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Date Updated: November 9, 2011

Health System Reform Policies Appendix

The National Board of Medical Examiners (NBME): a model for the development of standards

The NBME plays a key role in quality assurance at the point where physicians become licensed to practice medicine in the United States. As the cosponsor and testing agency for the United States Medical Licensing Examination® (USMLE®), the NBME oversees the selection of medical content – the relevant knowledge and skills – to be formally assessed as a precondition for medical licensure. The NBME guides the process of establishing the common national performance standard for the USMLE. Every doctor9 – including the international medical graduates who comprise nearly 25% of new practicing doctors – must meet these standards in order to receive an initial license to practice in the United States.

Since its founding as a certifying body for physician licensure in 1915 by eminent leaders in medicine10, the NBME has fulfilled its mission by convening medical, measurement, regulatory and other professionals to certify competence. The core of NBME's mission has focused on licensure of physicians, first through NBME Certification, and then through additional services including the Federation Licensing Examination and various examinations developed for the Educational Commission for Foreign Medical Graduates (ECFMG®), and finally (since 1992) through the USMLE. The USMLE is jointly owned and sponsored by the Federation of State Medical Boards (FSMB) and the NBME.

The NBME also partners with FSMB to provide resources for the assessment of doctors after initial licensure for purposes of supporting state licensing authority investigations, granting a license in a new jurisdiction, and documenting competence upon practice reentry. Further, the NBME has assisted sister organizations in national certifying assessments for physician specialists, physician assistants, medical assistants, electrophysiology technicians, genetics counselors, veterinarians, and most recently Doctors of Nursing Practice who engage in comprehensive primary patient care.

The USMLE, developed by nonprofit organizations in the private sector, establishes consensus among regulatory, academic, practitioner, and measurement stakeholders. It not only holds individual physicians (both domestic and international medical school graduates) accountable to common standards when they seek the legal authority to practice anywhere in the United States, but also provides unique benchmarking information for medical schools, residency training programs, and other educational institutions preparing these doctors for practice. The USMLE has consistently sought to expand the range of knowledge and skills assessed. For example, in the past 10 years, USMLE has added a complex simulation of patient management skills and a test of interpersonal, communication, and physical examination skills11. The latter is the only known example of a professional licensing examination in which some pass/fail decisions are based on ratings of communication skills and professional behavior by members of the public. A comprehensive review is currently under way; the future USMLE will more fully integrate fundamental science into the clinical context, enhance assessment of clinical skills, and expand assessment of professional behavior and the ability to work within complex healthcare systems.

In addition to the USMLE and other licensing and certifying tests, the NBME provides standardized assessments used by essentially all US (and many international) medical schools and in graduate medical education. These tools allow schools to assess individual student mastery of curricular content using benchmarks based on student performance across the United States. The NBME also provides a variety of self-assessment tools for use by students and physicians.

For nearly 100 years, the NBME has developed and refined its skills in convening stakeholder experts to create valid and reliable assessments that will inform decisions of licensing authorities and guide medical educators. These assessments' content and standards represent a detailed description of the minimum standards for entry into medicine as a profession. This expertise is a unique resource for defining standards for health professionals and for creating appropriate measurements to assure that these standards are met12.

9 Osteopathic physicians may utilize the USMLE in most jurisdictions; however, most osteopathic physicians are licensed based on COMLEX, the national licensing examination developed by the National Board of Osteopathic Medical Examiners.

10 Among the founders were Rear Admiral William C. Braisted, Surgeon General, US Navy (the NBME's first President); William L. Rodman, President, American Medical Association (the NBME's founder); Major General William C. Gorgas; Colonel Louis LaGarde; Rupert Blue, Surgeon General, US Public Health Service; W.C. Rucker, Assistant Surgeon General, US Public Health Service; Victor C. Vaughn, Past President, American Medical Association and Dean, University of Michigan School of Medicine; Horace D. Arnold, Dean, Harvard Graduate School of Medicine. See Hubbard, JP and Levit, EJ. The National Board of Medical Examiners: The First Seventy Years. NBME, Philadelphia, 1985.

11 The USMLE clinical skills examination is developed and administered through the Clinical Skills Evaluation Collaboration (CSEC), a joint project of the NBME and Educational Commission for Foreign Medical Graduates. CSEC provides another example of private, professional organizations collaborating to improve the assessment standards for health professional competence in the United States.

12 For further description of the NBME, see www.nbme.org. For further information on USMLE, see www.usmle.org. Comprehensive information on the programs of the NBME is provided in its Annual Report(PDF).


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