I'm currently on the PRITE editorial board and think I can shed some insight into this.
As with all exams, the exam is divided into content areas, all of which must be represented on the exam, though the degree to which they are represented is variable. The challenge here is that, in general, answers to questions must be able to be cited and be uncontroversial. In other words, you should not be able to do a literature review and successfully challenge the answer to a question unless a particular study or argument is clearly an outlier.
For many content areas, this isn't necessarily a problem. For other areas, it's a huge problem. It's extremely difficult to craft questions for some content areas with non-controversial, objectively "correct" answers. The result is that there is a relatively small pool of questions that can be written and topics that can be addressed. Some of these questions have absolutely zero relevance to the clinical practice of psychiatry, but they can be substantiated on the basis of evidence, so they're included. Other potential questions may be more clinically relevant, but it can be difficult if not impossible to translate them into actual questions with objectively "correct" answers on a standardized exam.
There's the further issue of the members of the board having different opinions about what should be on the exam and what should be important to test. I think this gets more at the actual construction of the exam and choices with respect to what content areas will be covered and how heavily they'll be weighted, but this also comes up during the individual discussions of specific questions. My own view as someone who writes questions and votes on which questions to approve is to focus on content that is clinically relevant to the practice of psychiatry. I don't care about the history of psychiatry in the context of this exam, and given that, by definition, the content covered will be limited, I would much rather eliminate these questions and, instead, include more questions about diagnosis and treatment. However, this is not a universally shared opinion... and it seems that the people who disagree tend to "win out."
I think the exam could be much more useful and clinically relevant, but, as with all things, making large changes like that is challenging.
