The Exam That Never Ends….Or Does it?

As I sit here, at 5am, staring at my screen, trying to absorb random medical knowledge from a set of board review questions, I wonder whether this, “board exams”, will ever end. Like many physicians, I have been taking one big board exam after another. It was USMLE Step 1, COMLEX level 1, followed by USMLE step 2, COMLEX level 2, COMLEX level 3, the “CS” and now the American Board of Internal Medicine initial certifying examination. Soon, I’ll be taking the American Board of Pediatrics Initial certifying examination. Sitting here, let’s add up the times in total for the board examinations: 64 hours in total. At least “16 more hours” of testing to go.

Each examination comes with its own step of challenges: Step 1 practically weeds out people from “competitive” specialties. Step 2, well step 2 is there for you to not fail or perform worse than Step 1, and for some to redeem themselves if Step 1 wasn’t a stellar score. Step 3, well, we all think step 3 is a bullshit of an exam that essentially regurgitates most of what’s on Step 2, or am I the only one to think that? Nevertheless, it’s a never-ending cycle of board examinations.

Well, I needed a break from shoving random medical information into my frontal cortices and I decided to write this piece. My brain doesn’t care about the fact that membranous nephropathy has subepithelial deposits, as opposed to membranoproliferative glomerulonephritis, which has subendothelial deposits or that the systemic causes of nephritic syndrome with low complement include SLE, endocarditis and cryoglobulinemia, as opposed to systemic causes of nephritic syndrome that have normal complement are all your vasculitidies, TTP/HUS, and the list goes on or does it? Nor does it care about the fact that for Burkitt’s Lymphoma the go to treatment is “Hyper-CVAD” but if its CD20+ ten add rituximab or that shy-drager syndrome, or


another name for it, multiple system atrophy, mimics Parkinson’s to the tee, except that it has severe orthostatic hypotension and MRI will show necrosis of the putamen.

Did I even get any of the above information correct? Well, it doesn’t matter, now does it. The reality is I, along with thousands of others will sit through yet another board examination that will test random facts, and concepts that perhaps may not be practical at all.

Now, now, I am not complaining about taking the initial certification examination, but believeit’s a right of passage, and must be taken. But for heaven’s sake, shouldn’t this exam be more practical? These examinations are a perfect example of how medicine is run in this country, at least in my opinion, impractical.

Practicality and common sense do not go together, well not in the US healthcare system, at least. The rules and regulations physicians must abide by…Well I won’t go into the details of it, as I know the ones reading understand what I am talking about.

Well I wouldn’t want this to be a rant, so I’ll just add some facts here. The ABIM was established in 1936 and administered its first certification examination that same year, since then, more board examinations have been added as internal medicine has expanded with the latest being Adult Congenital Heart Disease in 2015. During its initial launch, the internal medicine board certification was a one-time thing, however, in 1990, this was to change. Starting that year, physicians had to take a test every 10 years and during the decade they were required to complete certain number of educational credits in order to prove they were keeping up with the new knowledge. The in-between requirements called “maintenance of certification” has become its own industry with online medical modules, practice improvement modules, and random projects now requiring performance improvement and to top it off, the costs and requirements are continuingly increasing. Well, I’ll worry about this AFTER the board examination, assuming I pass.

The bane of physicians existence, as I have continuingly heard is the decennial ~10 hour examination that they must take. Initially, I thought that wasn’t a bad idea – physicians should be required to stay up with their knowledge but now that I am sitting here and learning medicine, I am realizing the wealth of information one is required to know. Interestingly the estimated doubling time of medical knowledge in 1950 was 50 years and in 1980, it was 7 years, but in 2010 it was only 3.5 years and its projected to be every 3 months by 2020! Well, I won’tworry about this, until I get to the 10 year mark. Or better yet there’s this other option where internists can now do a “knowledge check-in” every 2 years as opposed to MOC every 10 years to maintain their board certification.

Or better yet, a physician can leave medicine altogether and work as an administrator and never have to worry about exams again and give up providing direct care to patients. Or just start his or her own practice without taking any insurance, if he/she so desires and then, he/she will be free from all these requirements and can focus on learning the medicine that he/she believes to be of practical importance. I’ll just end with this:


Densen, Peter. “Challenges and Opportunities Facing Medical Education.” Transactions of the American Clinical and Climatological Association, American Clinical and Climatological Association, 2011,

Change Board Recertification,