The ASN in-training examination and the ABIM certifying examination: time for a new testing paradigm

In 2009, a new computer-based in-training examination (ITE) was created by the American Society of Nephrology (ASN) in conjunction with the National Board of Medical Examiners to assess the medical knowledge of fellows training in nephrology. The ITE, patterned after the American Board of Internal Medicine certifying examination for nephrology (ABIM-CE), allowed fellows and training program directors (TPDs) to compare their performance with programs in the nation. However, despite using case vignettes to simulate real-life clinical experiences, the nation's graduating fellows answered a mean of only 69% of the questions correctly. Although unpublicized, the ABIM-CE passing grade can be estimated to be approximately 65%, resulting in the current passing rate of 94%. The ABIM states that they are testing 85% synthesis and clinical judgment, rather than recall memory. So are we to conclude from these two exams that the medical knowledge of our graduating nephrology fellows allows them to properly manage only about two-thirds of their patients? Rather, the construction of the test questions and their relevance to clinical practice should be reassessed. The time has come for a new testing paradigm, one that would require candidates passing the ABIM-CE to score 85% to 90% correct answers to more relevant "core" examination questions that assess the actual medical knowledge needed to practice competently in our subspecialty. If the ABIM-CE was revised, the ASN ITE, with no specific passing grade, could then test core and "factual" recall knowledge with feedback of questions to TPDs to assess and help fellows in training.