In-training Exams, Performance, and Exam Fatigue

I read with great interest Dr. Zhou et al.’s article regarding the effect of instituting the BASIC examination on anesthesiology knowledge acquisition.¹  The authors should be commended for their hard work and dedication to educating future leaders of our specialty.

As a recent graduate of anesthesiology residency in a large tertiary academic medical center, and as a member of the second class to take the American Board of Anesthesiology BASIC examination, my perspective on the examination differs somewhat from that of its developers. Scores on the in-training examination have been shown to correlate poorly with clinical performance in a variety of medical specialties and practice environments,^2–4  and therefore a statistically significant increase in these scores may not translate into any real clinical improvement. In addition, the advent of frequent standardized testing is a likely factor of the burnout epidemic among anesthesiology trainees. I was not immune to this phenomenon, and personally experienced intense periods of detachment and depersonalization during my residency as a result of exam fatigue. This problem is only likely to worsen with the rollout of the new American Board of Anesthesiology Applied examination, which includes an Objective Structured Clinical Exam component in addition to the Standardized Oral Examination exam.

The rollout of the United States Medical Licensing Examination Step 2 Clinical Skills should be a cautionary tale to all in the world of medical education. Initially used as a method for ascertaining the bedside manner and communication skills of foreign medical graduates, it was expanded to include all U.S. graduates. The costs associated with finding a “legitimate failure” are estimated at over $1 million per failure,⁵  a sum financed largely by examinees mired in worsening educational debt. Much ink has been spilled (including by the authors of the article under discussion)^6,7  about the rollout of the Objective Structured Clinical Exam exam, but it is important to put a human face to the discussion. The majority of residents experience burnout at some point during their time in education, and most anesthesiology residents personally know someone whose training was interrupted for mental health reasons. Maybe this would happen less if we had to jump through fewer hoops to prove our baseline competence—or maybe not. But we cannot afford to keep adding on exam after exam without serious thought to the toll it’s taking on our trainees.

Although an increase in in-training examination scores is impressive and laudable, like everything else in medicine there should be a constant examination of the risks and benefits of our interventions. The question we should be asking ourselves is not whether additional exams raise performance on our exams: Instead, maybe we should think about whether it will make us better anesthesiologists in the long run. We do what we do for the benefit of our patients, and they deserve us to be at our best educationally and in terms of our mental health.

The author declares no competing interests.