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Emergentology: On My Emergency Medicine Oral Boards

Walker, Graham MD

doi: 10.1097/01.EEM.0000427058.57976.46

Dr. Walker is an emergency physician at Kaiser San Francisco. He is the developer and co-creator of MDCalc, a medical calculator for clinical scores, equations, and risk stratifications (, and The NNT, a number-needed-to-treat tool to communicate benefit and harm ( Follow him on Twitter (@grahamwalker) for daily thoughts on emergency medicine.





Well, they've done it now. They passed me on my oral boards. “Recertification in 2022” sounds like a date in the far distant neo-future that I'll never get to, but all my recertifying colleagues swear it'll happen before I can blink an eye.

After my fairly critical review of the written boards about a year ago now, I received a lot of good feedback; the vast majority was completely in agreement: the test didn't really live up to people's expectations one way or another, and was pretty disappointing overall. (And it was way too expensive.)

Other feedback included, “Why would you publish that before you were sure you passed?” and “I was worried that you published actual test questions in violation of ABEM policy, and you could be working urgent care for the rest of your life!” (To which I first replied, “I'm a daredevil,” and then secondarily replied, “OK, fine, I'm not a daredevil. I took the policy very seriously, made triple-sure I made up my own examples and used nothing from the exam itself.”) I was mostly hoping to start some sort of dialogue about our own board assessment, but that never really happened.

So this time around, I thought I'd share my much more positive thoughts on the oral exam. (I try to give credit where credit is due!)

I thought all the cases and examiners were great, and I really appreciate the time and effort that they and everyone at ABEM did to make the experience a professional one. (I still think people would perform better if they were in scrubs instead of suits. Read some social/environmental psychology if you don't believe me.)

The cases on the oral boards had no big curveballs, and were all much more reasonable and easy to understand than many of the written exam questions. They always say that one of the cases may be a test or sample case to see how well it scores and if it can be added to the oral board case mix; I felt they were all so good that I couldn't tell which was which. And I'd be hard-pressed to label any of the cases so esoteric that a properly trained emergency physician wouldn't be able to pass them. To be completely honest, I'm not sure that I'd want an emergency physician to take care of my family member if he couldn't pass the oral boards; the cases seemed really fair. And while I know that ABEM and residencies obviously strive for the best performance and training, there's obviously got to be a bar above which most well-trained physicians can pass.

Standardized testing is always going to have issues — nerves and anxiety make some really great doctors flop, brain farts, the false environment of mentally managing patients in a hotel room outside O'Hare Airport, the difficult-to-gauge progression of time throughout the case — but if you average all of this over multiple participants (which I know ABEM does with some complicated statistics), you can confirm that the cases are valid and appropriate. Sure, it's a little frustrating and difficult to talk through a case sequentially when you're really doing parallel-processing in the real world (push on the belly while you take the history, get a quick EKG while the patient's getting into a gown), but all things considered, it seemed as realistic as it can get. (I was even second-guessing myself. Talk about realism!)

That being said, I would like to see ABEM embrace technology to improve the realism of the cases and to make the exam more convenient (and less expensive) to physicians attempting to pay down hundreds of thousands of dollars of medical school debt.

First off, I'm a simulation guy. I think simulation does a great job adding realism to scenarios and helping to engage learners. It might be a great addition to the oral boards. It would certainly add some technical complexity to cases — and that is the major downside — but it would definitely make scenarios seem more realistic. (Most people who have done simulation are used to a big monitor and physical patient mannequin, but a number of great iPad-based apps act as a simulated monitor and forego the need for a large, heavy, costly patient mannequin, which is sometimes only really useful for procedural-based competencies, like intubating or placing a central line.) Simulation would add a lot of “realness” to the cases, if it could be pulled off without too much technical frustration.

But maybe the cases need to be kept the same. If that's the case, then why not do them over Skype? Or Facetime? Or Google Hangouts? If the goal of the oral boards is to have a face-to-face encounter where you have to think on your feet, why can't this be done digitally? For naysayers concerned about cheating, have the cases run in a testing center. Or pay 15 residencies across the country to host Skype sessions throughout the year. This would certainly be far more convenient and less expensive for ABEM, its examiners, and its examinees than renting out an entire hotel twice a year. It's an enormous effort for everyone to get the weekend off and to coordinate a plane trip and hotel to Chicago. Examiners could do it in the comfort of their own homes or offices, and many examinees could potentially drive to a site for a one-day trip. That's $100 instead of $1000.

Speaking of the examiners: Wow, they were great. It was really neat to see so many people dedicated to the field that they would give their time to help assess new residency graduates. I was expecting all the examiners to be flat-affect, intentionally dysthymic, and emotionless sages, but I found they were all friendly and did not try to be overly tricky. Thank you for your time!

Overall, I think the exam was much more worthy of the ABEM name. If I have any advice for the next crop of examinees, it'd be this: Don't panic and don't stress. I lost way too much sleep and popped way too much Prilosec over the exam. It felt fair, reasonable, and pretty straightforward. Study with a friend, review all those topics you know you need to review, and you'll be fine. Good luck!

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