Rites of Passage: Professional Identity Formation and the OTOHNS Oral Board Exam

This study utilizes thematic analysis of interviews with nineteen participants to demonstrate that while both virtual and in-person formats of the ABOHNS Oral Board Examination contribute to Professional Identity Formation, the traditional in-person format uniquely acts as a catalyst for ongoing identity development and community integration.

The Gist

The Big Picture: The "Rite of Passage" for Doctors

Imagine becoming a doctor is like climbing a mountain. You spend years training (residency), learning the ropes, and getting stronger. At the very top, there is a final gate: the Oral Board Exam. This is the test where senior doctors grill you on your knowledge to see if you are ready to practice on your own.

For a long time, this gate was a physical place. You had to travel to a hotel, sit in a room with three judges, and answer questions face-to-face. But when the pandemic hit, the American Board of Otolaryngology (the group that runs the test) moved the gate online. Suddenly, you could take the test from your living room via Zoom.

This study asks a simple but deep question: Does it matter how you cross that final gate? Does taking the test in person feel different than taking it virtually, and does that difference change how you see yourself as a doctor?

The Study: Listening to the Climbers

The researcher, Dr. Kevin McMains, interviewed 19 doctors who had recently finished their training.

• Group A (The Travelers): Doctors who took the old-school, in-person exam.
• Group B (The Virtuals): Doctors who took the new, online exam.

He asked them: "How did this test change who you are as a professional?"

The Three Big Findings

The study found three main themes, which we can think of like this:

1. The "Crunch Time" Effect (Educational Impact)

The Analogy: Think of preparing for the exam like training for a marathon.
The Finding: Both groups agreed that the process of studying for the oral exam was a huge turning point. It wasn't just about memorizing facts; it was about forcing themselves to think like a surgeon. This "crunch time" helped them solidify their identity as doctors, regardless of whether they took the test in a hotel or at home. The written test (the qualifying exam) felt like just another school test, but the oral exam felt like a real-life simulation.

2. The "Backpack" vs. The "Wi-Fi" (Different Stresses)

The Analogy: Imagine two hikers. One has to carry a heavy backpack full of gear (travel, hotels, flights). The other has a backpack that is light, but their map is a digital app that might crash.
The Finding:

• The Travelers (In-Person): Their stress was logistical. They were tired from flying, worried about hotel costs, and nervous about the face-to-face pressure. However, for some (like a pregnant doctor), the virtual option was a lifesaver because they couldn't travel.
• The Virtuals: Their stress was technical. They worried about their internet connection, the camera angle, and whether the software would glitch.
• The Equity Win: The virtual option was a huge win for inclusivity. It allowed a doctor who was 38 weeks pregnant to take the test without having to wait a whole year to travel. It removed a barrier that might have stopped her from becoming a board-certified doctor on time.

3. The "Graduation Ceremony" vs. The "Zoom Call" (The Rite of Passage)

The Analogy: This is the most important part. Think of the difference between walking across a stage to get your diploma while the crowd cheers, versus getting an email that says "You passed."
The Finding:

• The In-Person Group: They described the exam as a true "Rite of Passage." Sitting in the room, looking the judges in the eye, and feeling the weight of the moment made them feel like they had officially "arrived." It was a magical moment where they felt a deep connection to the community of ear, nose, and throat doctors. They felt a surge of confidence: "I am one of them now."
• The Virtual Group: While they passed, many felt a lingering doubt. They questioned, "Did this really count?" They felt a bit like imposters. The lack of physical presence meant they missed that emotional "spark" that cements your identity as a member of the club. They felt less connected to the "tribe" of specialists.

The Conclusion: Why This Matters

The paper concludes that while the online test was fair and valid (it tested the knowledge correctly), it missed a special ingredient: The Ceremony.

The in-person exam wasn't just a test; it was a ritual that helped doctors transform their identity. It was the moment they felt fully accepted into the profession.

The Takeaway:
The author suggests that while we should keep the virtual option for people who need it (like new parents or those with financial hardships), we should try to bring back the in-person format whenever possible. Why? Because that physical gathering isn't just about checking a box; it's about building confidence, belonging, and the feeling that "I am officially a doctor."

It's the difference between getting a driver's license in the mail versus driving your car out of the DMV with a parent cheering in the passenger seat. Both get you the license, but only one makes you feel like a real driver.

Technical Summary

1. Problem Statement

The study addresses a critical gap in medical education regarding Professional Identity Formation (PIF)—the process by which individuals internalize the values and norms of the medical profession to "think, act, and feel like a physician." Specifically, the authors investigate the impact of the American Board of Otolaryngology-Head and Neck Surgery (ABOHNS) Oral Board Examination (OBE) on PIF.

The core problem arises from the shift in examination administration during the COVID-19 pandemic, where the ABOHNS pivoted from traditional in-person (IP) exams to virtual (V) formats. While the virtual format maintained psychometric validity and safety, it is unclear whether it retained the "catalytic effect" of the in-person exam. The authors posit that high-stakes exams may serve as "rites of passage" that solidify a candidate's identity within the medical community. The study seeks to determine:

1. How OBEs shape examinee professional identity.
2. Whether the format (in-person vs. virtual) differentially affects PIF.

2. Methodology

The study employs a qualitative research design utilizing thematic analysis, adhering to the Standards for Reporting Qualitative Research (SRQR) checklist.

• Participants: 19 practicing Otolaryngologists who completed residency in 2019 and 2020.
  • Cohort A (In-Person): 9 participants who took the OBE in the last year of in-person administration.
  • Cohort B (Virtual): 10 participants who took the OBE in the first year of virtual administration.
• Data Collection: Semi-structured interviews (15–30 minutes) conducted between November 2023 and April 2024. The interview guide was adapted from Bebeau's "Professional Identity Essay" to foreground PIF effects related to exam formats.
• Analysis: Iterative coding and thematic analysis were performed by the author (a clinician-educator and PhD candidate). The analysis focused on lived experiences, stressors, and the perceived legitimacy of the exam.
• Ethical Considerations: The study was IRB-approved. Demographic data (gender, race) were largely redacted to ensure anonymity, though specific quotes were used to illustrate themes.

3. Key Contributions

This study makes several novel contributions to the literature on medical assessment and professional development:

• First Deliberate Exploration: It is the first study to explicitly investigate the impact of the Otolaryngology Oral Board Exam on Professional Identity Formation.
• Comparative Format Analysis: It provides empirical data comparing the PIF outcomes of in-person versus virtual high-stakes examinations, moving beyond psychometric validity to assess "catalytic effect."
• Theoretical Application: It applies Situated Learning Theory (Lave & Wenger) and Rites of Passage theory to the context of board certification, framing the exam not just as a test of knowledge, but as an initiation into a "Community of Practice" (COP).
• Equity vs. Identity Trade-off: It highlights the tension between the equity benefits of virtual testing (accessibility for pregnant candidates, reduced financial burden) and the potential loss of the "catalytic" identity-forming experience provided by in-person rituals.

4. Results

The analysis of interview transcripts coalesced around three primary themes:

A. Educational Effect of OBE on PIF

• Both groups reported that preparation for the Oral Board Exam significantly crystallized their professional identity, whereas preparation for the written Qualifying Exam did not.
• The OBE preparation process forced candidates to synthesize clinical reasoning and professional norms, acting as a distinct educational intervention compared to standard academic testing.

B. Distinct Stresses by Format

• In-Person Group: Experienced higher emotional loads and travel-related stresses (cost, logistics).
• Virtual Group: Experienced stress related to technology uncertainty and finding compliant testing environments.
• Equity Note: The virtual format provided critical access for specific demographics. One participant noted she was 38 weeks pregnant and would have been unable to travel; the virtual format allowed her to complete her certification without delay.

C. Rite of Passage: Catalytic Effect of In-Person OBE

• In-Person Group: Described the exam as a transformative "rite of passage." They reported a heightened sense of belonging to the Otolaryngology Community of Practice, increased self-efficacy, and a feeling of legitimacy ("a stamp" of approval). The face-to-face interaction with examiners and peers cemented their identity as board-certified specialists.
• Virtual Group: While they passed, many expressed lingering doubts about the legitimacy of their experience and reported feelings akin to imposter syndrome. They lacked the symbolic initiation and the sense of communal validation provided by the in-person ritual.
• Conclusion on Trajectory: The in-person format acted as a catalyst for ongoing PIF, whereas the virtual format, while valid, did not provide the same psychological "inflection point" for identity formation.

5. Significance and Implications

The study suggests that while virtual exams are psychometrically valid and equitable regarding access, they may lack the formative value necessary for deep professional identity integration.

• Recommendation for Policy: The authors argue that future OBE administration should prioritize in-person formats to capitalize on the "catalytic effect" on professional identity. This ritual is viewed as essential for integrating candidates into the professional community.
• Balancing Act: The paper acknowledges the need for accommodations (e.g., for pregnancy or financial hardship) but suggests that the loss of the "rite of passage" experience in virtual formats may have long-term psychological consequences for new specialists.
• Broader Context: The findings challenge the view of board certification as purely summative. Instead, the OBE is re-framed as a hybrid assessment with significant formative impact on the physician's trajectory, serving as a critical mechanism for socializing new members into the medical profession.

Limitations: The study is limited to a single specialty (Otolaryngology) in a North American context, uses single interviews (which may not capture the full developmental arc of identity), and lacks detailed demographic data on race and gender due to anonymity protocols.