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November 3, 1989

The Abyss: Sinking Scores in Internal Medicine

JAMA. 1989;262(17):2438. doi:10.1001/jama.1989.03430170100037

It is an experience unlikely to be forgotten by anyone who undertakes it: two grueling days of mental and physical exhaustion overlaid with the psychological stress that a poor performance may sabotage 7 previous years of hard work and the rest of one's career. It's probably not that bad, but at the time, to those taking the certifying examination for the American Board of Internal Medicine, it seems like it.

The group examination usually takes place in a large lecture hall or classroom and subjects the examinees to 15 hours of more than 600 multiple true-false and single-best-answer questions. In the past, residents taking the "boards" had only one day of the "multiple-guess" questions and one day of patient-management problems. These problems were realistic simulations of patient encounters, in which physicians could "take" a medical history, "perform" a physical examination, and even "order" laboratory tests.

These patient interactions were accomplished