The Board Exam as Formation Ritual

Board examinations are described as knowledge tests. They are also rites of passage. The rite is the part the literature does not name.

Every American physician has taken at least three board examinations to enter independent practice — USMLE Step 1, Step 2 CK, and Step 3 — and at least one specialty board examination to remain in independent practice across a career. Nurses take the NCLEX. Subspecialty physicians take additional sub-boards. Recertification examinations repeat the structure on a ten-year cycle.

The institutions that administer these examinations describe them as assessments of clinical knowledge. The description is partially correct. The description is also incomplete. The examinations also do work that no knowledge assessment alone would do. They form the clinicians who take them.

This essay is about the formation.

The Ritual Structure

Arnold van Gennep's 1909 study of rites of passage identified the three-phase structure that anthropologists have used to analyze ritual transitions for more than a century. Separation: the candidate is removed from ordinary social existence. Liminality: the candidate occupies a transitional state, marked by ordeal, ambiguity, and the suspension of ordinary roles. Reincorporation: the candidate returns to ordinary social existence in a new status.

The board examination process follows this structure precisely. The candidate withdraws from ordinary clinical work for months of dedicated study. The study period is marked by exhaustion, social withdrawal, the suspension of relationships and obligations that ordinary life requires the candidate to maintain. The examination itself is the ordeal — eight hours at a Prometric testing center, multiple-choice questions of high stakes, time pressure that forecloses careful reasoning, the test-taker isolated from any external resource. The candidate emerges from the examination drained, often unsure of performance, having endured something whose subjective duration exceeds its clock duration. Then comes the waiting period — weeks for results, during which professional status hangs in suspension. Then the result. Then reincorporation, now as a board-certified physician with the credential that ordinary clinical practice requires.

Victor Turner's elaboration of van Gennep added the concept of communitas — the intense fellow-feeling that develops among candidates undergoing the same liminal ordeal. Medical board candidates know this. Study groups form around shared suffering. The cohort that took Step 1 in the same month carries a bond that outlasts most professional relationships. The shared experience of having endured produces a community of those who have endured.

The structure is the structure of a rite of passage. The examination's function as ritual is independent of its function as assessment. Both functions operate at once.

The Bilateral View

I have taken both. The physician sequence — USMLE Step 1, Step 2, Step 3. And the NCLEX, the nursing licensure examination. Most clinicians stand in one of these rites. A small number stand in both. The view from inside both is not the sum of the two views. It is a third thing.

The NCLEX is a different ordeal, and the difference is instructive. It is computer-adaptive: the examination lengthens or shortens in response to the candidate's answers and ends when the algorithm has gathered enough evidence to render a verdict. There is no score. There is pass and there is fail. The candidate leaves without a number, without a rank, without knowing the margin — holding only the binary that will or will not arrive. The clock is shorter than the physician examination's. What it does to the person taking it is not.

The two examinations form two professions. The physician boards, scored and ranked, form a clinician oriented toward hierarchy and individual standing. The nursing examination, pass/fail, forms a clinician for whom the threshold is competence — whether you are safe to practice, not where you place among those who are. These are different formations. They produce different dispositions toward authority, toward error, toward what it means to have passed.

Having stood in both, I can name what neither rite sees from inside itself. The physician who has only taken physician boards experiences the ranked, scored ordeal as simply what a board examination is. The nurse who has only taken the NCLEX experiences the pass/fail threshold as simply what licensure is. Each is a particular ritual choice with particular formative consequences. The bilateral view is the vantage from which the choice becomes visible as a choice.

What the Ritual Forms

A rite of passage does not just mark transition. It forms the candidate.

The candidate who emerges from the board examination process has been formed in specific ways. The capacity to endure prolonged isolation and study under high-stakes time pressure. The internalization of the discipline's accepted knowledge base in compressed form. The acceptance of a particular institutional authority — the licensing board, the specialty society — as legitimate arbiter of one's competence. The acquired identity as a member of the professional community defined by having passed the examination. The acquired hierarchy that distinguishes those who have passed from those who have not, those who have passed with high scores from those who have passed with low scores, those who have passed in first attempt from those who required additional attempts.

These dispositions are not incidental. They are part of what the profession produces. A physician without them is a different kind of physician than a physician with them. The medical profession depends on the formation, not just on the assessment of knowledge.

The formation also has costs. The capacity to endure prolonged isolation produces clinicians for whom isolation is normalized. The acceptance of institutional authority produces clinicians who internalize that authority's judgments about what knowledge counts. The hierarchy of scores produces clinicians who carry status anxiety about test performance into clinical practice. The shared ordeal produces a community whose internal solidarity can shade into protective indifference to those who have not endured the same passage.

The formation produces what it produces. The literature on board examinations describes the assessment function. It does not, with rare exceptions, describe the formation function. The result is a discipline that depends on a ritual structure it has not named.

What Naming It Would Change

A medical education system that named the board examination as a formation ritual, alongside its function as knowledge assessment, would have to do several things differently.

It would have to acknowledge that the formation effects are part of the curriculum, not external to it. Curricular reform would address what the formation forms and ask whether those dispositions are the ones the discipline wants. The endurance, the hierarchy, the acceptance of institutional authority — each is a teachable disposition with alternatives. The current ritual produces one version. Other rituals would produce others.

It would have to make the ritual's costs visible. Trainees experience the costs as personal failures or private hardships. Naming the ritual structure would relocate the costs from individual psychology to institutional design. The trainee who breaks down during board preparation is participating in a ritual structure that has historically broken down a certain percentage of participants. The breakdown is information about the ritual, not just information about the trainee.

It would have to ask whether the ritual structure is producing the formation the profession needs. The discipline has changed substantially since the modern American board examination structure was established. The clinical conditions of practice have changed. The patient populations have changed. The technology of clinical reasoning has changed. The ritual has not. A formation ritual that produces dispositions appropriate to mid-twentieth-century academic medicine may not be producing dispositions appropriate to twenty-first-century limited-resource medicine.

It would have to consider whether the recertification cycle continues to function as ritual or has degenerated into compliance theater. The original board examination is a formation ritual. The tenth-year recertification examination, taken in the middle of an established career, does not occupy the same ritual position. It separates the candidate from ordinary practice for a study period that competes with clinical obligations rather than displacing them. It produces communitas only with other recertifying physicians in the same boat. The reincorporation is not into a new status but into the same status one already held. The ritual structure is attenuated. The cost is not.

These are large changes. They would require the licensing and certifying institutions to acknowledge a function they have not historically named. They would require medical education researchers to study formation alongside assessment. They would require the discipline to be willing to ask whether the ritual it depends on is the ritual it needs.

The examination is the test. The examination is also the rite. The first description is on the institutional website. The second description has not yet been written into the curriculum the institution administers.

About the author

Peter Schindler, MD, PhD is an Assistant Professor of Medicine and Associate Program Director of the Community Health Center Family Medicine Residency Program at the University of Nebraska Medical Center. He practices at Winnebago Comprehensive Health System, OneWorld Community Health Center, and Nebraska Medicine. He completed a Primary Care Research Fellowship at McGill University and holds a BSN from the University of Wisconsin-Oshkosh, an MS and PhD in nursing from Emory University's Laney Graduate School, a Diploma in Tropical Medicine from the Liverpool School of Tropical Medicine, and an MD from the Medical College of Wisconsin-Green Bay. He is board certified by the American Board of Family Medicine. The Interprofessional publishes new essays every week at the intersection of medicine, nursing, and the clinical knowledge that lives between them.

Disclaimer. The views in The Interprofessional are Peter Schindler's own and do not represent the official positions of the University of Nebraska Medical Center, Winnebago Comprehensive Health System, OneWorld Community Health Center, Nebraska Medicine, or any other affiliated institution.