Conceptual challenges in tailoring physician performance assessment to individual practice.

Practice inevitably narrows over time. Therefore, testing of established doctors requires that their assessment be tailored to a far narrower practice than is appropriate for testing of new doctors who have not yet differentiated. In this paper, we address the conceptual challenges of tailoring physician assessment to individual practice. Testing of established doctors needs to reflect that physicians specialise, often in idiosyncratic ways; otherwise, the testing will not be credible among established doctors and will not reflect the realities of their practice. Despite the importance of these goals, the conceptual and methodological challenges of creating tailored assessments remain daunting.

Review of the score-reporting policy for the United States Medical Licensing Examination.

In 1998, the authors, acting on behalf of the National Board of Medical Examiners (NBME), undertook a review of the scoring policy for the United States Medical Licensing Examination (USMLE). The main goal was to determine the likely effect of changing from numeric score reporting to reporting pass-fail status. Several groups were surveyed across the nation to learn how they felt they would be affected by such a change, and why: all 54 medical boards; 1,600 randomly selected examinees (including 250 foreign medical graduates) who had recently taken either Step 1, Step 2, or Step 3 of the USMLE; 2,000 residency directors; the deans, education deans, and student affairs deans at all 125 U.S. medical schools accredited by the Liaison Committee on Medical Education; and all 17 members of the Council of Medical Specialty Societies. Responses from the different groups surveyed varied from 80% to a little less than half. The authors describe in detail the various views of the respondents and their reasons. Some members in each group favored each of the reporting formats, but the trend was to favor numeric score reporting. The majority of the responding examinees desired that their USMLE scores be sent to them in numeric form but sent to their schools and to residency directors in pass-fail form. Based on the responses and a thorough discussion of their implications, the Composite Committee (which determines USMLE score-reporting policy) decided that there is no basis at this time for changing the current policy, but that it would review the policy in the future when necessary.

Nutrition coverage on medical licensing examinations in the United States.

The 1985 National Academy of Sciences report Nutrition Education in US Medical Schools recommended that the National Board of Medical Examiners (NBME), who develops the US Medical Licensing Examination (USMLE), cover basic nutrition knowledge. According to the NBME, the USMLE includes nutrition on their Step 1 and 2 exams; however, this coverage has been questioned. To document whether the NBME adequately addresses nutrition, the 1986 Part I and Part II and the 1993 Step 1 and step 2 exams, which replaced the Part I and II exams, were reviewed by five nutrition professionals. This review identified the nutrition-related areas of the two-part exams and how the extent of nutrition coverage changed from 1986 to 1993. Nutrition items were coded on four dimensions: 1) specific nutrition-related topic area, 2) normal or abnormal scenario, 3) related organ system, and 4) importance in clinical medicine. The percentage of nutrition-related items, as identified by the nutrition professionals, increased from 9% on the 1986 Part I exam to 11% on the 1993 Step 1 exam and from 6% on the 1986 Part II exam to 12% on the 1993 Step 2 exam. The percentage of nutrition items related to vitamin deficiencies increased from 1986 to 1993 on both halves of the exam. Nutrition coverage on the USMLE Step 1 and Step 2 seems adequate in amount, however, the content and appropriateness of the items were not evaluated. The observed increased focus on vitamin deficiencies should be further considered.

Impact of the USMLE step 1 on teaching and learning of the basic biomedical sciences. United States Medical Licensing Examination.

Medical licensure in the United States is in transition. In June 1991, the National Board of Medical Examiners (NBME) made major modifications in the content, format, pass/fail standards, and score reports of the NBME Part I examination. This year, Part I became Step 1, the first of three components of the United States Medical Licensing Examination (USMLE), which will shortly be the sole examination pathway to initial licensure for allopathic physicians. This essay describes Step 1, reviews the phase-in plans for the USMLE, and discusses the potential impact of both on medical schools' teaching and students' learning of the basic biomedical sciences. The authors recommend that medical schools (1) abandon the use of Step 1 as a sole criterion for student promotion to the third year and (2) carefully review other examination-related requirements for promotion and graduation.

An inventory of the personal computers for students' use at 143 U.S. and Canadian medical schools.

The National Board of Medical Examiners (NBME) has been developing new tests to be administered using computers. As these tests near readiness for use, logistical issues of test administration have become important. In 1989-1990, in order to plan for the implementation of computer-based testing in NBME examinations of the future, the authors, under the auspices of the NBME, conducted a telephone survey of knowledgeable individuals at the 143 LCME-accredited medical schools in the United States and Canada to gauge the numbers and types of microcomputers and workstations available for students' use at these schools. The findings, based on the responses of all the schools surveyed, are reported.

Phenytoin-salicylate interaction.

Ten healthy adult subjects took a single daily dose of phenytoin for 9 days to achieve a steady-state serum phenytoin concentration in the therapeutic range. While continuing on phenytoin, subjects took increasing doses of salicylate in a step-wise fashion, each dose (325, 650, and 975 mg) given every 4 hr for 48 hr. Serum (total) and salivary (free) phenytoin concentrations and serum salicylate concentrations were measured before and after each dose level of salicylate. Protein binding displacement of phenytoin by salicylate occurred only at the highest salicylate dose. Serum phenytoin control levels fell from 13.5 +/- 1.2 to 10.3 +/- 0.8 micrograms/ml (p less than 0.01), salivary phenytoin levels rose from 0.97 +/- 0.09 to 1.13 +/- 0.12 micrograms/ml (p less than 0.05), and phenytoin free fraction (salivary/serum ratio) increased from 7.14 +/- 0.34% to 10.66 +/- 0.57% (p less than 0.01) in the highest salicylate dose periods. There was no difference in these parameters during low-dose or intermediate-dose salicylate therapy. Linear-regression analysis failed to show a relationship between serum salicylate concentration and serum or salivary phenytoin concentration. Although high-dose salicylate induced protein binding displacement of phenytoin, it is unlikely that this is of clinical importance since the rise (16%) in the free (salivary) phenytoin concentration was small. Serum total phenytoin concentration may fall during salicylate therapy but the dose of phenytoin should not be altered unless there are overt signs of toxicity.

Future management of diabetes mellitus.

A review of therapies for diabetes mellitus reveals little that is new for the diabetic today. Also, there is little evidence that progression of diabetic complications can be slowed or halted with currently available therapeutic modalities that are acceptable to patients and can be applied in an everyday clinical setting. Few new drugs are likely to be ready for marketing in the immediate future, and most of the pharmacologic approaches that are now under study do not address the basic problem of lost sensitivity of the beta cell to endogenous glucose. In the longer term, it is likely that an oral insulin, allowing more convenient management of diabetes, will be available, as well as several new drug classes that may offer therapy adjunctive to insulin. As more is learned of the cellular physiology of the islet cell and the pathology of diabetes mellitus, some additional therapeutic breakthrough may occur. It is highly likely that an implantable or portable infusion system, either of the closed- or open-loop type, will be available when technologic problems are overcome. Islet cell transplantation may provide a definitive treatment for diabetes. At the very least, the questions should be resolved relating to careful physiologic control of the metabolic aberrations of diabetes mellitus. Unfortunately, because of the relatively slow evolution of diabetic vascular pathology, it will be several decades before current studies can provide the answers. If present hypotheses are confirmed, future therapeutic approaches can be more clearly defined; if the hypotheses must be rejected, the therapeutic dilemmas will remain.