Third time’s the charm

First round: I just don’t know

My first attempt for the CCFP took place in 2010 at a centre that had been my last choice among the possible sites, some 400 km away from home. That fall, as I drove into the city, its unfamiliar roads and unique regulations baffled me. When I finally arrived and checked in to the hotel next to the examination centre, I met a few residents from my department, and naturally they requested my help in coaching them for the simulated office orals (SOOs), 1 of 2 components of the examination. I only had a few turns to practise being the candidate, as I spent my time acquainting the residents with the necessary skills and knowledge. I skimped on my preparation for the short-answer medical problems (SAMPs), the written component of the examination, and did not go through the 99 priority topics and key features of the evaluation objectives from the College website. I had brought along past SAMPs questions but did not bother to flip through them, convinced that I could rely on my daily working knowledge. Regret soon overtook me, as I found the actual SAMPs paper contained most, if not all, of the 99 topics. Gaps in my knowledge translated to blanks in the answer book, but I consoled myself, rationalizing that it had been a tough paper. For the SOO examination, my strategy was based on the marking schemes that I knew so well. Oddly enough, the simulated patients were pretty passive in response to my questioning, giving only yes and no answers. Oh well, perhaps it was one of their ploys. The examination weekend over, I drove back home, not too concerned. Six weeks passed uneventfully, until I received the results of a double failure. Not only was I shell-shocked, my ego was badly bruised—all the residents that I had coached that day had passed! Amid my confusion and disappointment, I applied for feedback from the College, hoping to understand what had gone wrong. At the same time, I excused myself as best I could from delivering teaching related to the Certification examination.

Second round: I just don’t know enough

Convinced by a few colleagues that I had failed because of sheer bad luck, I set forth on a second attempt. To play it safe, I flew to Saskatchewan for a CCFP study course to boost my ego and brush up my examination techniques in preparation for the spring sitting. This time I went through the 99 key topics and circled the ones I reckoned to be the hot topics. I read guidelines from suggested websites to enrich the bank of my skills and knowledge. I practised more SOOs, as a candidate this time, giving due respect to the 15-minute time limit and using the required FIFE (feelings, ideas, function, and expectations) approach to questioning, to determine the problem’s effects on my patient. I also took some time off work for self-study. I was pleased to realize the knowledge gaps revealed by my first CCFP attempt were gradually closing.

The examination weekend arrived. On this occasion, the College had assigned me to take the examination in my hometown, and I was delighted to save the transportation and lodging costs. As I finished the written portion, I felt more confident about the results. At least I had answered all the SAMPs, leaving none blank. I also took more time to listen during the SOOs, and the examiner-“patients” seemed more engaged and interested. But just when I was convinced I had surely passed, I got the results: I had failed the SAMPs but passed the SOOs. What a joke. How could that be? I was mired in denial for the next 2 weeks. They must have miscalculated my marks; it had happened twice in my previous school years. I filed an appeal to the College; nevertheless, the decision stood.

Third round: now I know

My hopes down the drain, I was by now really irate with myself. The days of the following summer dragged, my frustration exacerbated by an untimely letter from my department requesting my CCFP before the July 1, 2012, deadline from the College of Physicians and Surgeons of Ontario. I frantically sought out other routes to Certification. The CFPC’s Alternative Route to Certification looked feasible, yet on further inquiry I was told I was ineligible because I had yet to accrue 5 years of practice experience in Canada—a milestone that I would not reach until after July 1, 2012. I had thoroughly discouraged myself from a third attempt by the traditional route, reasoning that the odds for success would be about the same as those for passing the driving test after failing twice: dismal. To make things worse, with my consecutive failures on the examination, there were speculations among my colleagues about my competence as a preceptor in family medicine.

One morning, as I was overwhelmed with stress and frustration, a Chinese proverb suddenly flashed into my mind: Within every crisis, there is a turning point. Without hesitation, I submitted the application for my third and final Certification attempt. To ensure I left no stone unturned, I went through each of the 99 topics and embraced every single one, devouring the available guidelines and reading materials from textbooks and electronic sources (MEDLINE, EMBASE, and UpToDate). I read through all materials religiously and reviewed the whole set twice before the examination. I attended yet another SOO training workshop to make sure my skills were maintained. When I finished the examination in fall 2011, I realized I had enjoyed it—I felt that I had given the correct answer for 95% of the SAMPs, and I had sailed through all 5 SOOs, totally oblivious to the fact that I was a candidate! When the time came for me to get my results online, my wife was on tenterhooks but I barely held my breath. And I passed, thank God!

A few reflections

Some time later, as I enjoyed my mug of hot chocolate on Christmas Eve, I wondered how many practising family physicians would attempt the CCFP the way I did via the practice-eligible route. A quick PubMed search returned a graph from an article in Canadian Family Physician written by Handfield-Jones and Rainsberry,¹ plotting the ratio of practice-eligible versus residency candidates as ranging from 1:1 in 1977 to 1:20 in 1990. Data for subsequent years were unavailable. How about the CCFP passing rate for practice-eligible candidates? Well, it was described as “somewhat higher,” without any accompanying figures, in another article by the same authors and their colleagues.² How about my being an international medical graduate (IMG), did that put me at a big disadvantage for writing the CCFP examination? Andrew³ in British Columbia and MacLellan and colleagues⁴ in Quebec analyzed the performance of IMG residents taking the Certification Examination and found that the passing rate was 56% to 58%, versus 93% to 95% for their Canadian non-IMG cohorts. Finally, for those repeat examination takers, how successful could they be? How many practice-eligible candidates had failed all 3 attempts? Why limit them to 3 attempts and not give them, say, 5? I could not find any answers to these questions, despite an extensive search. Nevertheless, the American Board of Family Medicine, the sister college of our CFPC, annually discloses the passing statistics for its Board Certification Examination, stating that IMG candidates are 20% less likely to pass than their US colleagues, and that their repeat attempts have a success rate of only 50%.⁵ While language proficiency, cultural differences, and knowledge mismatch are recognized as factors in IMGs’ lower rates of passing professional examinations, one must also acknowledge the variations in scope and objectives upheld by certifying examinations of different geographical jurisdictions. Reverse the point of view for a moment and consider how any graduate from a Canadian medical school following residency training in China might experience a similarly low passing rate for the local board certification examination! Recalling my experience in specialist examinations in family medicine from other countries, I knew the Fellowship Examination of the Royal Australian College of General Practitioners required more detailed clinical knowledge, to the level of hospital internist, while the Membership Examination of the UK Royal College of General Practitioners focused more on practical issues such as clinic administration, preventive care programs, and ethical dilemmas. Our College’s CCFP examination has patient-centred care as the kernel of the discipline of family medicine, hence requiring candidates to enact such skills in a clear and precise manner to achieve a pass. As an IMG and a practice-eligible candidate, I had foundations in the UK and Australian philosophies of family medicine, which might have obscured for me the focuses of Canadian family medicine practice as stipulated by the CFPC. Should there be a global consensus on best practice in family medicine anyway?

Epilogue

I believe everything happens for a reason. It was obvious that I failed my CCFP examination twice because I underestimated my deficiencies and relied too heavily on my practical knowledge. Contrary to common belief, I was more handicapped than advantaged by being a family medicine preceptor, which had biased my mindset in one way or another in preparing for Certification. The turning point in my crisis only came when I let go of my “old self” and reincarnated as a learner and examination candidate.

Learning is indeed lifelong, and change is continuous. In fact, the Certification Examination itself has evolved since I wrote it in 2011, now including an objective structured clinical examination component as part of the written segment, in addition to the SAMPs. Despite other practice-eligible candidates’ perception that the CCFP examination is insurmountable, I have personally concluded, after 3 attempts, that it has been extremely fair and consistent, mandating a level of knowledge and consulting skills that one would expect from a specialist in family medicine. In a way, I felt proud to be endorsed for such professional competence as a family physician in Canada. The journey toward successful Certification was a great and humbling experience for me, reminding me not to take certain knowledge and skills for granted. According to a statement issued in 2007 by the Federation of Medical Regulatory Authorities of Canada Revalidation Working Group, evidence is still lacking as to how well continuing professional development programs enable family physicians to translate the acquired knowledge and skills into clinical practice,⁶ hence putting into question the actual value of continuing professional development in professional revalidation. This uncertainty fuels the debate about whether all family physicians in Canada should follow the example of their American colleagues, who must recertify themselves every 10 years by resitting the board examination in order to renew their practising licences.

Writing the Certification Examination as a practising physician was stressful and challenging for me. Yet, thinking about the differences in how I practise and teach my learners now, I realize it was definitely a worthwhile experience that I would highly recommend to all practice-eligible colleagues contemplating the examination.