Pediatric endocrinology was formally recognized as a subspecialty in Türkiye in 1973, alongside pediatric metabolic diseases. It subsequently attained the status of an independent subspecialty in 2002. ^{1, 2} The establishment of the Turkish Society for Pediatric Endocrinology and Diabetes (TSPED) in 1994 marked a critical milestone in the institutional development of the field. Since its inception, TSPED has played a central role in advancing pediatric endocrinology and diabetes care through the promotion of professional collaboration, standard-setting initiatives, and a broad array of educational activities—including conferences, workshops, and training programs—designed to enhance the competencies of healthcare professionals. ³

In alignment with international practices for professional certification, the Turkish Pediatric Endocrinology Subspecialty Board Examination (TPEBE) was introduced in 2015. Administered by the Turkish Board of Pediatric Endocrinology Exam Committee (TBPEC) under TSPED, the TPEBE serves as a formal mechanism to evaluate the clinical knowledge and competencies of pediatric endocrinologists in Türkiye. Board certification examinations are globally recognized as essential instruments for safeguarding the quality of clinical practice and maintaining high professional standards across medical specialties. ⁴ Pediatric subspecialty board examinations are key instruments of international competency assurance. The implementation of the TPEBE underscores Türkiye’s commitment to aligning its training and certification processes with global standards in medical education. Thus, the establishment of the TPEBE represents a significant step in harmonizing Turkish pediatric endocrinology training and credentialing processes with international norms in medical education and assessment.

During the initial three years, the examination process exclusively employed multiple-choice questions (MCQs). They are recognized as a highly effective tool for evaluating comprehensive knowledge across broad content areas, as they facilitate extensive content coverage and contribute to strong content validity. ⁵ This approach supports making valid inferences about the entire content domain. Furthermore, MCQs are extensively utilized because they offer high reliability and are easy to score, ensuring precision, uniformity, and efficiency. ⁶ However, poorly designed MCQs may inadvertently target superficial content and fail to measure higher-order cognitive processes. ^{7, 8}

Consequently, the selection of item formats for any given assessment should be guided by a clear understanding of their respective strengths and limitations. A robust assessment strategy integrates diverse methods, each tailored to meet specific evaluative objectives. ⁹ While MCQs ensured coverage and reliability, concerns about assessing higher-order reasoning prompted the integration of new formats.

In response to these considerations, the TPEBE incorporated key feature problems (KFPs) into its format starting in 2019, with the objective of enhancing the assessment of candidates’ clinical decision-making skills. ¹⁰ KFPs are designed to simulate real-life clinical scenarios that require the integration of complex data to make clinically meaningful decisions. ^{9, 11} The format focuses on pivotal points in case management—referred to as “key features”—which represent the most essential and error-prone aspects of clinical problems. ^{12, 13} Originally introduced at the Cambridge Conference in 1984, the key features format was adopted by the Medical Council of Canada in 1992 as part of the MCC Qualifying Examination (MCCQE) Part I. This innovation aimed to replace the older Patient Management Problems (PMPs) format and reduce the overreliance on MCQs in licensure examinations. ^{11, 12, 14} The adoption of KFPs by the TPEBE reflects a parallel intent: to augment the assessment of clinical competence beyond the limits of traditional MCQs.

This manuscript presents a comprehensive 10-year review of the Turkish Pediatric Endocrinology Subspecialty Board Examination, focusing on its structural evolution, aggregated examination outcomes, and candidates’ perspectives on the examination process.

This 10-year evaluation of the TPEBE provides the first comprehensive overview of its evolution, psychometric performance, and candidates’ perceptions since its inception in 2015. The findings reveal a trajectory of increasing structural improvement and reliability, particularly following the integration of KFPs in 2019. The transition from a purely MCQ format to a mixed MCQ–KFP design has progressively strengthened the exam’s ability to assess higher-order clinical reasoning while maintaining fairness and organizational quality. Pass rates fluctuated over time, likely reflecting the combined influence of item difficulty calibration, evolving training quality, and candidate preparedness. Importantly, reliability coefficients for both sections improved steadily, indicating the maturation of item-writing processes and enhanced internal consistency.

Throughout the decade, mean total scores and pass rates varied between exam years, with notably higher performance during the early years and lower outcomes after 2021. Several factors may explain this trend. The early sessions (2015–2018) consisted exclusively of MCQs, a format known for high reliability and broad content coverage but limited depth in assessing clinical judgment. ^{5, 6} As the examination evolved to include KFPs, which emphasize reasoning and decision-making, overall scores declined—an expected phenomenon also observed in other board examinations that introduced performance-oriented formats. ^{4, 11} The temporary disruption of training schedules and reduced clinical exposure during the COVID-19 pandemic may have further contributed to decreased performance in 2021–2023, a possible concern reported in other research in postgraduate assessments. ^{15– 18}

The introduction of KFPs in 2019 represents a major pedagogical advancement in the TPEBE. Designed to target “key decision points” in clinical management, KFPs enable a more valid assessment of problem-solving and integrative reasoning than MCQs alone. ^{12, 13} The progressive increase in KFP reliability—from α = 0.312 in 2021 to α = 0.854 in 2024—indicates improved case design, examiner calibration, and standardization procedures. This pattern suggests growing psychometric robustness and aligns with findings from international studies reporting that mixed-format examinations achieve better construct validity. ^{7, 8, 19, 20} The balanced use of two complementary item types—MCQs for breadth and KFPs for depth—reflects an evidence-informed approach to assessment design consistent with contemporary medical education principles. ^{9, 21}

In this study, although male candidates achieved slightly higher MCQ and total scores, gender differences in pass rates were not statistically significant. Comparable findings have been reported in other nationwide postgraduate assessments, with several studies showing no overall gender differences in examination outcomes, and in some cases, female candidates performing significantly better in certain domains or clinical components. ^{22, 23} The observed score gap may reflect differential exposure to standardized testing environments or self-perceived exam confidence. Importantly, the absence of significant disparities in KFP performance suggests that case-based, reasoning-oriented formats may reduce gender-related score variance, supporting their inclusion as a more equitable assessment component.

Candidates’ feedback provides valuable qualitative insight into the examination’s educational value and perceived validity. The majority of participants rated the exam highly for its organization, content balance, and reflection of real clinical practice. The strong endorsement of the KFP format underscores its perceived authenticity and relevance to day-to-day decision-making in pediatric endocrinology. Participants consistently reported that the exam highlighted their knowledge gaps and motivated targeted self-study—confirming the dual function of certification assessments as both evaluative and formative instruments. These findings echo international reports emphasizing the educational impact of well-designed board examinations in promoting reflective practice and continuing professional development. ^{4, 24}

After the introduction of KFPs, the most consistent area of dissatisfaction concerned the perceived inadequacy of examination duration (x̄ = 5.14 ± 2.97). The relatively large standard deviation indicates considerable variability in respondents’ perceptions, suggesting diverse experiences or expectations regarding the sufficiency of the allotted time. This concern likely arises from the inherent cognitive load of the KFP section, which requires interpretive reasoning and the formulation of written responses. Similar challenges have been reported in previous studies, noting that constructing answers under open-ended conditions is cognitively demanding and time-consuming, as it involves articulating reasoning and justifying decisions rather than merely recognizing correct options. ^{11, 25, 26} Addressing time constraints—either through adaptive scheduling or improved question pacing—could enhance candidate experience without compromising assessment validity.

The TBPEC’s iterative review of item performance and appeals, coupled with scoring adjustments for omitted questions, reflects a transparent and learner-centered quality assurance framework. The continuous monitoring of reliability and cut-score consistency over time has strengthened the exam’s credibility and accountability. Looking ahead, the transition to digital or hybrid exam delivery may offer opportunities for enhanced item analysis, automated scoring, and secure remote administration, aligning the TPEBE with global advancements in high-stakes assessment.

Over the past decade, the TPEBE has evolved from a traditional knowledge-based test into a multidimensional assessment aligned with international best practices in medical education. The integration of KFPs, progressive enhancement of reliability indices, and strong candidate endorsement collectively indicate a maturing and credible certification process. Continued investment in psychometric monitoring, examiner training, and technological innovation will further enhance the examination’s role in ensuring clinical competence and fostering excellence in pediatric endocrinology practice in Türkiye. It is anticipated that these examinations will be increasingly recognized and utilized by educational institutions and regulatory authorities as a benchmark for achievement in both education and professional practice.

The study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the Ege University Faculty of Medicine Medical Research Ethics Board Ref. Date: 25.05.2023 #23-5.1T/46. Informed consent was obtained verbally from all participants prior to data collection. Verbal consent was obtained because the survey was anonymous, posed minimal risk, and did not involve the collection of any identifying or sensitive personal information.