A fresh set of eyes

This past June, I was invited to observe the oral certification examination being administered by the American Board of Ophthalmology to more than 300 ophthalmologists. The experience gave me a deeper appreciation for what physicians have to do in order to become board certified. And, as a public (non-physician) member of the American Board of Medical Specialties, I feel better equipped to discuss issues related to physician certification.

I learned that the path to certification in ophthalmology is similar to the process used by several other specialty boards: a computerbased qualification examination followed by the oral certification exam.

The oral certification examination lasted three hours. Examinees were assigned to panels of six, along with six examiners and a panel leader. Over three hours examinees rotated through six stations, each covering a different area of ophthalmology (glaucoma, neuroophthalmology, pediatrics, and so forth), and each with a different examiner. Following the session, examiners and the panel leader met to discuss the physicians that they had just examined. The certification decision is based on input from these panels.

Administering the oral examination is no small undertaking, even after the patient management problems have been written, fieldtested, and formatted for the exam. It involved 150 physician examiners, some mentoring first-time examiners, as well as the panel leaders and physicians who provided orientation and training.

Dr. George Bartley, Chief Executive Officer of the American Board of Ophthalmology (ABO) as well as a practicing ophthalmologist, was my host. During one of our conversations he commented that from time to time, ABO leadership reconsiders whether or not the oral exam is worthwhile, as administering it is expensive and the costs fall to ophthalmologists who typically are not yet financially established. In light of my experience, I believe it is.

Why administer an oral exam?

An obvious reason is that it tests different things than the computer-based multiple-choice examination. The qualifying exam requires ophthalmologists to demonstrate that they have the knowledge at their disposal-sometimes called “walking around knowledge”- necessary to practice independently. The oral examination requires ophthalmologists to exercise judgement in applying that knowledge to a variety of patients and conditions.

A model of professionalism

In addition to assessing a physician’s judgement and underlying knowledge, I believe the oral examination has three benefits.

First, the panel meeting following each exam session provides an opportunity to discuss physicians who didn’t clearly pass or fail the oral exam. No matter how an examination is structured, there will always be candidates who fall in this category. Having a process to evaluate these physicians, using a dialog between seven practicing ophthalmologists, and especially just after interacting with the candidates, seems to me as reasonable and fair.

Second, the oral examination meeting provides physicians being examined an opportunity to meet new colleagues, and develop or nurture peer relationships.

Finally, and I believe most importantly, it offers a model of professionalism to ophthalmologists, most just beginning their careers. (In a recent Editorial, Dr. Peter McDonnell illustrated the importance of role models in acquiring knowledge.) The examiners volunteer their time and pay their own way to the exam site, where they welcome all candidates as peers. Physician examiners look and act like the professionals they are, and that their younger colleagues can aspire to become.

Physicians may feel themselves under pressure, faced with ever higher expectations, sometimes leading to “burnout” and its manifestations. Developing peer relationships and having role models can help physicians maintain their sense of professionalism and fulfillment in what they do. I believe that this benefits physicians, as well as those of us who rely on them for care.