a proposal for

A Single Examination

For Medical Licensure

presented by

The Task Force to Study

Pathways to Licensure

This document was unanimously endorsed byparticipants in the meeting of the TaskForce to Study Pathways to Licensure heldon February 17, 1989.

a proposal for

A Single Examination

For Medical Licensure

presented by

The Task Force to Study

Pathways to Licensure

A PROPOSAL FORA SINGLE EXAMINATION FOR MEDICAL LICENSURE

Table of Contents

Page

Preface :1

Background 7

Agencies and Organizations Involved in theLicensing Process 10

The Current Examination Requirements forLicensure 16

Concept of a Single Examination for MedicalLi censure 21

Underlying Principles 21The Proposed Examination 22Procedural and Operational Issues 27

Issues Identified Relative to a SingleExamination 33

Preface

In early 1988, under the sponsorship of the EducationalCommission for Foreign Medical Graduates (ECFMG), the Federation of State Medical Boards (FSMB) and the NationalBoard of Medical Examiners (NBME), a coalition of voluntarymedical organizations came together as a task force todiscuss the concept of a single examination for medical1 i censure.

The organizations represented in the task force discussions have an interest and involvement in assuring thatthe highest quality of medical care is available in thiscountry. While each licensing authority has the responsibility and prerogative to make determinations as to theexamination(s) to be used as a part of the medical licensingprocess, the members of this task force, recognizing therole of examination requirements for medical licensurein assuring the quality of medical care, wished to explorethe concept of a single medical licensing examination.

The Proposal for a Single Examination for Medical Licen—sure evolved from the deliberations of the task force andits subcommittees at multiple meetings during 1988 andearly 1989, and was endorsed by members of the task forceat a meeting on February 17, 1989. (A listing of the membership of the task force and its subcommittees is shownon pages 5 to 6.) Through this proposal, the task forceattempts to facilitate consideration of the concept ofa single examination as a component of medical licensure.

As is more fully described in subsequent portions ofthis proposal, there are currently two examinations utilizedin the medical licensing process in the United States:the Federation Licensing Examination (FLEX) of the FSMBand the certifying examinations of the NBME consistingof Parts I, II, and III. The FLEX is the examination takenby all graduates of foreign medical schools seeking licensurein a state or territory of the United States and is alsotaken by approximately one—fourth of the graduates of accred—

1

ited U.S. medical schools. The NBME certifying examinations

are taken for purposes of medical licensure by approximately

three-fourths of the graduates of accredited medical schools

in the United States.

Both examinations are recognized by the medical licensing

authorities in this country as high quality evaluation

instruments, appropriate for use in the licensing process.

The discussions regarding a single examination were not

prompted by and were not pursued as a result of any dissat

isfaction with the quality of either or both of the two

existing examination routes to licensure. Rather, review

of the examination requirements for medical licensure was

prompted by and pursued as a result of questions regarding

the very existence and utilization of two different examina

tions for the same purpose.

Given the general level of satisfaction with the quality

of the existing examination programs, it is difficult to

examine the advantages and/or disadvantages of a single

examination in the abstract. The desirability of any such

single examination is felt to be contingent, in large measure

upon the retention of characteristics of the existing exami

nation programs which have been proven to be effective

and valuable in the assessment of knowledge for purposes

of medical licensure. The task force reviewed the background

on medical licensure, the roles of agencies and organizations

which have interactions in or are peripheral to the licensing

process, and the current examination requirements for medical

licensure. After this review, this paper was developed

to describe a single examination proposal for purposes

of discussion. Variations in the structure or characteris

tics of the examination program proposed could well be

expected to produce variations in opinions as to the desir

ability of the concept of a single examination for medical

licensure.Throughout the discussions leading to the development

of this proposal, the task force was aware of and accepted

the fact that the licensing authorities in this country

determine the qualification for licensure of applicants

2

who have graduated from a variety of different medicalschools. For those applicants who have graduated fromaccredited U.S. or Canadian medical schools, the licensingauthorities have knowledge that they have completed aneducational process which meets published, pre—existirigstandards. Given the absence of any comparable systemof accreditation for the majority of foreign medical schools,such knowledge is generally lacking for applicants whohave graduated from many such schools. A single medicallicensing examination would provide a common evaluationsystem against which to measure applicants for licensure,regardless of the source of their medical education.

An important issue considered, however, was whetherutilization of the same examination for all applicants,regardless of the source of medical education, might serveto obfuscate significant differences which may exist inthe quality or what is known about the quality of suchmedical education. Therefore, a fundamental principleunderlying the development of this proposal is that theconcept of a single examination for medical licensure isnot intended to and should not ignore or obscure differenceswhich may exist in the quality of the medical educationreceived by applicants for licensure or in any way serveto diminish the importance of education and educationalstandards in the licensing process. The educational standards acceptable to the licensing authorities should notbe affected by any single examination which might evolve.Those educational standards, as well as the standards forany single examination which may be used for medical licensure, should be and remain at a level significantly highto assure that, in granting a medical license, the licensingauthority is fulfilling its responsibility to protect thepublic.

3

Organizations Represented on the Task Forceto Study Pathways to Licensure

Accreditation Council for Graduate Medical Education (ACGME)

American Medical Association (AMA)

Association of American Medical Colleges (AAMC)

Department of Health and Human Services (DHHS)

Educational Commission for Foreign Medical Graduates (ECFMG)

Federation of State Medical Boards (FSMB)

National Board of Medical Examiners (NBME)

National Board of Osteopathic Medical Examiners (NBOME)

4

Members of the Task Force to Study Pathways toLicensure Attending the February 17, 1989, Meeting

L. Thompson Bowles, MD, PhD (NBME)J. Lee Dockery, MD (AMA)Bryant L. Galusha, MD (FSMB)John C. Gienapp, MD (ACGME)Donald G. Kassebaum, MD (AAMC)Louis J. Kettel, MD (AAMC)Robert E. Mancini, PhD, DO (NBOME)Carlos J.M. Martini, MD (AMA)Howard G. McQuarrie, MD (FSMB)William J. Reals, MD (ECFMG)Robert L. Volle, PhD (NBME)Donald L. Weaver, MD (DHHS)Marjorie P. Wilson, MD (ECFMG)

Other Past and Present Members of the TaskForce to Study Pathways to Licensure

Ronald B. Berggren, MD (ACGME)Stanley S. Bergen, Jr., MD (ECFMG)Madison B. Brown, MD (ECFMG)Ray L. Casterline, MD (ECFMG)Anthony J. Cortese, DO (FSMB)Richard L. Egan, MD (AMA)William H. Luginbuhl, MD (AAMC)Magdalene Miranda (DHHS)Richard J. Reitemeier, MD (NBME)Lawrence Scherr, MD (ACGME)M. Roy Schwarz, MD (AMA)August G. Swanson, MD (AAMC)

5

Subcomittee A of the Task Force to StudyPathways to Licensure

J. Lee Dockery, MD (AMA)

Bryant L. Galusha, MD (FSMB)

John C. Gienapp, MD (ACGME)

Louis J. Kettel, MD (AAMC)

Robert E. Mancini, PhD, DO (NBOME)

Carlos J.M. Martini, MD (AMA)

Robert L. Voile, PhD (NBME)

Marjorie P. Wilson, MD (ECFMG)

Subcomittee B of the Task Force to StudyPathways to Licensure

Henry G. Cramblett, MD (FSMB)

Bryant L. Galusha, MD (FSMB)

Donald E. Melnick, MD (NBME)

Robin D. Powefl, MD (NBME)

Marie Shafron (ECFMG)

Marjorie P. Wilson, MD (ECFMG)

Resource Person for the Task Force and its

Subcommittees: Janet D. Carson, JD (NBME)

6

A PROPOSAL FOR A SINGLE EXAMINATION FOR MEDICALLICENSURE

BACKGROUND

1. License: This is the approval given by the designatedlegal authority permitting the individual to practicemedicine.

A. The designated legal authority has as its primarypurpose the protection of the public health, safetyand welfare.B. The designated legal authority protects this publicinterest by granting permission to practice medicineonly to those individuals whom the legal authorityhas legitimate reason to believe are qualified toengage in the practice of medicine in a safe and competent manner.

2. Generally, determinations of qualification have beenmade by the designated authorities on the basis of education,examination, and experience.

3. Education Requirement: Historically, this has consistedof two components:

A. The individual has satisfactorily completed theeducational program of a medical school leading tothe award of the MD; andB. The quality of the education and training providedby the educational program of the institution grantingthe degree is accepted by the licensing authority.

(1) Even in the days of the apprentice system,prior to the establishment of formal processesfor the granting of licenses by governmental authorities, it was recognized that some participationon the part of the individual in an educationalprocess designed to impart the knowledge and skillsof a physician was necessary to give the public

7

the requisite confidence in that individual as

a physician.(2) Attention then focused on the quality ofthe educational program, in part as a result ofthe Flexner report of 1910 which drew attentionto the extreme variability in the quality of medicaleducation throughout the U.S. and the “enormousoverproduction of uneducated and ill trained medicalpractitioners.”

4. Examination Requirements: At one point in time, priorto the creation of the Liaison Committee on Medical Education(LCME) and an accreditation process, licensing standardswere established by medical schools, i.e., the receiptof the degree, at least from some schools, qualified theindividual for practice. Loosely applied “licensing standards” established by some medical schools led most statesto adopt procedures to determine the qualification ofindividuals seeking licensure by a designated legal authority. The widespread use of examinations which followedreflected a desire for more stringent requirements foradmission to practice, i.e., in addition to the completionof an educational program to the satisfaction of the educational institution, the individual must also demonstratea level of medical knowledge satisfactory to the licensingauthority.

5. Experience Requirement: This can be viewed as partof the education requirement, i.e., part of the continuumof medical education. This requirement generally consistsof two components:

A. Satisfactory completion of some period of graduatemedical education which provides experience in thepractice of medicine; andB. Acceptance by the licensing authority of the qualityof graduate medical education provided by the institution in which the individual gains such experience.

8

6. In summary, approval to practice medicine is grantedby the designated licensing authorities when each of thefollowing questions is answered in the affirmative:

A. Has this individual satisfactorily completed aneducational program designed to, and for which thereis legitimate reason to believe does, impart the knowledge necessary for the safe and competent practiceof medicine?8. Has this individual satisfactorily completed agraduate medical education program designed to, andfor which there is legitimate reason to believe does,provide experience in the application of the knowledgeand skills necessary to the safe and competent practiceof medicine?C. Has this individual satisfactorily demonstratedthrough examination the acquisition of the knowledge,which can be tested, necessary for the safe and competentpractice of medicine?

7. Many licensing authorities additionally have requirements for medical licensure which relate to character”and/or “fitness. These might include, for example, arequirement that the individual should be physically,mentally, and professionally capable of practicing medicinein a manner acceptable to the licensing authority; orthat the individual should have demonstrated a consistentpattern of socially acceptable behavior; or that the individual should not have been found guilty by any competentauthority of any conduct that would constitute groundsfor disciplinary action by the licensing authority.

9

AGENCIES AND ORGANIZATIONS INVOLVED IN THE LICENSING PROCESS

1. While decisions to grant or deny medical licensureare the prerogative of the individual states, the licensingprocess involves, directly or indirectly, the activitiesof a variety of entities in addition to the state medicalboards.

A. Federation of State Medical Boards (FSMB)(1) The voluntary association of the individualstate medical boards.(2) Makes available to its member boards theFederation Licensing Examination (FLEX).

(a) Actively participates with the NBMEin the development of the FLEX and reviewsthe FLEX in order to assure that it is anappropriate evaluation instrument for itsmember boards to use for purposes of theexamination requirement for licensure.(b) Through its FLEX Board, establishespolicies and procedures for the FLEX Programand recommends passing requirements on theFLEX to the state medical boards.(c) The individual state medical boardsdetermine eligibility requirements, administerthe FLEX, and determine the test score requiredto meet the examination requirements in theirjurisdictions.

B. National Board of Medical Exaniiners (NBJ€)(1) A voluntary, independent organization whichprepares and administers examinations, the successful completion of which, together with the completion of other requirements, leads to the awardof its certificate. State medical boards may,in their discretion, accept the certificateof the NBME as qualification for licensure.

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(a) NBME certification is accepted asqualification for initial licensure bythe medical licensing authorities of allstates and territories except Louisiana,Puerto Rico, Texas, and the Virgin Islands.(b) NBME determines design, content, standards and eligibility for and administersits certifying examinations.

(2) Participates with FSMB in the design, development and scoring of the FLEX.(3) Participates with the ECFMG in the design,development and scoring of the Foreign MedicalGraduate Examination in the Medical Sciences(FMGEMS).

C. American Medical Association (AMA)(1) A professional, non-profit organization,whose purpose is to promote the science andart of medicine and the betterment of the publichealth and provide service to its membership.The key objective of the AMA is “to contributeto the professional and personal developmentof member physicians to the betterment of thehealth of the public by developing and distributing information; by advocating health-relatedrights, responsibilities, and issues; and byrepresenting the profession as a whole wherethe image, expertise and national scope of theAMA prove useful.(2) Since its establishment in 1847, the AMAhas continued and strengthened its commitmentto medical education. Through its sponsorshipand representation on the Liaison Committeeon Medical Education (LCME), Accreditation Councilfor Graduate Medical Education (ACGME), twenty-fourresidency review committees, Accreditation Councilon Continuing Medical Education (ACCME) andCommittee on Allied Health Education and Accredi

11

tation (CAHEA), the AMA is directly involvedin accreditation at each level of the continuumof medical education. The AMA also maintainsan Office of Physician Credentials and Qualifications. By direct representation, the AMA participates in the activities of the ECFMG and theNBME. In addition, the AMA has interest inthe activities of the FSMB.(3) AMA’s formation of the Council on MedicalEducation (CME) and establishment of the MedicalSchools Section (MSS) are further evidence ofAMA’s commitment to medical education. In accordance with AMA Bylaws, the CME studies and evaluates all aspects of medical and allied healtheducation and, as necessary, recommends policiesto the House of Delegates. The purpose of theMSS is to provide a direct means for approvedmedical schools to participate in AMA activities.

D. Association of American Medical Colleges (AAIIC)(1) An educational association which has asits purpose the advancement of medical educationand the nation’s health. In pursuing this purpose,the AAMC works with many organizations, andindividuals interested in strengthening thequality of medical education at all levels,the search for biomedical knowledge, and theapplication of these tools to providing effectivehealth care.(2) As an association representative of membershaving similar purpose, the AAMC assists thosemembers by providing services at the nationallevel which will facilitate the accomplishmentof their mission.(3) While not directly involved in the licensingprocess, the AAMC has indirect involvement throughits participation in and/or sponsorship of theACGME, LCME, and ECFMG.

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E. Liaison Coninittee on Medical Education (LCME)(1) Established by the AMA and the AAMC, withresponsibility for establishing the criteriafor accreditation of medical schools and, bymeans of periodic visits of inspection, fordetermining if the criteria have been met.This accreditation function is performed forschools in the U.S. and Canada.(2) LCME accreditation is one of the basesupon which state medical boards have assuredthemselves of the quality of the educationalprogram which the individual applicant has completed.

F. Accreditation Council for Graduate Medical Education(ACGME)(1) Composed of representatives of the AmericanBoard of Medical Specialties (ABMS), the AmericanHospital Association (AHA), the AMA, the AAMC,and the Council of Medical Specialty Societies(CMSS), public members, resident physician members,and federal government representatives.(2) The agency with responsibility for assuringthe quality of a graduate medical educationprogram, a responsibility which includes thedetermination of the essentials for accreditedtraining programs.(3) ACGME accreditation is a basis upon whichstate medical boards have assured themselvesof the quality of the graduate training andexperience which the individual applicant hasreceived.

G. Educational Coninission for Foreign Medical Graduates(ECFMG)(1) A voluntary organization which is sponsoredby the ABMS, AHA, AMA, AAMC, Association forHospital Medical Education (AHME), FSMB, and

13

National Medical Association, and includes public

member representation in its governance.

(2) Through its program of certification, assesses

the readiness of graduates of foreign medical

schools to enter accredited programs of graduate

medical education in the U.S.(a) Successful completion of the FMGEMS,

or, previously, the ECFMG Examination or

the Visa Qualifying Examination, together

with the English language proficiency require

ment, and complete documentation of thespecified medical credentials, leads tothe award of the ECFMG certificate.

(i) This latter requirement includes

documentation of all educational require

ments to practice medicine in the

country in which the medical education

is completed. Documents providedto ECFMG are referred for verification

by appropriate officials of the foreign

medical schools.(ii) NBME develops the FMGEMS, which

is reviewed and approved by ECFMG

as an appropriate evaluation instrumentfor purposes of the medical science

examination requirement for ECFMG

certification.(iii) Through agreement with the

NBME, ECFMG will administer the NBMEPart I and Part II to foreign medical

graduates, commencing in September1989, as an alternative to the FMGEMS

for purposes of ECFMG certification.

(b) The ECFMG certification process is

one step removed from the licensing process:

The certificate is required of foreign medicalgraduates seeking entry to accredited graduate

medical education programs, participation

14

in which is required for licensure. Also,with rare exception, the successful completionof the FMGEMS or ECFMG certification isan eligibility requirement for the licensureof foreign medical graduates.

H. Department of Health and Human Services (DHHS)(1) Federal agency responsible for implementationof Public Law 94—484 which requires, among otherthings, that alien physicians seeking to participatein graduate medical education in the U.S. havesuccessfully completed the NBME Part I and PartII examinations or an examination determinedto be equivalent thereto.(2) Its activities in this respect are onestep removed from the licensing process: Theyrelate to qualification to enter graduate medicaleducation programs, participation in which isrequired for licensure.

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THE CURRENT EXAMINATION REQUIREMENTS FOR LICENSURE

1. Current Requirements

A. Individuals who are graduates of LCME accreditedmedical schools may meet the examination requirementfor initial licensure in all but four licensing jurisdictions (Louisiana, Puerto Rico, Texas, and the VirginIslands) in one of two ways: Successful completionof the Part I, Part II, and Part III certifying examinations of the NBME or successful completion of Component1 and Component 2 of the FLEX. LCME graduates whoare applicants for initial licensure in Louisiana,Puerto Rico, Texas, or the Virgin Islands must meetthe examination requirement by successful completionof FLEX Component 1 and Component 2.

B. Individuals who are graduates of medical schoolsnot accredited by the LCME must meet the examinationrequirement for initial licensure by the successfulcompletion of FLEX Component 1 and Component 2. Inmost jurisdictions, a graduate of a foreign medicalschool must successfully complete Day 1 and Day 2 ofthe FMGEMS or hold ECFMG certification in order tobe eligible to take the FLEX.

2. NBME Certifying Examinations

A. Part I(1) a two—day written (multiple choice) examinationin the basic medical sciences.(2) content specifications reflect the scientificprinciples and basic medical knowledge that a studentshould understand for subsequent educational experiences in the continuum of medical education andfurther learning as a physician.(3) one of the three parts of the NBME certifying

16

examination program which is accepted as meetingthe examination requirement for licensure in allU.S. licensing jurisdictions, except Louisiana,Puerto Rico, Texas, and the Virgin Islands.(4) only students in and graduates of LCME accredited medical schools are eligible to take PartI for purposes of NBME certification.(5) performance on this examination is used byLCME accredited medical schools as part of an externalevaluation of the progress of their students and/ora source of information regarding the effectivenessof their programs.(6) items in the Part I pool of test items areused in Day 1 of the FMGEMS.

B. Part II(1) a two-day written (multiple choice) examinationin the clinical sciences.(2) content specifications reflect the clinicalscience principles and medical knowledge that astudent should understand for subsequent educationalexperiences in the continuum of medical educationand further learning as a physician.

(3) one of the three parts of the NBME certifyingexamination program which is accepted as meetingthe examination requirements for licensure in allU.S. licensing jurisdictions, except Louisiana,Puerto Rico, Texas, and the Virgin islands.

(4) only students in and graduates of LCME accredited medical schools are eligible to take PartII for purposes of NBME certification.(5) performance on this examination is used byLCME accredited medical schools as part of an externalevaluation of the progress of their students and/ora source of information regarding the effectivenessof their programs.

(6) items in the Part II pool of test items areused in Day 2 of the FMGEMS.

17

C. Part III(1) a one—day written examination intended tomeasure a candidat&s possession and use of medicalknowledge which is deemed appropriate for the unsupervised practice of general medicine.(2) the final part of the NBME certifying examination program which is accepted as meeting the examination requirement for licensure in all U.S. licensing jurisdictions except Louisiana, Puerto Rico,Texas, and the Virgin Islands.(3) only graduates of LCME accredited medicalschools, who have passed the Part I and Part IIexaminations, and who are participating in an ACGMEaccredited graduate medical education program (orwho have satisfactorily completed one full yearin such a program) are eligible.

D. The successful completion of these certifying examinations satisfies one of the three requirementsfor NBME certification. To be eligible for NBMEcertification, an individual also must have receivedthe M.D. degree from a medical school in the UnitedStates or Canada accredited by the LCME and musthave completed, with a satisfactory record, onefull year in a graduate medical education programaccredited by the ACGME. Thus, the NBME certificatereflects the necessary combination of educationaland examination requirements.

3. Federation Licensing Examination (FLEX)

A. Component 1(1) a 1½ day written (multiple choice) examinationdesigned to evaluate measurable aspects of knowledgeand understanding of basic and clinical scienceprinciples and mechanisms underlying disease andmodes of therapy.(2) places special emphasis on fundamental knowledge

18

of the diseases and problems frequently encounteredin a supervised setting on an in—patient basis,i.e., knowledge required of a physician assumingclinical responsibilities associated with graduatemedical training.(3) eligibility requirements are determined byeach state medical board.

(a) all state medical boards require receiptof an M.D. degree.(b) most, if not all, state medical boardsrequire successful completion of FMGEMS orECFMG certification for graduates of foreignmedical schools.(c) jurisdictions using FLEX for licensure

in osteopathic medicine all require receipt

of a D.O. degree.

B. Component 2(1) a 1½ day written examination designed to assess

the additional knowledge and cognitive abilitiesrequired of a physician assuming independent respon

sibility for the general delivery of medical care

to patients.(2) focuses on a core of critical abilities andknowledge required for diagnosis and managementof selected clinical problems most frequently encountered by the physician licensed for the independent,unrestricted practice of medicine.

(3) eligibility requirements are determined byeach state medical board.

(a) all state medical boards require receiptof an M.D. degree.(b) most, if not all, state medical boardsrequire successful completion of FMGEMS orECFMG certification for graduates of foreign

medical schools.(c) some state medical boards require success

ful completion of Component 1.

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(d) some state medical boards require someperiod of graduate medical education in anaccredited program.(e) jurisdictions using FLEX for licensurein osteopathic medicine all require receiptof a D.O. degree.

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CONCEPT OF A SINGLE EXAMINATION FOR MEDICAL LICENSURE

1. Underlying Principles

A. A variety of issues may surface relative to theeducation and experience requirements for medical licensure (e.g., How can/should state medical boards effectively assess the quality of an educational programin the absence of an accreditation process such asthat of the LCME? What can/should be required forqualification for entry to accredited programs of graduatemedical education?). Without minimizing the importanceof such issues, the context of the current discussionsof the task force is the examination requirement forlicensure, and accordingly, that is the focus of thisproposal. This in no way implies that the examinationrequirements for medical licensure are more importantor should be given greater weight than the other requirements in the licensing process. To the contrary, itis presumed that educational and training componentswill and should be separate requirements to be metby individuals seeking medical licensure.

(1) While well—designed standardized examinationscan and do provide reliable and valid assessmentsof the cognitive components of competence, performance on examinations cannot be considered in isolation.(2) The complete assessment of competence alsorequires the evaluation of clinical and interpersonalskills, as well as behavioral characteristics.These components of physician competence can beassessed only through direct observation over timeby those responsible for the educational processes.

B. The purpose of current discussions is to identifyand examine issues related to the concept of a singleexamination for medical licensure in lieu of the currentdual examination programs.

21

C. An underlying premise of this proposal is that

an examination used for purposes of licensure should

allow a licensing board to “examine,” to the extentpossible, whether an individual, who has participated

in educational and training processes acceptable for

purposes of licensure, has acquired the knowledge which

such processes are designed to impart and which isdeemed necessary for the safe and competent practiceof medicine.

2. The Proposed Examination

A. The examination will consist of three components,designated as “steps.”

Step 1 and Step 2 will focus on the foundations ofmedical knowledge and understanding of scientific principles that an examinee should have in the basic biomedical sciences and in the clinical sciences, respectively.Step 3 will focus on a core of critical knowledge andother cognitive competencies that an examinee shouldhave for diagnosis and management of clinical problemsfrequently encountered during the practice of medicine.This longitudinal series of examinations or steps willenable examinees to obtain an early evaluation of theirprogress and their likelihood of successfully achieving

1 icensure.

The three steps together will assess the examinee’spossession of and ability to apply concepts and princi

ples that are important in health and disease and thatconstitute the basis of safe and effective patientcare.

B. Step 1: An examination component in the basicmedical sciences based upon NBME Part I.

(1) Purpose: The purpose of Step 1 will be todetermine if an examinee understands and can apply

22

key concepts of basic biomedical science, witha special emphasis on principles and mechanismsunderlying disease and modes of therapy.(2) Rationale

(a) The inclusion of this component willensure that due attention is devoted to scientific principles as the underpinnings of andfoundation for the safe and competent practiceof medicine.(b) The curricula of LCME accredited medicalschools generally devote the first two yearsof medical education to the basic sciences.The licensing authorities have accepted LCMEaccreditation as evidence of the quality ofsuch educational programs, i.e., their acceptability for purposes of licensure. The inclusionof this component in the examination wouldreflect the recognized importance of knowledgein the basic medical sciences, as demonstratedby the fact that it is the focus of a significant portion of LCME accredited educationalprocesses leading to and deemed acceptablefor licensure.

(3) Characteristics(a) Step 1 would be the responsibility ofthe NBME, with advisory participation fromthe licensing community. The NBME, utilizingqualified examiners from the academic andlicensing communities, would structure thisstep based on the scientific principles andbasic medical knowledge expected to be acquiredby a student educated in an LCME accreditedschool(b) Students in LCME accredited schools wouldserve as the reference group in standard setting.

(4) Other Uses(a) LCME accredited schools, at their discretion, could continue to use performance on

23

Step 1 for purposes of intramural assessment.

(b) Step 1 could be used by foreign medicalgraduates for purposes of meeting the basic

science requirement of Public Law 94-484 and

part of the medical science examination requirement for ECFMG certification.

C. Step 2: An examination component in the clinicalsciences based upon NBME Part II.(1) Purpose: The purpose of Step 2 will be todetermine if an examinee possesses the medicalknowledge and understanding of clinical scienceconsidered essential for provision of patient careunder supervision.(2) Rationale

(a) The inclusion of this component willensure that appropriate attention is devotedto the clinical science principles which areunderpinnings of and a foundation for thesafe and competent practice of medicine.(b) As with Step 1, the inclusion of thiscomponent in the examination would reflectthe fact that LCME accredited education isrecognized by the licensing authorities aseducation acceptable for medical licensureand that such LCME accredited education includesa significant focus on the clinical sciences.

(3) Characteristics(a) Step 2 would be the responsibility ofthe NBNE, with advisory participation fromthe licensing community. The NBME, utilizingqualified examiners from the academic andlicensing communities, would structure thisstep based on the principles of clinical science and clinical medical knowledge expectedto have been acquired by a student educatedin an LCME accredited school.(b) Students in LCME accredited schools would

24

serve as the reference group in standard setting.(4) Other Uses

(a) LCME accredited schools, at their discretion,could continue to use performance on Step2 for purposes of intramural assessment.(b) Step 2 could be used by foreign medicalgraduates for purposes of meeting the clinicalscience examination requirement of Public

Law 94—484 and the remaining part of the medicalscience examination requirement for ECFMGcertification.

D. Step 3: A final examination component to assess

the knowledge deemed requisite for the safe and competent

practice of medicine which has not yet been tested

in the other components or which warrants further exami

nation, based upon elements of current FLEX Component

1 and Component 2.(1) PurposeThe purpose of Step 3 will be to determine if an

examinee possesses the medical knowledge and under

standing of biomedical and clinical science considered

essential for the unsupervised general practice

of medicine, with a special emphasis on patient

management in common clinical situations.

(2) RationaleExtensive clinical experience with the management

of patients with acute and chronic medical, behav

ioral, and surgical problems in a supervised setting

should be essential prior to the awarding of an

unrestricted medical license. The inclusion of

Step 3 will ensure that due attention has been

devoted to the integration of clinical experience

with an understanding of the biomedical and clinical

sciences that undergird such experience.

(3) Characteristics(a) This examination would be the responsibility

of the FSMB working in collaboration with

25

the NBME and would assess aspects of the knowledge,skills, and competencies expected to be acquiredduring the medical education continuum, includingthe experience of residency training, anddeemed to be requisite for the safe and competentpractice of medicine.(b) Graduates of LCME accredited schoolswould serve as the reference group in standardsetting.

E. A composite committee, including representationfrom the FSMB and the NBME, and the ECFMG in an advisorycapacity, would be charged to review and approve thethree steps of the examination and to assure that thethree steps constitute a unified, cohesive examinationprogram.

A general system of standard setting would be developedby the composite committee as part of the examinationsystem design. The best approaches to standard settingwould be applied and the standards set would continueto assure the quality of the physicians who qualifyfor licensure through the examination.

F. The need for and/or desirability of a test of clinicalskills, either as a component of the examination forlicensure or as an eligibility requirement for entryinto graduate medical education, has been suggestedand was considered. While well—designed standardizedexaminations are useful and valuable tools in assessingthe cognitive components of competence, such evaluationinstruments have limitations in that they do not andcannot assess all aspects of physician competence,e.g., behavioral characteristics, psychomotor skills.Therefore, when valid and reliable methodologies becomeavailable to evaluate such clinical skills, it is anticipated that they will be incorporated into Step 2 and/orStep 3 of the proposed examination.

26

3. Procedural and Operational Issues

A. Certain consistencies in policies and procedureswould be necessary among the users of the single examination, i.e., the licensing authorities, to assurethe validity, reliability, and utility of the examinationprogram.

B. Organizational Structure: The single examinationprogram would be structured through contractual relationships between and among the organizations which wouldbe directly involved in the program, with each of the

involved organizations retaining and maintaining itsseparate identity and independence.

(1) FSMB and NBME would both have direct roles

and responsibilities relative to the development

and administration of the program.(2) ECFMG would have responsibility relative tothe administration of Steps 1 and 2 and would have

a role by reason of the expectation that Steps1 and 2 of the examination would be utilized in

ECFMG’s certification program.(3) Through contractual agreements, a joint group

or composite committee, as referenced earlier,would be created and would include representation

from FSMB and NBME, and ECFMG in an advisory capacity.

C. Roles and Responsibilities: A proposed plan regarding

roles and responsibilities relative to the single exami

nation program is displayed and discussed below.

- -,

mCTh

—z

z

TEST DEVELC. ....... F/PRODUCTION

27

(1) In the above diagram, which describes the participants and the functions and components in a singleexamination program for medical licensure, each ringrepresents a major functional area. The diagram demonstrates how each functional segment would interrelatewith all others, requiring a highly cooperative relationship among those responsible for various roles.(2) Test System Design: The upper quadrant represents the overall examinations system design. Responsibilities in this segment would include developmentof an overall examination system design, with specialattention to the complementary nature of the individualsteps. This design activity would include the development of clearly defined examination objectives dealingboth with content and competencies. A general systemof standard setting would be developed as part of theexamination system design, with special attention tothe complementary nature of standards across the examination steps. Test system design would also includetasks related to recommended eligibility requirements,administration procedures, security standards, etc.The composite committee, referenced above, would beresponsible for test system design across all threesteps. The committee would draw on information fromeach of the other functional areas and would providethe integrative focus both for the other functionalareas and for the steps of the examination.(3) Step Design/Content/Item Writing: Activitiesin the right quadrant include detailed planning, design,and writing of items for the individual examinationsteps by appropriately selected content experts. Following the examination system blueprinting developedby the composite committee, examination step blueprintswould be developed, test materials written, and standardsfor the individual steps established. As referencedearlier, responsibility in this regard for Steps 1and 2 would be that of the NBME, with advisory participation from the licensing community, and for Step 3

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would be that of the FSMB, working in collaborationwith the NBME.(4) Test Development/Production: The lower quadrantrepresents professional test development activities.These include support for the step design/content/itemwriting activities, described above, such as item bankmaintenance, item writing assignment, item editing,and coordination of review, examination production,and scoring and analysis. In addition, research onvalidation and development of new methods and formatswould fall within the domain of the testing professionals.Activities of the lower quadrant would be carried outfor all three steps by NBME staff.

D. Test Administration: The left quadrant incorporatesall activities relating to registration, eligibility,test centers, shipping, and examination administration.These activities would be carried out in the contextof general policies applicable to the entire examinationsystem, to be developed by the composite committee.Activities in this left quadrant for applicants forlicensure would be carried out by the licensing authorities, under the guidance of the FSMB, for Step 3.For Steps 1 and 2, the NBME would serve LCME studentsand graduates and ECFMG would serve students and graduatesof foreign medical schools.

(1) The administration of all three steps wouldbe conducted in accordance with policies and procedures established by the composite committeeto assure the security and integrity of the examination.(2) The composite committee would set eligibilityrequirements for Steps 1 and 2, with the provisothat a licensing authority could sponsor an individual who did not meet those requirements to takeStep 1 and/or Step 2 by exception. While recommendations would be provided by the composite committeeregarding eligibility for Step 3, the licensing

29

authorities would determine eligibility for Step

3.(a) It is recommended that eligible individuals

would be able to write Steps 1 and 2 duringor after their undergraduate medical education.

(b) It is recommended that individuals wouldbe eligible to write Step 3 at any point after

(i) receipt of an M.D. degree acceptableto the licensing authority;(ii) successful completion of Step 1and Step 2 and, additionally, for graduatesof foreign medical schools, the receiptof the ECFMG certificate; and(iii) completion of at least one yearof graduate medical education acceptableto the licensing authority.

(c) It is recommended that individuals whoare students in or graduates of unaccreditedmedical schools in the United States or itsterritories would not be eligible for the examination.(d) Given that some licensing authoritiesmay request the use of this examination forpurposes of evaluation of osteopathic physicians,the three steps of the single examination formedical licensure should be made availableto students in and graduates of schools ofosteopathic medicine.

E. Transition: There is a number of factors whichwould need to be addressed in considering the mechanismand timeline for a transition from the current examinationsfor medical licensure (FLEX and NBME certifying examinations) to a single examination. Important among thesewould be: the lead time required in some jurisdictionsfor statutory or regulatory changes; the time requiredfor necessary test design and development activities;the need to accommodate individuals who may have passed

30

a part or a component of one of the current examinations;the desirability or lack thereof of using “hybrids,”i.e., parts of two examinations, to meet requirementsduring a transition period; the time necessary forother entities, e.g., medical schools, to make anyrevisions which may be required in their policies andprocedures relating to the current examinations; andthe continuation or discontinuation of the FMGEMS.Further consideration and study would be required relative to these issues.

(1) Additionally, there would be a need for atransition task force to provide to legitimatelyinterested agencies information and assistancewhich might be required for transition to a singleexamination program.(2) One proposal for transition is displayed onthe following chart. On the chart, an “X” indicatesthe administration of the examination identifiedon the horizontal axis in the year identified onthe vertical axis. In year 1, Step 1 would beintroduced and NBME Part I discontinued; in year3, Step 2 would be introduced and NBME Part IIdiscontinued; in year 4, Step 3 would be introducedand NBME Part III and FLEX discontinued.

Pt I Pt II Pt III FMGEMS FLEX Step 1 Step 2 Step 3

Year0 X X X X1 X X X X2 X X X X3 X X X X4 X X X5 X X X

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In reviewing this chart, it should be expressly

noted that it does not make provision for certain

examinees in the “pipeline, e.g., those who have

not followed the usual time sequence of examinations;

those with a passing score on FMGEMS; those with

a passing score on N8ME Part I and/or Part Il;

and those with a passing score on Component 1 or

Component 2 of FLEX. Further consideration would

need to be given to ways to accommodate such indi

viduals.

SINGLE EXAMINFITIOHFOR MEDICAL LICENSURE

LCME Hon—LCME

Step 1Step

M.D. ECFMC cert.

Craduate Medical Education Requirement(minimum 1 year)

Step 3

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ISSUES IDENTIFIED RELATIVE TO A SINGLE EXAMINATIOII

1. Point: A single examination eliminates the notionof ‘separate, but equal” which is viewed as a disfavoredconcept in our society, and removes the impetus forlegislative initiatives in states concerned about thisissue.

Counterpoint: For graduates of LCME accredited schools,there is assurance that the educational program leadingto the award of the M.D. has met nationally recognizedstandards. For graduates of unaccredited medical schools,there is no comparable assurance. The two groups are different and the different examinations currently in placereflect this fact.

2. Point: Issues raised by differences in educationalprograms should be addressed in the context of theeducation requirement for licensure and not in thecontext of the examination requirement. A single examination would eliminate the use of a variety of differentexaminations in an attempt to compensate for lack ofcertainty about the quality of the education.

Counterpoint: There presently exists no accreditationor other system for assuring the quality of education innon-LCME accredited medical education programs. Questionnaires and other forms of off-site comparisons are difficultto implement as substitutes for on—site surveys and accreditation methodology. In the absence of a system for assessingthe quality of these educational programs, examinationsat least provide a mechanism for assessing the out—putof such programs. The addition of a clinical skills testto the examination sequence prior to entering graduatemedical education would add further assurances in lieuof LCME accreditation, but to date such a test remainsto be validated.

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3. Point: A single examination assures that there isat least one common denominator in the licensing process.While presumably all education and training relied

upon for licensure should meet some acceptable levelof quality, there will be substantial variations inthe quality of the education and training received

by applicants. A single examination for licensure

would enable state licensing authorities to have a

standardized examination base for assessing all appli

cants.

Counterpoint: There is a risk that the quality of the

examination would be reduced to the lowest common denomi

nator.

4. Point: Using the same examination for all applicants

regardless of source of education might imply that

the quality of the education programs are the same

and erode the meaningfulness of LCME accreditation.

Counterpoint: LCME accreditation would continue to be

important in providing licensing authorities with assurance

of the quality of the educational programs so accredited.

Currently, not all graduates of LCME accredited medicalschools follow the NBME certification route to licensure:

Some of them currently take the FLEX, i.e., the same exami

nation taken by graduates of non-LCME accredited schools.

5. Point: Testing of broad knowledge of basic scienceswould eventually be eroded in favor of more emphasison clinical competence.

Counterpoint: The proposed structure of a single examinationwould assure continued recognition of the importance ofthis essential foundation for the safe and competent practice

of medicine.

6. Point: Step 1 and Step 2 would become relegated to

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the position of qualifying examinations for entry tograduate medical education.

Counterpoint: The requirements for entry to graduate medicaleducation for LCT4E graduates do not currently include thesuccessful completion of Part I and Part II. Such a requirement could be established now or in the future regardlessof whether a single examination pathway for licensure isimplemented.

7. Point: Step 1 and Step 2 would become relegated tothe position of eligibility requirements for the finallicensing examination.

Counterpoint: The possibility of Step 1 and Step 2 becomingeligibility requirements for the final licensing examinationcould be eliminated if the three components of the examinationdid not need to be taken in sequence. It does not makeany substantive difference, however, whether a licensingauthority’s examination requirement is that an applicantmust successfully complete the three steps of the examinationprogram or whether it requires an applicant to successfullycomplete Step 3, with successful completion of Step 1 andStep 2 being an eligibility requirement for that finalexamination. Under both structures, the licensing authorityis requiring the successful completion of all three steps.

8. Point: A single examination for licensure could resultin loss of meaning for the NBME certificate.

Counterpoint: The NBME could continue to grant its certificate to LCME graduates.

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