Adding Context to the Declining Board Pass Rate in Emergency Medicine

The American Board of Emergency Medicine (ABEM) recently published data that highlighted longitudinal downtrends in performance on both the In-Training Exam (ITE) and the Qualifying Exam (QE) in Emergency Medicine (EM) [1]. These results merit attention particularly given the longitudinal nature of this downward trend. The cause of these trends is likely multifactorial and may include changes in the population entering medical school, subsequent changes in the population entering the field of emergency medicine, as well as changes to the learning and assessment environment. The drop in performance on standardized tests is not unique to emergency medicine. Cardiology, family medicine, internal medicine, nephrology, pediatrics, and surgery have also seen declines in their ITE or board exam pass rates in recent years [2-7]. This suggests that influential factors exist beyond the distinctive training environment of emergency medicine. Systemic factors in medical training may be reducing trainee readiness for board certification exams. US medical school enrollment recently underwent a dramatic expansion of both osteopathic and allopathic programs to mitigate a predicted physician shortage resulting from general population growth and particularly the now-aging massive baby boomer generation [8]. This goal was achieved by expanding the total number of medical schools as well as increasing class sizes [9-11]. The enrollment surge may be straining educational resources [11]. Larger class sizes may mean reduced individualized faculty attention and mentorship, potentially contributing to the decline in exam performance noted by ABEM and other credentialing bodies. Similarly, emergency medicine has seen a recent expansion both in the number of programs and resident positions per program [12, 13]. The negative effects of class size and program expansion may carry over to the Graduate Medical Education (GME) level. In addition to increased enrollment, the current emphasis on holistic review and de-emphasis on standardized test scores may also mean that the current pool of medical trainees is different from prior cohorts [14]. Current cohorts may not be as strong test-takers but may have other strengths such as resiliency, leadership skills, or grounding in health equity. We also cannot ignore the possibility of changes in the learning environment influencing exam performance. Clinical and educational work hour limitations and changes in shift distribution to address wellness may translate into less clinical exposure, fewer educational opportunities, and changes in learning priorities. These constraints on clinical learning were further compounded by the COVID-19 pandemic and the subsequent boarding crisis, which have greatly limited clinical rotations, number of patient encounters, diversity of experience, and in-person learning [15, 16]. These are all known critical factors for expertise development. Additionally, the demands of residency, especially with these stressors, have likely contributed to higher burnout rates, which can negatively impact cognitive performance and exam scores [17-20]. While limited evidence from prior to the pandemic cited by ABEM indicates that burnout does not impact ITE scores, this study based their conclusions on the results of only two items from the Maslach Burnout Inventory [21]. There are many studies across disciplines that suggest that burnout impedes academic performance [17-20, 22, 23]. This suggests that the impact of burnout and wellness during graduate training and board certification is an unsettled question. The expansion of scope within emergency medicine without additional required training time may also increase the difficulty of subject matter mastery [24]. We must also acknowledge the change in the assessment environment in undergraduate medical education. Many medical schools now utilize pass/fail grading systems and there is evidence of increasing grade inflation in those maintaining tiered grading [25-27]. The shift of regulatory exams such as the USMLE Step 1 to pass/fail may also shift the mindset of medical trainees to only aim to achieve “what is necessary” instead of “what is possible” [27, 28]. The decline in performance on the ABEM ITE and QE is concerning although not a crisis. It should, however, prompt us to critically reflect on recent changes and broader challenges within the medical education system and the spectrum of learning that exists across the undergraduate medical education (UME) and GME continuum. We have significant evidence that foundational clinical knowledge is critical to the development of clinical reasoning, which remains an essential skill of the physician [29]. The changing landscape of medical education may require that we as educators spend more time intentionally developing this core element especially as there is an increasing body of evidence that links successful board certification with patient outcomes [30, 31]. We have a duty to our trainees and our patients to continually iterate our training programs to ensure that the physician workforce is capable of delivering not only adequate, but instead excellent, patient care. Addressing these challenges requires a multifaceted approach, including re-evaluating and improving clinical training, optimizing our assessment systems so they are aligned with meaningful outcomes, and providing appropriate mentorship and support. The aim of emergency medicine training is not to create test-takers; it is to graduate competent, confident physicians capable of caring for patients in their most vulnerable moments. Examinations mark progress, but they cannot be the endpoint. Competence is the endpoint. The modest decline in performance on the ITE and QE signals that we must take a closer look at how well our systems are cultivating that competence. By strengthening foundational knowledge, refining our assessments to measure what truly matters, and recommitting to robust clinical mentorship, we position our trainees—and our specialty—to meet the demands of modern patient care with excellence. B.B., J.J., and L.R.H. are current members of the board of directors of the Council of Residency Directors in Emergency Medicine. J.L.S. is a prior member of the board of directors of the Council of Residency Directors in Emergency Medicine. The authors have nothing to report.