Are We Cheating Ourselves Out of Our Competency?

Last October, I attended the CAP Residents Forum where I heard the President of the American Board of Pathology speak about the use of remembrances for boards studying and how it was considered cheating and a breach of the honor code. I was a bit surprised when we took a live vote via text that the majority of residents felt that the use of remembrances was not cheating. But this all goes back to the medical school culture (and maybe even before that) in which we were trained.

During my 1st year of medical school, I remember feeling that it was inequitable that some students got old exams from their assigned 2nd year “big siblings” and that others got nothing. So I did something to neutralize the playing field – before every test, I scanned the old exams I had and emailed them to the class listserv. For the few exams that I didn’t have an old exam, other classmates stepped up and scanned and emailed them out. And so we built a culture of sharing. I was very proud that my classmates did not put having a personal advantage over the concept of equity.

But unexpected and unintentional shenanigans ensued. Once a classmate emailed out what was thought to be an old exam but was later found to be a “stolen” exam as that professor purposely did not give back his exams. This required our waiting while he re-wrote parts of the exam as this was discovered only on the morning of our actual exam. And during my 1st year of PhD (I was initially DO/PhD), when my original classmates were in the midst of their 3rd year rotations, a classmate emailed some study materials they had obtained from a friend at another DO school that unbeknownst to them were remembrances from previous NBOME shelf exams.

Eventually as the year went on, my classmates began to realize that what they had were remembrances and one classmate actually stepped up and turned them into one of our deans. Since I was no longer in this class, I only heard after the fact, but our dean had called the NBOME to warn them to retire the questions in these remembrances and had also called the school from which they originated to let them know what their students had done. At that time, I was not very invested in what was unfolding as I was in the graduate school portion of my dual degree program. But I do understand the fear of others having advantages that you may not and having that thought cloud one’s thinking.

These memories flooded back into my mind as I listened to this talk at the Residents Forum and voted. I didn’t realize it then when I watched from the sidelines but do now, that the use of remembrances—whether it is considered cheating or not—is in fact cheating oneself. A Machiavellian “ends justify the means” mentality is often used to justify such actions. But in the end, what have we truly accomplished? Yes, maybe passing our boards. But what happens when we become practicing pathologists if we didn’t understand what it was that we so diligently memorized off of remembrances?

It may be slower and more difficult, but I’ve pledged to myself that I won’t take the easy road, no matter how tempting it may be (I admit I’m just as vulnerable to temptation as everyone else). I tell my M2 students when I TA their pathology small group discussion lab that if they don’t know even one word when they are reading to learn a concept…to stop immediately and look it up, even if it just means to Google. And I’ve tried to practice this as well. I still may not pick up on surgical pathology concepts (especially grossing) as quickly as I do clinical pathology concepts, but I have noticed a difference. Concepts seem to stick better in my aging brain because I have shifted how I focus my efforts. I try not to waste as much time on worrying (but I still sometimes do) that others may have an advantage over me because that is wasted effort.

Gaining competency means to take ownership and responsibility for one’s learning. Figure out how you learn best and make a plan to do it. And if you fail, keep trying until you make it. Really try to understand the mechanisms and not just memorize minutiae or facts. I find that I can figure out the answers this way if I had a solid foundation. And don’t take too many shortcuts, which invariably, remembrances may turn out to be. But I’d like to hear your take on the topic…is the use of remembrances cheating or not? And do you think that using remembrances cheats you out of obtaining competency as fast and as well as you might have gotten there without them?



Betty Chung, DO, MPH, MA is a second year resident physician at the University of Illinois Hospital and Health Sciences System in Chicago, IL.

2 thoughts on “Are We Cheating Ourselves Out of Our Competency?”

  1. Very true! In our pathology program, people who cannot describe an entity properly or make a reasonable diagnosis, score very high in the annual RISE exams, just because they use the questions from previous years, which is cheating oneself for sure

  2. Good for you for taking on this controversial subject! My personal view is that remembrances are cheating. But, it really doesn’t matter what one’s personal view is. The public and the American Board of Pathology regard it as cheating. I think the explanation for the explosion in remembrances (up until two years ago, that is) is the feeling that our certifying exam questions seemed unfair. They were outdated, too esoteric, too rooted in the old school perspective.

    Having attended an ABP meeting before, I can say that those sitting on the ABP Board are phenomenal people and phenomenal pathologists with the right objectives. They sincerely want to make a fair, comprehensive examination that tests what medical knowledge is needed to be a competent, critical pathologist.

    That being said, I feel that many of the questions asked on my ABP exam were dated and of suboptimal relevance and/or quality. This may be a consequence of the “tried and true” concept – “an exam question has worked for decades, why try to fix what ain’t broken?” This may result in statistically favorable examination results but I think we need to ask for more than that.

    I think it starts with a few simple changes. For instance, the solicited feedback at the end of the ABP exam allows for something ridiculous like 36 typed characters (I don’t think I’m exaggerating). How can that be fair to examinees? We study for 4 years and pay thousands of dollars to be told: you get a few dozen characters to provide us ways to improve the exam? Let’s get a more formal way of giving the ABP some constructive criticism.

    And while I didn’t do it while on the ASCP Resident Council, I would hope that our resident representatives will speak up to ABP and let them know our thoughts. If exam questions seem unusual to the majority of path residents taking the exam, either they aren’t being taught what they need despite the best efforts of program directors – or there is a discrepancy between what program directors think is important and what the ABP thinks is important. Luckily, the RISE exam is helping to bridge this gap and I recommend using this valuable tool to study for the ABP exam. There’s a clear (published) correlation between success on the RISE and success on the ABP exam.

    So, you’ve touched on a hot topic among path residents, fellows, and pathologists alike…let’s continue the conversation!

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