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Taking the American Board of Internal Medicine (ABIM) nephrology subspecialty board exam is the culmination of 2-3 years of rigorous clinical training in nephrology. The exam is capable of striking fear into anyone, both at initial certification and when recertification comes along every 10 years. Failing the ABIM nephrology exam is not only expensive but a major time commitment. For a majority of fellows this occurs while starting a new job. The timing couldn’t be worse, with many examinees juggling a new city, a new job, and new responsibilities. Many fellows are also starting families. The time and mental constraints of failing can be exhausting, not to mention the humiliation and possibility of derailing initial employment. Yuan et al, in a recent editorial in AJKD highlight a troublesome trend of declining initial board pass rates in the ABIM nephrology subspecialty exam. Nephrology has witnessed the sharpest decline in board pass rates of all of the major subspecialties during the last 4 years. The fall in board pass rates comes at the same time when we are seeing a decline in the number of applicants to nephrology suggesting a convenient, though not necessarily true, explanation of lower quality fellows. From an all time high pass rate of 98% in 2010 to a low of 80% in 2014 (see red broken line in figure). Are we failing at educating our fellows? Or is certification broken? Yuan et al offer up several potential reasons for this decline.

1. Nephrology programs are admitting more fellows incapable of mastering the material.
2. Training programs are not providing adequate education.
3. Recent ACGME and ABIM educational initiatives, specifically the Next Accreditation System and the Milestone Project, are failing.
4. The ABIM nephrology certifying examination is losing validity and relevance.

Let’s take a look at each of these factors.

Items 1 & 2: The fellow, the program, or both are contributing to the decline in the nephrology ABIM board pass rate. Fellowship training is more than rounding in the hospital, clinics, and dialysis units. Fellowship incorporates weekly seminars, board reviews, journal clubs, case conferences, and pathology conferences among other didactics into their curriculum. This is an intense process, taking between 2 or sometimes up to 4 years of training. Making the subspecialty exam even more high stakes is that it (and other subspecialty exams) comes right on the heels (a mere 2 years) after the initial internal medicine ABIM board examination. Even though the internal medicine board pass rates have been relatively flat at 85% in the last 4 years, the subspecialty exam pass rates have seen a small decline from 90% to 87%. However, the nephrology pass rate has declined from 98%–> 86%–>87%–>87%–>80% from 2010 to 2014 (see figure, red dashed lines).

Data from ABIM website.

Is this trend real? Will it be sustained? Has the exam become more difficult over time? What were the IM board pass rates of the fellows who took the exams in each of these years? These are important questions to which we currently do not know the answer. In my opinion, fellows who finish an accredited nephrology fellowship program should be able to easily pass a high stakes exam. The pass threshold should identify only those below that of a minimally competent nephrologist. Are we willing to say that 1 in 5 fellows trained in the US are below that threshold? I hope not. Are our fellows working so much they are not able to take time to study and read? I hope this is not the case as well. We must continue to ensure dedicated time for self study, reflection, and growth. Where are the failing fellows coming from? Are they IMGs or USMGs? Are they from community programs or medical school-based academic centers?

On that same note, programs should aim for a perfect pass rate. Improving fellowship training in nephrology should always remain a goal no matter the pass rate. I’m not convinced that this 4-10 year decline is solely due to a global decline in nephrology education at the fellowship level. However, we should strive to provide better educational opportunities for our trainees. There are many initiatives at both the institutional and global nephrology level that are tackling this problem. I see the nephrology community more interested than ever before in redefining our field and pushing the envelope in education. As an example of this, the education sessions at ASN Kidney Week have been standing room only. But, we can do better. We can always do better.

Now for items 3 & 4: The educational initiatives of the ACGME or the ABIM exam itself that is contributing to the decline in the nephrology ABIM board pass rate. Yuan et al makes a heeded call for more transparency during test question development for the ABIM nephrology subspecialty examination. This is long overdue. They also call for more diversity of membership on the ABIM Nephrology Board Examination Committee through inclusion of younger nephrologists and those who practice in the community outside of academia. In essence, the exam needs to be more patient-focused and less esoteric. This will make studying and taking the exam more practical and meaningful. In the same light, ABIM board exams should be more about how one acquires and synthesizes information instead of relying heavily on rote recall. The practice of medicine has dramatically changed since the ABIM first started testing. We now have the ability to glance at our phone for an instant refresher. No need to go to the library and look up information. The internet, once littered with outdated material, is constantly refreshed and more current than many textbooks. Many nephrologists are very adept at finding accurate information online. Let the examinees take the exam just as if they are caring for patients. The exam should allow for an approach to answering questions more akin to reality. Moreover, the authors suggest that external oversight and a clear delineation on how committee members are selected is urgently needed. Yuan et al point to a recent paper from Robert Brown questioning the validity of the ABIM exam in its ability to determine medical competence. Rapid fluctuations in board pass rates should not be occurring as the consequences are disastrous. The ABIM continues to face intense scrutiny on several fronts, from the MOC initiative, to the declining board pass rates, to their finances. It is prudent that the ABIM begins to not only listen, but act upon these issues before implementing yet more onerous programs such as MOC. Alternative certification programs are already gaining ground. As an example, the National Board of Physicians and Surgeons recently launched an alternative board certification that utilizes a combination of prior certification, state licensure, CME credits, and active hospital privileges.

Who will certify and administer board exams to nephrologists in the future? Will the ABIM listen and adapt to the future? Or, will another group take this over? What is accounting for the decline in first time takers of the nephrology board exam? It is clear we need to tackle this problem on many levels. However, the ABIM needs to listen to the physicians it certifies to get this right, or risk becoming irrelevant. Please give us your thoughts about these issues below in the comment section.

Dr. Matthew Sparks
AJKD Blog Advisory Board member

To view the article full-text or PDF (freely available), please visit AJKD.org.