Reacting to CNN reports last year about the widespread use of "recalls" and "airplane notes" by radiology and dermatology residents, Gregory W. Ruhnke, MD, MS, MPH, of the Department of Medicine, University of Chicago, and David J. Doukas, MD, of the Department of Family and Geriatric Medicine, University of Louisville, call on leaders in medical education to establish guidelines and change the culture of medical school and training programs.
Illegal reproduction and transmission of board certification examination questions have received wide public attention recently. In 2010, the American Board of Internal Medicine (ABIM) suspended or revoked the certification of 139 physicians found to be disclosing or soliciting examination questions for a board review prep company in New Jersey; the company encouraged physicians to recall questions from memory and convey them to the course director for inclusion in course materials. In early 2012, CNN revealed that doctors training to become dermatologists and radiologists had for years shared exam questions by memorizing them and writing them down after their board certification examinations.
Ruhnke and Doukas say there is a crucial distinction between cheating and guided study, noting that historical test questions are routinely used throughout higher education. They cite the American College of Physicians' Medical Knowledge Self-Assessment Program, which includes a summary of high-yield information vetted by post-examination residents to choose material likely to appear on future examinations. Some physicians have defended the use of "recalls." Moreover, "the difference between the use of questions reproduced verbatim and a focused study guide based on examinee input lies in the detail and specificity of information transmitted," they say.
The authors review the literature and discuss what drives dishonest behavior. Cheating is surprisingly common among medical students, with estimates ranging widely between five and 88%. Of medical students surveyed, 59% believed that cheating was impossible to eliminate because of its pervasiveness. Perhaps of greatest concern for the public, cheating on examinations by medical students correlates with falsifying information in a patient's medical record.
"Difficult exam content unnecessary for clinical care, the desire to assist friends, and peer behavior are important factors," says Ruhnke. For example, subjects not immediately relevant for clinical care, such as biochemistry and pharmacology, are seen as a "rite of passage." Assignment and test content that medical students view as unnecessary for clinical care makes them more likely to cheat.
The authors consider a number of potential interventions that might reduce the impetus to reproduce questions in verbatim form, such as not reusing test questions and the return of oral examinations, but recognize separate challenges of such solutions. Avoiding the reuse of test questions might threaten the statistical reliability and consistency of passing standards. In addition, harsh punishments are unlikely to be completely effective because their impact on peer behavior is not sufficiently powerful.
The authors urge the American Board of Medical Specialties and the Association of American Medical Colleges to establish guidelines regarding the detail and specificity of information that examinees may ethically disclose, and to be proactive in requiring examinees to acknowledge that reproduction or dissemination of test materials is both illegal and a violation of professional standards.
"Successful certification must demonstrate that physicians are vested with the trust of their peers but also the public. Sponsoring rigorous examinations that cover material critical for patient care will bolster what the profession provides to patients," according to the authors. "The literature suggests that this can best be achieved by embedding academic honesty into institutional cultures. Ultimately, the sanctity of our profession and the faith that patients place in us as physicians demands the highest moral standards."
In an accompanying Editorial, Christine K. Cassel, MD, Eric S. Holmboe, MD, and Lorie B. Slass, MA, of the American Board of Internal Medicine (ABIM), Philadelphia, welcome the work of Ruhnke and Doukas as an important "call to action" for academic medicine to actively, and intentionally, strengthen the culture of medical school and training programs to value integrity and to respect the need for examinations to demonstrate competence throughout a professional career.
In its legal actions and information campaign related to the board review prep company transgressions, "ABIM conveyed a clear message to the physician community that ABIM will not tolerate unethical behavior from board candidates, that test takers need to know that this kind of 'brain dumping' is grossly unethical, and that any physician who seeks to compromise the integrity of the ABIM examination process will face swift and serious consequences," explains Cassel.
"The certifying examination is one of the first tests of professionalism for physicians. 'Everyone does it' is never a sufficient answer when faced with an ethical dilemma, and if the profession is to meet its societal obligation to uphold the highest ethical standards, we most certainly cannot accept such an excuse from board certified physicians," she concludes.