The year 2015 represents an important milestone for the members and staff of the National Board of Medical Examiners (NBME) in Philadelphia. Few organizations earn the chance to mark a centennial, the way the Federation of State Medical Boards (FSMB) did two years ago, and the National Board is among this select group. The National Board began a full year of commemorative activities with their 2014 annual meeting by returning to the site of the organization's first annual meeting in 1915, the Willard Hotel in Washington, D.C. This celebratory year has continued with multiple commemorative and philanthropic activities, including the launch of NBME U, a free online series of course offerings covering various aspects of assessment, and several centennial prize awards to individuals and institutions engaged in research and/or innovations in the field of assessment. The occasion of this centennial also inspires reflection at the FSMB, as board members and staff alike consider the long history of collaboration, collegial relations and joint initiatives between the two influential organizations.
THOSE FAMILIAR WITH THE NATIONAL BOARD AND THE FEDERATION MOST LIKELY THINK OF THE TWO ORGANIZATIONS IN LIGHT OF THEIR SUCCESSFUL TWO DECADE PARTNERSHIP IN THE UNITED STATES MEDICAL LICENSING EXAMINATION™ (USMLE™).
Those familiar with the National Board and the Federation most likely think of the two organizations in light of their successful two decade partnership in the United States Medical Licensing Examination™ (USMLE™). While the USMLE is undoubtedly the most highly visible initiative undertaken by these two organizations, it is only a more recent example of collaboration. The two organizations share a long history of mutual support and collaboration dating back to the earliest days of both organizations. What follows is a modest attempt to capture the high points of this relationship and the essence of the mutual respect and support that each has displayed for the other over the past century.
The Federation's support for the National Board can be traced to the earliest years of the latter's establishment. Dr. William Rodman, the driving force in the establishment of the National Board, was a fixture at the earliest annual meetings of the Federation in Chicago. For many years, Rodman had championed the cause of a national examining board as one of the best means to facilitate licensure portability at a time when every state medical board wrote and administered its own licensing examination and when recognition among the state boards of each others' exams was limited. Rodman envisioned the National Board of Medical Examiners as a body that would develop and write an examination of such high quality that it would be recognized by all state medical boards by virtue of eligibility criteria and testing rigor that exceeded all state examinations.
Such aspirations were not uniformly embraced at the time, however, including by some among the medical board community concerned that the states' prerogative for licensure might be undermined through an independent body working in an area (i.e., testing) that overlapped the statutory authority of state medical boards. Ultimately, Federation leaders such as Drs. Charles Cook (Massachusetts), Walter Bierring (Iowa), Herbert Harlan (Maryland) and John Baldy (Pennsylvania) proved staunch advocates of the National Board. Indeed, much of the Federation's 1916 annual meeting was dedicated to discussions of the fledgling National Board. Dr. Rodman was present, offering full and thoughtful responses to the many questions posed by the assembled state board members. What was most telling, however, were the statements from the many individuals within the state board community who understood and shared Dr. Rodman's vision as one intended to complement — not replace — the work of the state medical boards.1 Beginning in 1916 and continuing for years to come, the Federation Bulletin consistently published news, updates and annual reports on NBME activities and performance on the National Board's certification examination.
During the National Board's first forty years, Walter Bierring served as one of the key linkages between the two organizations. Those familiar with the Federation's history know that Dr. Bierring served more than 40 years as Secretary-Treasurer of this organization. What is less well-remembered today is that Bierring also provided a vital link with the National Board as well, serving 27 years as a member of that board, including a two-year term as its President in 1931–33. Bierring, the “quiet diplomat” of the medical board community, offered a valuable bridge between the medical licensing community and the National Board.2 This relationship with the FSMB's most senior member later proved invaluable in the early 1950s when the National Board encountered skepticism among some members of the medical board community about its planned adoption of a more objective testing format (i.e., multiple-choice questions) for its certifying examination. Bierring counseled the National Board to create a committee on state board relations as an ongoing mechanism to ensure a clear understanding of the many benefits of the new testing formats.3
THESE MECHANISMS FOR MAINTAINING STRONG RELATIONS BETWEEN THE FEDERATION AND THE NATIONAL BOARD HAVE PROVIDED AN OPPORTUNITY FOR PERSONAL CONNECTIONS AND RELATIONSHIPS TO DEVELOP.
While Bierring's personal touch and influence proved helpful in this particular instance, his was not the only connection between the leadership of the Federation and the National Board. In establishing the NBME in 1915, Dr. Rodman created an organizational framework calling for a Federation representative to serve on the original 15 member board. In carving out a designated position for organizational representatives such as those from the Federation, the National Board ensured that they, as well as the representative organization, would benefit from a formal conduit for open communications and mutual interest for years to come. This mechanism worked remarkably well in helping create an ongoing, long-term relationship among the leadership at both organizations. By the mid-1980s, 32 individuals with service on the Federation board of directors had also served as members of the National Board or on its executive board. This “cross-pollination” between the two organizations meant that both were positioned to remain abreast of developments outside of, but immediately relevant to, their respective primary fields of medical regulation and assessment. In recent decades another mechanism has been used to maintain strong relations between the two organizations: Every three years or so, the full executive boards of both organizations meet jointly to discuss common interests and priorities. This practice began in 1990 with the first meeting of the two boards as part of talks inaugurating the USMLE.
These mechanisms for maintaining strong relations between the Federation and the National Board have provided an opportunity for personal connections and relationships to develop that have proven fruitful to both organizations. The creation of the USMLE is one such example. Negotiations leading to the creation of the USMLE were greatly aided by the participation of Drs. Bryant Galusha and David Citron, both of whom had connections and experiences with both organizations that fostered mutual trust on the part of FSMB and NBME staff as they hammered out the specific responsibilities and tasks of each organization in support of the USMLE. Even before the advent of the USMLE and during his early tenure as the Federation's CEO in the 1980s, Galusha tapped into the expertise of colleagues at the National Board when the Federation was exploring its first computer system for digitizing its backlog of hard copy records of disciplinary actions. The opportunity for hearing directly from trusted colleagues at NBME about their experiences in computerizing their own records and data provided invaluable lessons that the Federation was able to draw upon in the first computerization of its records. During the early 2000s, the strong working relationship between FSMB and NBME CEOs Drs. James Thompson and Don Melnick reaped added benefits. The two executives built upon their longstanding personal relationship as a foundation to explore projects and initiatives that were mutually beneficial to both organizations' missions, e.g., the development over time of a Coalition for Physician Accountability and an early variation of a multi-organizational information-sharing enterprise now called Data Commons®.
If nothing more than personal relationships had developed between the leaders of both organizations, this would have been a positive development and sufficient to justify the attention given to fostering this connection. These relationships took more concrete form with the development of extraordinary joint initiatives by the two organizations. The first of these dates to the mid-1960s when the FSMB turned to the National Board and its expertise in assessment to develop the Federation Licensing Examination (FLEX). This was the first formal major initiative between the two organizations and it provided the Federation with a major achievement in its licensure portability efforts. The FLEX allowed the Federation to assure meaningful state board participation in developing and maintaining the framework for a national assessment tool, open to both U.S. and international medical graduates, for use by boards in their licensing decisions. This was a critical consideration because by that time the science of testing had evolved significantly and assessment in the high stakes arena of medical licensure required specialized, professional and technical expertise. As few state boards possessed the resources for incorporating such expertise into their own state-developed examination, the opportunity to create a national assessment with major input and guidance from the medical board community represented a positive development for all concerned.
The mid-1980s witnessed the start of another assessment initiative between the National Board and the Federation — the Special Purpose Examination (SPEX). The Medical Board of California contacted the Federation in 1985 asking for assistance in assessing its “licensure by endorsement” candidates, some of whom were decades removed from their initial licensure exam. The Federation immediately reached out to the National Board for assistance. The result was the SPEX, an objective test that provides state boards with an additional resource in their evaluation of physicians previously licensed in other jurisdictions. That state boards desired such a tool was quickly evidenced by 40 boards using the exam to assess 700–800 physicians annually in the early 1990s and their continued use of SPEX today. The SPEX later became a key piece of the Post-Licensure Assessment System (PLAS) created by the Federation and the National Board.2 The PLAS system provides diverse assessment modalities that generate comprehensive and pertinent data regarding a physician's medical knowledge, clinical judgment and patient management skills in his or her current or intended area of practice. These tools are also utilized by physician evaluation and remediation programs around the country to complement other performance-based methods of assessment, such as medical record reviews, peer (preceptor) assessment and feedback, patient evaluations and case-based evaluations of physician care. The PLAS system's collaborative relationships provide medical boards with the basis for a comprehensive assessment program to support their decision-making, especially in cases of licensure by endorsement.
THE FLEX ALLOWED THE FEDERATION TO ASSURE MEANINGFUL STATE BOARD PARTICIPATION IN DEVELOPING AND MAINTAINING THE FRAMEWORK FOR A NATIONAL ASSESSMENT TOOL, OPEN TO BOTH U.S. AND INTERNATIONAL MEDICAL GRADUATES.
Still, it is the USMLE that remains the signature collaboration between the National Board and the Federation. First administered in 1992, the USMLE has seen more than 2.6 million test administrations with the result that by 2012 approximately 42% of the nation's 878,000 physicians had taken all or a part of the USMLE Step sequence.4 The depth and breadth of staff interactions between the two organizations to support the USMLE is significant. From policy development and strategic planning to coordinated registration systems and committee support, staff and members of the two organizations have worked in concert over the past 20 years in providing the nation's primary assessment for medical licensure. This collaborative work shows all indications of continuing into the distant future. In May 2014, the Federation and the National Board revised and updated their contractual agreement for USMLE with a signing ceremony at the first meeting of the USMLE Management Committee. In many ways, the USMLE has cemented a truly unique relationship between two organizations sharing distinct but complementary missions that support the medical board community, and protect the public, through high quality assessment of health professionals.
The close working relationships developed through more than two decades of USMLE activity have fostered other streams of collaborative endeavor. The National Board has been a reliable supporter of FSMB policy initiatives such as Maintenance of Licensure (MOL). NBME colleagues contributed their expertise and insight into the multiple special committees, task forces and panels that fleshed out between 2004 and 2010 the policy statements about MOL that were endorsed by the FSMB's House of Delegates. Today, staff from both organizations continue work on a range of activities and research in the field of continued professional development.
Another recent example of this collaboration includes international efforts such as the 2010 meeting of the International Association of Medical Regulatory Authorities (IAMRA) in Philadelphia — a gathering co-sponsored and logistically supported by the Federation, the National Board and the Educational Commission for Foreign Medical Graduates (ECFMG). Like the Federation, the National Board has been a constant presence at IAMRA gatherings over the years, routinely sharing their assessment expertise in panels and presentations — a contribution that has been especially welcomed by those IAMRA members from countries still seeking to bolster their own assessment capabilities.
FOR MORE THAN 40 YEARS, THE FEDERATION AND THE STATE BOARD COMMUNITY HAVE BENEFITTED FROM FSMB COLLABORATIONS WITH THE NATIONAL BOARD, DRAWING UPON THE LATTER'S SIGNIFICANT EXPERTISE IN ASSESSMENT.
An even newer initiative of the National Board and the Federation involves the Data Commons®. This initiative of the two organizations, in which the FSMB serves as a data collaborator, involves four other partner organizations: American Board of Family Medicine; American Board of Pediatrics; Association of American Medical Colleges®; and the Educational Commission for Foreign Medical Graduates. Collectively these organizations have committed themselves to enable innovative data sharing for software makers, researchers, analysts, policy makers, health professionals and others seeking information about health care professionals. Leadership at the Federation and the National Board are particularly enthusiastic about the research potential of the Data Commons as research is an area of growing collaborative work between the two organizations.
Finally, in reflecting on the relationship of the Federation and the National Board over the course of a century, one cannot help but be struck by the good fortune that each organization has enjoyed by virtue of its relationship with the other. For more than 40 years, the Federation and the state board community have benefitted from FSMB collaborations with the National Board, drawing upon the latter's significant expertise in assessment. In creating high-quality assessment tools to inform the licensing decisions made by medical boards, the National Board has contributed to strengthening the system of state-based medical licensure and regulation championed by the Federation on behalf of its members. This nexus to the Federation and the medical licensing community has benefitted the National Board immeasurably by providing it with a highly visible platform demonstrating its assessment acumen both in the United States and internationally. In recent years, this latter arena has proven particularly fruitful for the National Board as educators and regulatory authorities in various parts of the world have looked increasingly to the NBME for assistance in crafting assessments for a variety of purposes. As both organizations move into their second century, those of us at the Federation look forward to both continued success in the current joint FSMB-NBME initiatives and welcome the opportunity for new collaborative ventures.
About the Authors
- Copyright 2014 Federation of State Medical Boards. All Rights Reserved.
References
