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Doctors 'Cheating' On Board Certifications
Maximum Prophet writes "After taking board exams, doctors have been routinely getting together to remember and reproduce as much of the exam as they can. These notes are then bound and reproduced. According to the American Board of Dermatology, the exams are protected by copyright laws, and any reproduction not approved by the board is illegal. While I have no doubt that the Board believes this, and pays lawyers to believe it as well, I don't think they understand copyright. Perhaps they should invest in better testing methods."
Keep it up and getting your MD degree will be worth about as much as most IT certificates. You can buy copies of most of those tests online from companies that somehow steal the cert test, probably using the same method these doctors are.
not just medical examination. it is just a co-incidence that the medical profession is one that is tangled with most examinations. speaking of examinations, though, the most important examination for us medical doctors are usually conducted in the oral style (viva examination) which allowed impromptu questions set immediately, testing the doctor on how they would handle a patient step-by-step. i'm not sure about the american system but that's true for most british systems.
Speaking as an MD, and posting anonymously through more proxy jumps than you can count, I can tell you that the ABR is a disgrace.
They have elected to ELIMINATE the oral exams. Whats next, calling us providers?
Humans are not computer problems, and solving computer questions is not an appropriate screening method for certification.
Bottom line: Oral Examiners should be PAID, CAREFULLY TRAINED, GRADED and only the BEST kept year after year... like NFL REFS !
Of course, the overpaid ABR administration might* have to take a pay cut to achieve this.... AND THEREFORE, THIS WILL NEVER HAPPEN.
A DISGRACE UPON MEDICINE
this is a sign that the overall school / testing needs change and new ways to learn / test people. We need more apprenticeships / trades learning system and less end less classroom with test that people who can cram can pass and get rid of tests that have little to do with the real job.
I thought prohibiting students from sharing past copies of tests was a standard and acceptable method. Is it because they are using copyright to attack the practice?
The American method of 'learning' is mostly rote learning. This does not help. As Einstein once said, "Imagination is more important than knowledge."
How shall we as Americans be able to steer our future when what we mostly test is the ability to cram? As a former educator, one of my best times in class was when a student was 'teaching' me. Even when they were wrong, the dialogue enriched both of us and for the student, it was invaluable.
Multiple choice questions make matters worse. No wonder foreign kids beat us in math and science. It's not funny at all.
I had a chance to teach a group of refugees from an African country and it was amazing to see how they approached a problem. While our Americanized kids reached for their calculators, these kids internalized the problem in their heads, then wrote down the range of where they thought the answer would lie, then solved the question. 100% of the time, they were right.
I will ask my doctor what she thinks about this issue when I see her in a fortnight.
Copyright is a dumb way to protect a test.
A much simpler and easier way would simply be for the AMA to have test takers agree to a very simple NDA. You agree not to share specific questions from this test with anyone. Covers the actual problem, is enforceable, doesn't require twisting copyright law in crazy ways. What's the downside?
If the exam is copyrighted, and as the story states each question is reproduced "verbatim" and then reproduced, that is unquestionably a violation of Federal copyright law. /. needs to avoid publishing nonsense from people who clearly never went to law school.
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in most subjects i would agree with you, but i don't think i would want an imaginative doctor (at least not at the expense of a strong level of basic competence). some things damned well should be done by rote, based on centuries of hard-won experience.
some people do have to come up with the new stuff, but most doctors don't and shouldn't be trying.
"They were pure niggers." – Noam Chomsky
The American method of 'learning' is mostly rote learning
Overall? No. I'd say the US has been much better in this respect than many other countries. (Though "No Child Left Behind" has done its damndest to screw that up by encouraging teachers to teach-to-the-test.) However, it is like this for premeds, and that's what matters!
Why? The stakes are too high. Push up the stakes high enough, and people don't think; they memorize. Indeed, when faced with very high incentives in psychological studies, people bomb IQ tests. You can't think when something as important as a career as a doctor is on the line. (That's why classes need to be exactly as hard as necessary -- and no easier -- but also no harder!!)
It's also how biology is taught in college. "Go memorize this arbitrary chemical pathway. No, we won't talk about 'why.' Yes, you can forget it later. We all know this class is just for weeding, anyway." Partly because it's all premeds. (And partly because there's no helping the fact that, compared to physics, biology is much more about facts than principles. It's messier. Such is life.)
The first 2 times I ran into this, at about the same time, was for FAA & FCC (Federal Aviation Admin., Fed. Comm. Comm.).
You used to have to have at minimum a 2nd Class Radio Telephone license from the FCC to be a broadcaster in radio. You could actually have a 3rd class only to talk if the station had someone else on duty with a 2nd class to actually run the equipment. The stations often didn't want to pay for a 2nd person with the higher level license, so...
For FCC testing back in the 60s & 70s, there used to be outfits that came to cities periodically that would guarantee passage after a weekend course (12 hrs per day) during which you would be taught the answers to the test questions. The way they got the answers is what is talked about here. It had likely been going on for some time already when I found out about, but the 70s is when I was working on my FAA & FCC licensing, so that when I knew about it.
There was the same thing for FAA written tests and I seem to remember hearing that the FAA stuff came first. This may be the actual reason for calling them "Airplane Tests".
I live in India, and such Notes are very common here for almost every branch of Higher Education. In some cases of post-graduate and doctoral courses, the question papers are legitimately distributed by the University to students after an examination. For tests where the board does not distribute question papers, several companies which claim to be vestigial 'education' and 'training' companies pay examinees for reproducing or recollecting the questions. It is also common practice in India for corporates to hold screening examinations prior to fresh candidate intake. These question papers are also reproduced, solved by a team of experts and a key is published before the next examination. A good example is FreshersWorld.
This also happens for NCERT, Medical Entrance Examinations, Engineering Entrance Examinations among several others. No Legal action has been taken in the recent past to stop such recollection, despite the fact that it merely promotes rote learning, textual recall or fundamental pattern matching. Interestingly, in India, no one has referred to this practice as cheating, although it is. It is only in the past two years that Computer Aided Tests which shuffle questions and stagger timelines are being introduced to avoid this practice. Enforcement of legal sanctions in India especially across Educational boards, Varsities and Corporate Testing groups have not been easy.
Question papers, by themselves for any test are never copyrighted officially. Most Board question papers in India, Pakistan, Sri Lanka, Bangladesh and Nepal do not come with any Copyright notices. Boards and Academic members have until recently been in the dark about 'Copyright Law' and have little idea as to how it is enforced. A vast number of books published are not registered for copyright, nor do they have ISBN assigned to them.
Part of the issue is the inability to enforce exclusivity on 'recalled' or 'reproduced' testing material. Another part is ignorance of the full extent of 'Copyright Law' itself, though this is significant in nations like India and China where their implementation has only now begun.
No Greater Friend, No Greater Enemy! (Lucius Cornelius Sulla)
The American method of 'learning' is mostly rote learning. This does not help. As Einstein once said, "Imagination is more important than knowledge."
Really? As a Canadian living in Romania, I have to strongly disagree. The education system here appears to be heavily based on rote learning (much moreso than I saw in Canada or attending American schools in my childhood). The folks I have hired have had excellent imagination, in spite of, not because of, their education (and have generally been the ones who skipped a lot of classes at university and taught themselves the required material).
That said, I previously worked (in Canada) as a physics researcher in a hospital, and we would regularly "joke" about the MDs not being "real doctors" (in contrast to how most people view PhDs), since their main skill appeared to be rote memorization. (See also Richard Feynman's story about his diagram of cat anatomy when he gave a presentation to some med students.) Of couse, as a sibling post says, most medicine comes down to reproducing what is already known (as it should be).
I now look at doctors the way I look at lawyers. To get in, you don't need to be creative (and in fact, you probably shouldn't be, or should suppress it until you've already proven yourself), you just need to know the existing "case law" very very well. Mostly, your job is to identify stuff that has been seen before (taking into account quite a lot of subtle data) and go directly to the most successful known solution. If you want to be imaginative as a doctor, you can go the MD/PhD route (which, in my opinion, makes you a superstar), I suppose, or run the risk of losing your job by doing something no one else has done before (and hence is not "approved").
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There is a lot of confusion among people who aren't physicians about what, exactly, is meant by "boards" and "board certified". Just remember: medicine is populated entirely by people who are good at tests. They may have other skills, and they may not. But they're all good at taking tests.
When a physician is described as "board-certified", that means that s/he has taken a specialty examination given (in almost all cases) by a member of the American Board of Medical Specialties. In some fields, this only has a written component; in others, especially surgical fields, oral examinations are standard as well as the writtens. These examinations serve to certify that you know that particular specialty. They are not required to practice medicine, and physicians are not limited by law to practice only in areas of medicine for which they have received formal training. Insurers providing coverage and hospitals allowing privileges outside of your area are a different matter, but as a matter of law, a general-practice MD can perform neurosurgery in his office.
A permanent, unrestricted medical license in the US is predicated on passing the US Medical Licensure Examination Steps 1, 2, and 3 (unless you're an osteopath and you take the COMLEX, but that's a small number of people and in any case the principle is very similar). Furthermore, you will have to do at least an internship (the first year of residency after medical school) in order to be granted a permanent, unrestricted medical license. (Graduates of non-US/Canada medical schools may have to do two or even three years of residency.)
So yes, people do get together and discuss things. In particular, memorizing questions serves the purpose of identifying what the question-makers think is important. This is not always trivial; as medical specialties have moved their written examinations onto computers in recent years and K-type (Choose A if 1 and 3 are right, B if 2 and 4 are right, C if 4 only is right, D is 1, 2, and 3 are right, and E if all are incorrect) questions have been eliminated, there has been a significant influx of new questions from younger examiners. Like all examiners, they tend to submit questions from their own interests rather than just covering a broad enough base to be sure that the examinee is capable of practicing safe medicine. The line between pass and fail has to fall somewhere, and if you're academically relatively weak, knowing the likely subject matter (or the likely rare association between two things) can make the difference between pass and fail.
The USMLE 1/2/3 all have prep courses and study books with sample questions, just like the SAT. If you don't study how the questions are asked, you are unlikely to do your best. However, the base of knowledge is just immense - Step 3 considers anything that you might encounter in a general practice to be fair game. To pass the test, you're going to need to know the stuff.
The specialty board examinations don't take anyone who couldn't 1) get a residency in that specialty and 2) pass their way through it (which is not a given - people fail out of residencies all the time). Dermatology, the subject of this article, is populated exclusively by people who gradated in the top 5-10% of their med school class. Their intelligence and drive to study isn't really in question. What's happening is mostly a matter of pride; even though only a vanishingly small percentage of people who take the test will fail, it is incredibly embarrassing to be the one who does.
I want to go to a doctor who studied a year of molecular biology as an undergraduate. I don't want him to get his education on the job from the drug company salesman.
I believe in a liberal education. I also want a doctor who took a few courses in English, poly sci, economics, history, etc. I want a doctor who can write a coherent sentence and read a well-organized article. I want a doctor who knows when the American Medical Association is trying to put one over on them. I want doctors who know when their politicians are trying to put one over on them.
Right now the Obama administration is making promises and assumptions about the value of health care IT that are (sometimes) patent nonsense. I want doctors to know enough about IT to understand that.
There's always the question in medical education of, "How much is enough." I'd rather err on the side of too much. Especially when that doctor is applying a sharp object to my testes.
Bullshit is entirely subjective. I know engineers who are focused on engineering to the extent that they know (and care) nothing about anything else. So maybe you have a point. People like that do the bare minimum work necessary to pass their out-of-major courses and retain nothing. Maybe it's not worth teaching some people anything but what they will most predictably use in their career.
But a doctor is more than a technician. He or she is in the business of caring for people. A one-dimensional engineer might be competent and get the job done, but he might lack in creativity -- I know plenty like that. A one-dimensional doctor doesn't understand his patients. He doesn't understand that two patients with the same disease may express themselves in very different ways or that two patients that *say* the same thing about their condition may be describing different systems. He may not understand the psychological aspects of living with disease. Etc.
The more a doctor knows about PEOPLE, the better it enables him to practice MEDICINE.
To some extent, the same is true of engineers and programmers. You might know how to perform a certain task, but where do you learn to understand what customers want? They sure to hell don't teach that in your engineering classes and it damn sure is important to know.
It's saddening to see that the overall intent of a university curriculum, which is to both nurture the well-roundedness of the student through exposure to a number of, potentially disparate, disciplines and also impart some measure of domain-specific knowledge, is being unjustly frowned upon and criticized by many such as yourselves. Instead of dismissing the courses outside of your major as unnecessary, you should view them as an opportunity to not only try and expand your capabilities and views, but also bring a fresh perspective to those fields that may end up being of use to others.
As an example from my own life, I ended up taking a handful of philosophy and cognition courses, as a sort of stress relief, while finishing up the dissertation for my maths Ph.D. Thanks to my years spent, as a doctoral candidate, pouring over thousands of manuscripts, I was able to propose some rather interesting ideas/theorems focused on a nonlinear dynamical system standard of thought. Had I not opted to take those humanities classes, I probably would have never considered merging the concepts together; at the same time, those in the class would likely not have come to view maths as an excellent tool for building up their own theories.
Paraphrasing is paraphrasing. Copying is copying. And tests are valuable only when they test what they are designed to test, and not rote memorization(*)
(*) Apologies to any pharmacology majors who have to memorize more than most people memorize in their life.
One of my high school friends is a doctor. He finally finished his last year of school/residency/fellowship/whatever and got a Full Time Job around when we were both 32.
His job is to look at slides of liver cells and decide if they are cancerous. That's it. Now, I understand that could be a very tough decision, and a huge one in many people's lives, and I'm sure making that decision earns him a doctor's salary.
But... did he really need 15 years of education to make that decision? I know his last two years of education were in a fellowship just for liver cancer, and I assume some previous amount of his training covered cancer and livers, but all the rest is sort of wasted. Isn't there an option for those that want to specialize to learn less and be licensed for less?
I'm an electrical engineer. I know that I could never design a safe bridge (unless there's a good application note I could read). If engineering was like medicine, I would have been expected to go to school for 15 years to become an "engineer" capable of doing civil/electrical/mechanical/software/materials science/etc. and I would need to be paid drastically more to cover the staggering loan payments. But instead engineers figured out how to specialize and keep costs low.
Why can't doctors?
It doesn't hurt to be nice.
As a molecular biologist I have to ask: how would that matter? The MDs that have patients don't really need to be thinking about ATPases or the Michaelis–Menten equation. The MDs that are taking basic research and putting it into the field seem to be getting their PhDs which can't be easily faked. And the just regular PhDs are in theory doing the really basic research that involves knowledge of mobio, we don't go to med school or see patients.
Having gotten my Ph.D in the basic research wing of a major medical school, I can concur that MD's typically have only a vague understanding of mechanistic biochemistry, and that the Ph.D's designing future treatments have only a vague understanding of human physiology. Exactly how is this a satisfactory state of affairs?
If you were ill with some condition that presented in an unusual way, (say, a borderline metabolic deficiency), would you prefer your M.D. to actually be able to figure out on their own what's wrong with you, or just blindly follow diagnostic recipes they memorized from the New England Journal of Medicine?
The only reason I can see for wanting a premed student to take molecular biology is to add another level of selection to deter the weakest students from becoming doctors.
You are aware that intro molecular biology is now taught in the second year of any standard biology major, or sometimes combined with biochemistry in your third year? My wife is an ecologist and she took it. Pre-vets take it. Nurses take it in nursing school. Heck, my dentist took advanced biochemistry as well. So why are you against pre-meds taking it? You think a doctor doesn't need to be as capable as a nurse, vet, or dentist? It's not exactly quantum physics, and it's extremely useful since you may only get the abbreviated "molecular medicine" type of crash course in med school since they assume you already took it as a premed.
Interestingly, I've heard that the major that scores the highest on average on the MCAT is actually not premed, biology, or chemistry. Philosophy majors do the best on the MCAT. Granted, there's a lot of self-selection going on there, they probably make up at most 1% of the MCAT takers, and the MCAT is not necessarily an indicator of who will be a good doctor.
You can see a list of the topics covered on the MCAT below which covers (surprise!) molecular/cell biology and biochemistry. Unless the philosophy majors are cheating, they must have at least self-studied the material to score so highly, but more likely than not they took a course or two. I'm really puzzled what you are trying to prove here.
https://www.aamc.org/students/download/85566/data/bstopics.pdf
MD degree is to long and the school mindset may be to much drilled in to people. Going to med school do they really need a full 4 year BA with all the filler classes before med school? Why not 2-3 years and then Med school? Now I can see what that setting in a class room for years with lot's of tests and some stuff that you will never use can do to your mindsets. Testes become more about craning for the test then studying the full topics. Now some of this comes from poor tests and the other part comes from the tech the test idea.
Well, it wasn't always this way. Used to be, you didn't need a B.A. to enter medical school. Heck, you didn't even need to have any contact with real patients before you set up your own practice (i.e. no residency or clerkships). Medical schools used to be giant diploma mills that would take any paying student. Accreditation and board certification were a complete joke.
Then the civil war came along, many of those doctors were drafted to help the army, and to the horror of wounded soldiers everywhere, it soon became clear that your chances of survival were often *better* if you were not treated at all than if you were allowed to be operated on by one of these diploma mill graduates with no real qualifications.
Since then, all medical schools have required a bachelor's degree.
I entirely agree one could theoretically teach all the relevant pre-med material in 2-3 years, nothing is stopping anyone from simply finishing a B.A. a year early if they want. Most pre-meds I knew could have too, they just chose not to because they wanted to live a little before going to med school, or buff their resume and get into a really good one.
And sure, you can always argue pre-meds are being weeded out with only slightly relevant material (yes, orgo II, I'm looking at you). But, you know what? I aced that class without really understanding it and all it took was applying a few key chemical concepts and a fair bit of rote memorization. If you can't hack that, I don't want you interpreting my MRI scan or prescribing me an immunomodulator that might or might not interact with my heart medication.
The entire point is that they are not. The US "health" system is really an insurance system. Now do you see why the rest of the world is laughing at those idiots in the USA that got sucked in by the PR campaign from the insurance companies about doing a tiny bit to shift it back to healthcare again. Leave the doctors alone and complain to those in politics that over the years colluded with insurance companies to take health care away from them. Vote out your local idiot that was bribed to help keep the insurance profits high.
Yes, but did the guy reading the slide HAVE to do all those other things?
I got an ECG a few years ago and it was interpreted by an MD (a cardiologist). No doubt a hospital generates so many of these in a day that you could easily employ somebody full-time to do nothing but interpret them. However, instead of giving somebody a year of training and turning them lose for $60k/yr they instead send them to a team of cardiology MDs each taking maybe 10% of the load and being paid $200k/yr easily.
No doubt the MD who read my ECG could have done a holistic evaluation of my situation and provided all kinds of recommendations, and they no doubt do that for other patients all the time. However, they weren't doing that for me. What they did do is render a few sentences of opinion purely based on the test, perhaps with a recommendation for follow-up. I'm not convinced that this couldn't have been done FAR less expensively by a technician.
Now, we'll always need generalists, and we'll always need the occasional House for the 0.1% of cases that truly boggle the mind. However, the problem with our medical system is that we make everybody a generalist and we don't triage cases well. Everybody who wants to gets to see House, and House is so busy that he probably doesn't get to spend adequate time on the cases that really do demand his expertise. I know a diabetic who was treated by a well-respected endocrinologist and it took the guy two years to get her blood sugars under control, and then only poorly with a bunch of side-effects. It took another two years to really get things working well, and in the meantime there were numerous cardiovascular complications (you name it). The problem was that the guy was so popular that he was overbooked, and he didn't spend more than a single 15-minute appointment per quarter dealing with her. So, he'd prescribe something, then review numbers 3 months later (maybe fasting sugars have dropped from 250 to 220), then adjust medications, and repeat. If the guy had handed things off to a nurse who followed-up one week after a medication switch they could have probably titrated her meds in a few months at most. I'm sure reimbursement structures don't help - doctors don't have much incentive to do things between periodic appointments unless you're in a hospital.
A triage-based system with less doctor involvement would greatly reduce costs and potentially increase access to care. A nurse who can check in on a patient biweekly is probably a lot more useful for the average patient than a doctor who can check in twice a year. Sometimes the simple stuff matters most when it comes to things like compliance and spotting problems.
Doctors are an important part of the system, but right now they're a one-size-fits-all solution.
I'm almost at a loss as to how to be informative on this post because it's so lacking in facts or actual observation.
1. Doctors are primarily (with a few notable exceptions like Kaiser-Permanente and the military health system) small partnerships of under 5 physicians. They don't run "big operations with high margins."
2. Hospitals are generally not-for profits (again some exceptions) with net excess revenues less the 5-7%, about the cost of capital replacement.
3. Doctors do expect compensation for the 4 years of college, 4 years of medical school, and 3-8 years of internship, residency, and fellowship, since they give up 7-12 years of post-college years of income generation for the same life expectancy. However, huge salaries for a few do not equate to massive salaries for all. Just like baseball players, a few get the big bucks, but many more play in the minor leagues. Check out the National Bureau for Labor Statistics data.
4. Some doctors make lots (neurosurgeons, for example), but then they also pay millions of dollars (YES, MILLIONS) of dollars in malpractice insurance because people expect perfection from doctors, not acknowledging how complex and variable human biology is.
5. The most complex part of the healthcare system is the insurance system, which is completely out of the control of the medical professionals.
6. AMA is not a union, has no collective bargaining rights, and has as its membership AT BEST maybe 10-15% of all physicians. It's a voluntary professional membership society.
7. The major evolving complexity in the state of healthcare in the US is the federal government, which through tax laws, federal mandates, and regulatory actions, have created a never-ending chain of requirements, complexity, and frustration. The decades long effort at vilification of the medical profession and poor financial management coupled with government regulation will give you increasingly lower quality of medical care delivered by less trained salaried employees.
8. On the plus side, technology can assist in improvement in the application of scientific knowledge to the delivery of care, but not if legislated and dictated by Congress and political forces.
The IT profession (at least NOT YET) doesn't have state regulated boards, mandatory licensing, bureaucratic payment policies, and direct government intervention in almost every aspect of your professional career.
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