No One's Talking About It': Infertility and Rad Onc Board Exams - Medscape

Laura Dover, MD, had carefully timed her pregnancy around the four exams required to achieve board certification in radiation oncology. But when the pandemic hit in 2020, the final test, offered each May, was pushed to October — the week of her due date.

It would be impossible for her to fly the 2500 miles from New York to the test site in Tucson, Arizona, when she could go into labor at any moment. She asked the American Board of Radiology — which oversees the process — if she could take the oral exam on Zoom or shift the timing a few weeks earlier or later.

The response: If she "decided" not to sit for the exam in-person on the date specified, she would have to wait an entire year for the next test.

"I felt: Angry. Sad. Helpless. Inconsequential," Dover tweeted. "But I will not be silent."

The experience motivated Dover and six colleagues to conduct a study about how radiation oncology's onerous four-exam board certification process has disproportionately burdened women.

The study, published online in Practical Radiation Oncology on November 3, revealed that almost 60% of the early-career female radiation oncologists surveyed had delayed or were timing their pregnancies to accommodate their board exams. Women who chose to delay pregnancy were 2.5 times more likely to experience infertility.

"When we started doing the study, we didn't realize just how common it was for people to wrap so much of their [family planning decisions] around taking these board exams," said study co-author Adrianna Henson Masters, MD, a radiation oncologist at Springfield Clinic in Springfield, Illinois. "How crazy is that? And no one's talking about it."

However, once the study appeared online, physicians took to Twitter to comment on the challenges of the board certification process, while others demanded change. One radiation oncologist even shared her decision not to have a child until she passed her board exams.

The study also got the attention of the American Board of Radiology, which governs certification for the specialty. In a response, leaders of the organization agreed that "the issues raised are significant and worthy of thoughtful consideration" and highlighted how, in light of the COVID-19 pandemic, the Board has provided greater flexibility to the exam process — transitioning to remote testing and offering two dates for each exam in 2021.

But will the changes last? And will they help reduce the burden these exams place on families and family planning?

Inside Board Certification Before the Pandemic

While other specialties require one or two exams for board certification, radiation oncology is the only medical field that requires candidates pass four exams — three qualifying written tests, followed by a certifying oral exam. Since 2004, these exams, which cover physics, radiation biology, and clinical radiation oncology, have taken place over 3 years at specific locations across the country.

Radiation oncology residents have reported spending hundreds of hours preparing for each of these high-stakes evaluations. Fail or miss one and an already time-consuming process draws out, with major repercussions for career advancement and earnings.

"Passing and achieving board certification is the capstone of medical specialty training and, for many, is a prerequisite for attaining partnership or a promotion," said study co-author Chelain Goodman, MD, PhD, a radiation oncologist at MD Anderson Cancer Center in Houston, Texas.

To top it off, this process may be contributing to the gender disparity in radiation oncology, the study suggests. Only 25% to 30% of practicing radiation oncologists are women, making it one of the lowest-ranking specialties when it comes to female representation.

"I think [this exam process] creates some disincentive when female medical students see that these are issues that early-career radiation oncologists are facing," said Dover, who practices at Memorial Sloan Kettering Cancer Center in New York City. "[Students may instead] choose a specialty that they believe will be more supportive of them and their family planning goals. That's definitely a big concern for a field that wants to attract the top candidates."

For those who do pick radiation oncology, the system of board exams often requires prospective parents to choose among three options: Try to time delivery before or between exams, put off pregnancy or adoption until exams are done, or delay board certification.

A Balancing Act: Board Exams and Family Planning

Like Dover, Masters opted for door number 1. She tried to time the birth of her daughter to fall several months before her first board exam.

She hoped her careful planning would reduce the stress of both major life events. But that was not the case. At 35 weeks, Masters found herself in the hospital with preeclampsia and symptomatic hypertension.

While receiving a magnesium sulfate drip to prevent a seizure, she frantically typed her patient list before her vision got too blurry to see the screen.

"That is ridiculous," Masters said. "But so is a system that makes this the expectation [for pregnant physicians]."

During her hospital stay, Masters was induced. She suspects the stress of prepping for the board exam coupled with being pregnant and continuing to work long hours as a resident contributed to her pregnancy complications.

This juggling act can bleed into exam day as well. When interviewing women for their study, Masters and colleagues uncovered personal accounts of the challenges pregnant women and new mothers faced during their exams.

One woman described being granted lactation accommodation ahead of time, but when she arrived for her first two written exams, the testing center had no record of her request. She ended up breast-pumping in a coat closet next to the cleaning supplies while her male co-residents ate lunch and reviewed their notes.

"I started my physics exam in tears, completely anxious," she reported. "I didn't get to eat lunch. I was physically uncomfortable and emotionally wiped during both exams."

Another woman had contractions during her written clinical boards, but "thankfully" passed her exam and gave birth 2 days later.

"It might sound crazy that we would put ourselves through things like that just to take an exam," Dover said. "But because it does have the potential to sharply shape our early professional trajectory, we push through it. Otherwise, we're going to be left behind by our male peers."

This pressure to push through can be intense.

Still recovering from a difficult pregnancy, Masters returned to work when her daughter was just 5 weeks old. Although not ready to return to work, she felt too scared to ask for more time off after seeing other new mothers receive negative comments about not working hard enough.

Enter door number 2: The pregnancy and post-pregnancy experiences were so traumatizing that she decided to put off trying for a second child until after her exams.

Now board certified and 38 years old, Masters is worried she won't be able to conceive as easily as before.

"So, we're stuck in limbo, starting the process again and being nervous about it because what if it's not so easy at this age?" she said. "And what if it could have been easy, in different circumstances, with a different specialty?"

Masters' concerns are justified. Of the 126 women interviewed for the study, those who delayed pregnancy because of the board exams were significantly more likely to have fertility problems (46% vs 18%), and 20% reported experiencing infertility.

This finding dovetails with previous research showing that almost 25% of female physicians who attempt to become pregnant are diagnosed with infertility — nearly twice the rate of the general population. This high rate of infertility has been attributed to professional pressures and stress, long hours on the job, and delaying pregnancy during medical training.

But choosing door number 3 — focusing on family over exams — has downsides as well. Board certification is a prerequisite for almost every partnership position or promotion track within academic medicine and delaying certification can significantly hinder a physician's career and finances.

Radiation oncologists who aren't certified often remain in salaried positions until they can make partnership and earn a portion of the practice's profits, "which could easily change your annual compensation by six digits," Dover said.

According to the team's study, annual compensation typically increases by $30,000 to $50,000 after board certification, with some reporting an increase of over $100,000. That salary hike also impacts physicians' ability to pay off medical school loans, make financial investments, and afford the cost of childcare.

In other words, when it comes to family planning, there's often no good option.

Change on the Horizon

When the pandemic struck, the American Board of Radiology quickly went into triage mode, postponing in-person board certification exams scheduled in 2020 and brainstorming solutions.

By June, the organization announced that the exams would switch to a virtual format in 2021. Each test would be offered twice — once early in the year for candidates like Dover whose postponed 2020 exams had ultimately been canceled, and then again for those already planning to take their tests in 2021.

The shift to remote testing was a boon. Taking the tests from home not only allowed candidates to forgo the cost, stress, and time of travel, it also mitigated the burden of juggling pregnancy and parenting needs.

For example, Courtney Hentz, MD, a pediatric radiation oncologist at Loyola Medicine in Illinois and a study co-author, was given the choice to take a virtual exam in one day with two breastfeeding breaks or to spread the exam over 2 days with one breastfeeding break each day.

"Transitioning exams to a virtual format has been a really big achievement that the American Board of Radiology should be applauded for," Dover said. Not only that, offering the exams multiple times a year has "significantly increased flexibility for candidates as they juggle completing residency, starting at their first practice, and balancing time with their family," Goodman added.

Brent Wagner, MD, MBA, executive director of the American Board of Radiology, Tucson, told Medscape Medical News that remote exams are here to stay. "I don't foresee us ever going back to in-person board exams," said Wagner, a diagnostic radiologist. "Administering exams remotely last year worked better than I could have expected."

Wagner says the American Board of Radiology also plans to keep two dates for the oral certifying exam for the foreseeable future, though will revert to one date for the written qualifying exams.

"In a perfect world, we'd offer an exam every quarter," he said. However, providing multiple dates for the written exams "is not practical with a cohort of a few hundred people," given the staff resources needed to create and score twice the number of items each year. The Board did not rule out reassessing this decision in the future, "as examination development software improves and more resources become available."

Another big change, proposed by Dover, Goodman, and others, would be to combine the four exams into fewer tests, such as consolidating the three written exams into one. Such a shift would allow physicians to launch their careers sooner and begin focusing on other career-advancing endeavors such as research and publishing. It would also significantly improve radiation oncologists' quality of life.

"The amount of time that you spend studying for these very high-level, high-stakes exams really puts a toll on your mental health," Dover said. "The longer it's dragged out, the longer you're dealing with that, and it contributes tremendously to poor job satisfaction and work-life balance." 

The American Board of Radiology said it is discussing options for consolidating the exams, but the challenge with combining the three written exams into one comes down to scoring. "We need to get a statistically valid result in all three categories," Wagner said.

Another recent change: The American Board of Radiology is now allowing residents flexibility on the sequence of the written exams.

"In the past, we said you had to pass the physics exam before moving on to clinical radiology, but now we're letting residents decide the order for themselves," Wagner said. "This change may introduce more flexibility for someone who missed their first opportunity to take the physics exam but is ready to take the clinical exam."

Wagner added, "We're learning as we go, and I tell our staff that there's no reason we should think we're done making improvements. It's going to keep getting better."

The recent changes have already made a difference to radiation oncologists. And many hope to build on this new foundation to move the specialty toward a more family-friendly, equitable culture.

"I think as people in a caregiver profession, it's hard to prioritize doing things for yourself or your own family sometimes; it's hard to speak up and say, 'We need something different,' " Masters said. "I think we have [an opportunity] to capitalize on the momentum we have now."

Keridwen Cornelius is a freelance journalist and editor based in Phoenix, Arizona. Follow her on Twitter @keridwen77.

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