The Art and Science of Medicine … and Standardized Test Scores.

For the past decade, there has been much discussion about declining interest in nephrology careers. The special article from Berns et al. about nephrology board scores opens with a comment about this trend and discusses it as a potential reason for declining scores. However, over the past 18 months, we have witnessed increased interest in our specialty while training programs and academic institutions have been appropriately consumed by coronavirus disease 2019 and focused on dismantling systemic racism. From 2019 to 2021, the numbers of applicants to nephrology fellowship training programs have increased (https://asndataanalytics.github.io/AY2020-Nephrology-Match/), with IMG and USMG applicant numbers rising. What has led to this positive change? In 2019, new kidney-targeted therapies began to emerge, including SGLT2 inhibitors and nonsteroidal mineralocorticoid receptor antagonists, potentially transforming the course of kidney diseases for millions. During the first peak of the pandemic in 2020, the world watched as the international kidney community addressed some of the most difficult problems related to that crisis, resolving resource shortages and developing new protocols to treat kidney failure. During the past year, the nephrology community also addressed pressing societal issues that have clinical consequences, becoming the first medical specialty to rigorously study and recommend a unified solution to remove race from a clinical algorithm—the kidney function estimating equation (eGFR). Perhaps medical students and residents saw that nephrology does not shy away from complex problems but that it unites, charges forward, and solves them. Berns et al. focused on understanding the reasons for lower American Board of Internal Medicine (ABIM) certifying examination pass rates from 2010 to 2019. They performed a retrospective observational analysis of first-time nephrology board test takers (n54079) from 150 accredited nephrology fellowship programs in the United States. They relied on data from ABIM and the Accreditation Council for Graduate Medical Education (ACGME) and identified associations between self-reported characteristics of nephrology fellows (age, sex, IMG/USMG status, birthplace, and prior internal medicine [IM] certifying score) and of the nephrology programs (geography, size of the program [three or more defined as large], university versus nonuniversity based, and mean ABIM IM examination scores by tertile). The investigators found that the IM certifying score was the dominant determinant associated with the ABIM nephrology board examination score. To educators, this finding comes as no surprise. Standardized tests, within and outside medicine, exhibit widely recognized associations with socioeconomic status and scores as well as racial and ethnic bias. The unintended and still unresolved negative consequence(s) of standardized test flaws affect college and medical school students as well as people in other positions. To address that bias and recruit the best future physicians, many medical schools and training programs have adopted a more holistic review process, assessing applicants’ experiences, attributes, and academic metrics to begin to eliminate inequity and promote justice. Because IM test scores are not available to nephrology training program directors at the time of fellowship application, Berns et al. suggest identifying resident characteristics that track with IM certifying examination performance to predict trainee success. However, testtaking ability should not be the only measure to predict success. Indeed, it should not be given more weight than other applicant qualities that help us choose the best future physicians and nephrologists. When the American Society of Nephrology launched a loan mitigation program (https://www.asn-online.org/education/ training/lmp.aspx), the society chose to exclude board certification as a criterion for initial eligibility, given the evidence that standardized testing has a negative effect. Similarly, the association between older age of trainees at the time of the qualifying examination and lower test