I am strongly in favor of written and especially oral boards. It is crazy to me that people view an 88% pass rate as inappropriately low and blame the ABR.
Please remember:
1) As the quality of residents goes down in the future, should we “demand” that the pass rate remain the same and cry bloody murder if the pass rate dips? Spare me the socially progressive nonsense on critical race theory and non-traditional applicants, the fact is that many trainees who matched in 2021 are, in aggregate, less prepared to self study for board exams and will struggle unless residency didactics improve.
2) Absent rigorous recertification, there is no other mechanism for ensuring quality rad onc physicians. The adorable baby rad onc trainees of today will, if coddled, become incompetent boomer rad oncs of tomorrow.
For me, it's more about the style and content of the boards, not a question on whether exams should exist or not.
For writtens, I would prefer them consolidated into one exam. I ABSOLUTELY do not mean just taking the 100 questions from RadBio, 100 questions from Physics, and 200-300 questions from Clinicals, and administering a single ~500 question exam, like I've seen some people implying. I mean a thoughtful integration of the questions into a single ~300 question exam with a question breakdown reflective of reality: maybe 75% clinical, 15% physics, 10% radbio. Physics actually has much more real-world value than radiation biology for an exam intended for MDs. I am qualified to make this assertion, as someone with a PhD in Radiation Biology who also practices clinical medicine. People should have the option of taking this anytime after the start of their PGY4 year. There should be at least 3 administrations of this exam per year. It should be administered using the new remote exam platform, which is amazing. I think this is an easy fix that could be implemented almost immediately. I could go on and on about the questions themselves...but I'll leave it alone for now.
For orals, we should copy the Neurosurgeons (
here's a link to their format). They have three, 45 minute sections. Each section is five questions. The first section is general Neurosurgery. The second section consists of questions from "pre-identified area of focused practice chosen by the candidate", or they can just choose to do five more general questions. The final section is about five cases from the candidate's own practice (they submit 10, the examiners choose 5 at random).
I find this format RIDICULOUSLY more valuable than the hot mess RadOnc has designed, which, as others have noted, seems more like sanctioned hazing than assessing competence. Obviously, we don't know the truth behind the ddAC+Herceptin story and what else happened during that session, but no one should FAIL a RadOnc exam because of a NON-CONCURRENT chemotherapy question. This is different than
@Chartreuse Wombat's story of ADT, where, even if Urology is giving the ADT, it should be concurrent, thus you will be seeing (and managing) ADT-related side effects in your patients.
Regarding upcoming pass rates: I assume the ABR will actually make zero changes and this same archaic hazing system will remain in place. If nothing changes, then I would ABSOLUTELY expect pass rates to drop in the coming years. I expect this because, on average, the incoming residents have objectively lower test-taking stats than the Golden Era generation. I'm not making a comment about whether or not I think good test-takers are good doctors (I believe those are unrelated skills). I would not cry murder if pass rates dip. I will, however, cry murder if the pass rates don't change.
I will forever think of the
Amdur and Lee editorial on the board exams. In the Golden Era, average USMLE scores of RadOnc residents continued to rise over the years with pass rate remaining relatively unchanged, suggesting that the ABR was "moving the goal posts" and making the exams harder to pass. The ABR (and our good friend Lisa Kachnic), of course, denies this. None of us mere mortals are privy to how these exams are actually scored each year, other than the ABR assuring us (you know, the people being subjected to this process) that their Angoff process is bulletproof. If the Angoff process is so good, and the ABR's assertion that the goalposts don't change from year to year, then we should start to see a dip in pass rates starting in maybe 2022 or 2023.
If pass rates don't dip, it's just more evidence that The American Board of Radiology - this black box organization which we have decided has a monopoly of power over who gets to practice Radiation Oncology in the United States, a paternalistic organization which has proven that it is beyond the reach of any sort of accountability by the doctors beholden to its stamp of approval - is not maintaining a consistent measure of what it means to be "board certified". This ties in to why other specialties did away with oral boards, after evidenced-based metrics demonstrated how fallible they were to bias and interpersonal dynamics.
So, while I agree that there needs to be mechanisms in place to ensure that the doctors delivering radiation therapy in America are competent, I am unsure that our current system, as it is designed and implemented, is actually doing that. I think the entire enterprise of Radiation Oncology, from individual residency programs to the ABR itself, needs the 2021 version of Abraham Flexner.
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