The American Journal of Surgery (2015) 210, 972-977
Southwestern Surgical Congress: Edgar J. Poth Memorial Lecture
A history of the American Board of Surgery: vignettes from the certifying examination The Edgar J. Poth Memorial Lecture John Patrick Walker, M.D., F.A.C.S.* Department of Surgery, Houston County Medical Center, P. O. Box 481, Crockett, TX 75835, USA
KEYWORDS: American Board of Surgery; History; Southwestern Surgical Congress; Edgar Poth; Oral examination; Certifying examination
Abstract The American Board of Surgery was established in 1937 to certify surgeons who through training, experience, and examination meet the highest standards of surgical care. This lecture was given as the Edgar Poth lecture at the April 2015 meeting of the Southwestern Surgical Congress. Dr Poth was a surgical educator from the University of Texas Medical Branch, Galveston who was President of the Southwestern in 1963. The paper presents the history of the founding of the American Board of Surgery, with particular emphasis on the certifying examinationdPart 2. Vignettes of occurrences associated with the ‘‘Oral’’ examination are given. The examination has changed substantially from a 2-day event involving an actual surgical procedure to the 90-minute quiz given today. The oral examinations remain an important part in the process of certification of surgeons of the highest quality. Ó 2015 Elsevier Inc. All rights reserved.
Few events in the life of a surgeon are as exciting as the day they sit for the certifying examination of the American Board of Surgery (previously Part 2)dcommonly referred to as the ‘‘oral’’ examination. More than just a rite of passage in the journey to board certification, this examination clearly states that we are differentdwe are SURGEONS. We are those who use our skills to invade the sanctity of the human body to make change: to do no harm in the narrow path between disease and complication. The oral examination’s purpose is and has always been to certify those who through training and experience will be allowed to practice this higher callingdSURGERY. This historical litany is, like all history, the story of men, surgeons who are trying hard to define and test who can The Edgar J. Poth Lecture given at the Southwestern Surgical Congress, April 2015. The authors declare no conflicts of interest. * Corresponding author. Tel.: 11-936-544-7757; fax: 11-936-5450972. E-mail address: [email protected] Manuscript received May 13, 2015 0002-9610/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjsurg.2015.05.038
become Board Certified in Surgery. It began with the formation of the American Board of Surgery, with its maturation a continual work of the Directors and the Staff of the American Board of Surgery (ABS).
Formative Years From the beginning of medical education physicians have searched for knowledgeable colleagues with which to study. In the latter half of the 19th century, surgeons often spent time in Europe studying with the giants of the day. A number of American surgeons such as John Murphy studied in Vienna with Theodor Bilroth. By the 1880s, internships were common in the United States and by 1914 about 75% of US trained physicians had completed internships. In 1889, William Halsted (who had also studied with Bilroth) began establishing the formal Surgical Residency at Johns Hopkins. These were pyramidal with only one ‘‘chief resident.’’ William Mayo stated in 1919 that these residencies should be a minimum of 3 years. The American Medical Association
J.P. Walker
A history of the certifying exam of the American Board of Surgery
(AMA) in 1928 established standards for internships. Graduate Medical Education was already having problems; by 1939 there were only 1,791 residency positions for 5,400 graduates. The AMA, in 1933, established an Advisory Board for medical specialties. It consisted of representatives from the following: National Board of Medical Examiners, the American Hospital Association, the Federation of State Medical Boards, Ophthalmology, Otolaryngology, Obstetrics and Gynecology, Dermatology and Syphilology, and the American Association of Medical Colleges. Noticeably absent was a surgical representative. This prompted the Board of Regents of the American College of Surgeons (ACS) to establish a Committee on Graduate Training in Surgery. In the presidential address at the spring meeting of the American Surgical Association, Edward A. Archibald criticized the standards recommended by the collegedrecommending that they be strengthened. A Joint National Committee was proposed. A group of surgeons met at the college offices on October 23, 1935 and Evarts Graham proposed an independent Certifying Board. There were to be 6 representatives from the ACS, 6 from the American Surgical Association, 6 from the AMA, and 2 each from the Southern Surgical, the Pacific Coast Surgical, the New England Surgical Society, and the Western Surgical Association. The first real organizational meeting was on February 15 and 16, 1936. Seventeen members were able to attend. It was chaired by Evarts Graham (Fig. 1) and the Vice Chair was A.O. Whipple (Fig. 2). Two subcommittees were establisheddSubcommittee A (Table 1) on organization and Subcommittee B (Table 2) on training. The Organizational Committee established that there would be a Founders Group of membersdbasically those that would be ‘‘grandfathered’’ in, and then those members who would be ‘‘Certified’’ in surgery. The Founders Group would include all members of the American Surgical and the other 4 founding organizations as well as professors and assistant professors of surgery of all accredited medical schools in the United States and Canada who had limited their practice to surgery for at least 15 years. Eventually, this Founding group numbered 1,151. The Certified Group would have completed an internship, 3 years in training, 2 years in practice, and then take the written (Part 1) and oral (Part 2) examinations. Meanwhile, Subcommittee B (training) that was meeting at the same time established proper standards for apprenticeship and training. There should be teaching in basic medical science and structured instruction in surgical pathology. A ward service of nonprivate patients, but with supervision, was required. They set standards for equipment and laboratories with radiology, pathology, and bacteriology services. There should be an adequate record system and library. There should be training conferencesdemphasizing unfavorable resultsdwith great importance placed on obtaining autopsies. There must be periodic surveys of the designated hospitals. This was the template which was used by the ACS, AMA, and the American Hospital Association to form the JCAHdlater the JCAHO (Joint Commission on the Accreditation of Healthcare Organizations). The training component became the accredited residencydthe precursor
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to the Residency Review Committee for Surgery. It is amazing that all of this was accomplished in 2 meetingsdthe afternoon of February 15 and morning of February 16. Today this would require 3 committee meetings over several years and this would be to decide if we should have coffee and tea at appraisal sessions or just coffee. When Frank Lewis (the current Executive Director of the Board) was in college he recalls visiting with Dr Whippled‘‘When I enrolled at Princeton in 1958, I entered a Premed track there. At the time Dr. Whipple had retired from Columbia, but was a Princeton graduate, and he came back to Princeton to function as a pre-med advisor. I therefore met with him on two or three occasions during my first couple of years there to get his advice about medicine, but at the time had no appreciation of who he was or what he had done. He was a kindly old gentleman who gave sage advice. This was at the tail end of his career when he was in his late 70’s. His office was in Nassau Hall, which was the oldest academic building in North America, having been built in 1756.’’
Figure 1 Evarts Graham (1883 to 1958). He was born in Chicago and attended Princeton as an undergraduate. He did his Med school at Rush and his father was a surgeon. He underwent surgical training at Presbyterian Hospital in Chicago. He served in the Army Medical Corps during World War I and developed techniques for treating empyema (commonplace after the influenza epidemic of 1918). He became Chair of Surgery at Wash U in 1919. He also developed cholecystography and did some of the first experimental work on the carcinogenic effects of tobacco. He performed the first successful pneumonectomy for lung cancer and died of the same disease in 1958.
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The American Journal of Surgery, Vol 210, No 6, December 2015 Table 2
Subcommittee B
Charged with training - Set standards for properly qualified hospitals and training: - Carefully directed and supervised apprenticeship - Increase basic knowledge in fundamental medical sciences; structured training in surgical pathology - A ward service of nonprivate patients under the control of a director - Set standards of equipment and laboratories with radiology, pathology, and bacteriology services - An adequate record system and library - Training conferencesdemphasizing unfavorable resultsdwith great importance placed on obtaining autopsies - There must be periodic surveys of the designated hospitals This was the template which was used by the ACS, AMA, and the American Hospital Association to form the JCAHdlater JCAHO The training component became the accredited residencydthe precursor to the Residency Review Committee for Surgery
Figure 2 Allen Oldfather Whipple (1881 to 1963). Whipple was born to missionary parents in Urmia, West Azerbaijan, Iran. He attended Princeton University and received his MD from the Columbia University College of Physicians and Surgeons. He was a professor of surgery at Columbia University from 1921 to 1946 and began work on pancreaticoduodenectomy in 1935. During his lifetime, he performed 37 pancreaticoduodenectomies.
Certification Begins The first Part 2 (certifying) examination was given in Philadelphia in May 1938. It was a 2-day examination beginning at 8 am with registration. This was followed by Clinical Surgery (diagnosis and management). Then there were sections on surgical pathology, physiology, Table 1
Subcommittee A
- Founders Group (grandfathered)d1,151 - All members of the American Surgical Association and the 4 regional societies - Professors and assistant professors of all approved medical schools in the United States and Canada, who had limited their practice to surgery for 15 years - Certified Group - Internship plus 3 years of residency, then 2 years in practice followed by a written examinationdPart 1, then an oral examinationdPart 2
biochemistry and bacteriology, X-rays, and anesthesiology. On day 2, there was a section on Operative Surgery (with performance of a surgical procedure) followed by special examinations. There was a 20% failure rate. All examiners were ABS Directors. Other examinations were given later that year at academic medical centers. For the first examination the operation was a hernia repair, after that it could be any abdominal procedure. One of the more interesting examinations was given in Atlanta later that year. Daniel Elkins, one of the first vascular surgeons in America, was Chair of Surgery at Emory University (Grady Hospital). He put together a Certifying team of Fred Rankin, of Lexington, KY, and Harvey Stone of Baltimore. Both these surgeons were of considerable national renowndDr Rankin was Charles Mayo’s son-in-law and later became President of the American Surgical, the AMA, and the ACS. Dr Stone was a well-known surgeon at Johns Hopkins who had done experimental work in transplantation of parathyroid tissue. The candidate was a young trainee of Alton Oschner of New OrleansdMichael DeBakey. Dr DeBakey was given a patientda young maledabout 40 years of age who had undergone emergency appendectomy about 10 days prior. He had persistent postoperative fever and leukocytosis. He complained of malaise and abdominal discomfort. On examination Dr DeBakey noted tenderness along the right rib cage. The chest radiograph showed elevation of the right hemidiaphragm. Dr DeBakey correctly made the diagnosis of subphrenic abscess. Dr Rankin noted that Dr Oschner and DeBakey had just published an article on this topicdtheir personal experience with 25 patients and a review of 3,533 patients in the literature. Dr DeBakey obviously passed the examination and was given certificate number
J.P. Walker
A history of the certifying exam of the American Board of Surgery
172 by the American Board of Surgery. Shortly thereafter World War II began. Dr Rankin was a Colonel and head of the Surgical Consultant Division of the Office of Surgeon General. Upon hearing of Dr Debakey’s commission in the Army Medical Corps, he requisitioned his transfer to his office where he spent the next 5 years. In this position, Dr DeBakey was able to assist in major advances in Military Medicine, in particular moving surgical care closer to the front lines. He also was instrumental in establishing the National Library of Medicine from the Army Medical Library and later in establishing the Veterans Affairs Hospital system. Dr DeBakey said: ‘‘Perhaps fate played a role in all these favorable events, but I cannot help thinking that writing and publishing that article played the major role. My own conviction is that critical bibliographic reviews, well-designed research, and participation in the preparation of manuscripts for publication during surgical training not only enhance surgical maturation but also contribute significantly to a rewarding and fulfilling career.’’ I strongly believe that Dr DeBakey’s assessment is correct; that surgical research, presentation, and publication are critical in the education of a surgeon. In 1938, the cost for the written examination was $20.00 and for the oral examination was $50. This would be $328.80 and $822.00 today. In comparison, the written examination is $400.00 today and the oral examination is $1,100.00. So there has been an increase from $1,150.80 to $1,500.00. So you do pay a bit more for the initial certification, but you get less for it: a 90-minute examination as opposed to a 2-day examination. After the first year, several changes were made: the practical examination in the operating room (a surgical procedure) was eliminated, local examiners were added, and the content structure was reweighted (50% clinical cases, 30% anatomy, and 20% pathology). The examination continued to be at major medical centers. By the 1940s, examinations were held at 10 to 11 medical centers across the United States. The fail rates varied widely from 11% to 44%, with an overall average of 21%. Examinations utilized microscopes, slides, gross specimens, and cadavers. There was already discussion of discontinuing the oral examination because of subjectivity. In 1945, a young William Longmire, an Oklahoman from Sapulpa, was finishing his training in Baltimore. Longmire was advised by several of his faculty that there was no reason for him to take the board examinations because he was a ‘‘Hopkins Resident.’’ Fortunately he did, and after becoming the first chair of surgery at University of California, Los Angeles, he was Chairman of the American Board of Surgery in 1961 and 62. Changes in 1953 had the candidates interviewing and examining 2 patients in the morning and then discussed their management with 2 sets of examiners. In the afternoon, there was a 40-minute examination session addressing anatomy, pathology, and basic sciences. Cadavers, microscopes, and X-rays were utilized. The examination was reduced to one patient in 1956. In 1957, live
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patients were discontinued, instead using patient scenarios. There were 2 teams, each with a Board Director and a Guest examiner, with two 45-minute examination sessions. Basic sciences were incorporated in the patient cases. There was dissatisfaction with the discontinuation of the basic sciences and a 45-minute session on just basic sciences was returned to the exam in 1958. Therefore there were 2 clinical sessions in the morning and the basic science session in the afternoon. By 1962, the examination was changed to three 30-minute sessions. Examiners brought their own propsd radiographs and so on. There was a separate session using projected microscope slides. In 1967, to avoid duplication of cases, broad ‘‘topic area’’ sheets were utilized. Microscopes were discontinued in 1968. At the 1966 examination in Lexington, KY, one of the directors was Robert Zollinger, who often started his examination with the question ‘‘How many grams of protein are in an egg?’’ (Its 6 to 7 g depending on the size of the egg). One candidate walked out of a room, having just been examined by Zollinger and Richard L. Varco, from Minnesota (both feared examiners) and ran into Ward Griffen (then an Associate examiner, and later the Executive Director of the Board). Dr Griffen asked how it went: he responded that it was actually not baddZollinger asked the first question, he responded, and Zollinger and Varco got into a heated discussion between themselves about the correct answer that lasted for most of the session.
The Modern Examination In 1970, a major change occurreddthe examinations were moved from academic medical centers to a hotel. The first was the Dallas Sheraton. This continues today, although the use of the dedicated testing center of the Obstetric–Gynecology Board (also in Dallas) has been utilized by the ABS for a couple of the surgery certifying examinations and for the vascular certifying examination. Although some hotels provide an excellent venue for the examination, others are sometimes lacking. A hotel does allow for the candidate to be placed near the window with the sun in their faceda technique now discouraged. By 1972, the examination was changed to 6 examinations per year. In 1976, the name of the examination was officially changed from Part 2 to the certifying examination. There began a process of standardization of the questions as well as an outline of examination content. During the 1980s, a community surgeon, J. D. Ashmore (Fig. 3) from Greenville, South Carolina, was added to the board in an effort to get representation from full-time practicing physicians. Dr Ashmore personified the southern gentleman and established the surgical residency that is now the foundation of the University of South Carolina Medical School in Greenville. He was paired with a wellknown surgeon from Memorial Sloan-Kettering, Murray Brennan, to give the certifying examination in New York
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The American Journal of Surgery, Vol 210, No 6, December 2015
Figure 3 Spence Taylor (current Chair of the Maintenance of Certification Examination Committee) with J. D. Ashmore.
City. A young man presented appearing striking in a grey leisure suit and grey alligator cowboy boots. The questioning ensued and it became apparent that the candidate had a substantial deficiency in knowledge. Upon completion of the examination, Dr Brennan asked the very polite Dr Ashmore what he thought. Dr Ashmore replied that ‘‘where I come from the manure is on the outside of the boot.’’ (I might not have the correct wording with this quote.). The candidate obviously failed. There are now 3 ‘‘at-large’’ positions on the board as an effort to continue representation from community surgeons. In 1980, the Certifying Examination Committee was established independent from the Exam Committee. Dictation was begun on failing candidatesda practice that continued until a couple of years ago. The board under Hiram Polk began grading candidates after their examination, rather than grading as a group. Alexander Walt further standardized the examination by the addition of a casebook with 10 to 12 cases per area (2 to 3 sentences per case). Part of this was done to minimize the effects of marginal guest examiners. Guest examiners began to be assessed by the directors. The interpretive skills sessions were removed. A new grading system was added: from critical fail (3) to high pass (7). Probably one of the more significant changes occurred in 1985: At the January meeting (the board has a winter retreat every January at a location other than Philadelphia, usually someplace warm) it was proposed that the oral examination be changed to 3 successive 30-minute examinations with 2 examiners each (one board member and
one guest examiner), followed by a miniappraisal sessiondthe 6 examiners would discuss the 3 candidates who had just been examined. Before this all candidates were discussed by all examiners at the end of the day. The new format was first used in May 1985. Don Trunkey was the local arrangements director in San Francisco. Among those examiners attending were Frank Lewis, Bill Schecter, and Carlos Pelligrini. The fail rate was 34.2%. The new format was deemed a complete success and is still used today, although now we do not change any grades at the discussion session. It was felt that strong directors might overly influence mild associates and distort their opinions. Later in the 1980s, the examiners’ own graphic material was eliminated and ‘‘guest’’ examiners officially became ‘‘associate’’ examiners. Examiner grading patterns began to be documented in 1984. In 1987, there were several important changes madeda dress code was formalized (I can remember at my certification that several of the examiners had their coat off with rolled up sleeves and a loose tie); smoking was prohibited during the examination; and coffee was discontinued in each room, only being sent to the appraisal room (team leader). I expect that changing the coffee availability at examinations took several committee meetings with considerable discussion. One of the more memorable examinations was given in April 1991 in Omaha, NE, at the Hilton Hotel (later Red Lion Inn). On Friday April 26, 55 tornadoes swept across the Midwest, killing 24 people and injuring 100s. An F5 (Fujita scale) tornado came through Haysville, KS, killing 13 people at the Golden Spur trailer park. McConnell Air Force Base suffered 62 million dollars in damage. This one tornado was responsible for 17 total deaths. Examiners traveling to Omaha the next day and Sunday were well aware of the violence that had just struck this region. So on Monday morning when the hotel loudspeaker announced a tornado warning for Douglass County (Omaha), the Hilton turned into what Jon Thompson (an associate examiner that day, later to become a director) described as ‘‘complete mayhem.’’ Examiners not exactly sure what to do moved the examinations to the bathroomsdthe candidates were often placed on the toilets and the examiners sat on the side of the tub. Andrew Warshaw (a director at that time) was on the 13th floor. He, along with his associate examiner (from Wichita, KS, and very respectful of tornados) and candidate, ran to the stairwell and descended, giving the examination in the stairwell at a lower level. One examination team went to the basement where they apparently all sat at the edge of the Jacuzzi with their feet in the water. Maybe this added some relaxation to an already tense situation. Another team continued in their room while the associate examiner watched out the window for the progress of the tornado. I suspect that many candidates have feared the examiners more than a tornado over the years. Incidentally, the fail rate was 13.3%, relatively low. In 1992, each of the 3 areas was divided into 4 subsections of questioning. The examiners were required
J.P. Walker
A history of the certifying exam of the American Board of Surgery
to use cases (or at least topics) from the proscribed subject matter. An attempt was made to add assessment and management to each case. In 1994, cases were added with moral, ethical, and humanistic content. In 1995, the ABS conflict of issue policy was issued. This prevented directors from participating in mock orals. In 1997, key management points were added to cases where possible. In 1998, the first examiner training video was produced. In the 2000s, the certifying examination continues to be improved. A candidate orientation film was added. Geographical scheduling was eliminated. Candidates are allowed to take the examination 5 times rather than 3. Five larger examinations are now held, rather than 6. Examiners are matched for severity/leniency (hawks with doves). And for the past few years, examination grades are computer ‘‘neutralized,’’ so that regardless of the rigidity of the examiner, all candidates are judged to the same standard. On a tragic day for our country on September 11, 2001, the American Board of Surgery was giving the examination at the Harbor Court Hotel in downtown Baltimore. Thirty miles away American Airlines flight 77 struck the Pentagon at 9.45 am. All 64 on board were killed, along with 125 on the ground. The news of the other tragedies quickly reached the board members giving the examination. David Herndon was giving the examination that day. He relates that he was initially informed by a candidate about the first aircraft striking the World Trade Center. The entire event was surreal to the directors. The directors and associates from the District of Columbia area and New York areas quickly returned home to treat the casualties, most of which never came. This left only a limited number of examiners to give the examination. It was decided to go forth with only one examiner per room. The examination continued and was considered to be valid. A number of examiners were stranded in Baltimore and had to find innovative ways to get home. Many rented cars and drove to friends or relatives in the Northeast. Dr Herndon rented a car and drove to his mothers in Cleveland to stay for a week or so until commercial air travel resumed.
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Conclusion The truth is that while the board often states that while it is there to protect the public, in reality it is there to protect surgeons as well. The ABS certifies those who train to high standards, test to higher standards, and continue to prove it through Maintenance of their Certification. These Diplomates represent the very best of American medicine. They continually put the patient before themselves and their families. This is what the surgeons who founded the American Board of Surgery did and the current board expects of today’s candidates. No written examination can supplant the value of an oral examination in determining a qualified surgeon. It continues to be a righteous bar for those who wish to call themselves Board Certified by the American Board of Surgery. Special thanks to Tom Biester, the Psychometrician (that’s a fancy word for a statistician who really knows a lot) and the soul of the board; to Frank Lewis, the Executive Director of the Board, whose has a photographic memory of all events that have ever happened at the Board; to Andrew Warshaw, Murray Brennan, David Herndon, Hiram Polk, Spence Taylor, Jon Thompson, Lois DeBakey, the staff at the Board Offices, and especially to all the directors of the boarddpast and present. They serve endless hours, days, weeks, and months as complete volunteersdalways striving to improve American surgery and do the best for the patients we serve.
Suggested Reading 1. DeBakey ME. Kismet or assiduity. Surgery 2005;137:255–6. 2. Oshner AE, DeBakey ME. Surgery, Gynecology and Obstetrics, Subphrenic Abscess, 66;426–438. 3. Rodman JS. History of the American Board of Surgery 1937-1952. Philadelphia, PA: J. B. Lippincott Company; 1956. 4. Griffen Jr WO. The American Board of Surgery in the 20th Centuryd Then and Now. Philadelphia, PA: The American Board of Surgery; 2004. 5. Nahrwold DL, Kernaham PJ. A Century of surgeons and surgery, the American College of Surgeons 1913-2012. The American College of Surgeons, ISBN: 978-1-880696-99-6
Southwestern Surgical Congress: Edgar J. Poth Memorial Lecture
A history of the American Board of Surgery: vignettes from the certifying examination The Edgar J. Poth Memorial Lecture John Patrick Walker, M.D., F.A.C.S.* Department of Surgery, Houston County Medical Center, P. O. Box 481, Crockett, TX 75835, USA
KEYWORDS: American Board of Surgery; History; Southwestern Surgical Congress; Edgar Poth; Oral examination; Certifying examination
Abstract The American Board of Surgery was established in 1937 to certify surgeons who through training, experience, and examination meet the highest standards of surgical care. This lecture was given as the Edgar Poth lecture at the April 2015 meeting of the Southwestern Surgical Congress. Dr Poth was a surgical educator from the University of Texas Medical Branch, Galveston who was President of the Southwestern in 1963. The paper presents the history of the founding of the American Board of Surgery, with particular emphasis on the certifying examinationdPart 2. Vignettes of occurrences associated with the ‘‘Oral’’ examination are given. The examination has changed substantially from a 2-day event involving an actual surgical procedure to the 90-minute quiz given today. The oral examinations remain an important part in the process of certification of surgeons of the highest quality. Ó 2015 Elsevier Inc. All rights reserved.
Few events in the life of a surgeon are as exciting as the day they sit for the certifying examination of the American Board of Surgery (previously Part 2)dcommonly referred to as the ‘‘oral’’ examination. More than just a rite of passage in the journey to board certification, this examination clearly states that we are differentdwe are SURGEONS. We are those who use our skills to invade the sanctity of the human body to make change: to do no harm in the narrow path between disease and complication. The oral examination’s purpose is and has always been to certify those who through training and experience will be allowed to practice this higher callingdSURGERY. This historical litany is, like all history, the story of men, surgeons who are trying hard to define and test who can The Edgar J. Poth Lecture given at the Southwestern Surgical Congress, April 2015. The authors declare no conflicts of interest. * Corresponding author. Tel.: 11-936-544-7757; fax: 11-936-5450972. E-mail address: [email protected] Manuscript received May 13, 2015 0002-9610/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjsurg.2015.05.038
become Board Certified in Surgery. It began with the formation of the American Board of Surgery, with its maturation a continual work of the Directors and the Staff of the American Board of Surgery (ABS).
Formative Years From the beginning of medical education physicians have searched for knowledgeable colleagues with which to study. In the latter half of the 19th century, surgeons often spent time in Europe studying with the giants of the day. A number of American surgeons such as John Murphy studied in Vienna with Theodor Bilroth. By the 1880s, internships were common in the United States and by 1914 about 75% of US trained physicians had completed internships. In 1889, William Halsted (who had also studied with Bilroth) began establishing the formal Surgical Residency at Johns Hopkins. These were pyramidal with only one ‘‘chief resident.’’ William Mayo stated in 1919 that these residencies should be a minimum of 3 years. The American Medical Association
J.P. Walker
A history of the certifying exam of the American Board of Surgery
(AMA) in 1928 established standards for internships. Graduate Medical Education was already having problems; by 1939 there were only 1,791 residency positions for 5,400 graduates. The AMA, in 1933, established an Advisory Board for medical specialties. It consisted of representatives from the following: National Board of Medical Examiners, the American Hospital Association, the Federation of State Medical Boards, Ophthalmology, Otolaryngology, Obstetrics and Gynecology, Dermatology and Syphilology, and the American Association of Medical Colleges. Noticeably absent was a surgical representative. This prompted the Board of Regents of the American College of Surgeons (ACS) to establish a Committee on Graduate Training in Surgery. In the presidential address at the spring meeting of the American Surgical Association, Edward A. Archibald criticized the standards recommended by the collegedrecommending that they be strengthened. A Joint National Committee was proposed. A group of surgeons met at the college offices on October 23, 1935 and Evarts Graham proposed an independent Certifying Board. There were to be 6 representatives from the ACS, 6 from the American Surgical Association, 6 from the AMA, and 2 each from the Southern Surgical, the Pacific Coast Surgical, the New England Surgical Society, and the Western Surgical Association. The first real organizational meeting was on February 15 and 16, 1936. Seventeen members were able to attend. It was chaired by Evarts Graham (Fig. 1) and the Vice Chair was A.O. Whipple (Fig. 2). Two subcommittees were establisheddSubcommittee A (Table 1) on organization and Subcommittee B (Table 2) on training. The Organizational Committee established that there would be a Founders Group of membersdbasically those that would be ‘‘grandfathered’’ in, and then those members who would be ‘‘Certified’’ in surgery. The Founders Group would include all members of the American Surgical and the other 4 founding organizations as well as professors and assistant professors of surgery of all accredited medical schools in the United States and Canada who had limited their practice to surgery for at least 15 years. Eventually, this Founding group numbered 1,151. The Certified Group would have completed an internship, 3 years in training, 2 years in practice, and then take the written (Part 1) and oral (Part 2) examinations. Meanwhile, Subcommittee B (training) that was meeting at the same time established proper standards for apprenticeship and training. There should be teaching in basic medical science and structured instruction in surgical pathology. A ward service of nonprivate patients, but with supervision, was required. They set standards for equipment and laboratories with radiology, pathology, and bacteriology services. There should be an adequate record system and library. There should be training conferencesdemphasizing unfavorable resultsdwith great importance placed on obtaining autopsies. There must be periodic surveys of the designated hospitals. This was the template which was used by the ACS, AMA, and the American Hospital Association to form the JCAHdlater the JCAHO (Joint Commission on the Accreditation of Healthcare Organizations). The training component became the accredited residencydthe precursor
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to the Residency Review Committee for Surgery. It is amazing that all of this was accomplished in 2 meetingsdthe afternoon of February 15 and morning of February 16. Today this would require 3 committee meetings over several years and this would be to decide if we should have coffee and tea at appraisal sessions or just coffee. When Frank Lewis (the current Executive Director of the Board) was in college he recalls visiting with Dr Whippled‘‘When I enrolled at Princeton in 1958, I entered a Premed track there. At the time Dr. Whipple had retired from Columbia, but was a Princeton graduate, and he came back to Princeton to function as a pre-med advisor. I therefore met with him on two or three occasions during my first couple of years there to get his advice about medicine, but at the time had no appreciation of who he was or what he had done. He was a kindly old gentleman who gave sage advice. This was at the tail end of his career when he was in his late 70’s. His office was in Nassau Hall, which was the oldest academic building in North America, having been built in 1756.’’
Figure 1 Evarts Graham (1883 to 1958). He was born in Chicago and attended Princeton as an undergraduate. He did his Med school at Rush and his father was a surgeon. He underwent surgical training at Presbyterian Hospital in Chicago. He served in the Army Medical Corps during World War I and developed techniques for treating empyema (commonplace after the influenza epidemic of 1918). He became Chair of Surgery at Wash U in 1919. He also developed cholecystography and did some of the first experimental work on the carcinogenic effects of tobacco. He performed the first successful pneumonectomy for lung cancer and died of the same disease in 1958.
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The American Journal of Surgery, Vol 210, No 6, December 2015 Table 2
Subcommittee B
Charged with training - Set standards for properly qualified hospitals and training: - Carefully directed and supervised apprenticeship - Increase basic knowledge in fundamental medical sciences; structured training in surgical pathology - A ward service of nonprivate patients under the control of a director - Set standards of equipment and laboratories with radiology, pathology, and bacteriology services - An adequate record system and library - Training conferencesdemphasizing unfavorable resultsdwith great importance placed on obtaining autopsies - There must be periodic surveys of the designated hospitals This was the template which was used by the ACS, AMA, and the American Hospital Association to form the JCAHdlater JCAHO The training component became the accredited residencydthe precursor to the Residency Review Committee for Surgery
Figure 2 Allen Oldfather Whipple (1881 to 1963). Whipple was born to missionary parents in Urmia, West Azerbaijan, Iran. He attended Princeton University and received his MD from the Columbia University College of Physicians and Surgeons. He was a professor of surgery at Columbia University from 1921 to 1946 and began work on pancreaticoduodenectomy in 1935. During his lifetime, he performed 37 pancreaticoduodenectomies.
Certification Begins The first Part 2 (certifying) examination was given in Philadelphia in May 1938. It was a 2-day examination beginning at 8 am with registration. This was followed by Clinical Surgery (diagnosis and management). Then there were sections on surgical pathology, physiology, Table 1
Subcommittee A
- Founders Group (grandfathered)d1,151 - All members of the American Surgical Association and the 4 regional societies - Professors and assistant professors of all approved medical schools in the United States and Canada, who had limited their practice to surgery for 15 years - Certified Group - Internship plus 3 years of residency, then 2 years in practice followed by a written examinationdPart 1, then an oral examinationdPart 2
biochemistry and bacteriology, X-rays, and anesthesiology. On day 2, there was a section on Operative Surgery (with performance of a surgical procedure) followed by special examinations. There was a 20% failure rate. All examiners were ABS Directors. Other examinations were given later that year at academic medical centers. For the first examination the operation was a hernia repair, after that it could be any abdominal procedure. One of the more interesting examinations was given in Atlanta later that year. Daniel Elkins, one of the first vascular surgeons in America, was Chair of Surgery at Emory University (Grady Hospital). He put together a Certifying team of Fred Rankin, of Lexington, KY, and Harvey Stone of Baltimore. Both these surgeons were of considerable national renowndDr Rankin was Charles Mayo’s son-in-law and later became President of the American Surgical, the AMA, and the ACS. Dr Stone was a well-known surgeon at Johns Hopkins who had done experimental work in transplantation of parathyroid tissue. The candidate was a young trainee of Alton Oschner of New OrleansdMichael DeBakey. Dr DeBakey was given a patientda young maledabout 40 years of age who had undergone emergency appendectomy about 10 days prior. He had persistent postoperative fever and leukocytosis. He complained of malaise and abdominal discomfort. On examination Dr DeBakey noted tenderness along the right rib cage. The chest radiograph showed elevation of the right hemidiaphragm. Dr DeBakey correctly made the diagnosis of subphrenic abscess. Dr Rankin noted that Dr Oschner and DeBakey had just published an article on this topicdtheir personal experience with 25 patients and a review of 3,533 patients in the literature. Dr DeBakey obviously passed the examination and was given certificate number
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A history of the certifying exam of the American Board of Surgery
172 by the American Board of Surgery. Shortly thereafter World War II began. Dr Rankin was a Colonel and head of the Surgical Consultant Division of the Office of Surgeon General. Upon hearing of Dr Debakey’s commission in the Army Medical Corps, he requisitioned his transfer to his office where he spent the next 5 years. In this position, Dr DeBakey was able to assist in major advances in Military Medicine, in particular moving surgical care closer to the front lines. He also was instrumental in establishing the National Library of Medicine from the Army Medical Library and later in establishing the Veterans Affairs Hospital system. Dr DeBakey said: ‘‘Perhaps fate played a role in all these favorable events, but I cannot help thinking that writing and publishing that article played the major role. My own conviction is that critical bibliographic reviews, well-designed research, and participation in the preparation of manuscripts for publication during surgical training not only enhance surgical maturation but also contribute significantly to a rewarding and fulfilling career.’’ I strongly believe that Dr DeBakey’s assessment is correct; that surgical research, presentation, and publication are critical in the education of a surgeon. In 1938, the cost for the written examination was $20.00 and for the oral examination was $50. This would be $328.80 and $822.00 today. In comparison, the written examination is $400.00 today and the oral examination is $1,100.00. So there has been an increase from $1,150.80 to $1,500.00. So you do pay a bit more for the initial certification, but you get less for it: a 90-minute examination as opposed to a 2-day examination. After the first year, several changes were made: the practical examination in the operating room (a surgical procedure) was eliminated, local examiners were added, and the content structure was reweighted (50% clinical cases, 30% anatomy, and 20% pathology). The examination continued to be at major medical centers. By the 1940s, examinations were held at 10 to 11 medical centers across the United States. The fail rates varied widely from 11% to 44%, with an overall average of 21%. Examinations utilized microscopes, slides, gross specimens, and cadavers. There was already discussion of discontinuing the oral examination because of subjectivity. In 1945, a young William Longmire, an Oklahoman from Sapulpa, was finishing his training in Baltimore. Longmire was advised by several of his faculty that there was no reason for him to take the board examinations because he was a ‘‘Hopkins Resident.’’ Fortunately he did, and after becoming the first chair of surgery at University of California, Los Angeles, he was Chairman of the American Board of Surgery in 1961 and 62. Changes in 1953 had the candidates interviewing and examining 2 patients in the morning and then discussed their management with 2 sets of examiners. In the afternoon, there was a 40-minute examination session addressing anatomy, pathology, and basic sciences. Cadavers, microscopes, and X-rays were utilized. The examination was reduced to one patient in 1956. In 1957, live
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patients were discontinued, instead using patient scenarios. There were 2 teams, each with a Board Director and a Guest examiner, with two 45-minute examination sessions. Basic sciences were incorporated in the patient cases. There was dissatisfaction with the discontinuation of the basic sciences and a 45-minute session on just basic sciences was returned to the exam in 1958. Therefore there were 2 clinical sessions in the morning and the basic science session in the afternoon. By 1962, the examination was changed to three 30-minute sessions. Examiners brought their own propsd radiographs and so on. There was a separate session using projected microscope slides. In 1967, to avoid duplication of cases, broad ‘‘topic area’’ sheets were utilized. Microscopes were discontinued in 1968. At the 1966 examination in Lexington, KY, one of the directors was Robert Zollinger, who often started his examination with the question ‘‘How many grams of protein are in an egg?’’ (Its 6 to 7 g depending on the size of the egg). One candidate walked out of a room, having just been examined by Zollinger and Richard L. Varco, from Minnesota (both feared examiners) and ran into Ward Griffen (then an Associate examiner, and later the Executive Director of the Board). Dr Griffen asked how it went: he responded that it was actually not baddZollinger asked the first question, he responded, and Zollinger and Varco got into a heated discussion between themselves about the correct answer that lasted for most of the session.
The Modern Examination In 1970, a major change occurreddthe examinations were moved from academic medical centers to a hotel. The first was the Dallas Sheraton. This continues today, although the use of the dedicated testing center of the Obstetric–Gynecology Board (also in Dallas) has been utilized by the ABS for a couple of the surgery certifying examinations and for the vascular certifying examination. Although some hotels provide an excellent venue for the examination, others are sometimes lacking. A hotel does allow for the candidate to be placed near the window with the sun in their faceda technique now discouraged. By 1972, the examination was changed to 6 examinations per year. In 1976, the name of the examination was officially changed from Part 2 to the certifying examination. There began a process of standardization of the questions as well as an outline of examination content. During the 1980s, a community surgeon, J. D. Ashmore (Fig. 3) from Greenville, South Carolina, was added to the board in an effort to get representation from full-time practicing physicians. Dr Ashmore personified the southern gentleman and established the surgical residency that is now the foundation of the University of South Carolina Medical School in Greenville. He was paired with a wellknown surgeon from Memorial Sloan-Kettering, Murray Brennan, to give the certifying examination in New York
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The American Journal of Surgery, Vol 210, No 6, December 2015
Figure 3 Spence Taylor (current Chair of the Maintenance of Certification Examination Committee) with J. D. Ashmore.
City. A young man presented appearing striking in a grey leisure suit and grey alligator cowboy boots. The questioning ensued and it became apparent that the candidate had a substantial deficiency in knowledge. Upon completion of the examination, Dr Brennan asked the very polite Dr Ashmore what he thought. Dr Ashmore replied that ‘‘where I come from the manure is on the outside of the boot.’’ (I might not have the correct wording with this quote.). The candidate obviously failed. There are now 3 ‘‘at-large’’ positions on the board as an effort to continue representation from community surgeons. In 1980, the Certifying Examination Committee was established independent from the Exam Committee. Dictation was begun on failing candidatesda practice that continued until a couple of years ago. The board under Hiram Polk began grading candidates after their examination, rather than grading as a group. Alexander Walt further standardized the examination by the addition of a casebook with 10 to 12 cases per area (2 to 3 sentences per case). Part of this was done to minimize the effects of marginal guest examiners. Guest examiners began to be assessed by the directors. The interpretive skills sessions were removed. A new grading system was added: from critical fail (3) to high pass (7). Probably one of the more significant changes occurred in 1985: At the January meeting (the board has a winter retreat every January at a location other than Philadelphia, usually someplace warm) it was proposed that the oral examination be changed to 3 successive 30-minute examinations with 2 examiners each (one board member and
one guest examiner), followed by a miniappraisal sessiondthe 6 examiners would discuss the 3 candidates who had just been examined. Before this all candidates were discussed by all examiners at the end of the day. The new format was first used in May 1985. Don Trunkey was the local arrangements director in San Francisco. Among those examiners attending were Frank Lewis, Bill Schecter, and Carlos Pelligrini. The fail rate was 34.2%. The new format was deemed a complete success and is still used today, although now we do not change any grades at the discussion session. It was felt that strong directors might overly influence mild associates and distort their opinions. Later in the 1980s, the examiners’ own graphic material was eliminated and ‘‘guest’’ examiners officially became ‘‘associate’’ examiners. Examiner grading patterns began to be documented in 1984. In 1987, there were several important changes madeda dress code was formalized (I can remember at my certification that several of the examiners had their coat off with rolled up sleeves and a loose tie); smoking was prohibited during the examination; and coffee was discontinued in each room, only being sent to the appraisal room (team leader). I expect that changing the coffee availability at examinations took several committee meetings with considerable discussion. One of the more memorable examinations was given in April 1991 in Omaha, NE, at the Hilton Hotel (later Red Lion Inn). On Friday April 26, 55 tornadoes swept across the Midwest, killing 24 people and injuring 100s. An F5 (Fujita scale) tornado came through Haysville, KS, killing 13 people at the Golden Spur trailer park. McConnell Air Force Base suffered 62 million dollars in damage. This one tornado was responsible for 17 total deaths. Examiners traveling to Omaha the next day and Sunday were well aware of the violence that had just struck this region. So on Monday morning when the hotel loudspeaker announced a tornado warning for Douglass County (Omaha), the Hilton turned into what Jon Thompson (an associate examiner that day, later to become a director) described as ‘‘complete mayhem.’’ Examiners not exactly sure what to do moved the examinations to the bathroomsdthe candidates were often placed on the toilets and the examiners sat on the side of the tub. Andrew Warshaw (a director at that time) was on the 13th floor. He, along with his associate examiner (from Wichita, KS, and very respectful of tornados) and candidate, ran to the stairwell and descended, giving the examination in the stairwell at a lower level. One examination team went to the basement where they apparently all sat at the edge of the Jacuzzi with their feet in the water. Maybe this added some relaxation to an already tense situation. Another team continued in their room while the associate examiner watched out the window for the progress of the tornado. I suspect that many candidates have feared the examiners more than a tornado over the years. Incidentally, the fail rate was 13.3%, relatively low. In 1992, each of the 3 areas was divided into 4 subsections of questioning. The examiners were required
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A history of the certifying exam of the American Board of Surgery
to use cases (or at least topics) from the proscribed subject matter. An attempt was made to add assessment and management to each case. In 1994, cases were added with moral, ethical, and humanistic content. In 1995, the ABS conflict of issue policy was issued. This prevented directors from participating in mock orals. In 1997, key management points were added to cases where possible. In 1998, the first examiner training video was produced. In the 2000s, the certifying examination continues to be improved. A candidate orientation film was added. Geographical scheduling was eliminated. Candidates are allowed to take the examination 5 times rather than 3. Five larger examinations are now held, rather than 6. Examiners are matched for severity/leniency (hawks with doves). And for the past few years, examination grades are computer ‘‘neutralized,’’ so that regardless of the rigidity of the examiner, all candidates are judged to the same standard. On a tragic day for our country on September 11, 2001, the American Board of Surgery was giving the examination at the Harbor Court Hotel in downtown Baltimore. Thirty miles away American Airlines flight 77 struck the Pentagon at 9.45 am. All 64 on board were killed, along with 125 on the ground. The news of the other tragedies quickly reached the board members giving the examination. David Herndon was giving the examination that day. He relates that he was initially informed by a candidate about the first aircraft striking the World Trade Center. The entire event was surreal to the directors. The directors and associates from the District of Columbia area and New York areas quickly returned home to treat the casualties, most of which never came. This left only a limited number of examiners to give the examination. It was decided to go forth with only one examiner per room. The examination continued and was considered to be valid. A number of examiners were stranded in Baltimore and had to find innovative ways to get home. Many rented cars and drove to friends or relatives in the Northeast. Dr Herndon rented a car and drove to his mothers in Cleveland to stay for a week or so until commercial air travel resumed.
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Conclusion The truth is that while the board often states that while it is there to protect the public, in reality it is there to protect surgeons as well. The ABS certifies those who train to high standards, test to higher standards, and continue to prove it through Maintenance of their Certification. These Diplomates represent the very best of American medicine. They continually put the patient before themselves and their families. This is what the surgeons who founded the American Board of Surgery did and the current board expects of today’s candidates. No written examination can supplant the value of an oral examination in determining a qualified surgeon. It continues to be a righteous bar for those who wish to call themselves Board Certified by the American Board of Surgery. Special thanks to Tom Biester, the Psychometrician (that’s a fancy word for a statistician who really knows a lot) and the soul of the board; to Frank Lewis, the Executive Director of the Board, whose has a photographic memory of all events that have ever happened at the Board; to Andrew Warshaw, Murray Brennan, David Herndon, Hiram Polk, Spence Taylor, Jon Thompson, Lois DeBakey, the staff at the Board Offices, and especially to all the directors of the boarddpast and present. They serve endless hours, days, weeks, and months as complete volunteersdalways striving to improve American surgery and do the best for the patients we serve.
Suggested Reading 1. DeBakey ME. Kismet or assiduity. Surgery 2005;137:255–6. 2. Oshner AE, DeBakey ME. Surgery, Gynecology and Obstetrics, Subphrenic Abscess, 66;426–438. 3. Rodman JS. History of the American Board of Surgery 1937-1952. Philadelphia, PA: J. B. Lippincott Company; 1956. 4. Griffen Jr WO. The American Board of Surgery in the 20th Centuryd Then and Now. Philadelphia, PA: The American Board of Surgery; 2004. 5. Nahrwold DL, Kernaham PJ. A Century of surgeons and surgery, the American College of Surgeons 1913-2012. The American College of Surgeons, ISBN: 978-1-880696-99-6
