, but I actually don't remember clinical writtens being much about numbers. In-service yes, clinical writtens not as much

 

[ramsesthenice]

Its been a few years, but I actually don't remember clinical writtens being much about numbers. In-service yes, clinical writtens not as much

There is definitely some year to year variation on these things. On my physics boards I barely needed a calculator and finished in less than half the allotted time. The next year apparently there was so much math people were barely finishing. I’d say I got the better draw on that one 😀

 

[elementaryschooleconomics]

There is definitely some year to year variation on these things. On my physics boards I barely needed a calculator and finished in less than half the allotted time. The next year apparently there was so much math people were barely finishing. I’d say I got the better draw on that one 😀

They tricked me on my physics boards. I had several equation-based questions in the first ~dozen or so questions, then the next ~75 were mostly concepts. I thought I was in the clear...then the last dozen were equation-based and left me questioning everything.

Very tricky, ABR.

 

[speakeroftruth]

The rad onc board exams are yet another reason for prospective medical students to avoid this field. Taking the rad onc board exams feels like going to a random neighborhood bar to play trivia. A common refrain that is heard from rad onc residents around the country during board exam time is "what am I even studying".

As @ramsesthenice pointed out, the OLA questions are actually relevant and educational. So clearly the ABR has a bank of reasonable questions that they can use but choose not to. Paul "I hate breastfeeding mothers" Wallner and Lisa "residents are f*cking stupid" Kachnic must think they are giant intellectuals of rad onc, protecting our field by weeding out the riff raff by asking detailed questions about pediatric rhabdomyosarcoma staging and risk groups. Everyone knows that in real life we won't be able to use a computer to look up papers, refer to a textbook, text a colleague that treats pediatrics, or heaven forbid, refer that patient to a pediatric center of excellence.

 

[thecarbonionangle]

you know when to give 45 vs 50 for an orbital rhabdomyosarcoma, but hey you lucky if you even get A job. Great stuff. Rad onc rocks!

You need to breastfeed? F&@! your “breastfeeding”, says PW. It is in quotation marks for an unclear reason unbeknown to most. Rad onc rocks.