Farokh Saidi MD

Candidates sitting for any medical specialty examination are frequently too engrossed with how to pass the examination and want to know why the examination has to be taken in the first place. Afterwards, it really makes no difference.

Historic records show that the first ever medical examination was administered 12 centuries ago in Baghdad.¹

Ali Ibn Rabban of Tabaristan, a Persian physician from the southern part of the Caspian sea, entered the service of Caliph Al-Mutawakkil as court physician in Baghdad. In 850 AD, he completed his 550-page medical compendium called “The Paradise of Wisdom” in which he wrote:

“He who perpends this book with understan-ding resembles one who wanders in fruitful and pleasant gardens, or in the markets of great cities, wherein is provided for each of the senses its pleasure and delight. But just as he who limits his knowledge of such gardens and cities to the contemplation of their gates is as one who sees naught of them, so he who enumerates the chapters of this my book without attentively reading what is contained in each, doth not understand the true meaning of what I say… But he who masters this book, and fully fathoms and perpends it, will find in it the greater part of what the young graduate needs of the Science of Medicine and the action of the natural forces in this Microcosm and also in the Macrocosm.”

The reference to “graduate”, translated from the Arabic “mutakharrij”, meaning one who has “exited through” a course of medical study, is undoubtedly a historic first.

Not long thereafter, a case of malpractice came to the attention of the Caliph Al-Muqtadir in 931 AD, prompting an edict that no physician in Baghdad would be allowed to practice unless he was able to satisfy the foremost authority in medicine, the court physician Sinan Ibn Thabit of Harran, of his competence and proficiency. Exceptions were made for a few physicians of recognized standing who, on account of their reputation, were exempted from this test to which the remainder, numbering some 860, had to submit.

As far as is known, this was the first time in history that a medical examination was put legally into effect. Remarkably enough, the new law incorporated a grandfather clause. Even more remarkable is the fact that the proclaimed impetus behind the edict was the need to protect patients’ rights.

The examination proceeded and one dignified and well-dressed old man of imposing appearance presented himself. The candidate was asked who his teacher was, whereupon the old gentleman laid a packet of money in front of the examiner and said, "I cannot read or write well, nor have I read anything systematically, but I have a family whom I maintain by my professional labors, which, therefore, I beg you not to interrupt.” The examiner laughed and replied, "On condition that you do not treat any patient with what you know nothing about, and that you do not prescribe phlebotomy or any purgative drug save for simple ailments.”

Next day, among those who presented themselves for the examination, was a well-dressed young man of pleasing and intelligent appearance. He was also asked, “With whom did you study?” “With my father”, “And who was your father?” Answered the youth, “The old gentleman who was with you yesterday.”

The philosophic definition of Truth is that which has lasted the longest. It should not have come as a surprise, therefore, that 2,000 Fellows of the American College of Surgeons should now feel somewhat the same way as did physicians in Baghdad 12 centuries ago. Truthfully speaking, therefore, a candidate’s perception will always differ from that of the examiner. The American Board of Surgery Examination was felt to “aid a career...” rather than be an “indicator of a surgeon’s clinical competence” by a factor of 3.56 to 2.14.² It is most unlikely that this perception will change any time soon. It will be equally difficult to decide what constitutes clinical competence.

Regardless of what history may prove about certifying medical examinations, there should be no reason to abandon or alter the aims of such tests.³ Whatever the candidates’ perception, the objectives of the American Board of Surgery should not be altered in any way, as it will have dire consequences for surgical education. One experiment, very recent but again from the Near East, bears this out:

Until 1975, surgical training, or for that matter all specialty training in Iran, was done on the basis of single apprenticeship. In that year, a new policy of well-conducted specialty examination boards was introduced by the Minister of Science and Higher Education, Dr. Abdolhossein Samiy, a USA-educated physician and a graduate of Cornell University Medical College. This enlightened step had a profound impact on the overall quality of medical practice in all specialties in Iran, so much so that the new Revolutionary Government of Iran has continued these examinations. Reasonably high standards of medical care were maintained despite great socioeconomic upheavals, including an imposed 8-year-long brutal war with Iraq. Recently, however, mounting pressure from candidate groups that examination questions are not always relevant or well thought out, prompted a new policy of announcing the source of references used in formulating examination questions. The results were predictable and have been palpable, but are not recountable.

Looking across a long historic span and a broad geographic distance, the conclusions are that: 1) human nature, including that of surgeons, is not likely to change; 2) protection of conceived rights of candidates can be secured only at the expense of patients’ incontestable rights; and 3) clinical competence, though an unexaminable art, has to be distinguished somehow from exact sciences measurable by objective assessment of cognitive knowledge.

1. Browne EG. Arabian Medicine. Cambridge: The University Press; 1962: 38 – 41.

2. Panagopoulos G, Schein M, Wise L. Perceived value of the American Board of Surgery certificate: a survey of 2,000 Fellows of the American College of Surgeons. J Am Coll Surg. 1999; 188: 1 – 5.

3. Ritchie WP. Certification by the American Board of Surgery: the task ahead. J Am Coll Surg. 1999; 188: 53 – 4.