ABSTRACT
State medical boards have long recognized the importance of evaluating the ongoing knowledge and competence of licensed physicians under a variety of circumstances. Before granting or renewing a license, it may be necessary for state boards to evaluate physicians as part of a disciplinary process or following a period of inactivity for either disciplinary or non-disciplinary reasons. The Post-Licensure Assessment System (PLAS), a joint program of the Federation of State Medical Boards (FSMB) and the National Board of Medical Examiners (NBME), has played a role in assisting state boards with evaluating physicians' basic medical knowledge in all of these circumstances by providing the Special Purpose Examination (SPEX). While SPEX has been administered since 1988, there has not been a nationally published study summarizing the characteristics of physicians taking the exam and their examination pass rates. To address this, we examined physicians who took SPEX between 2003 and 2011, and the outcomes of their exams. Our research demonstrates that the majority of examinees take SPEX for non-disciplinary reasons, with those who take SPEX for disciplinary reasons having lower pass rates. Future research should focus on evaluating the ultimate outcomes for physicians taking SPEX, including the ability to attain and retain a license to practice medicine.
Introduction
This article is intended to be the first in a series regarding SPEX utilization and outcome measures. As such, this article provides background information on the history and development of SPEX, a synopsis of the current SPEX examination, and an overview and evaluation of the population of physicians who have taken SPEX between 2003 and 2011.
In 1985, the Medical Board of California contacted the Federation of State Medical Boards (FSMB) requesting assistance in expanding its process for re-examining endorsement and reciprocity applicants. Subsequently, a 1986 survey conducted by FSMB assessed the needs of state medical boards for an examination to determine whether physicians seeking to reinstate or reactivate their license after a period of inactivity — whether due to illness, a period of non-clinical activities, disciplinary action, or some other circumstance — had the requisite knowledge to return to medical practice. The survey results indicated that there was an interest and need for this type of assessment.1
In response to state boards' concerns, the FSMB partnered with the National Board of Medical Examiners (NBME) to develop the Special Purpose Examination (SPEX), a single-day exam focusing on the clinical knowledge and basic science principles needed for the general, undifferentiated practice of medicine. Prior to the introduction of SPEX, when determining the fitness to practice of license applicants who were some years beyond the initial licensing examination, state boards had to rely on resources such as outdated examination results and letters of reference and recommendation that were not always complete or accurate. Most state boards with examination requirements in place for endorsement and reciprocity applicants utilized the Federation Licensing Examination (FLEX) Component 2 or oral examinations. However, oral examinations were deemed too subjective, and while the FLEX Component 2 was a good component of a comprehensive initial licensing examination, it was not designed to assess, by itself, the broad scope of knowledge needed for qualification of a general, undifferentiated medical license. The state boards agreed that a special, standardized exam would be a better tool to assist them in assessing the current competence of physicians seeking to return to medical practice or applying for licensure by endorsement and reciprocity.1
PRIOR TO THE INTRODUCTION OF SPEX ... STATE BOARDS HAD TO RELY ON RESOURCES SUCH AS OUTDATED EXAMINATION RESULTS AND LETTERS OF REFERENCE AND RECOMMENDATION.
While the early SPEX was built on the practice model design of FLEX, and test items for SPEX were derived from content from the FLEX Component 1 and Component 2 exams, the SPEX was narrower in coverage and focused on assessment of physicians who had been in practice for five or more years. The already established FLEX Board, led by Chair Dr. Henry Cramblett (of the Ohio medical board), guided early SPEX efforts. In March 1988, SPEX was administered for the first time as a one-day paper-and-pencil examination. Seventeen state boards directed 275 physicians to take SPEX in 1988, and by the early 1990s, 700–800 physicians were taking SPEX annually at the request of 40 state boards.2
In 1995, the SPEX program became a pioneer in medical licensing testing with the implementation of SPEX in a computer-based format. As the first medical licensing examination to move away from administration in a paper-and-pencil based format, computer-delivery of SPEX in 1995 ushered in a new era of testing, enabling physicians to take SPEX at any time throughout the year on a date of their choosing, rather than on pre-designated testing dates, and expediting the release of scores to examinees and state boards.
SPEX utilization peaked in 1996, one year after conversion from paper-and-pencil to computer-based administration of the exam. Since 2002, SPEX volume has declined and in recent years has plateaued at roughly 200 examinees annually. This is mostly attributed to licensing boards' acceptance of ABMS certification or recertification exams in lieu of SPEX when considering applicants for licensure by endorsement.
Current SPEX
Today, SPEX is one of two services offered through the Post-Licensure Assessment System (PLAS), a collaborative initiative of the FSMB and the NBME. While SPEX still focuses on assessment of current knowledge requisite for the general, undifferentiated practice of medicine, the exam is now built on the practice model design3 of the United States Medical Licensing Examination (USMLE). The original practice model was developed for Component 2 of the FSMB's new FLEX examination program in 1983. It used a combination of empirical data and expert judgment to describe types of patient encounters confronting practicing physicians. The current USMLE design and the SPEX both remain rooted in this innovative model. Specifically, the exams evaluate physicians' knowledge of disease categories (e.g., cardiovascular, immunologic, and mental disorders) and physician tasks (e.g., applying scientific concepts, formulating a diagnosis, managing patient care).
...COMPUTER-DELIVERY OF SPEX IN 1995 USHERED IN A NEW ERA OF TESTING, ENABLING PHYSICIANS TO TAKE SPEX AT ANY TIME THROUGHOUT THE YEAR.
The SPEX content (i.e., test questions and blueprint) was most recently updated in 2010 to improve its relevance to physicians' daily activities by focusing more on topics such as patient management and care and less on themes related to the mechanisms of disease. The exam also now utilizes live content from the USMLE Step 3 item pools, which ensures the content of the exam is relevant to current standards of practice.
Physicians can take SPEX via one of two sponsorship categories — self-nominated or board-sponsored. Board-sponsored applicants must either hold or have held (at some point) a valid, unrestricted license in the U.S. or Canada and also meet any eligibility requirement(s) established by the state board for which they are taking the exam. A board may require a physician to take SPEX for a variety of reasons, including endorsement of licensure, as part of a disciplinary or investigative process, or to reinstate a physician's license after a period of inactivity (for either disciplinary or non-disciplinary reasons). Physicians who have a current (active), unrestricted medical license in a U.S. or Canadian jurisdiction can also apply to take SPEX via the self-nominated method, which does not require sponsorship or approval from a state board.
Since 2011, the PLAS Program has offered to all state medical boards the opportunity for a physician board member or staff person to take SPEX free of charge to assist boards in learning about the exam. This offer includes the option to have the exam scored (in an unofficial capacity) and for the physician to receive direct feedback about his or her performance on the exam. Feedback on the exam from those who have taken it has been overwhelmingly positive. One state board had a particularly good experience with the exam and reported the following feedback to PLAS staff: “The exam is current on topics, processes and content. As I mentioned at the onset of this process: could a 56 year-old physician, in practice 12–22 years demonstrate competency in many areas, based on the 336 questions? I believe so.”
While state boards accept other assessments (e.g., specialty board certification) as evidence of physician competence, SPEX remains an essential tool of medical licensure, which keeps the public safe. In particular, the focus of the SPEX evaluation of knowledge for the general, undifferentiated practice of medicine corresponds directly to state medical boards issuing general, undifferentiated licenses to the nation's physicians. As such, SPEX serves as a resource to state boards in evaluating the cognitive competence of physicians to practice medicine in a variety of situations (e.g., licensure by endorsement, return to practice, as part of a disciplinary or investigative process). Our research seeks to add to the overall understanding of SPEX by identifying the types of physicians who are taking SPEX and their patterns of exam pass rates.
OUR RESEARCH SEEKS TO ADD TO THE OVERALL UNDERSTANDING OF SPEX BY IDENTIFYING THE TYPES OF PHYSICIANS WHO ARE TAKING SPEX AND THEIR PATTERNS OF EXAM PASS RATES.
Methods
For our analysis we used SPEX data from the FSMB's repository. The FSMB maintains the test results from SPEX as well as self-reported data provided by examinees as part of the exam registration process. Notwithstanding the changes to the exam and a decrease in volume in more recent years, the demographic makeup of physicians taking SPEX has remained remarkably similar from year to year. For that reason, our final analysis and the findings outlined in this paper are based on all physicians who took SPEX between 2003 and 2011.4 We examined the data using the statistical analysis software package SPSS version 21.0. The demographic analyses examine all 2,257 physicians who took the exam between 2003 and 2011. However, several of these physicians took the exam more than once, meaning that the exam was administered 2,655 times between 2003 and 2011. The demographic analysis examines only the physicians (without duplicates), while the analysis of passing rates uses all exams as the unit of analysis.
THE SPEX CONTENT WAS MOST RECENTLY UPDATED IN 2010 TO IMPROVE ITS RELEVANCE TO PHYSICIANS' DAILY ACTIVITIES BY FOCUSING MORE ON TOPICS SUCH AS PATIENT MANAGEMENT AND CARE.
SPEX scores are reported as a two-digit scaled score, with the recommended minimum passing score set at 75. According to the specifications of the exam itself, “Recommended performance standards are based on a specified level of proficiency.” Based on these criteria, there is no predetermined percentage of examinees who pass or fail SPEX. Historically, examinees must correctly answer approximately 65% of the questions to pass the exam. For this analysis, examinees are analyzed based on whether they passed or failed, not their SPEX score.
Results
Forty-six percent of the exams were self-sponsored, while the remaining 54% were board-sponsored, meaning it was taken at the request of a state board as a requirement for endorsement of licensure, as part of a disciplinary/investigative process, or to reinstate a physician's license after a period of inactivity. Self-nominated examinees are not asked as part of the exam registration process to indicate why they are taking SPEX. Therefore, data on the reason for taking the exam is only available for the 1,422 examinees taking it through board sponsorship from 2003 to 2011. As illustrated in Figure 1, the most cited reason physicians take SPEX through board sponsorship is licensure by endorsement (36.2%), followed by disciplinary reasons (18.7%) and license reactivation (14.2%), which includes those reentering the work force after some time away from practice.
Reason for Taking SPEX (Board Sponsored Examinees)
These reasons mirror the results of an optional survey sent to self-nominated examinees at the completion of the SPEX registration process. Since 2006, FSMB has asked examinees applying for SPEX via the self-nominated method to voluntarily complete a brief survey regarding their reason for taking SPEX. The 246 responses received on the survey as of January 2013 indicate that the majority of these physicians (86%) took SPEX at the direction of a state board for purposes of licensure by endorsement. In addition, a total of 9.4% took it for reactivation of a license, 2.9% for reinstatement of a license and 1.6% as part of an investigation.
THE MOST CITED REASON PHYSICIANS TAKE SPEX THROUGH BOARD SPONSORSHIP IS LICENSURE BY ENDORSEMENT (36.2%), FOLLOWED BY DISCIPLINARY REASONS (18.7%) AND LICENSE REACTIVATION (14.2%).
Further examination of the data for all examinees (both self-nominated and board-sponsored) reveals that physicians who take the SPEX exam are more likely to be male (78.4%), graduates of a medical school in the United States (73.3%), a Doctor of Medicine (88.7%)5, and 50 year of age or older on average (Table 1). Essentially, the demographic breakdown for examinees mirrors the general population of actively licensed physicians in the United States6 with two exceptions — those who take SPEX are substantially more likely to be in the 50–59 age range and male (Table 1).
Basic Demographics of Physicians taking SPEX Compared with the 2012 FSMB Census of Licensed Physicians
Examining SPEX pass rates reveals that those who take the SPEX exam via the self-sponsored application are slightly more likely to pass the exam than those taking it via the board-sponsored application (Table 2). The physician's reason for taking the exam also yields different pass rates. As indicated in Figure 2, physicians taking SPEX because of disciplinary reasons have substantially lower pass rates (52.8%) than physicians taking the exam for non-disciplinary reasons. Physicians with specialty board certification and taking the exam at the request of a state board are much more likely to pass the exam than those without certification. Physicians with board certification have a 78.5% pass rate, while examinees without board certification have a 60.8% pass rate. Examinees without an active license to practice medicine have higher pass rates than their actively licensed counterparts (78.5% versus 62.6%).
PHYSICIANS TAKING SPEX FOR DISCIPLINARY REASONS HAVE SUBSTANTIALLY LOWER PASS RATES (52.8%) THAN THOSE TAKING IT FOR LICENSE REACTIVATION (71.3%) OR ENDORSEMENT (76.4%).
Pass Rates by Demographic
SPEX Pass Rates by Reason for Exam (board sponsored only)
A further examination of demographics and SPEX pass rates shows that the older a physician is when they take SPEX, the less likely they are to pass the exam (Table 2). Only 26.0% of physicians over the age of 69 passed the SPEX exam. Women (75.1%) are more likely to pass SPEX than men (69.2%), and graduates of U.S. and Canadian medical schools (78.8%) have higher pass rates than international medical graduates (51.7%).
Discussion
The patterns of SPEX performance are consistent with what one might expect for physicians as they become further and further removed from training, which indicates a reasonable sensitivity to detecting growing knowledge deficits that could also be attributable to extended leaves of absence for a variety of reasons. Similarly, physicians who were disciplined by their state medical board are also less likely to pass SPEX, adding further credibility to the claim that the examination measures strengths and weaknesses in key competencies.
While it may seem counter-intuitive, the presence of an active license for an examinee does not correlate with higher pass rates. This may signify that the physician has been disciplined or may simply be an indication that the individual is less likely to be fit to practice medicine. In contrast, physicians who are reactivating their license after a lapse in licensure (e.g., reentry) may have completed a course of study, which is generally helpful in attaining higher scores on competency-based examinations. These physicians often are highly motivated to return to clinical practice and may contribute to explaining the higher pass rate among those examinees without an active license.
WHILE IT MAY SEEM COUNTER-INTUITIVE, THE PRESENCE OF AN ACTIVE LICENSE FOR AN EXAMINEE DOES NOT CORRELATE WITH HIGHER PASS RATES.
While further research is needed on the ultimate outcomes for physicians taking SPEX (e.g., ability to attain or retain licensure), the results of this study reinforce that SPEX can be a useful tool to state boards. As an examination, SPEX is able to yield a useful assessment of a physician's basic medical knowledge, providing an additional source of information for and adding weight to a state board's decision about the physician's fitness and competence to practice medicine. Even though fewer physicians are taking SPEX in recent years, revisions to the exam in 2010 have further improved its relevance as an objective tool to measure a physician's ability to undertake the basic tasks of practicing medicine. Through examinations such as SPEX, the public can be assured that the physician population has the appropriate knowledge to practice medicine.
About the Authors
↵Frances E. Cain, MPA, is Assistant Vice President, Assessment Services at the Federation of State Medical Boards
↵Phil Davignon, PhD, is Research Analyst, Research and Data Integration at the Federation of State Medical Boards
↵Thomas R Henzel, EdD, is Research Analyst, Policy & Product Development at the National Board of Medical Examiners
↵Andrea L. Ciccone, MS, is Assistant Vice President, Policy & Product Development at the National Board of Medical Examiners
↵Aaron Young, PhD, is Assistant Vice President, Research and Data Integration at the Federation of State Medical Boards
- Copyright 2014 Federation of State Medical Boards. All Rights Reserved.
References
- 1.↵Hill IK. SPEX: The Federation's Special Purpose Examination. Federation Bulletin1989; 76(4):115–119.
- 2.↵Johnson DA , ChaudhryHJ. Medical Licensing and Discipline in America. Lanham, MD: Lexington Books. 2012.
- 3.↵LaDuca A , TaylorDD, HillIK. The Design of a New Physician Licensure Examination. Evaluation & The Health Professions1984; (7)2:115–140.
- 4.↵Statistical analyses of difference such as T-tests and Chi-Square are not necessary because the entire population of physicians who took SPEX between 2003 and 2011 are included in this analysis.
- 5.↵Doctors of Osteopathic Medicine can also take SPEX.
- 6.↵Young A , ChaudhryHJ, ThomasJV, DuganM. A Census of Actively Licensed Physicians in the United States, 2012. Journal of Medical Regulation2012; 99(2):11–24.
