Trust in Residents and Board Examinations: When Sharing Crosses the Boundary

Recently, illegal reproduction and transmission of board certification examination questions has received public attention. In 2010, the American Board of Internal Medicine suspended or revoked the certification of 139 physicians found to be either disclosing or soliciting examination questions for a board review company that encouraged physicians to relay questions from memory. In 2012, CNN reported on two circumstances of residents preparing for board certification examinations using questions reproduced by previous examinees.^1,2 Immediately after taking the American Board of Radiology (ABR) medical physics examination, radiology residents wrote down test questions to which they were assigned. These questions, known as “recalls,” were then shared among future trainees. Dermatology residents also reproduced questions (referred to as “airplane notes”) minutes after their certification examination, often in groups. In these two cases, 20% to 50% of test questions have appeared on previous examinations.^1,2

Reproduction of the questions clearly violates examination copyright policies, breaching the agreement to which their signature binds them.^3,4 In a relevant study, nearly all medical students and faculty members surveyed considered using a stolen copy of a board examination unethical.⁵ Moreover, the ABR considers using recalls cheating.¹ A profession is distinguished from a craft guild on the basis of educational standards, coupled with an established code of ethics in which a service rather than profit orientation is enshrined to engender the public trust.⁶ For this reason, ethical breaches and unprofessional behavior, such as the morally misguided use of reproduced questions, undermine the integrity of our entire profession. Yet, some physicians interviewed by CNN rationalized recall use as simply a study guide, whereby test questions are used to confirm understanding of the underlying knowledge rather than rote memorization of answers.

Cheating of this nature casts an overarching ethical pall over the moral formation and integrity of physicians, eroding public trust in professional practice, teaching, and scholarship. Cheating on examinations in medical school correlates with falsifying information in a patient’s medical record.⁷ Surprisingly, one third of medical students engaged or would consider engaging in such falsification.⁸ This behavior reflects poor moral reasoning and/or willingness to subordinate morality to the achievement of goals. Such morally unacceptable conduct violates the primacy of medicine’s beneficence-based responsibility and undermines the integrity of our profession. From the patient’s perspective, physicians should be certified on the basis of a valid assessment of the knowledge requisite to provide high-quality care. If patients cannot trust the knowledge that board certification is expected to measure, the medical profession loses the public’s trust and confidence. Moreover, patients will only benefit from certification if it indicates the ability to care for them, rather than efficient preparation for board examinations.

The distinction between cheating and guided study is crucial. Historical test questions are routinely used throughout higher education,⁹ and recent examination experience is commonly used to create focused study materials. The American College of Physicians produces the Medical Knowledge Self-Assessment Program, which includes a summary of high-yield information likely to appear on the examination.¹⁰ The introduction states, “The content was turned over to 11 carefully selected chief residents and fellows who had recently passed the certification exam. These physicians strained the essential testable points.” The editor continues, “As a frequent lecturer on Board preparation, I rely on input from hundreds of post-examination residents. With their ideas in mind, I refined the outline of Board Basics to target important topics and eliminate nonessential information.”¹⁰ Used by medical students for over 2 decades, the First Aid series is updated annually based on examinee reports. Using a focused study guide and sample questions created with examinees’ input bears some similarity to using practice questions that may have been on a recent examination as a vehicle for targeted learning. The difference lies in the detail and specificity of the information conveyed to future examinees. Nevertheless, from the public’s perspective, both practices represent shortcuts for examination success. Surprisingly, only 43% of medical students surveyed thought that it was clearly wrong for a student completing a clinical examination to convey information regarding its content to another student taking the examination.⁷ There is clearly a commonality between this finding and the interviewed physicians’ rationalized view of recalls.

The Drivers of Dishonest Behavior

Ethical considerations aside, cheating in education and sports is disdained because it creates unfairness between “competitors.”¹¹ Unlike performance-enhancing drugs in competitive sports, enhancement with caffeine, methylphenidate, and benzodiazepines to improve test performance is not considered cheating. This distinction may be based on the belief that insomnia, difficulty concentrating, and anxiety are physiologically abnormal states from which examinees deserve redress. The unfairness perspective is reflected in a dean’s observation in the CNN report that since recall use occurs pervasively, it reflects practice within radiology programs across the country and therefore does not cause any unfair advantage.¹ Unfortunately, 57% of surveyed medical students claimed that other students’ cheating had unfairly disadvantaged them.¹²

Although patients express a highly favorable view of physician certification,¹³ it was never intended to convey the privilege to practice, but rather to measure competence. Requirements for entry to the professions were created long ago more for the sovereignty of members’ authoritative judgment than to please customers. Professionalism has served as a basis of solidarity for resisting threats to social and economic position.⁶ Unlike licensure, most hospitals and health care plans do not require board certification for privileging and credentialing.^14,15 Appointment committees may realize that the evidence linking certification with higher quality is limited¹³ and that the knowledge it reflects is only one component of high-quality care.¹⁶ Moreover, the medieval conflict between the benefits of standards enforced by the European craft guilds vs those of free market entry⁶ is still evident today, as required certification can limit patient access to health care.¹⁷

The difficult content of the radiology physics examination is one driving force of the behavior described. The professions have long had requirements for entry that are not necessarily critical for practice, as did their antecedent craft guilds.⁶ For most physicians, the exhaustive study of biochemistry and pharmacology is a rite of passage based on knowledge rarely used in patient care. In fact, the physicians interviewed by CNN communicated the idea that recall use arises from the necessity to demonstrate proficiency of arcane material considered by many as unimportant for practicing radiologists. Consistent with this perspective, assignment and test content that medical students view as unnecessary for clinical care makes them more likely to cheat.¹⁸

Beyond the test characteristics, a desire to succeed naturally underlies the decision to cheat—40% of 665 medical students from 6 different schools admitted to having done something unethical to avoid a poor evaluation.¹⁹ However, fear of failure is not generally sufficient. One study of 6096 undergraduates demonstrated that academic dishonesty is most strongly associated with peer behavior,²⁰ suggesting that contextual factors are more important than individual ones.²¹ Many medical students believe that certain forms of cheating can be justified if the motivation is to assist friends.¹⁸ Cheating is surprisingly common among medical students, with estimates ranging widely from 5% to 88%.^{5,7,8,12,19,22,23} Of 2459 medical students from 31 schools, 41% had cheated during high school, and 59% thought that cheating was impossible to eliminate because of its pervasiveness.²³ When misconduct becomes an established norm, as it apparently has in the radiology and dermatology certification process, it does not become morally defensible but can be particularly difficult to stop.²⁴ In this case, a scarcity of employment opportunities rendering certification critical for radiologists may also have created a greater willingness to cheat.

Responding to the Problem

The American Board of Medical Specialties (ABMS) has responded to the CNN reports: “Whether someone is providing or using test questions, ABMS Member Boards enforce sanctions that may include permanent barring from certification and/or prosecution for copyright violation.”²⁵ As discussed previously, physicians’ views on the ethics of using reproduced examination questions is not uniform. However, it is clear that reproducing the questions is an infringement on copyright policies punishable under the law. The ABR has condemned both the creation and use of recalls. Nevertheless, consultation with recent examinees is used extensively throughout the physician training process to create targeted test preparation materials. Given this trend, we urge the ABMS and the Association of American Medical Colleges to establish guidelines regarding the detail and specificity of information that examinees may ethically disclose.

The use of reproduced questions for board examination preparation is a legal and ethical issue that threatens medicine’s integrity and its public trust. Moreover, indisputably dishonest behaviors are far too common among trainees. The literature has reported minimal success with punishments¹⁸ and honor codes²⁶ to limit academic dishonesty in medical education. Responses to unethical acts have also been hampered by divergent opinions about the severity of specific violations and appropriate sanctioning mechanisms.^18,27 However, the literature consistently suggests that peer behavior has a strong impact on ethical decisions.²⁴ Thus, perhaps the most critical step institutions can take is creating an environment in which academic and professional dishonesty is unacceptable.^20,28 The image of dermatology residents writing down test questions together in a restaurant certainly suggests that this established norm reflects cheating as a social activity. This is consistent with literature on social desirability demonstrating that trainees find it more acceptable to engage in unethical conduct when their friends are also doing so.²⁴

The most influential way to curtail unethical behavior is the embedding of academic honesty into institutional cultures. This might be achieved through role models and curricula development that emphasize the reverence and authority to be accorded a virtuous professional. There is some evidence that case-based ethics training improves moral reasoning,²⁹ a characteristic that has been used for medical school admission,³⁰ although the impact on actual conduct is not known. The ABMS Member Boards must be proactive in requiring examinees to acknowledge that reproduction or dissemination of test materials is both illegal and a violation of professional standards. Inappropriate transmission of information may also be limited by ensuring that examination content is highly relevant for the patient care activities that will be endorsed by graduation or certification. Esoteric or irrelevant questions bespeak of academic hazing, surely beneath ABMS goals, and should be eschewed.

Not reusing test questions would reduce the impetus to reproduce questions in verbatim form but might threaten the statistical reliability and consistency of passing standards.³¹ The physician labor required for question creation and vetting would also make examinations more expensive.³¹ Largely defunct oral examinations might reduce transmission of examination content, although repetition of cases would precipitate vulnerability.⁹ Harsh punishments are unlikely to be completely effective because their effect on dishonest peer behavior is not sufficiently powerful.²⁰ Efforts must be made to minimize burnout, which fosters dishonest behavior.³² In the end, the actions of some board examinees threaten the moral integrity of the medical profession. From these circumstances, it is clear that 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. Ultimately, the sanctity of our profession and the faith that patients place in us as physicians demands the highest moral standards.

Conclusion

The reproduction and transmission of board certification examination questions by physicians has received attention from both the media and professional organizations. Such ethical breaches undermine the integrity of the medical profession. Recent examination experience is used throughout higher education to create focused study materials. However, this does not justify misconduct such as using illegally reproduced questions, even if it becomes an established norm, as it apparently has in the radiology and dermatology certification process. Dishonest behavior, which is surprisingly common among physicians-in-training, is driven most strongly by test characteristics and peer behavior. Especially since cheating on examinations correlates with falsifying information in a patient’s medical record, academic dishonesty has critical implications for the preservation of professionalism. To limit unethical behavior, examinations should test material highly relevant for the activities that will be endorsed by graduation or certification. It is also critical to create institutional cultures that make academic dishonesty unacceptable and emphasize the respect to be accorded professionals with high moral standards.