We'll always have Louisville

I stayed at the Hampton Inn, across the street from the notoriously janky Executive West hotel near the Louisville airport. On the morning of my exam, I dutifully put on my suit and tie, double and triple checked my fly, then looked at myself in the mirror. I started pacing the room, trying to desperately recall vascular anatomy mnemonics, patterns of dwarfism, and nuclear medicine QA regulations. As I paced, I realized I was pretty tachycardic so I stopped and took a few deep breaths. I couldn’t get my heart rate to slow down and I felt like I was teetering on the brink of a panic attack. I am a calm person, generally speaking, but I was rattled.

The ABR (with program directors and chairs whispering in their collective ear) said that too much of the fourth year of residency was spent preparing for the oral exam which usually took place in June right before graduation (after intensively prepping from the previous January). Many residents were purposely put on less demanding clinical rotations (or no rotation at all) so they could attend the numerous hot seat board reviews that were scheduled every day. Why should programs be deprived of the most experienced residents during the last half of the year? A fair question, but I suspect the loudest of these voices came from programs that were, despite ACGME rules to the contrary, wholly dependent upon residents to get the work done. Will the new oral exam be administered during residency or after? Will the educational onus be placed on the residency programs (of whom, an ever-expanding fraction of their junior and mid tier faculty have never experienced oral boards or hot seats) or on the private practices (in which case you should buy stock in every hot seat prep course company you can find lol)?

When I became an examiner, it took several tries to get comfortable with what passing should look like; my expectations for the DR oral exam versus the IR oral exam were different: DR folks should not kill anyone and IR folks should do good for everyone. It was very rare to outright fail a candidate and when you did, your decision was reviewed by your group of examiner peers and the lead examiner. It was possible to review every case for every candidate as we were encouraged to keep meticulous notes from all of the reviewed cases. These decisions were never taken lightly and gut-wrenching. Variability in pass or failure rate was unavoidable from year to year (there was no quota, obviously) but examiners tried to be consistent in our expectations. True story: I was interviewing for a job and had individual meetings with faculty across the entire department. One of them reminded me that I had failed them on their oral exam. Cue the awkward music.

While I felt a duty and responsibility to the specialty to be an oral examiner, it was exhausting work. There are apocryphal stories of examiners packing their bags behind the back of an examinee who was discussing a case. I can relate: after several days of grinding work in a crappy hotel room, you just want to get out of there and go home! Aside from the $70 per diem and paid travel expenses, the only real compensation was getting to spend the after hours (and breaks) with your peers from around the country. It was like a gathering of the tribe (in Tucson or Louisville)- it was a cherished opportunity to connect with old friends and make new ones. I miss those days. I was an examiner during the last IR oral boards exam in Louisville: I watched Ann Covey ring the chimes for the proverbial last time. Trust me, none of the examiners were crying in their beer.

There was, I imagine, substantial expense associated with travel, accommodations, food, associated staff, and IT expenses with an in-person oral exam format (even though the rooms at the Executive West really should be free given how skeezy they were). Organizing the hundreds of examiners alone was a Herculean task. While a virtual format will mitigate some of the expenses for the ABR, the experience as an examiner will be significantly downgraded: no more in person camaraderie, no more networking, no more hotel room practical jokes and hijinks. I really do hope that the ABR offers a more meaningful acknowledgement of the examiners’ efforts, like not having to pay for a year’s dues in return for the hard and stressful work of examining.

On social media, most if not all of the pearl clutching about reinstatement of the oral boards structure is coming from folks who never went through it. I emphatically note that I am not the tacit “spokesperson” for my generation but it is my own observation that *most* folks of my era see the value of returning to an oral examination structure. I think there is very little of the “well, if I did it, you should do it too” attitude. Rather, I suspect that, like me, many more experienced radiologists have also observed that the overall ability of residents to eloquently and efficiently discuss an imaging study has diminished. When combined with the commoditization of diagnostic imaging and the increase in remote work, this diminished skill needs to be reemphasized lest we continue down the path of making it easier and easier to replace us completely.