Buyske_edited

Hey, BTK listeners. This is Jessica Millar here with Nina Clark, one of the other BTK fellows, Scott Steele. Dominate the day. So if you are a surgical resident or at all involved in surgical education, chances are you have heard about the upcoming change to the ab site exam and specifically how it's scored.

Starting next year in 2025, the American Board of Surgery will no longer be providing a percentile to go along with your overall score on the ab site. This change has occurred in the context of a larger conversation that extends far beyond the world of surgery about how we evaluate and compare learners across all domains of education.

So we're very excited to have Dr. Jo Beiske here with us today to talk about this change. Dr. Beiske is a repeat guest. She has been on Behind the Knife at least once in the past. Few years. She's been the president and CEO of the American Board of Surgery since 2017 and was staffed at A BS since 2008.

She's worked previously specifically as the director of evaluation. She's a former director of the

A-C-G-M-E, the A BMS and former president of sages. Currently she's listed as an adjunct professor of surgery at UPenn. If, and I noted from your bio that you are also a fellow Cornellian, so go big red. I am.

Dr. Boisky, we are really grateful to have you here with us to talk about this change to Abcite, the future of board exams and general surgery, as well as get your insight into how tests and test scores fit into the global context of general surgery training. So thank you so much for taking the time. My pleasure.

All right, let's jump into our questions. So obviously this year the ABS announced that moving forward percentiles are no longer going to be reported as part of the app site. Can you tell us a little bit about what inspired this change on the part of the board and your thoughts as to how board scores have been used previously and how they should be used moving forward?

Sure. The the change I think is less dramatic than people fear. You know, percentile scores are. a very imprecise measure. So the exam, you know, if you, you get that table when you get your scores and you can see that a lot of the scores are

clustered in the middle. So, if you are one of the vast majority of people who are in the middle and you get one or two questions right, you know, more right or more wrong you might leap multiple percentiles because there's so many people who are tied.

So, if, you know, if of the 8, 000 residents who take the ABSITE or the 1, 200 who take it at your level. a whole bunch of them are going to have gotten, you know, 70 percent of the questions right. So if you go up one, then you skip all those people. And all of a sudden you went from being in the 48th percentile to being in the 57th percentile or something very dramatic that doesn't actually reflect your change in knowledge.

And conversely, if you're at one of the extremes where no one else is, you know, if you are extremely low and you get 10 more questions right, no one else is extremely low. So your percentile score might go up by, you know, One point and not really reflect the fact that you did significantly better than you did.

So it's a very imprecise measure that really derives from the fact that the abcite was is intended,

originally intended sort of lost in the midst of time to fulfill a requirement of the ACGME that all programs have a knowledge assessment in training. So it's not part of the board certification process.

It's not required to be board certified. In fact, a lot of other specialties, it's not even designed by the board. It's designed by a specialty society or, you know, when I say designed, I mean, the questions are written or by the program directors, for example we offered to do it long before I came around, I think, in the 80s, because we happen to be really good at writing questions and had an infrastructure for it.

People have accepted it ever since. And it is, in fact, called the ABS in training exam. So it's sort of confusing, but it was intended as feedback for the program, not for an individual resident. But to say, look, all of your residents did poorly on surgical critical care, maybe you need to beef up your curriculum, not.

You know, that you specifically, you know, you Joe by ski did poorly in surgical critical care over time. The programs, of course, started to use it for individuals and it's not completely useless that way. And then, of course, my least favorite

use of it being as a gatekeeper for whether or not you get into fellowship.

So, you know, the precision of that relationship kind of didn't matter. And we we carried that forward for a really long time. So we're still gonna give. A score instead of the the percentile score will give the standard score, which is basically a percent correct mapped onto a standard. Same way.

The scores are reported. Same way. The U. S. M. L. E. scores are reported for the in training exam. The standard and actually the standard scores reported right now. So if you look at your scores, you get both the standard score and the percentile score. So the average is, or the mean is 500, and then about 100 points is a standard deviation away.

So that score will still be still be reported. So they'll know objectively how you did as opposed to the, it's a more precise measure as opposed to the less precise measure of percentile scoring. So I think it's a step forward. So, Dr. Bicek, you know, ultimately we want to be great surgeons, but ultimately everybody wants to pass their boards, right?

So can you talk a little bit more about the data tool that the ABS publishes that

ties those scores to the probability of hopefully eventually passing the written boards exam? And for all of the listeners out there, there's going to be some show notes that we'll be able to talk about the announcement and tie that in, which is available on absurgery.

org. So we have a great publicly reported data tool. If you just go to our website and report and Google, I think, you know, or put in the search function data or public data, you can see all kinds of things, you know, the history of board certification by gender by geographic location by fellowship. And it also includes the ab site tool that will show you by year.

5 and by confidence of likelihood of passing or the predicted probability really of passing the qualifying exam based on your scores. And if you're looking at it, I don't have it up right now, but if you look at the version where all of the years are separated, you can see that the PGY 1 year has a very flat curve.

It goes up slowly, it's shifted to the left. The confidence intervals

are very wide because. Because you're only a PGY 1 and it's not a great assessment of all the knowledge that you're going to accumulate by the end of your PGY 5 year. And then the curve gets steeper and the confidence interval gets tighter every year as you go from 2, 3, 4 to 5.

4 and 5 are pretty parallel. So the steeper curve implies a sort of a tighter relationship and the narrower confidence interval, of course, implies a tighter relationship. Tighter relationship, and you can just, you know, follow it backwards. So if a PGY 1 is, you know, has a standard score of, you know, 200, then they've got about a 30 percent chance of, I'm making this up because I'm not looking at the graph, a 30 percent statistical probability of being able to pass the qualifying exam.

So it's a good it's a good clue. Everybody, you know, it's, it is only a statistical model. So there are individuals who will fall on any which side of it but it's useful to take a look at. And it can be somewhat sobering, but not to worry too much about it in the PGY 1, 2, or even 3 years because you know, there's vascular surgery on the exam and you may

be at a program where you don't even do vascular surgery until your third year.

You're still scored against everybody else. So it's really the PGY 4. I think that's probably the most critical year for 4 and 5 years that you'd like to see that you're in the range that you're in. that predicts that you'll pass the qualified exam. If you're not, then you need to study more. Something that I know when I kind of made the jump from PGY1 to PGY2 was that drastic change in percentiles which fortunately I think a lot of our PGY2s won't have to worry about then in years coming up.

But I did have someone say, you know, look at your percent, correct? That is a true marker of, or one way to sort of measure how much knowledge you've gained over the course of the year. But I have heard that that number can change a little bit because the test isn't the same every year. Some years it's harder, some years it's easier.

So do you really feel like you're Looking at your percent correct is like a reliable way to sort of measure your growth, or are there other ways that you recommend that people sort of interpret these scores that they get? I think the standard score is probably a better way of doing it because it'll be standard deviations compared to your peers.

And when we say an exam is harder or easier, it

really is that means you're comparing it to peers across years. So on our high stakes exams, which we don't consider the in training exam to be high stakes, it's got lower security and again, it's supposed to be a formative feedback exam. We always, it's called equating, which is that there are questions that are used in two years.

And so we'll look at, say, you know, say there are ten questions that were used on this year's exam and last year's exam. And if, you know, last year the group as a whole got half the questions right, but this year, the group of a whole got only three of the questions right, then you say, well, the group as a whole this year is not as smart, or at least as well prepared or at least as good test takers as the as last year's, therefore the passing score needs to be adjusted accordingly.

So that's called equating when you use similar questions or the same questions actually and compare them a year to year. We don't do that on the in training exam. And so the best thing is that year, how did you do against your, peers, which is the standard score percent correct is interesting.

We're all pretty

competitive. I, of course, would want to know if I got, you know, you know, one of my friends used to say that they got 100 percent on all the ethics questions that they're highly ethical surgeon because they got 100 percent on all the ethics questions. Yeah, don't ask me what my my lowest score section on the app side is, you're right here.

I think you, you commented a little bit on this and I'm interested because whether it's intended for this purpose or not, there's obviously a lot of this anxiety that you've commented on already about demonstrating good performance in residency as a means for getting into a competitive fellowship.

And unfortunately, Abcite seems to really play a role in that. And I think, you know, Jess and I are both kind of starting to come into the years when we're going to be applying. And this is definitely a point of anxiety, I think, for a lot of residents as they get their scores back every year. Do you foresee difficulties if you are, you know, say a fellowship?

Director and you use these scores traditionally, and you've used percentiles to again be able to kind of compare year over year performance across your fellowship applicant pool. Do you foresee any changes or difficulties in

fellowship recruitment and in terms of how they kind of measure objective measures of success when there are kind of so few of them in residency to begin with?

I really think the standard score, it's something that's pretty familiar to people from the SAT and from the USMLE. So I think we're replacing an imprecise score with a more precise score. So, you know, is it more automatic for them because they're used to doing it for so many years? Sure. But this is more valid, and I don't think it's actually more complicated to understand.

It still shows up on a colored table, you know, with colored bars so it should be pretty straightforward. So I don't, and and then I hate to say this, but I didn't design it for them. It's not for them. They're not even supposed to use it. It's supposed to be a formative exam. So if it makes it a little harder for them, that's not my concern.

That's great. Well, as somebody who takes a look at those every year, I'm going to say it might have to have some readjustment because I do think to a certain extent people. Do you know right, wrong or indifferent? Do look at it at least somewhat, but I would kind of just dig in there a little further and just say, so what is the optimal role or use

case for app site scores during residence development and academic growth?

You mentioned a little bit earlier, but what is the optimal use of these? So, I think people's scores should get higher and higher they should be able to demonstrate that they're learning more and more. They shouldn't necessarily get higher according to their peers, but by their own internal measure.

You're, you know, your percent correct or your standard score should go up every year. We don't have a pass point. For the in training exam. That's something that we've talked about. You know, should it be a master exam? Should it be that by, you know, in order to leave your P. G. Y. two year or your P.

G. Y. three year that you should be able to get 75 percent or 65 percent or 80 percent correct. And we've never turned to that. It would then not fulfill the formative feedback function. So I think it's remains an open question about whether we need to get a little bit more stringent about what we expect of people at various points in residency.

And I think if we are going to move to modular training. that we would want to have a mastery exam to get out of the sort of basic module before you started to move into specialty modules. But that's a

little bit farther down the road, or theoretic, I'd say. To follow up on that, you mentioned before that the Abcite was really designed to evaluate programs and their ability to meet these goals and educational objectives.

So I guess I'll just mirror Scott's question and ask, you know, what's the optimal use of the Abcite for a program? And do you find that programs are actually using it in that way or have they really shifted more towards this as an individual or feedback on an individual's performance? You know, I can speak to pediatric surgery, which also has an in training exam, and they're very diligent about noting the nationwide trend of, you know, everybody's done poorly.

I think it actually was surgical critical care, pediatric surgery exam several years ago, and they fed that information back to APSA their main overarching society, and so they started to develop education tools around that. that issue, which is a perfect feedback loop. That's really, really nice.

And actually the ABMS, which is the oversight board that oversees all of the specialty boards or, you know, 23 other boards, radiology and medicine and

pediatrics and pathology and boards you might never have heard of, like medical genomics and genetics. They The ABMS now has a standard that requires that boards have such a feedback loop.

They don't actually have it for the in training exam because they don't oversee it, because it's not a board certification issue but for the high stakes exams, the certifying exams, we're supposed to promulgate that information to the societies and say, across the board our trainees did poorly in transplant and that they're supposed to respond by, you know, provide by developing new materials that hasn't been fully actualized yet.

But I think that's a really nice loop, you know, in the best of all possible worlds. There's tagged by, you know, by category that relates to the exams. And you can be like, wow, I, you know, I failed the exam and I did really poorly in these areas. And so, look, here's all the that will help me learn it.

That's the. That's the nicest loop that we haven't quite acquired yet, but I don't think it's very far before we get there. Did I answer the question? So for the individual, so for looking at the program, I think that they do actually. I think the program directors do tend to know. Now

I say that as though the program directors, that term is monolithic.

You know, we have 358 programs now and a lot of the program directors are within two or three years of becoming program directors. They're still trying to learn all of the Byzantine rules of the ACGME and their own hospital structure. And ours. are requirements. And so maybe not all of them do look at it, but I think a lot of them do know what areas they're weak in and what areas they're strong in.

And then most programs use it for their individual residents and they have something, you know, they have what they call a scholar's club or a extra education opportunities for people to, You know, to march their way up the curve. I love all this talk about AppSight, and I think it's something that, you know, during your five years of training every January or so, you know, you come and you get really stressful, but it's all leading up to our board exams.

And while we have you here, I know that there have been several changes to the actual board exams within the past several years 2020, whether we wanted to or not, made oral exams virtual and there's also some changes

regarding when. general surgery residents can qualify for their written exams.

I know that those are some of the changes that are currently underway. Can you talk a little bit about how they've gone and changes that you guys have made over the past several years since implementing them? Sure. So I, I am delighted with the PG, the exam after PGY4. I think that's fantastic.

Every year more people take it. The first year, I think it was twelve, and it the first year might have been four, because we didn't warn anyone at all. We just announced it at, like, the end of October, that you know, if your program director says it's okay, and you've met all the requirements, except for the time requirement, that you can take the exam.

So you had to have passed FLS and FES and done everything else, and I'll, somewhat to my surprise, I learned during COVID that a lot of programs leave those till the very end, because those are not supposed to be exit exams. They're supposed to be, learn this in a machine and not in a human, before you start doing lab coles and before you start doing endoscopy.

So when I say, you know, we talk about whether we should make more rules about timing of training. Should the abcite, should you have to meet an abcite score?

Should we require that you have passed FLS or FES before you leave your internship or your PGY2 year? We haven't done that. We've left it up to the programs.

When I started at the board, there were only 170 programs and now there's 358. So I do think that the heterogeneity is. Is significant and then maybe we do need to be more autocratic or set, set more standard set more standard expectations. So it started slowly that, that group, the group of PGY4s who take it always has a higher passing rate than the large group.

To some extent, I think the program director has to approve them. They have to have enough confidence to do it. So they're selected. They're pre selected. I think something like 70 people did it this year. It's still less than 10 percent of the people taking the exam. That's only about 6%. But and you know, when I go around and give grand rounds, a lot of residents don't know it's an option.

And I'm not sure, but I think some of the program directors don't know it's an option either. But I think it's great. I think it liberates you in your chief year to really focus on sort of knowledge attainment and skills attainment. Not worry if you pass the qualifying exam, why would you

even take the in training exam in your.

I think it's the fourth year, fifth year, actually, a shocking number of people do. I don't really understand why, but to be, you know, sort of freed up to really just do, you know, judgment learning and experiential learning is I think fantastic. I think that the residents in the places that really promote it are treated, seen a little bit differently in their PGY 5 years.

Maybe it's, you know, particularly competent or super achievers, whether that's valid I can't say, but I really like having it in your fourth year. We're actually talking about letting people take the oral exam also. We have a, when I say talking, making those moves takes a long time, and we're literally just talking about it.

So I'm very pleased with that. I think another bridge that we need to cross is that the qualified exam should probably be offered more than once a year for those people who are like, I'm, you know, for whatever reason, a major event is happening, you know, immediately before, immediately after, or perhaps on the day of, and then to have to wait a whole other year is really disruptive.

So I would like to see it. twice a year. And that's a, that's sort of a, an issue of just getting the

workforce generated. You know, we have to increase the number of volunteers. We have to increase the number of questions. We have to have, you know, more people to score the exam, more staff to do it. So it's a, that's just a question of gathering up the energy to pull the trigger on that.

But I think that that's a necessary near term. goal also. So looking at some of the changes in training, whether they're integrated programs or maybe some of the programs. So I'm a colorectal surgeon and you know, birth certified in both general surgery as well as recertified as well as colorectal. Do you see a time on the horizon where maybe with the integrated programs that you wouldn't be board certified in general surgery and you'll just go to that subspecialty board?

Thoughts there. So, you know, those are those, that's actually kind of not for me to say, because the specialty, it's the specialty board, the subspecialty board that is making that requirement, right? My only requirement is what it takes to be certified in general surgery. Or if I happen to be the, you know, the boss of that specialty we do have some examples of shortening the time.

And actually, let me take a step back. I had that question put to me about

transplant surgery, which is not an ACGME accredited program. And it's not one that we offer a certificate in. But at Wash U, they had a training, and I think they did this twice, that they wanted to keep there, and they wanted to use the flexibility and training option, meaning that they can shuffle rotations in the last three years up to twelve months of rotations in a particular specialty.

They said, if we can give them a year of transplant training in their last three years can we shorten the fellowship by a year, and then they'll, can they get their boards and be trained in transplant? So, the answer really for me is, yes, you can do that, and you'll get your boards. Will they be trained in transplant?

That part is up to you. So they did that with two people and I think they were highly satisfied. It's never been, we haven't done that or tried that with an ACGME accredited fellowship just because there's so many other, other rules to pass. So it's really up to the specialties and I would say that the reason that they do it, let me just get back to that 358 programs, completing a program, completing, it's not the same as completing a program, it's not the same as completing a program.

So getting your

boards is sort of the stamp. It's the stamp of your initial training. It's not sort of evidence that you're doing well in your practice that theoretically is CCA and some boards do wait for your certification for a few years orthopedic surgery, plastic surgery, and their assessment is more of your practice.

Ours is a stamp of your training, which is why it becomes so hard to pass it if you're six years out or seven years out or impossible to pass it. If you are on one of our alternate pathways and you're 15 years out, because it doesn't really matter how good you are at your specialty practice, that exam is built to say your training, was up to snuff in all these different ways.

And so that is what the colorectal surgery board is looking at, Scott. They want the proof that the training was high quality and done, and that proof is available through board certification. So that's what they're looking at. I don't know that they'll continue to do so. And the compressed pathways just have a lot of structure and rigor around them.

And actually for those pathways, they don't have to get there. Their boards, you don't have to get your boards and

CT surgery to become a CT surgery in the direct pathways. You don't have to take your general surgery boards in vascular. They have the zero five programs. They, of course, completely bypass general surgery, the five plus two programs.

They do require that you actually interestingly, you don't have to take your general surgery boards. You have to have a completed and accepted application. That means that you've kind of checked off all of the boxes required because that's the short route to saying, yes, you met all the requirements. On that note, as we get more of these integrated programs, specifically with vascular and thoracic, et cetera, those questions still show up, obviously, every year on the general surgery ab site and presumably on the boards.

And so is there a mind towards shifting away from asking those types of questions, given that more and You know, trainees are getting some specialty training right off the bat or do you think that the, you know, the general surgery boards will always have a component of vascular or thoracic surgery as part of it?

I would hesitate to say

always about anything in this sort of rapidly changing, you know, fluid environment. You know, we haven't really ever defined what like the core knowledge is, you know, Canada's got a core couple of years, I think it's two and a lot of countries do. We did take a swing at it many years ago, Stan Ashley was the chair, and we, and it just turned into like a tower of babble with everybody.

You know, we started by asking the fellowships what they would want people to know before they went into them. They all had different needs. Every specialty wanted to be represented in those first couple of years so that people would have exposure to it. So they would, and it just turned into a hot mess and we gave up.

We just weren't, we weren't ready for change at that point in time. I think that I think we're rolling into the EPA conversation, which is really my favorite topic right now because I think EPAs are the answer to a whole bunch of things that we haven't even started to think about yet. One of the most interesting to me is that, you know, we have this list of 18 EPAs and we don't know for sure that we picked the right ones, right?

We think we did. We used a lot of extra consensus, a lot of boots on the

ground surgeons, but probably we didn't, right? That would be sort of astounding if we got it right, right, right. Out of the. I won't tell you which ones I think might not be the winners, but I do think in five years, which is when the first class will finish or a few years after that, when we've accumulated a little bit of additional information, we're going to find out what it is.

We really train people to do. No, I was going to say you walked right into our next question that we were drafting as you were right. EPAs and how EPAs are going to factor into all of this stuff as we, you know, as you mentioned, kind of shift towards more modular learning, right? And so then you could say you could envision a future where, you know, the colorectal fellowships just say, in order to come to our fellowship, you have to be entrusted at the level of indirect supervision on these EPAs.

We don't care about those other EPAs. And we could say as a general surgery board, well, if you're, you know, if you're going to be certified in surgery, then you've got to be entrusted in all these EPAs. So I could imagine modularity occurring that way, or it could

occur in a more tightly structured where all of these, these EPAs have to be done in the first three years.

And after that, you can branch out into other specialties. But I think they're, I think they're really exciting. I think they're exciting for lots of reasons. I think they're a much better way for residents to do. to get the feedback that they need. I think the whole conversation, you know, EPA's competency based assessment has dragged for years because people love to throw really complicated questions at it.

Like, well, how could we possibly make training time variable? You know, the whole structure relies on there being five years of residence to, you know, do all the proper rotations and who's going to pay for the people who go more slowly. So I'll address that one first, which is, it's very hard for me to imagine that people are going to take longer in training if they got feedback every day.

about what they were doing and what they needed to do to get to the left but next level. I think that we're going to be surprised by how quickly people can advance under those circumstances. Might some people take longer? They might. They do right now anyway, so those are sort of, you know, false fears.

And we just

decided to not address the time variable part right now. It's too early. We don't know that they're valid. We don't know that we picked the right ones. So we've sort of planted a stake in the ground. This is the first necessary step to start addressing all those changes. And so for those reasons, I'm really excited because once we have a few years under our belt, then we can start talking about it.

Shortening training or time variable training or modular training. So I'm really excited about that. I hope I live long enough. I think a lot of residents share that excitement. I think Jess and I are going to swing back in clinical after this this summer. And I know that I'm very excited to see how this all works out.

So, yeah, a lot of programs started just with their interns and the other residents were jealous. And so now they're doing them across the residency, even though even though it's not required for people who are beyond their internship here right now. Always excited to get high quality feedback in the operating room.

You mentioned that EPAs are going to obviously bring some changes to board exams. Hard to know right now though what those changes are. I am curious though to talk

about other changes that are in the pipeline. One thing in particular that I know just amongst like my residency cohort that we've talked a lot about is what it takes as far as clinical requirements to qualify for your boards.

The you know, ABS says you have to average 48 weeks of full time clinical activity in order to qualify for your boards, but we've run into Issues or, you know, challenges recently with maturity leaves, paternity leaves, medical leaves, and how that can create a lot of stress, especially if those occur during your chief year.

I know other boards have different policies when it comes to clinical requirements and what it takes to qualify for your board. So is there any talk at the EBS about offering more flexibility as far as clinical requirements to allow for those types of leaves during training? So we have a fair amount of flexibility in a variety of different ways.

So you get the, you know, the regular four weeks every year. So you have to do 48 weeks a year. If you have an event of, which is a fairly

wide category, you know, including caring for an ill family member or your own illness, parental leave, and any other various forms that we become parents twice in your training, you can take an additional four weeks off.

So you get a total of eight weeks off. If that is not enough, you could also average across years. So, you know, so there's a little bit of flexibility built into there. If that's not enough, we were really, the ABS was the driver behind making fellowship start dates, August 1st. And that's as opposed, they were July 1st.

Y'all may be too young to know that. And so people would literally finish their residencies June 30th, and we're supposed to start a fellowship across the country or perhaps at their same institution on July 1st, which is inhumane and insane. And probably people were lying about it when they filled out their exams because it just wasn't happening.

Some people it was happening and that was terrible and some people it wasn't happening and they were taking more time off than we knew. So we did ratchet down and become quite a bit stricter about time and training because that was about 2009 when people, people,

program directors, and private practices were complaining about whether residents were ready to go.

to start practicing or to start fellowship. And we realized that we didn't actually know how much time people were taking. And time was the only measure that we had. Because some programs were letting everybody take as many days as they needed for interviews. So suddenly there are 30 days missing. Some people were sending them to research weeks for, you know, two weeks at a time.

Or for whatever CM, not CME in residence, but you understand, going to conferences. You know, some people were allowing extended leave. And all of those things are valuable, but it makes it impossible to measure what you're doing. So we were like, we need to know how much time people are spending in training.

The existing rule is it's supposed to be 48 weeks. We're going to say it has to be 48 weeks. So we could start to look and say, is 48 weeks the right number instead of being like, we think it's 48, but it's actually only 43 for this group, but it's actually 50 for this other, you know, so we wanted to standardize things so that we could start to measure what was really valuable.

So I'll, you know, I'll take some responsibility for the. Or maybe a lot of responsibility for the strictness of that measure. So as

to the fellowship start date, it did start to seem inhumane. And it also seemed that a lot of people were taking those last five days of residency off, understandably to get to their fellowship.

And so we had, we cottoned on to the idea that we could do what orthopedic surgery had been doing for many years, which was to give people a gap. And it was funny because when we first threw that idea up, we're like, hey, fellowships, can you start August 1st? And they were like, absolutely not. It's completely impossible.

We can't possibly do without the residents for that month because there was going to be one transition year where that was the case. They won't have any insurance. They won't have any pay. It's completely impossible. The hospital won't let us do it. We all have a simultaneous onboarding of all residencies and we can't do it.

And to which we just kept saying, but orthopedic surgery has been doing it for like 25 years. You sure you can't do it? So it was kind of a fun process. I'm very, very good at the long game. You know, just being patient and just being like, But also orthopedic surgery can do it. Can we talk about this? So first, just a few fellowships.

It was kind of optional. And then fellowships chunk by chunk made it mandatory. And now all fellowships are almost all

fellowships start August 1st. So, if you need more time, you can extend your training without moving your fellowship start date or your new job start date by a few weeks. And all that takes is a letter to the board saying that you're going to do it from your program director.

So, I know people don't want to delay their fellowships, but that gives you a couple of extra weeks. If that's not enough, you can actually delay your fellowship until or you can extend your training until, I think it's September 1st. Again, that's just an approval from us. And the last option is the five and six, which is that you basically have up to 12 months that you can take off.

You are, you submit a schedule for how you're going to use those additional 12 months. And I'd say. Single digits of people use that every year, but people do use that every year. But that does require moving your whole planned career back a year, but still is a useful tool. So we have a fair amount of flexibility around it.

And all of that is a placeholder until we have EPAs. And then I'm not going to count days at all. Not one tiny bit. Or rotations. None of them. We're not going to be bean counters

anymore. But we didn't want to leap into a void. Like we have a standard that we use. When the other standard becomes, you know, available and viable, we'll switch to that one.

And at that point, when we get a letter from a program director saying this person had to take three months off in their PGY3 year, but we think they're superb and ready for practice, we can say, are they entrusted across their EPAs? Fine. So that's the, that's another great thing about EPAs. We don't know, we're not even gonna ask you to tell us how many days you work, because we don't care.

We just want to know that you learned the things you were supposed to learn. So as we finish up here, I would be amiss. Anytime we mentioned app site or boards, it's absolutely one of the most highly listened to podcasts that we have. So just take this opportunity. Is there anything else that you feel would be important for our listeners to kind of take away regarding the boards, the board process, anything that you want to say?

You know what? We didn't cover it here, but here's a couple of quick hitters for us. Hmm. That's a really good question. I do think that we're in flux. You know, we're always looking at our own processes, trying to make them better. You know, we're interested in how AI is going to impact

both, you know, learning, both, now I have to say three things, so learning, practice, and the exam.

So I don't know for sure that the oral exam is going to look the way it does right now in as little as three or four years. So it's hard for me to say, What to expect. I mean, my, you know, my primary recommendation is take it as soon as you can out out of your training. Take it after your P. G. Y. four year.

If you can, you know, get this stuff out of the way. The closer you are to training, the better off you are and you want to get on with the rest of your life. So the temptation, you know, I am always want to push things off to the very last second. I wouldn't even tell you the things that I've pushed off to the very last second, even within the last week.

But, but, you know, we're like, try to take them and get them out of your way. And, yeah. And I guess the other thing is, as we make these changes, you know, we look for people to try them. So were we to move to an AI Bayesian network model for, or Bayesian matrix model for the oral exams, we'll need people who already took them to take them again to, you know, to validate them.

So sort of, you know, raising a hand to collaborate with us

as we try to move in these incredibly wonderful times. I think that's the thing. But other than that, you know, my favorite thing is really EPA is it's pretty consuming right now. That's great. I think you know, I know that we at Behind the Knife are really excited for a lot of these changes and it sounds like you guys share that excitement at the board.

So, I think this is all really, really interesting and I think our listeners will definitely be invested in a lot of these changes because they will be impacted by them. Well, for taking the time to chat with us today. Scott, do you want to do the honors and give us your catchphrase at the end here?

Okay. Cool. Yeah, on behalf of all the listeners again, Joe, we just cannot thank you enough for, you know, giving us this broad overview because it, regardless, it does to anxiety and at the day, we want every one of our listeners to dominate the day.