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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  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
                                      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
                                                  © 2022 Canadian Urological Association
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