Board passage rates and residency program quality

I am 3rd year med student thinking of surgery programs to apply to next year. I came across this document on the American Board of Surgery website. It shows the qualifying exam and certifying exam first-time pass rates for general surgery residents between 2008-2013.

Is this a worthwhile marker for evaluating surgery programs and identifying top programs? Also, is first-time pass/fail on the QE/CE a measure of preparation to practice as a general surgeon upon graduation or is it poorly correlated with a graduate's ability to function independently?

I have a moderately competitive Step 1 score and I want to choose a program that would make me a general surgeon without needing to take a fellowship upon graduation.

[Note: The email was edited for length.] 

Thanks for asking a couple of really good questions. The answers are not black and white. On page 23 of its requirements, the Residency Review Committee (RRC) for Surgery states that board passage rate is one measure for evaluating program effectiveness, and "At minimum, for the most recent five-year period, 65% of the graduates must pass each of the qualifying and certifying examinations on the first attempt."

A quick look at the board passage rates in the ABS document shows that 31% of programs, most of which are community hospital-based, did not reach the magic 65% quota.

Two years ago, I blogged about the two major reasons why the 65% board passage threshold on the first try discriminates against community hospital programs. You can read the full piece here, but briefly one issue is that university hospitals attract smarter residents who are better test takers, and the other is that smaller programs are statistically more likely to have test result outliers.

I am unaware of any correlation between passing the boards on the first try (or the second or third tries) and a surgeon's ability to practice independently. In fact, another post I wrote discussed a paper that surveyed 4882 surgical residents. It found that community hospital trainees were more satisfied with their operative experience and more confident that they could work independently than those who trained in university programs.

But there is another consideration. Fair or not, programs with first-time board passage rates chronically below 65% are at some risk for both RRC probation, which is detrimental to recruiting, and possible discontinuation. It is difficult to quickly turn around a low board passage rate because the number of graduates is small in most community programs and the stain left by a failed first-time taker lasts five years.

So what should you do?

Perhaps you should play it safe and apply to community hospital programs with adequate first-time board passage rates.

Comments from surgical educators, current residents or recent graduates of surgical training are welcome.

Why I left academic medicine

A medical student who thinks he wants a career in academic surgery asks, “You were deep into academic medicine and walked away from chairman, program director, etc. Why?"

[Background: For over 23 years, I was a full time surgical chairman and residency program director in three different community hospitals affiliated with medical schools.]

Good question. For many years I had always said something like, “No matter what crisis happens with the residents or the chairman’s job, it pales in comparison to having a patient with a complication.” In other words, non-clinical problems were annoying but manageable.

Then one day I realized that was no longer so. Patients with complications still caused me many sleepless nights and that hadn’t changed. What had changed was that resident issues and administrative hassles finally became intolerable.

The rules set by the accrediting bodies, the ACGME and the Residency Review Committee [RRC] for Surgery, had always been difficult to comply with, especially for a small program. They became more onerous every year or two until it reached the point where I can’t imagine how anyone can stand it. Residents can complain to the RRC anonymously and no matter how factually you refute the complaint, the RRC always believes the disgruntled resident. Add in the work hours rules and the lack of motivation of some of today’s med school graduates and I had had enough.

The position of surgical chairman in a community teaching hospital is like that of a football referee. At any given time, half your constituency is not happy with you. The administration pays your salary and expects you to spout the party line. But you need your attending surgeons to treat the residents well and support the program. Many times you have to make decisions that are guaranteed to alienate many people.

A lot of energy was spent investigating complaints. Families were unhappy with the residents; attending surgeons were unhappy with the residents and conversely; nurses were unhappy with the residents and/or the attendings; someone was rude to someone else; someone shouted; someone cried and on and on.

And the site visits. Drop everything; the state is here to investigate a case or the state is here to interview the residents about their work hours. The Joint Commission is coming in six months. We need to meet twice a week to make up for all the unnecessary but JC-mandated stuff we haven’t been doing for the last two-and-a half years. Countless hours were spent buffing up the paperwork for an RRC site visit. I think that’s where I learned creative writing.

And the meetings. Risk management meetings could last three hours during which time you would have the opportunity to try to explain why a surgical complication occurred to a room full of non-surgeon MDs and non-physician administrators. We used to deal with this sort of thing quite effectively at morbidity and mortality conference.

Then there were the committees. At one of my former hospitals I was either chairman or a member of the following committees: Pharmacy, Critical Care, Infection, Medical Executive, Operating Room, Surgical Performance Improvement, Strategic Planning Work Group, Product Evaluation, Library, Clinical Leadership Group, Cancer, Trauma, Budget, Graduate Medical Education, and Risk Management. I’ll save you the trouble. That’s 15 committees.

For a long time, I enjoyed being a residency program director. I am proud of the more than 50 chief residents I helped train. I view them as my legacy. I regret that running a program and teaching residents stopped being fun a few years ago. I also liked being a chairman until medicine took a turn toward the dark side.

I could go on but this post would reach 20,000 words.

So my young friend, think long and hard about that decision to become an academic chair.