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EDITORIAL RoCo riffing: Thoughts on the qualifying exam
Michael Leveridge here is a particular stomachache that pulses through the body when rounding a
curve at high speed and seeing a meaty police cruiser staring from the median. I
CUAJ Editor-in-Chief Twoke with a similar disquiet about a week before my Royal College exam in early
June 2008, and the feeling didn’t go away. The prior several months may sound familiar:
reciting lists, operating, differential diagnosis of radiolucent stones, answering 3 am
Cite as: Leveridge M. RoCo riffing: Thoughts pages, 11β hydroxylase deficiency is the second-most common cause of congenital
on the qualifying exam. Can Urol Assoc adrenal hyperplasia, hours and hours in the library, wondering why the overactive blad-
J 2022;16(8):239-40. http://dx.doi. der chapter is 86 pages, exhaling deeply with eyes closed after heaving a lawn chair.
org/10.5489/cuaj.8040 The morning of was not much better. Ashen faces as we were sombrely debriefed and
marched to waiting doors. Grownups suffering visibly in the moments before the whistle,
heads down, hands on knees, the clack and pop of parched-mouth swallows echoing.
Correspondence: Dr. Michael Leveridge, Department Someone shed an arc of molten soil midway through and needed extra time, rumor has it.
of Urology, Queen’s University, Kingston, ON, Canada; The rite of the qualifying exam is a shared trauma that most readers will viscerally
Michael.Leveridge@kingstonhsc.ca recall. I understand experiences are relative, but “trauma” still feels appropriate: the
minutia, the time, the stakes! Back then, it was clear to me. Abolish the exam! Let my
training speak for itself! Crack open the FITER!
But dang, did I ever know my stuff that day! Head crammed with urology —
approaches and guidelines and differentials tattooed and ready for deployment. And
perhaps the packed and stressful days and nights of the preceding months were, just a
wee bit, under my control? Five years to get a handle on the material, acknowledging
that perhaps I was skimming the asymptote towards the end, the act of studying as
much a hedge against anxiety as a necessity?
A recent CMAJ editorial picked the exam scab and has me thinking again about this
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winner-take-all event. The piece cites a lack of evidence of effectiveness of summa-
tive qualifying exams, as well as unclear salience of studied material. Costs in time,
money, and wellness are open wounds. For those inclined to agree, the first page is
a satisfying exposition on the fragility of the case for the exam. Having ignored the
second half of its title, I was amped for more confirmation bias, to read about bolstering
assessment within training and sending MDs into practice with a crisp high-five from
the program. The editorial, though, blooms into a framework for graduated licensing
after residency, and is a wild ride.
The implication of “make the training environment ensure competence and ditch
the exam” suddenly becomes “add years of limited practice with a new system link-
ing universities, hospitals, practicing MDs, and licensing authorities.” A Trojan horse;
pills snuck into kibble. The qualifying exam seems like small potatoes suddenly, and
the envisioned system seems unlinked from it entirely; if the exam doesn’t achieve the
objective of assessing true fitness for practice, it is immaterial to the vision of a post-
training system of checks and graduated outcome ownership. Our current system of
competence by design (CBD) within training is already fraught; you won’t convince
me that the EPAs and milestones really achieve much more than shoring up glaring
deficits. Tacking on additional years before independent practice places massive trust
in institutional effectiveness, surely doesn’t ease the financial burden of training debt,
and plans new administrative responsibilities on practicing physicians. Where would
residency end and graduated licensure begin? The authors acknowledge that “the
implementation of such a system would be challenging.” Indeed!
Back to the exam. I have softened a lot, and I land on the side of “the exam a good
thing, actually.” Thirty-two-year-old me is screaming through time, but I’m older now,
and a program director, and I really don’t believe that the CBD gauntlet has much to
do with ensuring competence or fitness to practice. A vetted, standardized summative
exam feels like an appropriate and equitable tool. Accreditation sniffs around the cellar
to make sure the curriculum, clinical substrate, and learning environment pass muster,
but doesn’t speak to proficiency or mastery. Imperfect or not, qualifying exams are a
CUAJ • August 2022 • Volume 16, Issue 8 239
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