US Medical Licensing Exam Performance and American Board of Surgery Qualifying and Certifying Examinations.

BACKGROUND: Program directors use US Medical Licensing Exam (USMLE) scores as criteria for ranking applicants. First-time pass rates of the American Board of Surgery (ABS) Qualifying (QE) and Certifying (CE) Examinations have become important measures of residency program quality. USMLE Step 1 will become pass/fail in 2022. STUDY DESIGN: American Board of Surgery QE and CE success rates were assessed considering multiple characteristics of highly ranked (top 20) applicants to 22 general surgery programs in 2011. Chi-square, t-test, Wilcoxon Rank sum, linear and logistic regression were used, as appropriate. RESULTS: The QE and CE first attempt pass rates were 96% (235/244) and 86% (190/221), respectively. QE/CE success was not significantly associated with sex, race, research experience, or publications. Alpha Omega Alpha (AΩA) status was associated with success on the index CE (98% vs 83%; p = 0.008). Step 1 and Step 2 Clinical Knowledge (CK) scores of surgeons who passed QE on their first attempt were higher than scores of those who failed (Step 1: 233 vs 218; p = 0.016); (Step 2CK: 244 vs 228, p = 0.009). For every 10-point increase in Step 1 and 2CK scores, the odds of passing CE on the first attempt increased 1.5 times (95% CI 1.12, 2.0; p = 0.006) and 1.5 times (95% CI 1.11, 2.02, p = 0.008), respectively. For every 10-point increase in Steps 1 and 2CK scores, the odds of passing the QE on the first attempt increased 1.85 times (95% CI 1.11, 3.09; p = 0.018) and 1.86 times (95% CI 1.14, 3.06, p = 0.013), respectively. CONCLUSIONS: USMLE Step 1 and Step 2 CK examination scores correlate with American Board of Surgery QE and CE performance and success. The USMLE decision to transition Step 1 to a pass/fail examination will require program directors to identify other factors that predict ABS performance for ranking applicants.

Regulatory justice following gross negligence manslaughter verdicts: Nurse/doctor differences.

Two professionals who treated Jack Adcock before his death were convicted of gross negligence manslaughter, receiving 24-month suspended sentences. His nurse, Isabel Amaro, was erased from the nursing register; but after reviews in the High Court and Court of Appeal, his doctor, Hadiza Bawa-Garba, was merely suspended. This article explores the proposition that nurses are at greater risk of erasure than doctors after gross negligence manslaughter through a close reading of the guidance for medical and nursing tribunals informed by analysis from the High Court and Court of Appeal in the Bawa-Garba cases. Examination of the relevant sections of the guidance for medical and nursing tribunals reveals no significant differences. An outline of the conduct that amounted to breach of duty of care by Amaro and Bawa-Garba shows that their conduct could satisfy the thresholds for erasure given in their professions' respective guidelines for tribunals. Both presented similar mitigating evidence, although this cannot be weighed heavily in a professional tribunal setting. Thus, Amaro was treated more harshly than Bawa-Garba without a simple explanation. However, I suggest that the Nursing and Midwifery Council's Conduct and Competence Committee made a mistaken 'presumption of erasure' for gross negligence manslaughter and misinterpreted the sway that sentencing remarks should hold over tribunals. Both of these types of error were criticised by the Court of Appeal in Bawa-Garba. Furthermore, the Conduct and Competence Committee did not flesh out its analysis of 'public confidence' or acknowledge Lord Hoffmann's caution against ending 'useful' careers for the sake of public confidence, but Bawa-Garba's legal team ensured these arguments were taken into account by the Medical Professional Tribunal. The Conduct and Competence Committee's failures are not inherent to Nursing and Midwifery Council procedure or policy. Rather Amaro's self-representation appears to have impaired her access to justice. Tribunals must accept their right, and responsibility, to reach their own conclusions.

Defensa de los derechos adquiridos: luchas y albures del ejercicio de la homeopatía en Colombia (1905-1950) / Defending entitlement: struggles and fate of the practice of homeopathy in Colombia (1905-1950)

Resumen El artículo analiza la práctica y el estatuto profesional de los homeópatas colombianos en el siglo XX, según las solicitudes de licencia de la serie "Teguas" del Archivo General de la Nación. Desde el contexto histórico del ejercicio de la medicina en Colombia, se estudia la práctica homeopática en su inserción en el debate entre medicina diplomada y medicina permitida. Ahí aparece la homeopatía como un campo subordinado a la medicina universitaria y los homeópatas como conjunto de practicantes no homogéneo ni organizado, pero caracterizado por compartir la lucha por el "derecho adquirido" a ejercer y por la defensa de un estatuto profesional mediante la judicialización constante de la reprobación oficial.

Abstract This article analyzes the practice and professional status of Colombian homeopaths in the twentieth century, based on applications for licenses in the "Teguas" series in the Archivo General de la Nación. Within the historical context of the practice of medicine in Colombia, it studies homeopathic practice within the framework of the debate between licensed and permitted medicine. In that context, the field of homeopathy was subordinate to university medicine and homeopaths were a group of practitioners who were neither homogeneous nor organized, but characterized by their shared struggle to become "entitled" to practice, and their advocacy of professional status through constant litigation against official reprimands.

Breaking the boundaries of professional regulation: medical licensing, foreign influence, and the consolidation of homeopathy in Mexico / Rompendo as barreiras da regulamentação profissional: licenciamento médico, influência estrangeira e consolidação da homeopatia no México

Abstract As doctors sought state support to regulate professional training and practice after Independence, Mexicans also developed different attitudes toward foreign ideas, influences, and professionals. Leveraging the allure of the foreign among Mexicans, homeopaths strategically used work, products, and organizations from abroad to establish their practices and fight changing professional policies in the country that threatened homeopathic institutions. Homeopaths inhabited the blurry and shifting boundary between professional and lay medical practice during the early Republican period, the Porfiriato, and the post-revolutionary era, and used the ambivalent feelings about medical licensing, and foreign influence in Mexican society to consolidate their position.

Resumo Após a independência do país, enquanto os médicos buscavam apoio do Estado para regulamentar o treinamento e a prática profissionais, os mexicanos desenvolveram atitudes diferentes em relação a ideias, influências e profissionais estrangeiros. Aproveitando o encanto dos mexicanos com o estrangeiro, os homeopatas usaram estrategicamente o trabalho, os produtos e as organizações de fora do país para implantar suas práticas e combater as políticas que ameaçavam as instituições ligadas à homeopatia. Os homeopatas ocuparam a barreira nebulosa entre as práticas médicas profissional e leiga no início do período republicano, no Porfiriato e na era pós-revolucionária, usando sentimentos ambivalentes sobre licenciamento médico e influência estrangeira para consolidar sua posição.

Analysis of the French national evaluation of radiology residents.

PURPOSE: In France, a national evaluation is given annually to radiology residents. The aim of this study was to perform both a docimological analysis of the quality of the questionnaire and a statistical analysis of the results. MATERIALS AND METHODS: This retrospective study, which included French radiology residents from Year 1 to Year 5 of residency, was performed from 2015 to 2017 across 25 medical universities in France. Both qualitative and quantitative docimological analyses were performed as assessed by the Cronbach alpha coefficient, the difficulty of question (PDI), and the coefficient of discrimination (Rir). Results to the questionnaire were compared between years of residency. RESULTS: The results of the analysis confirmed the quality of the questionnaire (Cronbach alpha coefficient=0.71, mean [PDI=0.40]) though the majority of questions could be answered by memory rather than cognitive ability. The mean Rir was 0.02, indicating that students could not be certified using only the questionnaire. The results measuring resident level of knowledge were moderate, with mean results ranging from 9.2/20 at the first year to 11.3/20 at the fifth year of residency (P<0.001). There were no significant differences in results obtained between the third, fourth, and fifth year of residency but results were significantly different among university hospitals. CONCLUSION: Even if close interactions exist between learning and pedagogic environment, our results suggest that it may be useful to further develop an evaluation process in relation with pedagogic instructions in order to provide more optimal training.

[Weighting of Orthopaedics & Trauma Surgery in the Medical State Examination - Comparison of the Written Examination with the National Catalogue of Learning Objectives in Surgery]. / Die Wertigkeit des gemeinsamen Faches Orthopädie-Unfallchirurgie im 2. Staatsexamen ­ Vergleich der schriftlichen 2. Staatsexamina mit dem Nationalen Kompetenzbasierten Lernzielkatalog Chirurgie.

BACKGROUND: The national competence-based catalogue of learning-goals in surgery (NKLC) defines competence levels for each of its 230 goals, including "competence level in 1: factual knowledge" up to "competence level 3: independent action". Aside from the cumulative examinations influencing the learning behaviour of students, those teaching targets do not affect the second state examination. This study analyses the extent to which the questions of the German second medical licensing examination compiled by the IMPP (central German institute for medical and pharmaceutical examinations) are congruent with the trauma-surgical and orthopaedic learning goals in the NKLC, in which this thematic focus is emphasised. MATERIAL AND METHODS: Exam questions from autumn 2009 to autumn 2014 (n = 11) were retrospectively analysed. Orthopaedic and trauma-surgical teaching targets defined in NKLC were identified by five senior orthopaedic physicians and trauma surgery experts. All questions addressing one of these learning goals were identified and analysed (re: the number of learning goals, the number of questions addressing a trauma-surgical, or orthopaedic goal, as well as different competency levels). RESULTS: We found 113 learning goals of NKLC (49.1% of the overall NKLC learning goals) identified as orthopaedic or trauma surgery subjects. During the study period, 543 questions included teaching targets referring to orthopaedic or trauma surgery subjects (15.6% of the total of 3480 questions). Per exam, a mean of 49.36 ± 14.1 questions (minimum 30; maximum 80) was identified that addressed a learning goal referring to these issues. For each exam, 13.45 ± 6.39 (minimum 6; maximum 24) questions referred to learning goals of competence level 3a and b, 21.45 ± 9.94 (minimum 9; maximum 39) questions referred to learning goals of competence level 2, and 14.45 ± 6.36 (minimum 6; maximum 25) questions referred to learning goals of competence level 1. Most questions addressed the topic: "disorders of the rheumatic spectrum" (n = 16 questions in autumn 2009). CONCLUSION: Questions focusing on orthopaedic and trauma surgery appeared sufficiently often during the second state examination. There is a thematic imbalance, and important clinical learning goals tagged with high competence levels were not addressed in a satisfactory manner. This indicates that a clear adjustment between the state examination and NKLC is necessary.

[The Medical Examination - Between Desire and Reality - Analysis of Consensus Between the Second Part of the Medical Licensing Exam (IMPP) and the National Catalogue of Expertise-based Learning Goals in Surgery (NKLC)]. / Medizinische Prüfung zwischen Wunsch und Wirklichkeit ­ Analyse der Übereinstimmung zwischen dem 2. Abschnitt der ärztlichen Prüfung und dem Nationalen Kompetenzbasierten Lernzielkatalog Chirurgie.

Background The working party of the German Society for Surgery (DGCH) on undergraduate surgical education has developed a national expertise-based catalogue of learning goals in surgery (NKLC). This study analyses the extent to which the questions of the German second medical licensing examination compiled by the IMPP are congruent with the NKLC and which thematic focus is emphasised. Materials and Methods Firstly, a guideline and evaluation sheet were developed in order to achieve documentation of the individual examination questions of the second licensing examination with respect to the learning goals of the NKLC. In a retrospective analysis from autumn 2009 to autumn 2014, eleven licensing examinations in human medicine were screened independently by three different reviewers. In accordance with the guideline, the surgical questions were identified and subsequently matched to the learning goals of the NKLC. The analysis included the number of surgical learning goals as well as the number of surgical questions for each examination, learning goal, and different levels of expertise (LE). Results Thirteen reviewers from six surgical disciplines participated in the analysis. On average, reviewers agreed on the differentiation between surgical and non-surgical questions in 79.1% of all 3480 questions from 11 licensing examinations. For each examination (n = 320 questions), 98.8 ± 22.6 questions (min.: 69, max.: 150) were rated as surgical. For each surgical learning goal addressed, 2.2 ± 0.3 questions (min.: 1, max.: 16) were asked. For each examination, 23.5 ± 6.3 questions (min.: 11; max.: 31) referred to learning goals of LE 3, 52.5 ± 16.7 questions (min.: 34; max.: 94) addressed learning goals of LE 2 and 22.8 ± 7.7 questions (min.: 9; max.: 34) were related to learning goals of LE 1. 64 learning goals (27.8% of all learning goals of the NKLC) were not reflected in the examinations. With a total of 70 questions, the most frequently examined surgical topic was "disorders of the rheumatic spectrum". Conclusion The number of surgical examination questions in the German second medical licensing examination seems to be sufficient. However, the questions seem to be unevenly distributed between different surgical areas of undergraduate education. In order to achieve a more homogenous representation of relevant surgical topics, improved alignment is needed between the state examination with existing catalogues of learning goals by the IMPP.

[Competence-based catalogue of learning objectives for conducting medical consultations]. / Kompetenzbasierter Lernzielkatalog ¼Ärztliche Gesprächsführung« .

ISSUE: In 2012 the German medical licensure regulations (Approbationsordnung) made teaching and assessing the conduction of medical consultations a mandatory part of medical education. A catalogue of learning objectives (LO) based on existing references was developed to assist medical schools in meeting this requirement. METHODS: A body of relevant material was compiled using literature research and surveying experts. Then, in a multiphase Delphi process, this was evaluated and condensed by an interdisciplinary working group in dialogue with external (clinical) experts. Competence levels and examples of clinical application were assigned to enhance implementation. The catalogue was revised by the medical faculties, professional associations and the BVMD. RESULTS: This learning catalogue comprised 116 learning objectives for the specific skills necessary to conducting medical consultations as well as exemplary application contexts. The catalogue proved to be practical in terms of developing curricula and networking at medical schools. DISCUSSION: This catalogue of learning objectives can serve as the basis for developing a sample communication curriculum for use by medical faculties.

The 19th Century Origins of Facial Cosmetic Surgery and John H. Woodbury.

John H. Woodbury was an incredibly entrepreneurial, self-trained dermatologist who, between 1870 and 1909, built an empire of cosmetic surgery institutes in 6 states, with 25 physician/surgeon employees and an advertising budget of $150,000/year (1892 data). Under his management, his surgeons, and perhaps Woodbury himself, performed multiple facial cosmetic surgeries, including early versions of browlifts, frown excisions, lower facelifts, mid-face lifts, rhinoplasties, double-chin reductions, and dimple creation. In addition, Woodbury developed a proprietary soap and cosmetic line, which he sold to Jergens for $212,500 in 1901 (retaining a 10% royalty). Woodbury's story has been unknown until now because this nonacademic concentrated his publishing in articles and advertisements in lay magazines. Woodbury's life ended in bankruptcy, litigation, and suicide when the corporate practice of medicine and advertising were made illegal. In his legal proceedings, Woodbury conceded that he was not a doctor, although he went by the title. Regardless, his surgical innovations are of major historical significance, as these cosmetic procedures are the first of their kind to be noted in the lay or academic press and predate, by years and even decades, the previously earliest known cosmetic surgeries in the United States.

"Alcohol and nicotine"--Concept and evaluation of an interdisciplinary elective course with OSPE in preclinical medical education.

In the last decade, increasing interest has been paid to interdisciplinary and practical courses in the medical education in Germany. This report describes the implementation and outcome of a preclinical interdisciplinary elective course with a team-teaching concept developed by lecturers in medical psychology, anatomy, physiology and biochemistry. The practical orientation of the course led to the implementation of a final interdisciplinary OSPE to ensure fair consideration of the different disciplines involved in grading. Individual OSPE results correlate well with the fact that different skills are required in medical psychology compared to those required in anatomy, physiology and biochemistry. Student course evaluation and lecturers` experience indicate the success of this elective course. Its concept can be well adapted to other interdisciplinary courses.

DEGAM criteria catalogue for training practices in primary care--a proposal for the assessment of the structural quality of training practices.

BACKGROUND: Whilst the structure of primary care vocational training in Germany is being increasingly formalized there remains an abundance of disparate locally defined criteria for the training practices. Advanced medical training in the ambulatory setting has also been identified as an area of need by other specialties. GOAL: In contrast to the current practice of a unregulated authorization by regional medical associations this catalogue provide transparent, clearly defined criteria for the assignment of training practice status. METHODS: The first draft of the criteria catalogue integrates feedback from 30 academic general practitioners. The feasibility of the catalogue was tested by a further 30 surgeries. Analysis included an assessment of the sociodemographic characteristics of the trainers and their practices as well as satisfaction of the participants with the approved authorization period. RESULTS: The criteria catalogue comprises 19 items within the domains of trainer qualification, practice infrastructure and patient specific factors as well as mandatory criteria. The points scored through this system confer a variable period of authorization. Of the 30 participants 17 were satisfied with the period of authorization they received, 10 were dissatisfied, and one was indifferent. Satisfaction showed no correlation with sex, experience as a trainer, or with the score achieved through the criteria catalogue. It correlated little with the length of time practicing as a doctor. CONCLUSION: The criteria catalogue reflects both the breadth of general practice as well as the skills of the trainers. Satisfaction of participants in the test group was good, and infers a basis for applying the catalogue through regional medical associations to assign teaching practice status. It may also be used as a blue-print for other medical specialties.

Crossing boundaries: a comprehensive survey of medical licensing laws and guidelines regulating the interstate practice of pathology.

In the United States, recent judicial interpretation of interstate licensure laws has found pathologists guilty of malpractice and, more importantly, the criminal practice of medicine without a license. These judgments against pathologists highlight the need for a timely and comprehensive survey of licensure requirements and laws regulating the interstate practice of pathology. For all 50 states, each state medical practice act and state medical board website was reviewed. In addition, each medical board was directly contacted by electronic mail, telephone, or US registered mail for information regarding specific legislation or guidelines related to the interstate practice of pathology. On the basis of this information, states were grouped according to similarities in legislation and medical board regulations. This comprehensive survey has determined that states define the practice of pathology on the basis of the geographic location of the patient at the time of surgery or phlebotomy. The majority of states (n=32) and the District of Columbia allow for a physician with an out-of-state license to perform limited consultation to a physician with the specific state license. Several states (n=5) prohibit physicians from consultation without a license for the specific state. Overall, these results reveal the heterogeneity of licensure requirements between states. Pathologists who either practice in multiple states, send cases to out-of-state consultants, or serve as consultants themselves should familiarize themselves with the medical licensure laws of the states from which they receive or send cases.

The origins of American health libertarianism.

This Article examines Americans' enduring demand for freedom of therapeutic choice as a popular constitutional movement originating in the United States' early years. In exploring extrajudicial advocacy for therapeutic choice between the American Revolution and the Civil War, this piece illustrates how multiple concepts of freedom in addition to bodily freedom bolstered the concept of a constitutional right to medical liberty. There is a deep current of belief in the United States that people have a right to choose their preferred treatments without government interference. Modern American history has given rise to movements for access to abortion, life-ending drugs, unapproved cancer treatments, and medical marijuana. Recently, cries of "Death Panels" have routinely been directed against health care reform proposals that citizens believe would limit the products and procedures covered by government health insurance. Some of the most prominent contemporary struggles for health freedom have been waged in court. But other important recent battles for freedom of therapeutic choice have taken place in other forums, from legislative hearings to Food and Drug Administration advisory committee meetings to public demonstrations. This attitude of therapeutic libertarianism is not new. Drawing mainly on primary historical sources, this Article examines arguments in favor of freedom of therapeutic choice voiced in antebellum America in the context of battles against state licensing regimes. After considering some anti-licensing arguments made before independence, it discusses the views and statements of Benjamin Rush, an influential founding father who was also the most prominent American physician of the early national period. The Article then analyzes the Jacksonian-era battle against medical licensing laws waged by the practitioners and supporters of a school of botanical medicine known as Thomsonianism. This triumphant struggle was waged in explicitly constitutional terms, even though it occurred entirely outside of the courts. The Thomsonian campaign thus offers one of the most striking examples of a successful popular constitutional movement in American history. This article shows that, at its origin, the American commitment to freedom of therapeutic choice was based on notions of not only bodily freedom, but also economic freedom, freedom of conscience, and freedom of injury. Finally, this Article considers ways in which this early history helps illuminate the nature of current struggles for freedom of therapeutic choice.