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       beacon of the intent to “uphold the medical social contract to guard patient safety and
       benefit society.”  Ensuring a comprehensive suite of knowledge and decision-making
       skill at the moment of launch into practice feels appropriate. So as an alternative to
       jettisoning, can we mitigate the ills while maintaining the usefulness? Let’s sprinkle
       some seeds for discussion of the issues.
         On cost — mountains of debt and years of opportunity cost mean a challenging launch
       for the predominately mid-30s graduate, and blithely heaping new expenses should be
       scrutinized. I have no idea the accounting balance sheet for these exams, and no doubt
       engineering an iron-clad assessment is costly. But I know that the urologists involved in
       setting the exam aren’t making a buck, and much of the infrastructure in delivering the
       exam can be diffused between all the specialties through the Royal College mothership.
       Does the marginal cost of adding a candidate to the roster account for $4415 out of the
       resident’s pocket? Lay bare the budget and decrease the burden on trainees.
         On triviality — it is a bad feeling to try and pack odd syndromes and rare side effects
       into a crammed mind, and the notion that fitness to practice rides on the decision to
       biopsy an azoospermic man’s testis in an OSCE is appalling. I have faith though, and
       some knowledge, that the exam has evolved to test germane knowledge and decision
       over ephemera and data points. A defence of studying the small details is that trains
       the muscle that recognizes zebras exist. Learning the bottom of the differential hones
       the radar for red flags that pop up in the routine of clinical life; rare things are rare (!)
       taken one by one, but there are a half dozen rare things a week in the aggregate, and
       that is where solutions to tenacious patient problems lie. “Something’s not right here”
       separates high-level memorization of guidelines from the rooting and reasoning that
       makes us good physicians.
         On stakes — it remains shockingly important to pass the exam, to the point where all
       of the prior assessment, training, and mastery development is subservient to assent by the
       College. The go/no-go model is not unique here, of course (you have a driver’s license,
       right?) but the exam simply dominates the training landscape to the point that our teach-
       ing methods are as geared toward exam prep as comprehensive urology practice. So,
       make it even easier to pass! Pass rates are very high, but perhaps the exam is a place for
       cruising over a reasonable bar rather than eeking over an exceptional one. As an exam of
       competence, every effort to build and vet the exam as a meaningful measure of a good
       urologist’s toolkit is essential. The urology exam committee is on the ball here over the last
       several years. Make remediation easier than one sitting per year! Quick opportunities for
       revision at three months, even raising standards or changing modality for the second go
       if needed, would loosen the yoke. No easy task for the exam committee, but a potentially
       vital one in the lives of candidates. The move to a fall exam is a helpful step, as the next
       sitting comes within five months of graduation rather than 11.
         In the end, the qualifying exam reminds me of Van Halen and brown M&Ms. You
       may be familiar, but buried in their exhaustive 1980s tour rider was a request for a
       bowl of M&Ms on the craft table, with the brown ones removed. Many saw this as
       apex rock star insolence, but the sneaky truth was that it was an indicator that the
       local team had done the work of reading the technical document. The band relied on
       pyrotechnics, high-voltage lights, and heavy equipment. Brown M&Ms in the bowl
       meant they couldn’t trust the safety and stability of the massive stage set. The rite of
       passage of the exam — the studying, the sweat, the stakes — is pretty unpleasant, but
       in the end, it’s a marker of doing the work of preparing oneself to know urology. Let’s
       whittle away at the pedestal a bit perhaps but beware a world without it.


       1.   Thoma B, Monteiro S, Pardhan A, et al. Replacing high-stakes summative examinations with graduated medical licensure in Canada. CMAJ 2022;194:e168-

       240                                       CUAJ • August 2022 • Volume 16, Issue 8
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