Trust in Residents and Board Examinations: When Sharing Crosses the Boundary

Recently, illegal reproduction and transmission of board certification examination questions has received public attention. In 2010, the American Board of Internal Medicine suspended or revoked the certification of 139 physicians found to be either disclosing or soliciting examination questions for a board review company that encouraged physicians to relay questions from memory. In 2012, CNN reported on two circumstances of residents preparing for board certification examinations using questions reproduced by previous examinees.1,2 Immediately after taking the American Board of Radiology (ABR) medical physics examination, radiology residents wrote down test questions to which they were assigned. These questions, known as “recalls,” were then shared among future trainees. Dermatology residents also reproduced questions (referred to as “airplane notes”) minutes after their certification examination, often in groups. In these two cases, 20% to 50% of test questions have appeared on previous examinations.1,2 Reproduction of the questions clearly violates examination copyright policies, breaching the agreement to which their signature binds them.3,4 In a relevant study, nearly all medical students and faculty members surveyed considered using a stolen copy of a board examination unethical.5 Moreover, the ABR considers using recalls cheating.1 A profession is distinguished from a craft guild on the basis of educational standards, coupled with an established code of ethics in which a service rather than profit orientation is enshrined to engender the public trust.6 For this reason, ethical breaches and unprofessional behavior, such as the morally misguided use of reproduced questions, undermine the integrity of our entire profession. Yet, some physicians interviewed by CNN rationalized recall use as simply a study guide, whereby test questions are used to confirm understanding of the underlying knowledge rather than rote memorization of answers. Cheating of this nature casts an overarching ethical pall over the moral formation and integrity of physicians, eroding public trust in professional practice, teaching, and scholarship. Cheating on examinations in medical school correlates with falsifying information in a patient’s medical record.7 Surprisingly, one third of medical students engaged or would consider engaging in such falsification.8 This behavior reflects poor moral reasoning and/or willingness to subordinate morality to the achievement of goals. Such morally unacceptable conduct violates the primacy of medicine’s beneficence-based responsibility and undermines the integrity of our profession. From the patient’s perspective, physicians should be certified on the basis of a valid assessment of the knowledge requisite to provide high-quality care. If patients cannot trust the knowledge that board certification is expected to measure, the medical profession loses the public’s trust and confidence. Moreover, patients will only benefit from certification if it indicates the ability to care for them, rather than efficient preparation for board examinations. The distinction between cheating and guided study is crucial. Historical test questions are routinely used throughout higher education,9 and recent examination experience is commonly used to create focused study materials. The American College of Physicians produces the Medical Knowledge Self-Assessment Program, which includes a summary of high-yield information likely to appear on the examination.10 The introduction states, “The content was turned over to 11 carefully selected chief residents and fellows who had recently passed the certification exam. These physicians strained the essential testable points.” The editor continues, “As a frequent lecturer on Board preparation, I rely on input from hundreds of post-examination residents. With their ideas in mind, I refined the outline of Board Basics to target important topics and eliminate nonessential information.”10 Used by medical students for over 2 decades, the First Aid series is updated annually based on examinee reports. Using a focused study guide and sample questions created with examinees’ input bears some similarity to using practice questions that may have been on a recent examination as a vehicle for targeted learning. The difference lies in the detail and specificity of the information conveyed to future examinees. Nevertheless, from the public’s perspective, both practices represent shortcuts for examination success. Surprisingly, only 43% of medical students surveyed thought that it was clearly wrong for a student completing a clinical examination to convey information regarding its content to another student taking the examination.7 There is clearly a commonality between this finding and the interviewed physicians’ rationalized view of recalls.