Novel Strategies to Optimize Individual Performance on the In-Service Training Exam: A Case Series

Abstract

Background

Obstetrics and gynecology residents in the United States take the Council on Residency Education in Obstetrics and Gynecology (CREOG) in-service training exam on an annual basis. Performance on the exam is essential to assess any deficits in a resident’s knowledge as well as to evaluate the probability of passing the American Board of Obstetrics and Gynecology (ABOG) qualifying board exam. Given the substantial number of residents who experience performance issues during the exam, residency programs and individual learners benefit from the development of personalized learning plans to ensure trainee success. Test-taking anxiety is a big part of these performance issues. Eye movement desensitization and reprocessing (EMDR) therapy is a psychological method used to treat trauma symptoms and to also improve performance anxiety. Thus far, there have not been reports in literature of utilizing EMDR in residency programs to help learners struggling with test anxiety.

Case Presentations

We describe a series of cases in which EMDR therapy was utilized to enhance learner performance. The first case describes a resident who started with a CREOG score in lowest percentile, but with additional support, including EMDR therapy, improved their score to 60% in their second year and improved to 70% in their third year. In the second case, a resident with very inconsistent CREOG scores passed their qualifying exam on the first attempt after EMDR therapy. In the third case, a resident had consistently declining CREOG scores throughout their program, but with the help of an EMDR therapist ultimately passed the ABOG qualifying exam on the first attempt.

Conclusion

This article highlights that EMDR can be an effective strategy to improve CREOG scores for residents with poor performance. The results we have seen in our residency program validate that EMDR is a successful tool for learners who experience test anxiety.

Background and Discussion

To assess knowledge base and performance growth, all residents take in-service training examinations specific to their specialty. For obstetrics and gynecology (OB/GYN), the Council on Resident Education in Obstetrics and Gynecology (CREOG) develops an annual exam comprised of 300 questions covering all aspects of OB/GYN, including subspecialty care and research and ethics. Score reports include a percentile comparison of residents in the same year of training as well as an overall score. It is well known that residents who score in a percentile in the lowest of the 10% are more likely to fail their board exam. Lingenfelter et al¹ found that a CREOG score less than 200 indicates higher risk of failure on the American Board of Obstetrics and Gynecology (ABOG) qualifying board exam.

Certainly, it is distressing for trainees to score poorly, and low scores could also be an indication of deficits in the education provided by a program. Numerous studies have sought to identify contributing factors that can hinder academic performance on exams. Some factors that affect performance include the effort of the learner, learning preferences, anxiety,² lack of desire to learn, and inadequate education supervision.³

Test anxiety has been recognized as an important contributor to academic performance. A large meta-analysis spanning more than 30 years demonstrated a significant negative correlation between test anxiety and academic performance in high-stakes testing, highlighting the enduring relevance of this construct.⁴ Test anxiety encompasses a range of cognitive, emotional, physiological, and behavioral responses to evaluative situations. Learners may experience intrusive thoughts, fear of failure, and difficulty concentrating, along-side somatic symptoms such as palpitations, gastrointestinal distress, and muscle tension. These responses are not merely uncomfortable; they have negative correlations with attention, working memory, and information retrieval, all of which are essential for optimizing test performance.^5,6

From a neurocognitive perspective, heightened anxiety has been associated with increased activation of limbic structures, including the amygdala, with corresponding reductions in prefrontal cortical regulation.⁷ This pattern impairs executive functioning and disrupts access to stored knowledge. As a result, individuals experiencing significant test anxiety may perform below their true level of competence despite adequate preparation. Over time, repeated experiences of underperformance may further reinforce anxiety and avoidance behaviors, creating a self-perpetuating cycle.

Resident physicians may be particularly susceptible to this process. Residency training is accompanied by prolonged work hours, chronic sleep disruption, emotionally charged clinical encounters, and continuous evaluation. These demands contribute to high rates of burnout, depression, and anxiety among trainees. Within this context, standardized examinations such as the CREOG in-service exam often assume significance beyond their stated educational purpose, becoming measures of perceived professional worth, future opportunity, and standing within a training program. For residents, prior negative testing experiences may evolve into conditioned stress responses, in which examinations reliably elicit autonomic arousal and cognitive interference.

Test anxiety in residency rarely occurs in isolation. It may overlap with imposter syndrome, maladaptive perfectionism, and internalized expectations of constant high performance. Residents who have previously struggled with standardized tests may develop persistent anticipatory anxiety, intrusive recollections of past failures, and negative self-appraisals. These experiences can undermine confidence, reduce engagement with study activities, and impair performance even further. Importantly, the consequences of test anxiety extend beyond examination scores. Ongoing performance anxiety has been associated with avoidant learning behaviors, reduced participation in educational activities, and worsening emotional exhaustion, all of which threaten both professional development and well-being.⁸

Despite its prevalence and impact, test anxiety in graduate medical education (GME) is often overlooked or reframed solely as inadequate preparation. These interpretations fail to account for the emotional and neurobiological processes that meaningfully influence performance under stress. Viewing test anxiety as a psychophysiological state rooted in maladaptive learning and memory networks supports the exploration of interventions that directly address these mechanisms rather than focusing exclusively on increasing knowledge base.

When a resident performs poorly on the CREOG in-service examination, remediation efforts traditionally emphasize increased exposure to content through structured reading plans, expanded use of question banks, and reinforcement of didactic participation. At a program level, reviewing aggregate test data is essential to identify potential curricular gaps or deficiencies in instructional delivery. At the individual level, assessment of study habits and engagement with required educational activities remains an important initial step.

However, when knowledge deficits and limited preparation do not sufficiently explain poor performance, test anxiety warrants consideration as a contributing factor. Residents who struggle with standardized testing often demonstrate adequate clinical reasoning and day-to-day knowledge yet are unable to effectively access this information under pressure during examinations. In these cases, exclusive focus on additional studying may fail to address the underlying barrier to performance.

A more comprehensive approach to residents with persistent testing difficulties should include screening for anxiety symptoms, burnout, sleep disturbance, and maladaptive coping strategies. Exploring their prior academic experiences, perceived examination failures, and negative self-belief may further clarify the emotional context in which testing occurs. Such an approach aligns with evolving remediation models in GME that emphasize individualized, learner-centered assessment rather than uniform academic prescriptions.⁹

Gender-related considerations are also relevant. Given the predominance of OB/GYN residents who identify as female, existing literature demonstrating higher reported levels of test anxiety among women warrants attention.¹⁰ Sociocultural expectations, stereotype threat, and heightened performance pressure may all contribute to increased vulnerability to evaluative anxiety in this population.¹¹ Recognition of these factors further supports the need for remediation strategies that address emotional and psychological dimensions of learning.

Interventions for test anxiety have commonly included cognitive behavioral therapy, mindfulness-based approaches, academic coaching, and structured study programs. These modalities may reduce anxiety by targeting maladaptive cognitions, improving emotional regulation, and increasing perceived control over preparation. While beneficial for many learners, these approaches often require sustained time commitments, consistent attendance, and high levels of cognitive engagement, which may limit feasibility within demanding residency schedules. Moreover, they may not directly address emotionally-encoded memories of past academic distress that continue to influence present-day testing experiences.

Emerging research has explored the use of eye movement desensitization and reprocessing therapy (EMDR) as a treatment for examination-related anxiety. Although early findings are encouraging, this approach has not been systematically examined among medical residents, particularly those who consistently score in lower performance quartiles. The absence of targeted psychological interventions within standard remediation frameworks represents a significant gap in GME. Interventions that are brief, adaptable, and capable of addressing conditioned fear responses may provide meaningful additions to existing educational strategies.

Eye movement desensitization and reprocessing therapy, developed by Francine Shapiro, was originally introduced as a treatment for trauma-related disorders, particularly post-traumatic stress disorder. Eye movement desensitization and reprocessing therapy is based on the Adaptive Information Processing model, which proposes that psychological symptoms arise when distressing experiences are inadequately processed and stored in isolation from more adaptive memory networks. These unprocessed memories retain their original emotional and physiological components, allowing them to be readily activated by present-day cues.¹²

Subsequent research has demonstrated that EMDR is effective in reducing a broad range of anxiety-related symptoms, including panic, behavioral responses, and somatic distress.^13,14 Eye movement desensitization and reprocessing therapy is thought to facilitate the integration of emotionally-charged memories into more adaptive neural networks, reducing their capacity to elicit autonomic arousal and negative self-appraisals. Neurobiological studies suggest that this process involves modulation of limbic system activity, including the amygdala, with enhanced engagement of regulatory prefrontal pathways.¹⁵

Standard EMDR treatment involves identifying distressing memories, associated negative beliefs, emotional responses, and bodily sensations. While the individual attends to these experiences, bilateral stimulation is applied, most commonly in the form of alternating eye movements but also through auditory or tactile cues. Over the course of reprocessing, emotional intensity typically decreases, cognitive appraisals shift, and physiological reactivity diminishes. Treatment is considered successful when previously distressing memories no longer provoke significant emotional or somatic responses and are accompanied by more adaptive beliefs.¹⁶

Although initially conceptualized as a trauma-focused therapy, EMDR has increasingly been applied to conditions characterized by maladaptive anxiety responses, including performance anxiety and academic stress. Examination anxiety may reflect conditioned threat learning, in which prior negative testing experiences become linked to strong emotional and physiological responses. Subsequent examinations may then trigger these networks, impairing concentration and access to learned material. Eye movement desensitization and reprocessing therapy offers a framework for targeting these experiences directly, allowing prior academic distress to be reprocessed and, consequently, its emotional impact reduced.

Eye movement desensitization and reprocessing therapy protocols range from single session interventions¹⁷ to brief, multi-session models. Bilateral stimulation can be tailored to visual, auditory, or tactile modalities, increasing flexibility for individuals with different preferences or constraints. This adaptability is particularly relevant in residency training where time limitations often restrict access to longer-term, psycho-therapeutic interventions.

By addressing emotionally encoded memories associated with prior testing experiences, EMDR has the potential to reduce performance anxiety, disrupt avoidant study behaviors, and improve access to previously acquired knowledge during examinations.¹⁸ Given its brief, targeted nature and growing evidence base, EMDR represents a promising and understudied intervention for residents who demonstrate persistent difficulty with standardized testing despite adequate academic preparation.

Case Presentations

The next paragraphs describe a series of cases in which EMDR therapy was utilized to enhance learner performance. Each situation presented unique challenges that most residency program directors are under-equipped to address. Some institutions have academic testing centers, but these resources are often challenging for our trainees to access and fully utilize.

The first case describes a resident who matriculated into the program and kept up with programmatic self-study. They demonstrated clinical competence for their post-graduate year (PGY) level with appropriate milestone progression. When they took their PGY-1 CREOG exam, they scored at the first percentile nationally. The results were personally devastating for the trainee and inconsistent with previous performance on standardized testing. The program director did a series of coaching sessions, and through these conversations, the learner revealed they had a remote history of ADHD. They had testing accommodations in high school and college but had not needed them in medical school. In addition, the trainee was on ADHD medication during college but not during medical school.

A plan was developed, which included self-referral for psychiatry and psychological support. The trainee restarted ADHD medications and worked with a therapist throughout the academic year. They also engaged a therapist who did EMDR as part of their practice. In addition, EMDR sessions were performed weekly in the 3 weeks leading up to the exam. It is also important to note that the program director and the resident created an Individual Learning Plan to provide direction on their self-learning. Testing accommodations for this resident were requested and granted by CREOG. The resident improved their score to 60% in their PGY-2 year and improved to 70% in their PGY-3 year.

In the second case, we describe a resident with very inconsistent CREOG scores in the training program. They had scored at 10% during their PGY-1 year but improved their score to over 50% in years 2 and 3. When they took the CREOG their PGY-4 year, the score dropped down to less than 10%. These scores indicated this resident was in danger of failing the ABOG qualifying exam for certification. When meeting with the program director, the resident had disclosed a history of test-taking anxiety and a recent cessation of ADHD medication. The resident was referred to a therapist who performed EMDR, restarted medication, and took a commercial board prep review course. The EMDR was performed in the 3 weeks prior to the exam in weekly sessions for a total of 3 sessions. The resident took the qualifying exam and passed on the first attempt.

In the last case, this resident had consistently declining CREOG scores throughout their program. They achieved their highest score of 30% at the PGY-1 level and slowly declined to 5% by their PGY-4 year. This resident received a diagnosis of depression and anxiety while participating in the training program and took a leave of absence for 6 months for intensive therapy. When they returned, an Individualized Education Plan was created to facilitate the resident’s education and programmatic re-entry. The resident had their own established team of providers for support, but they engaged with an EMDR therapist for weekly sessions prior to the ABOG qualifying exam. This resident ultimately passed the ABOG qualifying exam on the first attempt.

Conclusion

These cases illustrate the importance of a multifaceted approach to help struggling learners. Furthermore, residency programs strive to produce graduates who excel in clinical practice, professionalism behavior, and academic prowess. To achieve this goal, the path for each individual resident branches off from a core foundation of objectives. Doing well on CREOG in-service exams is an important goal to ensure that trainees meet academic standards and pass their board examination upon graduation. Program directors need to be equipped to identify struggling learners and offer various methods to improve trainee performances on high-stakes tests.

Eye movement desensitization and reprocessing therapy is effective for learners who experience test anxiety. The results we have seen in our residency program validate that EMDR is a successful tool. Many residents will experience trauma as a second victim due to clinical practice. Having familiarity with EMDR is also a benefit for treatment in this capacity as well. It is exciting to see how the intersection of social science with applied science can benefit medical students and resident physicians.

Funding Statement

This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare-affiliated entity