We All Fail When A Resident Fails Boards

By:  The Generation Y Surgeon (@GenYSurgeon)

This post is for surgeons, surgical residents and future surgeons.  This post is more than a rant–it’s information.  For surgeons and residents, this should be a wake up call. For my future surgeons, this is what no one tells you before match.  Please read on and take the time to comment because I’m interested in your thoughts…

Venturing Into The Light To Take The Test

It’s board season.  Well, it recently was boards season.  This is when tired and bitter chief residents first enter the ranks of the attendings (or fellows) and the dinosaurs emerge from their clinics, operating rooms and labs to re-certify.  No one is spared…the chairman, the worker bee, the non-operative surgeon, the researcher….everyone must participate at some point.  A mountain of paperwork, $1400 in registration fees, and 320-something questions for one exam with very high stakes.

18% Fail?!  Are You Kidding Me?!

Let’s talk a minute, however, about the results of the boards.  Per the ABS, pass rates are, at best, 82%.  So 18% do NOT pass…that means 1 in 5 fail!  Whether you’ve passed or failed, taken the exam once or thrice…you shouldn’t feel good about our testing schema.  What does this failure rate say about our training programs and surgery as a profession?

The way I see it this means one of three things:

One in 5 board eligible surgeons are retarded.

The exam is too difficult, too tricky or is testing information that is not included in surgical training. 

We aren’t teaching residents what they need to know to be considered a passable surgeon–or we’ve just testing them in a whacky way.

Obviously, by the time someone is taking their surgical qualifying exam, we can assume that they aren’t retarded.  So that leaves point 2 and 3 to discuss further.  First, consider the exam itself.


What Is The Purpose Of The Boards Really?

Start by asking yourself, what is the purpose of the surgical boards?  The boards should be a final test that double checks the core knowledge that all surgeons should have mastered.  The boards should cover the concepts that keep our patients safe.  The boards should demonstrate that our residents are trained appropriately and can uniformly pass a straightforward exam designed by senior, practicing surgeons.  It should not be a tricky exam that stratifies good and poor test-takers.  It should not be administered to any person who hasn’t already demonstrated adequate knowledge and skill.  Basically, this exam should be nothing more than a checkpoint for those who have performed adequately during their 9+ years of training–not an exam that lets good surgeons fail and poor clinical performers squeak by with good test taking skills. 

Seriously, should we feel ok about a fail rate of 20%?  Do you know anyone that is so far behind that they should fail?  We are all very smart people, skimmed off from the top of our undergraduate classes and funneled through the most competitive schooling and training to attain doctorates.  If surgeons can’t teach smart people to be surgeons then who can?  And if you know a resident or practicing surgeon who has fallen behind the curve, how long did it take for them to be left behind?  How long were they allowed to train before someone intervened?  Is their failure ignorance or is it failure of the system to identify and remediate theses surgeons appropriately?  Remember, we are a profession.  Therefore it’s our job to police ourselves and maintain the standards by which we mean to present ourselves.


When Someone Fails, It Means We All Failed Together As A System

After 9+ years of education, a surgeon who fails their boards represents more than a person who has inadequately prepared, it represents a person whom the profession of surgery, or at least a training program, has failed…and, oh, if the training program / profession says that person just wasn’t good enough?  Well, why don’t we select residents (future surgeons) well enough to only allow people in who will succeed?  Aren’t we, as people who help train others, good enough to select people properly?

Now here’s a challenging statement: if we did a better job of educating our future surgeons (or at least selected them properly), then after 9 years (4 medical school + 5 residency = at least 9!) there would be no point in even having a board exam.  All of the necessary knowledge and skills would have been demonstrated by each resident by the time they were able to graduate.  There’d be no need for the “final test.”  Did that blow your mind?  Yeah.  This is where the ACGME is really starting to do something right.  With the institution of the “milestone” system of resident education and the growth of the SCORE curriculum (however painfully primitive that website remains), focus is finally shifting toward the quality of time spent in residency while using appropriate measures of competency.  Unfortunately they missed one big thing…no one has taken the time to teach our teachers how to teach.  Once again, the profession of Surgery, despite its good intentions, has fallen short. 

To my generation-Y resident, medical student and junior attending colleagues:  I’m interested in what you have to say about this topic.  Old guys / Dinosaurs:  I’m interested in your perspective as well because you have seen more change in Medicine and in surgical education than the rest of us.  Please take the time to comment below!


dmkashmer moderator

I think we could do much better with resident education.