Lela A. Lee, MD

Older dermatologists may recall (or may have expunged from memory) taking the American Board of Dermatology (ABD) certification examination at the Holiday Inn in Rosemont, Illinois. I remember schlepping a borrowed microscope from Denver, Colorado; penciling in answers to questions about slides projected on a screen; and having a proctor escort me to the bathroom. On the flight home, the pilot kept my microscope in the cockpit for safekeeping.

Much has changed since then. Today’s examination takes 1 day instead of 2, is in July instead of October, and airline security would never allow me to stow a microscope in the pilot’s cabin. The content of the examination also has evolved. No longer does one have to identify yeasts and fungi in culture—a subject I spotted the ABD and hoped for the best—and surgery is a much more prominent part of the examination.

Nevertheless, over the years the examination continued to emphasize book knowledge and visual pattern recognition. Although they are essential components of being an effective dermatologist, there are other important factors. Many of these can be classified under the term clinical judgment, the ability to make good decisions that take into account the individual patient and situation.

In 2013, the ABD Board of Directors began the process of making fundamental changes in the certification examination with the goal of making it a better test of clinical competence. The process has included matters such as finding the correct technical consultant for examination development and psychometrics, writing and vetting new types of questions, gathering input from program directors, and building the electronic infrastructure to support these changes.

The structure of the new examination is based on a natural progression of learning, from mastering the basics, to acquiring more advanced knowledge, to applying that knowledge in clinical situations. It consists of the following:

• BASIC Exam, a test of fundamentals obtained during the first year of dermatology residency
• CORE Exam, a modular examination emphasizing the more comprehensive knowledge base obtained during the second and third years of residency
• APPLIED Exam, a case-based examination testing ability to apply knowledge appropriately in clinical situations

These new examinations will replace the In-Training Exam and the current certification examination, beginning with the cohort of residents entering dermatology training in July 2017.

The BASIC Exam is designed to test fundamentals such as visual recognition of common diseases, management of uncomplicated conditions, and familiarity with standard procedures. The purposes of the examination are to measure progress, to identify residents who are having difficulty, and to ensure that residents actually master the basics that we sometimes take for granted that they know. It is not a pass/fail examination and thus technically is not part of certification. A detailed content outline for the BASIC Exam can be found on the ABD website.¹ Because it is a new examination, it is anticipated that the content will be modified as we gain experience with it and obtain feedback from program directors as to how its usefulness may be improved.

The CORE Exam is designed to test a more advanced, clinically relevant knowledge base. It is part of the certification examination and consists of 4 modules: medical, pediatric, surgical, and dermatopathology. Basic science related to these clinical areas is included within each module. Each module consists of 75 to 100 questions and takes 1.5 to 2 hours. Modules are offered on 4 occasions during residency, beginning in the spring of the second year. Modules do not have to be taken in a specific order, and they do not have to be taken in 1 sitting. For example, a resident could choose to take the surgery module during the second year but wait until later in the third year to take the dermatopathology module, depending on when the resident feels prepared. If a module is not passed, it can be retaken at a subsequent offering without prejudice. All 4 modules must be passed to sit for the APPLIED Exam. Travel to a test center is not required; remote proctoring is available online.

The APPLIED Exam is the centerpiece of the new examinations and tests the ability to apply knowledge appropriately in clinical situations. It is case based and ranges from straightforward (most likely diagnosis based on examination) to complex (how to manage pemphigus not responding to the initial treatment in a patient with multiple comorbidities). It is designed to test skills such as knowing when additional information is needed and when it is not, recognizing when referral is indicated, modifying management depending on response to therapy, and recognizing and managing complications. The unique characteristics of an individual patient including patient preferences, ability to comprehend and communicate, comorbidities, financial considerations, and other concerns, will need to be taken into account. The APPLIED Exam will be given in July following completion of residency.

Writing knowledge-based questions with straightforward answers in a psychometrically valid format is actually rather challenging, as first-time question writers discover. Writing items (questions) that test clinical judgment is considerably more difficult. One of the challenges is ensuring that there truly is agreement about the answers. To ensure that there is consensus, we have initiated a new process in item vetting. Rather than sit around a table and come to consensus, a process that could be dominated by experts in a particular area or those with the strongest opinions, committees first vet new questions through a blinded review. Each committee member takes the “test” from home without knowledge of what is supposed to be the correct answer. The responses are anonymous, so members feel free to respond candidly. Then, at the in-person meeting, the anonymous blinded review responses are evaluated and the items are discussed. We have found the blinded review to be invaluable, not just for items testing judgment but for all items.

An enormous amount of work has been put into preparing for the new examinations. Item-writing committees have been working enthusiastically to develop questions. There also is a great deal of work that goes on beyond the ABD. The ABD must contract with vendors for the electronic item bank, editing, psychometrics quality control and scoring, electronic publishing of the examination, virtual dermatopathology, website software for examination registration and reporting, and proctoring. Although developing new examinations is a costly enterprise, the ABD is committed not to increase the financial burden for residents and can use reserve funds to defray new examination development expenses. To keep expenses low during training, we will not charge residents an examination fee for the CORE modules, though they will pay a modest proctoring fee to the proctoring vendor. Also, instead of traveling to Tampa, Florida, in July, candidates will take the APPLIED Exam at a nearby Pearson VUE test center.

It will be the end of an era. Perhaps some of us will feel a little nostalgia for the Rosemont Holiday Inn and the fungal cultures, but I doubt it. Sample items for the 3 examinations, content overviews, frequently asked questions, and more information about the Exam of the Future can be found on the ABD website.²

Older dermatologists may recall (or may have expunged from memory) taking the American Board of Dermatology (ABD) certification examination at the Holiday Inn in Rosemont, Illinois. I remember schlepping a borrowed microscope from Denver, Colorado; penciling in answers to questions about slides projected on a screen; and having a proctor escort me to the bathroom. On the flight home, the pilot kept my microscope in the cockpit for safekeeping.

Much has changed since then. Today’s examination takes 1 day instead of 2, is in July instead of October, and airline security would never allow me to stow a microscope in the pilot’s cabin. The content of the examination also has evolved. No longer does one have to identify yeasts and fungi in culture—a subject I spotted the ABD and hoped for the best—and surgery is a much more prominent part of the examination.

Nevertheless, over the years the examination continued to emphasize book knowledge and visual pattern recognition. Although they are essential components of being an effective dermatologist, there are other important factors. Many of these can be classified under the term clinical judgment, the ability to make good decisions that take into account the individual patient and situation.

In 2013, the ABD Board of Directors began the process of making fundamental changes in the certification examination with the goal of making it a better test of clinical competence. The process has included matters such as finding the correct technical consultant for examination development and psychometrics, writing and vetting new types of questions, gathering input from program directors, and building the electronic infrastructure to support these changes.

The structure of the new examination is based on a natural progression of learning, from mastering the basics, to acquiring more advanced knowledge, to applying that knowledge in clinical situations. It consists of the following:

• BASIC Exam, a test of fundamentals obtained during the first year of dermatology residency
• CORE Exam, a modular examination emphasizing the more comprehensive knowledge base obtained during the second and third years of residency
• APPLIED Exam, a case-based examination testing ability to apply knowledge appropriately in clinical situations

These new examinations will replace the In-Training Exam and the current certification examination, beginning with the cohort of residents entering dermatology training in July 2017.

The BASIC Exam is designed to test fundamentals such as visual recognition of common diseases, management of uncomplicated conditions, and familiarity with standard procedures. The purposes of the examination are to measure progress, to identify residents who are having difficulty, and to ensure that residents actually master the basics that we sometimes take for granted that they know. It is not a pass/fail examination and thus technically is not part of certification. A detailed content outline for the BASIC Exam can be found on the ABD website.¹ Because it is a new examination, it is anticipated that the content will be modified as we gain experience with it and obtain feedback from program directors as to how its usefulness may be improved.

The CORE Exam is designed to test a more advanced, clinically relevant knowledge base. It is part of the certification examination and consists of 4 modules: medical, pediatric, surgical, and dermatopathology. Basic science related to these clinical areas is included within each module. Each module consists of 75 to 100 questions and takes 1.5 to 2 hours. Modules are offered on 4 occasions during residency, beginning in the spring of the second year. Modules do not have to be taken in a specific order, and they do not have to be taken in 1 sitting. For example, a resident could choose to take the surgery module during the second year but wait until later in the third year to take the dermatopathology module, depending on when the resident feels prepared. If a module is not passed, it can be retaken at a subsequent offering without prejudice. All 4 modules must be passed to sit for the APPLIED Exam. Travel to a test center is not required; remote proctoring is available online.

The APPLIED Exam is the centerpiece of the new examinations and tests the ability to apply knowledge appropriately in clinical situations. It is case based and ranges from straightforward (most likely diagnosis based on examination) to complex (how to manage pemphigus not responding to the initial treatment in a patient with multiple comorbidities). It is designed to test skills such as knowing when additional information is needed and when it is not, recognizing when referral is indicated, modifying management depending on response to therapy, and recognizing and managing complications. The unique characteristics of an individual patient including patient preferences, ability to comprehend and communicate, comorbidities, financial considerations, and other concerns, will need to be taken into account. The APPLIED Exam will be given in July following completion of residency.

Writing knowledge-based questions with straightforward answers in a psychometrically valid format is actually rather challenging, as first-time question writers discover. Writing items (questions) that test clinical judgment is considerably more difficult. One of the challenges is ensuring that there truly is agreement about the answers. To ensure that there is consensus, we have initiated a new process in item vetting. Rather than sit around a table and come to consensus, a process that could be dominated by experts in a particular area or those with the strongest opinions, committees first vet new questions through a blinded review. Each committee member takes the “test” from home without knowledge of what is supposed to be the correct answer. The responses are anonymous, so members feel free to respond candidly. Then, at the in-person meeting, the anonymous blinded review responses are evaluated and the items are discussed. We have found the blinded review to be invaluable, not just for items testing judgment but for all items.

An enormous amount of work has been put into preparing for the new examinations. Item-writing committees have been working enthusiastically to develop questions. There also is a great deal of work that goes on beyond the ABD. The ABD must contract with vendors for the electronic item bank, editing, psychometrics quality control and scoring, electronic publishing of the examination, virtual dermatopathology, website software for examination registration and reporting, and proctoring. Although developing new examinations is a costly enterprise, the ABD is committed not to increase the financial burden for residents and can use reserve funds to defray new examination development expenses. To keep expenses low during training, we will not charge residents an examination fee for the CORE modules, though they will pay a modest proctoring fee to the proctoring vendor. Also, instead of traveling to Tampa, Florida, in July, candidates will take the APPLIED Exam at a nearby Pearson VUE test center.

It will be the end of an era. Perhaps some of us will feel a little nostalgia for the Rosemont Holiday Inn and the fungal cultures, but I doubt it. Sample items for the 3 examinations, content overviews, frequently asked questions, and more information about the Exam of the Future can be found on the ABD website.²

Older dermatologists may recall (or may have expunged from memory) taking the American Board of Dermatology (ABD) certification examination at the Holiday Inn in Rosemont, Illinois. I remember schlepping a borrowed microscope from Denver, Colorado; penciling in answers to questions about slides projected on a screen; and having a proctor escort me to the bathroom. On the flight home, the pilot kept my microscope in the cockpit for safekeeping.

Much has changed since then. Today’s examination takes 1 day instead of 2, is in July instead of October, and airline security would never allow me to stow a microscope in the pilot’s cabin. The content of the examination also has evolved. No longer does one have to identify yeasts and fungi in culture—a subject I spotted the ABD and hoped for the best—and surgery is a much more prominent part of the examination.

Nevertheless, over the years the examination continued to emphasize book knowledge and visual pattern recognition. Although they are essential components of being an effective dermatologist, there are other important factors. Many of these can be classified under the term clinical judgment, the ability to make good decisions that take into account the individual patient and situation.

In 2013, the ABD Board of Directors began the process of making fundamental changes in the certification examination with the goal of making it a better test of clinical competence. The process has included matters such as finding the correct technical consultant for examination development and psychometrics, writing and vetting new types of questions, gathering input from program directors, and building the electronic infrastructure to support these changes.

The structure of the new examination is based on a natural progression of learning, from mastering the basics, to acquiring more advanced knowledge, to applying that knowledge in clinical situations. It consists of the following:

• BASIC Exam, a test of fundamentals obtained during the first year of dermatology residency
• CORE Exam, a modular examination emphasizing the more comprehensive knowledge base obtained during the second and third years of residency
• APPLIED Exam, a case-based examination testing ability to apply knowledge appropriately in clinical situations

These new examinations will replace the In-Training Exam and the current certification examination, beginning with the cohort of residents entering dermatology training in July 2017.

The BASIC Exam is designed to test fundamentals such as visual recognition of common diseases, management of uncomplicated conditions, and familiarity with standard procedures. The purposes of the examination are to measure progress, to identify residents who are having difficulty, and to ensure that residents actually master the basics that we sometimes take for granted that they know. It is not a pass/fail examination and thus technically is not part of certification. A detailed content outline for the BASIC Exam can be found on the ABD website.¹ Because it is a new examination, it is anticipated that the content will be modified as we gain experience with it and obtain feedback from program directors as to how its usefulness may be improved.

The CORE Exam is designed to test a more advanced, clinically relevant knowledge base. It is part of the certification examination and consists of 4 modules: medical, pediatric, surgical, and dermatopathology. Basic science related to these clinical areas is included within each module. Each module consists of 75 to 100 questions and takes 1.5 to 2 hours. Modules are offered on 4 occasions during residency, beginning in the spring of the second year. Modules do not have to be taken in a specific order, and they do not have to be taken in 1 sitting. For example, a resident could choose to take the surgery module during the second year but wait until later in the third year to take the dermatopathology module, depending on when the resident feels prepared. If a module is not passed, it can be retaken at a subsequent offering without prejudice. All 4 modules must be passed to sit for the APPLIED Exam. Travel to a test center is not required; remote proctoring is available online.

The APPLIED Exam is the centerpiece of the new examinations and tests the ability to apply knowledge appropriately in clinical situations. It is case based and ranges from straightforward (most likely diagnosis based on examination) to complex (how to manage pemphigus not responding to the initial treatment in a patient with multiple comorbidities). It is designed to test skills such as knowing when additional information is needed and when it is not, recognizing when referral is indicated, modifying management depending on response to therapy, and recognizing and managing complications. The unique characteristics of an individual patient including patient preferences, ability to comprehend and communicate, comorbidities, financial considerations, and other concerns, will need to be taken into account. The APPLIED Exam will be given in July following completion of residency.

Writing knowledge-based questions with straightforward answers in a psychometrically valid format is actually rather challenging, as first-time question writers discover. Writing items (questions) that test clinical judgment is considerably more difficult. One of the challenges is ensuring that there truly is agreement about the answers. To ensure that there is consensus, we have initiated a new process in item vetting. Rather than sit around a table and come to consensus, a process that could be dominated by experts in a particular area or those with the strongest opinions, committees first vet new questions through a blinded review. Each committee member takes the “test” from home without knowledge of what is supposed to be the correct answer. The responses are anonymous, so members feel free to respond candidly. Then, at the in-person meeting, the anonymous blinded review responses are evaluated and the items are discussed. We have found the blinded review to be invaluable, not just for items testing judgment but for all items.

An enormous amount of work has been put into preparing for the new examinations. Item-writing committees have been working enthusiastically to develop questions. There also is a great deal of work that goes on beyond the ABD. The ABD must contract with vendors for the electronic item bank, editing, psychometrics quality control and scoring, electronic publishing of the examination, virtual dermatopathology, website software for examination registration and reporting, and proctoring. Although developing new examinations is a costly enterprise, the ABD is committed not to increase the financial burden for residents and can use reserve funds to defray new examination development expenses. To keep expenses low during training, we will not charge residents an examination fee for the CORE modules, though they will pay a modest proctoring fee to the proctoring vendor. Also, instead of traveling to Tampa, Florida, in July, candidates will take the APPLIED Exam at a nearby Pearson VUE test center.

It will be the end of an era. Perhaps some of us will feel a little nostalgia for the Rosemont Holiday Inn and the fungal cultures, but I doubt it. Sample items for the 3 examinations, content overviews, frequently asked questions, and more information about the Exam of the Future can be found on the ABD website.²