“While USMLE exam failure rates since 2014 remained steady between 2 and 6%, initial board certification exam failure rates have higher variance. For pediatrics, it ranged from 9 to 19%, internal medicine 9–13%, and general surgery 6–21% “ ¹ 

Board certification exams are a high-stakes, expensive, one-time assessment at the end of residency or fellowship training. Up to 20% of our GME graduates will not pass this initial certification exam, and the cost beyond dollars is substantial in terms of mental anguish, shame, and vulnerability. Many of these graduates become faculty members in our medical schools before board exams are completed, since most initial certifying exams are offered only every other year. So, if first-time board certification failure is not a rare event what can you, as their division chief or chair, tell them?  How can you help?

Earlier this month Faculty Feed, our online blog post, published a piece by Dr. Natalie Henderson (Department of Pediatrics), entitled Good Enough: Vulnerability and Shame in Medicine, in which she shared her personal story of failing the pediatric critical care medicine boards. Twice. I suggest that you read that piece before this one for context. When this happens, how can we best help them? Here are some strategies you could employ to assist them through this difficult time as they wait another 18-24 months before they can re-take the exam:

• Reassure them and share stories of failure or vulnerability. The embarrassment and feeling of isolation that can occur in this setting can be paralyzing, and your reaction and empathy can help them recover and move through this time. Share the fact that this is not uncommon and consider whether they should be put in touch with other recent graduates who struggled with the initial certification exam. If you experienced a similar event, share it with them. They need to know that they are not alone.
• Find out if test-taking anxiety contributed to the board exam failure. Counseling, anxiety-reduction techniques like meditation, and medications can be of help in impacting the symptoms of test-taking anxiety. Make a referral for an evaluation.
•  Encourage them to adopt effective learning strategies as they prepare for the next exam. Most of our trainees do not employ effective learning strategies, relying instead on cramming for the few months before the next board exam.

1. Get them to start studying early
2. Introduce them to effective learning strategies like spaced retrieval practice, interleaving, etc as summarized in the book, Make it Stick² . Here are three resources to guide them toward effective learning strategies:
1. Strengthening the Durable Memory
2. Creating a Durable Memory
3. Encouraging Students 

• Encourage them to adopt a growth mindset as they consider the next board exam. A growth mindset is characterized by the acceptance of failure as a learning opportunity and that failure simply represents that you have not mastered the content….yet. Carol Dweck’s book, Mindset3, is the best resource to review the importance of this approach to accepting failure in a positive light. 

References:

1. Greenky, D., Reddy, P., & George, P. (2021). Rethinking the Initial Board Certification Exam. Medical Science Educator, 31(2), 889–891. https://doi.org/10.1007/s40670-021-01209-x
2. Brown, P. C., Iii, H. R. L., & McDaniel, M. A. (2014). Make It Stick: The Science of Successful Learning (1st ed.). Belknap Press: An Imprint of Harvard University Press.
3. Dweck, C. S. (2007). Mindset: The New Psychology of Success (Updated Edition). Ballantine Books.