The 2020 American Board Of Surgery Qualifying Examination: Failure, Backlash, And Response

After many years of training, I have graduated from residency and am now a board-eligible general surgeon. I was one of more than 1,000 candidates who attempted to take the American Board of Surgery (ABS) Qualifying Examination on July 16, 2020. What should have been a major milestone rapidly devolved into a nightmare, as examinees were locked out of sessions, falsely accused of violations, and unable to attain certification due to an unfortunate and exquisite failure in virtual exam administration. My fellow candidates and I await the board’s decision on what the future will hold for us.

As one might imagine, the backlash on social media was swift and fierce. I commend the ABS for unequivocally accepting responsibility for this fiasco, but as our path to certification hangs in the air, their apologies have provided little consolation or reassurance. After years of training and weeks of studying, the myriad of sacrifices and frustrations we had been gracefully repressing for the past several months reached a boiling point. We graduated from training during a global pandemic. We have shouldered the fear of contracting COVID-19 at work and bringing it home and transmitting it to our loved ones. As an Asian-American, I am unsettled by increasing hateful speech from our nation’s leaders and violence in the streets. This provides new perspective, compassion, and support for the #BlackLivesMatter movement.

Within this context, I have been distressed by the reactions of several senior surgeons to the plight of the 2020 examinees. While numerous allies have surfaced to voice their support, others have admonished us for whining or asking for a “hand-out.” A cohort of mostly white, late-career surgeons have taken to Twitter to convey the sentiment that we weak and whining millennials should be ashamed by our lack of grit and resilience.

I would like to open a dialogue with those surgeons.

I am an Asian-American woman – the first physician in my family and quite proud to be joining your ranks. I have fought to earn everything I have, and deserve to be seen as your colleague, equal, and fellow diplomate of the ABS. Nonetheless, I am able to acknowledge that there are others whose fight has been a little bit harder. I am blessed to have the financial ability to purchase test prep materials. While I have certainly experienced racial bias and sexism, I know that many of my colleagues have seen far worse. I do not have children and remain in awe of my co-residents who managed to balance surgical training and family life. Though they sometimes made it seem effortless, the effort was certainly there.

The prospect of having to prepare, again, for the ABS qualifying exam later this year has been met with dismay. You seem to think that this reaction is driven by laziness or an underlying unwillingness to dust ourselves off and adapt to circumstances that are just a little bit harder than we expected or deserved. For me, preparing for the exam during fellowship will be a hardship, an annoyance, an expense, and a major investment of time. For military surgeons, the delay in certification will translate into thousands of dollars in lost earnings. For those facing a frightening job market, lack of certification will result in diminishing job opportunities amidst ongoing hiring freezes. For others, this could pose an insurmountable barrier to certification.

Earlier this year, Yeo and colleagues published their study, which showed that after controlling for performance on the ABSITE, women with children and racial minorities were less likely to pass the boards on their first attempt. As we, as a profession, strive to build a diverse and inclusive surgical workforce, we must re-examine our longstanding traditions and consider the possibility that what some view as a rite of passage may, in reality, contribute to the systematic exclusion of others.

Before you accuse someone who, like you, has chosen a future dedicated to caring for patients, I urge you to pause and reflect on the possibility that, although you have both arrived at the same destination, he/she/they may have walked a path that was just a little bit harder in order to get there. Perhaps your judgments on worthiness and resilience will fall away. Maybe then you will wonder how you could help this colleague make that path a little bit easier for all the hopeful and hardworking trainees following in their footsteps. Sometimes, a little bit can be everything.

Elizabeth J. Lilley is a surgeon.

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