Absite Smackdown! · Episode 53: Should The Absite Be Pass / Fail


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Dr. Kashmer: Hi, and welcome back to the Absite Smackdown podcast. With you today as always is Jessica Rizzo, our host. Hi, Jessica, how are you today?

Jessica: Good. How are you Dr. David?

Dr. Kashmer: Jessica. I'm doing great today. Thanks for the opportunity to do the intro. I really appreciate that I'm getting better at it. Today's episode guys is all about the Absite as usual, but this time it's about whether the Absite should be pass / fail for general surgery residents. And I think that's a timely question because as Jessica and I were just talking about before we went on air, the USMLE has recently gone to pass/fail. So, Jessica, what do you think?

Jessica: I only know a little bit about it because I was reading the article from September 20th 2020 and it was saying that people are really divided over whether they think it's a good or a bad thing for general surgery. It puts a lot of focus and a lot of pressure on that step one and getting into a residency program. So I'm just curious how that would apply to the Absite and what changes you think would happen if the Absite went pass / fail.

Dr. Kashmer: Jessica, when the USMLE went to pass-fail residency directors, especially in general surgery, we all said, "Oh my gosh". Because one of the things we look at (by no means the only thing) is the ability to perform to a certain level on USMLE step one, because it's been correlated in other studies with how you do on other exams. Like whether you're eventually going to pass your board exam on the first attempt, et cetera. And it gave us one of many tools we use to narrow down our applicant pool--by no means was it the only one. And by no means, was there just one set score that we would look at and say, well, anybody beneath that score, we're not just going to look at them, but it was one important tool in our arsenal and, you know, making the USMLE pass fail...it took that from us. So you're right. The community was divided.

Jessica: So with so much focus being on that with the residency program recruitment side, they're saying that a focus on USMLE scores causes a lot of mental health issues and stress within the students. And that it is detrimental. I mean, that's one side of the argument. What do you think about that?

Dr. Kashmer: Well, I think a couple of things. First, let me say that the original intent of the Absite, just like we say in the early lecture of the Absite Smackdown video review course, the original intent of the Absite was to tell us as program directors how good our educational program is for the residents. What are we doing? What do we need to do? And I think a couple of things: the author of a recent article that you talked about September 20th, (we'll probably include the link in the blog or the transcript) but that article runs us through the idea that, well, going to pass / fail on the Absite would return the Absite to its original intent, which is to tell program directors how well they're doing. I don't completely agree with that argument. And the reason why is that having a score for the Absite really helps us to know in an individual resident how they're progressing. So I think making it black or white go and stop or yes / no or pass / fail doesn't really give me a sense across all residents, how they're progressing over time, or where they are in terms of how much of the body of knowledge they've mastered. So a score can be useful for that because it shows me in gradations, how they're doing, I think black and white is a little tough. So that's one factor I disagree with. And the next I, maybe this is a little bit philosophic: I don't want people to be so stressed. They can't perform, I don't want that. However, there is the classic Yerkes-Dodson curve. This is a curve that talks about performance and anxiety. And there's some correlation where just a little bit of anxiety or just a little bit of being hyped up get us to peak performance.

And then we can go too far as surgeons. I think one of the important things we teach beyond just the facts review and the curriculum is how to deal with challenging situations, and how to manage difficult things. So if we say that a test is putting too much stress on our residents and we just have to make it pass / fail, and it's just too hard....something about that doesn't sit right with me. That does not mean (and I want to be really clear) that I think residents should be stressed out about an exam, you know, exhausted, completely depersonalized in a place where they can't learn or be effective surgeons. I completely disagree with that, but performance requires an optimum amount of stress to grow. And I think having a test that is challenging in some ways can really be useful for that. So that's my take on that part.

Jessica: So it was like a healthy medium, because if residents just had everything easy, it wasn't stress. If it was just study for an exam or Absite score, then when the real life situations, life or death situations came into play, they may not be as prepared. So yeah, you don't want them to be completely stressed to fail, to burn out, but you also want them to feel the pressure to know that what they're doing, what they've chosen, is incredibly important because it literally is life and death at some point.

Dr. Kashmer: You know, I didn't want to hang those, I guess, sort of that much drama on it, but I agree with you, the headline is there's an optimum amount of stress that it takes to grow. Whether you're playing sport, learning a craft, becoming a professional in surgery, you know, these are already doctors, they've already dealt with a lot. They've gotten into medical school, they've dealt with all the challenges of medical school. And now we're asking them to be able to study for a test effectively while in their profession. And while they're learning their body of knowledge for examination. And while they're learning about the practice of the art and science of surgery. So even when I was a resident, I would not, I feel, have agreed with just make the exam pass/fail. I mean, I've, would've gone along with it of course, but it wouldn't have resonated with me as much.

Dr. Kashmer: You know, you're going to study for this examination, you're going to take it. You're going to see how you do, because it helps you grow as a professional during general surgery residency. That's my take on it. I see where the author of this particular article is coming from, I really do. but I take issue with it because I bring the coaching mentality to it with residents. I think there's an optimum amount of stress and too much is just terrible for growth and makes people shut down. But too little and they are underperforming and they won't learn where they need to be. So there's some amount of, stretching. Stretching beyond what you can do to get you to the next level. And I think that's really important.

Jessica: So I want to make sure that I understood you correctly earlier. You said you feel like if they made the Absite test pass/fail, it would be a reflection on the program directors?

Dr. Kashmer: I wasn't clear. That's the argument people are making for making the Absite pass/fail. They're saying it returns it to its original intent, which is just to tell the programs, the program directors, how they are doing. And this is just one of the arguments to tell the program directors, how good a job they're doing, how good the program is doing at educating our residents and to my mind, making it pass fail. This doesn't achieve that for me as much.

Dr. Kashmer: You know, let's say you're in one of the many residencies that graduates three chief residents a year and one year everybody passes the test. All the categorical residents pass the next year, all the categorical residents pass. Then one year, one fails, two of the three pass, one fails, it's a 33% failure rate in the program. What does that mean?

Does that mean, did they have a borderline performance every other year? Could you have identified them earlier and brought them up? So when I wrestle with it, you know, what it would be practically I think about specifics of what it would mean. I just don't feel like it would work when I was in a program director role. I would be asking myself, what do I do? So unless you're a residency that has 10 categorical residents, this situation can be really challenging.

Jessica: Okay. So I think we kind of get where you fall on this without being too opinionated. And you know, what do you think at this point? What are the chances that they actually are going to make the Absite pass fail?

Dr. Kashmer: Well, the argument about resident wellness goes a long way nowadays, and I think it should. I think residents worked very hard. I remember what things were like in the past. And I think things, I think making sure residents are positioned to perform the best they can is a good thing. That argument nowadays carries a lot of weight. So I think the argument of, "Hey, let's take the pressure off the residents and make the test pass/fail. Because they're, you know, they'll just be under less pressure with that." And I'm not sure they would be, but let's say that's the argument that goes a long way nowadays. So I think it's possible, especially because the USMLE went that way. I think it's possible that the Abste will go that way. Now, remember Jessica, the Absite score has also been correlated with the ability to pass the qualifying exam, the exam that we take as part of our board certification that surgeons take for eventual board certification.

Dr. Kashmer: And it's the written part. The qualifying exam qualifies you to take the certifying exam, which is nicknamed the oral boards. So the issue is I would also lose the ability to determine, "Okay, this resident is at risk to not pass their boards on their first try." It doesn't mean that they won't pass their boards eventually. And in fact, even if they do poorly on the Absite or do score less than 35% in any one year, they're still more likely to pass the qualifying exam than not pass it. And we'd put that in one of our blog posts, we did the math to show based on the results of the study. That's still, even if you score low one year, you're still more likely to pass the qualifying exam than not pass it. Okay, fine. But it puts you at risk. It's a statistical marker of risk. We'll lose that. If we go to pass fail, we'll have to figure that out again. What does it mean if you fail one year, et cetera. So, I think that's another important factor for all this.

Jessica: Well, it's definitely a lot to think about, and I'm sure we're going to see more information coming out, more studies, more conversations about this as we get used to the potential change. So, is there anything that you want to add today?

Dr. Kashmer: Well, to wrap up my take on it, even though I think in some ways it will mean big changes for program directors and programs...I think there's a reasonable chance that it happens. I can't predict either way what the, where the board will go with it. I really can't, but I can say that it will impact a lot of things, including change the ability of program directors to use, the Absite as a tool to help support residents who are prone not to pass their qualifying exam on the first attempt. So I'm glad we talked about it. I do think there's a reasonable chance things go that way.

Jessica: Yeah. I mean, they could happen and we'll just see, let's see if it does. So again, guys, thanks for tuning in today. As always, you can follow us on all of our social media or on Instagram, Facebook, LinkedIn, Twitter, and you can always find our podcasts on iTunes or SoundCloud and any other ones you want to tell them about Dr. David?

Dr. Kashmer: Well, there's so many places that the Absite Smackdown podcast goes, let's say iTunes, Stitcher, SoundCloud, Google podcasts, Amazon, if you didn't say it already. It's all over YouTube where they can see us as we talk.

So with that, let me say again, just as Jessica said, thanks guys for tuning into this episode. Again, we think there's a reasonable chance that it's going to go to pass fail. We're not sure what that'll mean overall but it is possible regardless. We know that this Absite for 2021 is coming out for you soon. And we hope that the different free lectures, the book, everything from the coloring book to the crossword book to the review book are helping you out for it. So with that we say best of luck and Jessica, let me say it again today: #AbsiteSmackdown!

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