Medical Education and Licensure in the United Statesin the United States 

Peter V. Scoles MDSenior Vice President

NBME

NAVMECApril 30, 2010

NBME• Founded in 1915

• Independent non‐profit organization located in Philadelphia

• Governed by a broadly representative 60+ member board, and a 9 member Executive Board

• 420 emplo ees• 420 employees

– Psychometricians, statisticians, computer scientists, educational psychologists, security experts, editors, p y g , y p , ,logistics specialists

– 6 full time physicians

– 3 full time attorneys

Protect the health of the public through state of the art …Protect the health of the public through state of the art assessment of health professionals.

The NBME doesn’t have a marketing departmentdepartment

Our business model is based on effective collaboration with health ffprofessions organizations that value 

our unique expertiseq p

NBME Programs includeNBME Programs include

• USMLE

• Collaboration with NBMVE in NAVLE and VQE

• 8 US medical specialty board examinationsp y

• Medical school subject examinations and self assessment examinations

• Post licensure examinations 

• International programs on 5 continentsp g

• > 20 certification programs for allied health professionsp

NBME’s examinations are the international gold standards for valid and  reliable high g f g

stakes examinations in  health care professions

We are proud to count the NBVME among our sister organizations

ScalarsScalars

• 130 + medical schools in North America130 + medical schools in North America

• 19000 + graduates from LCME schools

3 00 S G i i i l h l• ~ 3500 US IMGs in international schools

• 27,000 Post graduate training slots in 26 specialty areas

• 7000+  international citizens apply for post pp y pgraduate training in the US each year

Responsibility Continuum in Human Medicinep y

Institutional

LCME ACGMEAAMC

Medical SchoolResidency and

FellowshipsPractice

Individual

NBME

ABMSECFMG ABMS

FSMB

ECFMG

Comparisons of Human and Veterinary Education Pathways

United States Educational Model

MD/DVM Professional Education TrajectoryMD/DVM Professional Education Trajectory

Foundational science

Required Clinical RRotations

“Selectives”

Year 1 Year 2 Year 3 Year 4 MD: Residency

DVM: Practice

Graduation

DVM: Practice

Graduation

Requirements for General Medical LicensureRequirements for General Medical Licensure

• Graduation from an accredited medical school within h U i d S C d ifi i b hthe United States or Canada, or certification by the ECFMG 

At l t 1 f t d t t i i• At least 1 year of post graduate training– Minimum requirement for IMGs is 2 years

• 3 Steps of United States Medical Licensing• 3 Steps of United States Medical Licensing Examination (USMLE)

There is little likelihood of specialty specific licensure in the US within the next decade

Licensure Timelines MD/DVMLicensure Timelines MD/DVM

Pre Med Undergraduate M di i

Post graduate PracticeMedicine

g

S i l

4 yrs 4 yrs 3-8 yrs 7-10 yrs

Undifferentiated Licensure

Specialty

Certification MOCProvisional Licensure

Licensure

Undergraduate Veterinary

License renewal

Pre Vet

4years

Medicine

4 Years Practice

Undifferentiated Licensure

The USMLE program is an integral part of medicalintegral part of medical 

education

P ll l i fParallel programs exist for Osteopathic education

United States Medical Licensing ExamUnited States Medical Licensing Exam

• Step 1: Basic science in clinical contextStep 1: Basic science in clinical context

• Step 2: Two partsCli i l di i d it i tifi f d ti– Clinical medicine and its scientific foundation

– Clinical SkillsD h i• Data gathering

• Communication and Interpersonal Skills

• Spoken English proficiency• Spoken English proficiency

• Step 3: Integration of medical knowledge into clinical practiceclinical practice

USMLE Step 2 CSEUSMLE Step 2 CSE• Insures basic data gathering and communication 

kill f i d i iskills necessary for entry into post graduate training

• 12 SP encounters, 25 minutes each

– Data gathering

– Communication and interpersonal skills

– Spoken English proficiency

• 5 CSE sites in US, 6 days/week, 50 weeks/year

• > 35,000 candidates/year

• $1200/candidate  plus travel expense

Current USMLE SequenceCurrent USMLE Sequence

Foundational science

Required Clinical RRotations

“Selectives”

Year 1 Year 2 Year 3 Year 4 Residency

USMLE USMLE St 2

USMLE Step 1 Steps 2

CK, CS Step 3

New USMLE SequenceNew USMLE SequenceFoundational science

Required Clinical Rotations

“Selectives”

Y 1 Y 2 Y 3 Y 4 R idYear 1 Year 2 Year 3 Year 4 Residency

“Decision point 1” “Decision point 2”

S i ifi f d i i Scientific foundations in clinical context

Clinical medicine in its scientific context Evidence based

Science and Medicine in clinical practice

context

Interpretation of evidence

Clinical Skills

Evidence based decision making

Advanced clinical skillsClinical Skills skills

USMLE ExaminationUSMLE Examination

• The USMLE is primarily a licensing examinationThe USMLE is primarily a licensing examination

• Co‐owned by the Federation of State Medical Boards (FSMB) and the NBME( )

• Governed by a Composite Committee comprising the FSMB, the NBME, and the ECFMG

• Prepared and administered by the NBME

The USMLE is the only acceptable licensing The USMLE is the only acceptable licensing examination for all graduates of LCME accredited

medical schools and all international medical graduates

Licensure Exams in the USALicensure Exams in the USA

U

FLEX

ECFMG ExamsU

S

MIndividual State Board Exams

FLEX M

L

1915 19921965

NBME Certifying Examinations E

Although the primary use of the USMLE is for licensing, it h i t t dit has important secondary uses

– Curriculum assessment, promotion, & graduation decisions. 

• Virtually all schools require that students pass Step 1 prior to entry into clinical yearsprior to entry into clinical years

• All schools require that students take Step 2 prior to graduation M t h l i t d t St 2 CS i t• Most schools require student pass Step 2 CS prior to graduation

– Residency selection – International graduates must pass Step 1, Step2 CK, & Step 2 CS for ECFMG certification.

Why bother?W y b

CaveatsCaveats

• We’ve never tested the hypothesis thatWe ve never tested the hypothesis that individuals who fail licensure exams would be bad doctorsbad doctors

• We know that some people who pass are very bad doctorsbad doctors

NeverthelessNevertheless

• Licensing examination scores are significantg gpredictors of behavior in practice, such as appropriate use of consultation, prescribing practices and mammography screening rates inpractices, and mammography screening rates in initial primary care practice

• Tamblyn et al., JAMA. 1998;280:989‐996

• Scores achieved in patient‐physician communication and clinical decision making on a gnational licensing examinationpredicted complaints to medical regulatory authorities.

• Tamblyn et al JAMA 2007;298(9):993 1001• Tamblyn et al., JAMA. 2007;298(9):993‐1001

A balancing act in licensureA balancing act in licensure

Continuance of medicine as a self governing profession

Protect the health and welfare of the public

a self-governing profession

p

Human Medical boards have statutoryHuman Medical boards have statutory authority to

• Identify acceptable examinationsIdentify acceptable examinations

• Set passing score

• Mandate content areas

• State Medical boards do not “accredit” schools

– Boards sometimes restrict international students from some schools from elective rotations

– Some Boards reserve the right to exclude graduates MDs from some schoolsMDs from some schools

Purpose of AccreditationPurpose of Accreditation

• Quality assuranceQ y– Promote internal review and continuous improvement

– Protect student and faculty stakeholders

A th t d ti t k l i i t d• Assure that education takes place in an appropriate and supportive setting– Encourage medical education in the context of the university

• Provides reference standard for external stakeholders– Government  funding sources

P t d t t i i– Post graduate training programs

– Regulatory agencies

Liaison Committee for Medical EducationLiaison Committee for Medical Education

• Accredits programs leading to MD degree inAccredits programs leading to MD degree in US and Canada

• Limited to schools geographically wholly• Limited to schools geographically wholly within the US or Canada, and operated by universities that are chartered within the USuniversities that are chartered within the US or Canada

S d j i l b h AMA d h AAMC• Sponsored jointly by the AMA and the AAMC

Medical Boards rely on certification of individualMedical Boards rely on certification of individual international graduates, not international schools

• There is no single accrediting authority for international medical schools

• There are more than 2000 schools listed in IMED

• Graduates from more than 900 international schools apply for provisional licensure in the US in any given year

• 50,000 +  international graduates take one or more steps of USMLE every year

ECFMG’s RoleECFMG s Role• Certify the readiness of international medical graduates for 

entry to graduate medical education and health care systemsentry to graduate medical education and health care systems in the United States

• Certification requirements include

– Documentation of credentials

• Graduate of a bona fide medical school

• Verified identity

– Pass USMLE Steps 1, Step 2CK, and Step 2CS

The ECFMG does not accredit medical schoolsmedical schools

What lessons might apply to the Veterinary community?

A f ll d i d hi h t kA carefully designed high stakes assessment system willassessment system will 

powerfully reinforce curriculum hchange

Stakeholder participation is essential!

You should debate the pro’s andYou should debate the pro s and cons of a single pathway to 

licensure for North American and International graduatesInternational graduates

Collaborations that protect the stake of each organization in the licensure process are 

possible

It is possible to develop valid andIt is possible to develop valid and reliable examinations to assess 

dcommunication and interpersonal skillsinterpersonal skills

You may or may not choose to do this, but you should actively choose

What might a multi step assessment l k l kprogram look like?

• Part 1– Foundational science in the practice of veterinary medicine

• Part 2– Essentials of veterinary medicine necessary forEssentials of veterinary medicine necessary for undifferentiated licensure

– Communication, Interpersonal and Clinical skills, p

• Part 3 (optional)– Track specific competency exams– Track specific competency exams

Potential NAVLE SequencePotential NAVLE Sequence

Foundational science

Required Clinical RRotations

“Tracking”

Year 1 Year 2 Year 3 Year 4 Practice

NAVMLE NAVLE St 2

Portfolio

Step 1 Steps 2 CK, CS

exams

Only wet babies like change!Only wet babies like change!

Closing RemarksClosing Remarks

Summary and SupplementSummary and Supplement• Human and veterinary medical education have similar 

iwaypoints

• Human and veterinary  boards have similar missions

• The multi‐step USMLE has primary and secondary uses• The multi‐step USMLE has primary and secondary uses

• A single pathway for licensure levels the playing field

• The LCME is the sole accrediting authority for NA medical g yschools

• International graduates are certified by the ECFMG

• There is no single accrediting authority for international schools

H di i li l l l iHuman medicine relies on a level playing field for all licensure candidates rather 

than selective accreditation of international medical schools

Responsibilities in “House of Medicine”

SMBs NBME USMLE LCME ECFMG ACGME ABMS

Define CurriculumDefine Curriculum Standards

Accredit schools

C tif IMGCertify IMGs

Requirements for licensure

d i iAdminister licensing exam

Set passing scores

Accredit post graduate training

Certify specialists

NBME’s RoleNBME s Role • Recruitment/maintenance of national faculty of medicine

• Examination design and contentExamination design and content

• Standard setting

• Oversight of administration, including security

• Scoring and reporting services

• Programmatic research

The NBME does not The NBME does not accredit medical schools