By Marilynn Larkin

Recent evidence suggests that more cardiologists are failing to pass their boards. Pass rates declined from a high of 96% in 2018 to a low of 86% in 2021 and 2022. COVID disruptions to training may be largely to blame, experts said.

Among the 1061 candidates who took their first American Board of Internal Medicine (ABIM) cardiovascular (CV) disease exam in 2022, about 80 fellows failed who might have passed had they trained in 2016-2019, according to Anis John Kadado, MD, University of Massachusetts Medical School-Baystate Campus, Springfield, Massachusetts, and colleagues.

"The purpose of board examinations is to test the knowledge, core concepts, and fundamental principles of trainees as they deliver patient care," said Kadado. "The decline in CV board pass rates reflects a potential gap in training, which may translate to suboptimal patient care."

Why the Downturn?

Reasons for the increased failures are likely multifactorial, Kadado said. While some blame the ABIM, the exam has remained about the same over the past 6 years, so the test itself seems unlikely to explain the decline.

The main culprit, according to the viewpoint authors, is "the educational fallout from the disruptions caused by changes made in response to the COVID pandemic." Changes that Kadado and colleagues said put the current class of graduating fellows at "high risk" of failing their boards in the fall.

The typical cardiology fellowship is 3 years or more for subspecialty training. Candidates who took the ABIM exam in 2021 had 18 months of training that overlapped with the pandemic response, and those who took the exam in 2022 had about 30 months of training disrupted by COVID. However, fellows who first took the exam in 2023 had essentially 36 months of training affected by COVID, potentially reducing their odds of passing.

"It is hard, if not impossible, to understand the driving forces for this recent decrease in performance on the initial ABIM certification examination, nor is it possible to forecast if there will be an end to this slide," Jeffrey T. Kuvin, MD, chair of cardiology at the Zucker School of Medicine at Northwell Health, Manhasset, New York, and colleagues wrote in response to the viewpoint article.

The authors acknowledged that COVID disrupted graduate medical training and that the long-term effects of the disruption are now emerging. However, they also pinpoint other potential issues affecting fellows, including information/technology overload, a focus on patient volume over education, lack of attention to core concepts, and, as Kadado and colleagues noted, high burnout rates among fellows and knowledge gaps due to easy access to electronic resources rather than reading and studying to retain information.

COVID disruptions included limits on in-person learning, clinic exposure, research opportunities, and conference travel, according to the authors. From a 2020 viewpoint, Kuvin also noted the loss of bedside teaching and on-site grand rounds.

Furthermore, with deferrals of elective cardiac, endovascular, and structural catheterization procedures during the pandemic, elective cases normally done by fellows were postponed or cancelled.

Restoring Education, Board Passing Rates

"Having recently passed the ABIM cardiovascular board exam myself, my take-home message at this point is for current fellows-in-training to remain organized, track training milestones, and foresee any training shortcomings," Kadado said. Adding that fellows, graduates and leadership should "identify deficiencies and work on overcoming them."

The viewpoint authors suggested strategies that fellowship leadership can use. These include:

-Regularly assessing faculty emotional well-being and burnout to ensure that they are engaged in meaningful teaching activities

-Emphasizing in-person learning, meaningful participation in conferences, and faculty oversight

-Encouraging fellows to pursue "self-directed learning" during off-hours

-Developing and implementing checklists, competency-based models, curricula, and rotations to ensure that training milestones are being met

-Returning to in-person imaging interpretation for imaging modalities such as echocardiography, cardiac CT, and cardiac MRI

-Ensuring that fellows take the American College of Cardiology in-training examination

-Providing practice question banks so that fellows can assess their knowledge gaps

"This might also be an opportune time to assess the assessment," Kuvin and colleagues noted. "There are likely alternative or additional approaches that could provide a more comprehensive, modern tool to gauge clinical competence in a supportive manner."

They suggested that these tools could include assessment by simulation for interventional cardiology and electrophysiology, oral case reviews, objective structured clinical exams, and evaluations of nonclinical competencies such as professionalism and health equity.

Implications for the New Cardiology Board

While the ABIM cardiology board exam days may be numbered, board certification via some type of exam process is not going away.

The ACC and four other US CV societies — the AHA, the Heart Failure Society of America, the Heart Rhythm Society, and the Society for Cardiovascular Angiography & Interventions — formally announced in September that they have joined forces to propose a new professional certification board called the American Board of Cardiovascular Medicine (ABCVM). The application to the ABMS for a separate cardiology board is still ongoing and will take time.

An initial certification exam would still be required after fellowship training, but the maintenance of certification process would be completely restructured.

Preparing for the new board will likely be "largely the same" as for the ABIM board, Kadado said. "This includes access to practice question banks, faculty oversight, strong clinical exposure and practice, regular didactic sessions, and self-directed learning."

"Passing the board exam is just one step in our ongoing journey as a cardiologist," he added. "Our field is rapidly evolving, and continuous learning and adaptation are part of the very essence of being a healthcare professional."