Lucian L. Leape, MD; John A. Fromson, MD
Potential Financial Conflicts of Interest: Grants received: L.L. Leape (Robert Wood Johnson Foundation).
Corresponding Author: Lucian L. Leape, MD, Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02215; e-mail, firstname.lastname@example.org.
Current Author Addresses: Dr. Leape: Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02215.
Dr. Fromson: MetroWest Medical Center, 67 Union Street, Natick, MA 01760-6099.
Physician performance failures are not rare and pose substantial threats to patient welfare and safety. Few hospitals respond to such failures promptly or effectively. Failure to ensure the quality and safety of the performance of colleagues is a breach of medicine's fiduciary responsibility to the public. A major reason for this deficiency is the hospitals' lack of formal systems to monitor physician performance and to identify and correct shortcomings. To develop and implement these systems, hospitals need better performance measures and substantial expansion of external programs for assessment and remediation. This is a task well beyond the capacities of individual hospitals; a national effort is required. The authors call on the Federation of State Medical Boards, the American Board of Medical Specialties, and the Joint Commission on Accreditation of Healthcare Organizations (organizations that already bear a fiduciary responsibility for ensuring safe, competent care) to collaborate on developing better methods for measuring performance and to expand programs for helping practitioners who are deficient.
Table 1. Examples of Disruptive Behavior
Table 2. Failure Rates for Specialty Board Recertification Examinations
Table 3. State Assistance Programs for Physicians
Table 4. National Assessment and Remediation Programs
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Mark S. Gold
University of Florida McKnight Brain Institute
January 25, 2006
Random Mandatory Drug Testing: A Potential System Level Solution?
We read with great interest the recent Improving Patient Care paper by Leape and Fromson on the issue of problem doctors(1). Substance abuse and dependence are significant problems among physicians and have negative impact on the individual physicians, their families and their patients. We have evaluated, treated, and reported on impaired physicians for more than three decades. While alcohol abuse and dependence are no more common among physicians than similarly matched controls, prescription misuse, opiate abuse and dependence and suicide appear to be more common among physicians. Physicians, however, may not be a single homogenous group. Our recent work has shown that anesthesiologists, surgeons, and emergency room physicians are over-represented among physician opioid addicts (2). We have reported on drug testing as a treatment for impaired physicians and think drug testing should be considered part of a system developed to improve patient care(4). Drug testing is also a method of case finding before an overdose or patient injury. However, as Leape and Fromson describe, few doctors are subjected to drug testing as a condition of employment (1). Physicians who are subject to pre-employment or random drug testing include those employed by the VA, military, physicians who are being monitored by state impaired professional programs and some new model programs at teaching hospitals(5). Our experience and research on impaired physicians suggest that pre-employment, for cause and random drug testing should be considered for all physicians. Testing complements prevention, education, early intervention and treatment initiatives. However, while being a physician is a risk group, we strongly recommend that specialties with greatest access and at greatest risk of occupational exposure (anesthesiology, surgery, emergency medicine), are the first priority for monitoring.
References 1. Leape LL, Fromson JA. Problem doctors: is there a system-level solution? Ann Intern Med. 2006 Jan 17;144(2):107-15. 2. Gold MS, Byars JA, Frost-Pineda K. Occupational Exposure and Addictions: case studies and theoretical implications. Psychiatr Clin North Am. 2004 Dec;27(4):745-53. 3. Gold MS, Melker RJ, Dennis DM, Morey TE, Bajpai LK, Pomm R, Frost- Pineda K. Fentanyl Abuse and Dependence: Further Evidence for Second Hand Exposure Hypothesis. J Addict Dis. 2006; 25(1):15-21. 4. Jacobs, WS, Repetto M, Vinson S, Pomm R, Gold MS. Random Urine Testing as an Intervention for Drug Addiction. Psych Ann 2004; 34(10 781-785 2004. 5. Department of Veterans Affairs. Drug-Free Workplace Program: VA Directive 5383. Washington, DC: Department of Veterans Affairs; 2004.
Martin T Donohoe
Portland State University
January 30, 2006
Drug testing not the solution to problem doctors
The explosive growth of pre-employment and random, not-for-cause drug testing (PERNFCDT) in industry and health care raises ethical, legal and policy questions.(1) Such growth has been fueled by popular misconceptions surrounding substance use and abuse, junk science, business interests (Institute for a Drug-Free Workplace, pharmaceutical and drug-testing companies), and the public relations campaigns of a multi-billion dollar industry whose entrepreneurial interest lies in magnifying the severity of drug-related problems in the workplace and extolling the benefits of drug testing as a solution.(2)
The cost of PERNFCDT to find one otherwise hidden drug abuser is estimated at $700,000 to $1.5 million for the federal government's program.(3) No solid data show that PERNFCDT deter drug use.(3) The National Academy of Sciences has concluded that frequently cited estimates of lost productivity due to drug use are based on flawed data.(4) PERNFCDT are subject to sabotage, false-positive and -negative results, and can negatively impact workplace moral, reduce productivity, and hinder recruitment of skilled workers. While no court has held an employer legally liable for not having a drug-testing program, employers have incurred substantial legal costs defending their programs against workers' wrongful dismissal claims.(1) It is impossible to completely safeguard that information obtained through drug testing programs will not be shared with other entities. The Canadian Human Rights Commission recently disallowed PERNFCDT of public employees, calling them human rights violations under the Canadian Human Rights Act.(1)
In 1999, 2/3 of 44 randomly selected large teaching hospitals had formal physician drug testing policies. Many involved PERNFCDT.(5) Most were vague on procedural details; only half mentioned confidentiality. Substantial numbers of practicing physicians, residency program directors, and medical students oppose PERNFCDT.(1)
To improve patient safety and enhance quality of care, the medical profession should improve substance abuse education and training; identify and refer impaired doctors for treatment; appropriately discipline impaired and incompetent providers; promote reference checking; increase attention to job- and life-satisfaction (depression and marital discord); enhance procedural training and oversight; support mandatory recertification, periodic hospital re-credentialing, and frequent skills appraisal and impairment testing (vision, reflexes, and coordination) to uncover substance abuse, physical disabilities, mental illness, and sleep deprivation; encourage reporting and analysis of errors; utilize computerized ordering systems to reduce prescribing errors; hire ancillary staff to assist residents in non-educational tasks; improve sign out protocols; and stop downsizing registered nurses in favor of less well- trained (but less expensive) licensed practical nurses and nursing assistants.(1)
1) Donohoe MT. Urine trouble: practical, legal, and ethical issues surrounding mandated drug testing of physicians. J Clin Ethics, 2005;16(1):69-81. 2) Lundberg GD. Mandatory unindicated urine drug screening: still chemical McCarthyism. JAMA 1986;256(21):3003-05. 3) Matlby LL. Drug testing: a bad investment. 1st ed. New York: American Civil Liberties Union; 1999. Available from: URL:http://www.aclu.org/news/1999/n090199a.html. Accessed 5/18/00. 4) Normand J. Under the influence? Drugs and the American workforce. Washington, DC: National Academy Press; 1994. 5) Montoya ID, Carlson JW, Richard AJ. An analysis of drug abuse policies in teaching hospitals. J Behav Services & Res 1999;26(1):28-38.
David R. Gifford
RI Department of Health
February 1, 2006
Reflections from a State Medical Board
While we agree with Leape and Fromsom's call for action about the need to address physician performance failures (1) , we believe that their strategy of relying on the hospital credentialing process, will not adequately address this vexing problem for several reasons. First, many physicians do not have admitting privileges to any hospital, Second, among those that do, most admit very few patients (2). Third, with the advent of hospitalists and a greater shift of health services to the ambulatory setting hospital credentialing committees only oversee a fraction of the practicing physicians' delivery of service. Lastly, as the authors summarize, many of the remedial programs are run by the state medical boards in cooperation with other groups such as the state medical society. In Rhode Island, our Board of Medical Licensure and Discipline works closely with the state medical society's Physician's Health Committee to provide treatment and rehabilitation for impaired physicians, assessment services for physicians with behavioral health problems, including sexual boundary violation, gambling, sexual and Internet addictions, and disruptive behaviors. Additionally, our Board is involved with the Practitioner Remediation and Enhancement Pilot Project [PREP] with the Citizen's Advocacy Center through a Health and Human Services grant . Thus, rather than relying on numerous hospital credentialing committees, we suggest that the state medical boards be empowered and supported to improve its oversight in these vital areas.
However, such expansion and in many cases reorientation of activities will require changes on many levels. More than Board's of licensure and Discipline, our medical boards must evolve into Board's of licensure, discipline and remediation. This will require legislative change and much better reporting of potential physician performance failures or physicians at risk for such failures (e.g. suspected drug abuse) by hospitals, insurers, and the physician community. For example, in RI most referrals to the BMLD come from patients, comparatively fewer from other physicians or licensed health care facilities such as hospitals. Our experience also supports Leape and Fromsom's argument to identify these physicians prior to performance failures. Most physician performance failures had a history leading up to the event or a number of suspicious colleagues but who did not want to "get involved". To be effective, however, improved reporting programs must offer meaningful protections to both the reporting entity and to the suspect physician. A culture of safety cannot be cultivated without a reorientation from the traditional disciplinary approach. This by necessity will require further legislative change and some degree of malpractice reform.
We are also intrigued that Leape and Fromsom did not discuss (A) the role the individual physician has in working to change the system that contributes to medical errors, (B) the responsibility physician administrators play in identifying and addressing system problems as well as physician performance failures or physicians at risk of committing such failures and (C) the potential role health insurers and managed care plans might play in reviewing and reporting physician performance in outpatient settings..
David R. Gifford MD MPH Director, RI Dept of Health Associate Professor of Medicine, Brown Medical School
Robert S. Crausman MD, MMS FACP Chief Administrative Officer, Board of Medical Licensure & Discipline Associate Professor of Medicine, Brown Medical School
Bruce W. Mcintyre JD Deputy Legal Council, RI Department of Health
1. Leape, LL and Fromsom JA., Problem Doctors: Is there a system- level solution? Ann Int Med 1006;144:107-115.
2. Miller ME, Welch WP, and Englert E. Physicians practicing in hospitals: implications for a medical staff policy. Inquiry. 1995;32(2):204-10.
Duncan M. Kuhn
Whitehead Institute, Cambridge, MA
February 8, 2006
Missing the More Important Problem?
Leape and Fromson should be commended for addressing physician performance failures (1). However, they overlook perhaps the most critical aspects of physician quality control, while arguing for more onerous burdens on practicing physicians.
As suggested recently (2), performance problems are often evident long before a physician enters practice. In fact, many doctors would agree there is a lack of quality control, starting in medical school. More directly, it seems nearly impossible to fail medical school, or be fired from residency. Regarding the latter, my and others experience has been no matter how incompetent the trainee, program directors and department heads are loathe to effectively discipline the individual. Concerns of legal action are often cited, which seem disingenuous Ã particularly considering the fiduciary responsibility noted by Leape and Fromson. Programs have a responsibility to train such individuals, and if that fails, prevent them from being unleashed on patients. There are also clear conflicts of interest: it is to the advantage of the host departments, in terms of time (dealing with deranged rotation and call schedules) and money (e.g. Medicare funding of the trainees position) to keep individuals on. Anyone who has been exposed to community hospital residency programs can testify that filling slots often takes precedent over the quality of the candidates.
Practicing physicians are engulfed in paperwork and requirements, which are only likely to increase, with questionable results (3). It seems unlikely additional testing (on top of residency in-service tests, multiple board exams and re-certifications, and CME requirements) will be of significant utility, but will add to the growing sense of intrusion. It is also unlikely that hospital credentialing, already an onerous process, will improve in its ability to address problem physicians (4). Finally, it is unclear how one could standardize evaluations: e.g. physicians practicing in rural areas cannot be held to the same knowledge standards as counterparts in an urban academic setting; nor should surgeons handling high-risk patients be expected to have similar outcomes to community practitioners.
The confrontational tone and anecdotal nature of sections of the article are disturbing, since both the authors and editors must realize this will be widely quoted in the lay press. The comment "at least one third of all physicians will experience, at some time in their career, a period during which they have a condition that impairs their ability to practice medicine safely" appears a) unsupported by data, b) discounts that most physicians will not practice during their compromise, and c) is over-dramatized by italics. While it may be true that the professional arena is the last affected by performance issues, one wonders about the significance of "In our experience" and the subsequent citation of a 25-year old article (5).
1. Leape, LL and Fromsom JA. Problem Doctors: Is there a system- level solution? Ann Int Med 2006; 144: 107-115. 2. Papadakis MA et al. Disciplinary action by medical boards and prior behavior in medical school. NEJM 2005; 353: 2673-82. 3. Krasner J. Plan would tie copayments to doctorsÃ• rankings. The Boston Globe. Jan 27 2006: A1. 4. Gifford DR, Crausman RS, McIntyre BW. Reflections from a State Medical Board. Ann Int Med 2006 (http://www.annals.org/cgi/eletters/144/2/107) 5. Talbott GD and Benson EB. Impaired physicians: the dilemma of identification. Postgrad Med. 1980; 68: 56-64.
New York Presbyterian Hospital
February 6, 2006
February 4, 2006
To The Editor:
In my opinion, the forecast of a continued decline in primary care physiciansÂ¹ is just the tip of the iceberg of problems in medical education and medical economics. Contemporary medicine is experiencing the best "“and worst of times. While scientific and technologic advances make the headlines, so does fraud and the burden of soaring medical errors. How can great science and poor care coexist? Easy. We allow it. Over the near-century since the Flexner report, every successive generation of physicians has been taught more science and less bedside medicine. We teach to test and so quality educational hours have been spent prepping for licensing exams at the expense of "hands on" time. Medical students and residents born of the computer age spend endless hours online checking lab results and ordering tests, and the "team" approach has replaced proprietary responsibility. Are we training today's physicians that the foundation of every medical encounter lies in a complete history, complete physical examination (when was the last time you heard a trainee mention the fundi "“ the window to the body?), assessment of routine laboratory tests, creation of a problem list (why was Weed weeded out?) with a differential diagnosis for each problem? Medical educators have not been explicit in expectations, nor have they adequately supervised our trainees. This has created the epidemic of "Hyposkillia" - trainees deficient in basic medical skillsÂ². The foundation of medical care is a dynamic, long-term patient-physician relationship which is based on a thorough psychosocial and clinically sound medical assessment, mutual respect and trust, as championed by Dr. Marcus Welby. The depth to which our profession has sunk in the public's eye (and the victory of science over art) is that television's new Marcus Welby is Dr. Gregory House. Why are physicians abandoning primary care? Because we are not educating them properly and, compared to their peers, we are paying them poorly. Can we fix the flaws? I believe so.
Some Immodest Proposals:
If we continue our present tack, things will continue to get worse. We need radical changes in medical education and medical economics. It's time for another American Medical Revolution.
I. Overhaul Medical and Pre-Medical Education.
Currently, our medical and pre-medical education is geared to creating medical scientists, at the expense of practical clinical training. While medical scientists are our hope for the future, properly trained clinicians are the foundation of the Ivory Tower. Many of our primary care physicians have been overtrained in science, and undertrained in bedside medicine and office management. They have not been given the appropriate skills, nor have they been selected for the altruism of Maimonides or the equanimity of Osler, to prepare for a career which is most rewarding when it is a passion, not a job, a calling and not a career. We need to re-instill in the profession the importance of attitude, to select trainees who will be gratified by their selected profession, and provide them with an education which best prepares them for the road that they have chosen. In my opinion, a working group should be established to create a nationwide change in both medical and pre-medical education. I propose that there be three distinct medical school tracts: the medical scientist, clinical scientist, and clinician. The first two- year basic science education should be overhauled and made clinically relevant. Those in the medical scientist tract would take additional training during first and second year elective periods, supervised by research scientists. Third year clinical clerkships and fourth year sub-internships would be requirements, but those in the medical scientist tract would take appropriate electives and time in the laboratories, while those in clinical scientist tracts would take electives in statistics and research methodology. Those in clinical tracts would take more electives in appropriate language skills such as Spanish, and spend time on home visits and in doctors' offices. The National Board examinations would reflect the new clinically oriented core curriculum, and all students would need to pass it. In addition, students can qualify for the M.D. degree with distinction in medical science, distinction in clinical science and distinction in clinical medicine, based upon a separate examination in which they can demonstrate acquisition of appropriate knowledge and skills. Internal medicine residency programs would seek a mix of graduates to ultimately fill appropriate positions on their faculty. Residency programs would similarly offer appropriate elective study. Creating three M.D. tracts would change pre-medical education. Students anticipating careers in medical science would be best prepared with an engineering, "hard science" or extensive life sciences background, while those interested in clinical investigation would have additional training in statistics and research methodology. Students anticipating as clinicians would take courses in psychology, sociology, anthropology, child development and management. Extracurricular activities for the medical scientist tract would involve participation in laboratory research, and reading and writing scientific papers. Clinical scientist candidates would have additional training in performing and analyzing clinical studies and writing clinically oriented papers. Those interested in a clinical tract in medical school would have extracurricular service commitments which would demonstrate their passion for helping others. Students should be exposed in high school to the existence of different careers in medicine, so that they could obtain an appropriate pre-medical curriculum in college.
II. Medical Economics
Our present system is worse than schizophrenic. It has multiple personalities which are hard to count. Primary care physicians waste precious time and are not reimbursed for paperwork and non-face-to-face patient care. Our system needs to pay our physicians for both time spent with patients and time spent caring for their needs when they are not physically there. We need to create a national health care system that is equitable. The President and CEO of United Healthcare had a 2005 salary with stock options of $1.125 billion dollarsÂ³. Simply stated: for-profit health care is an oxymoron. Another radical proposal: national universal healthcare "“ progressive/income-based. Every citizen would have a credit card with a picture. Every swipe of the card would lead to a deposit of both an income-related co-pay and fee from the patient's medical account, collected by the federal government. Physicians would be paid at the time of service. This program would have to be removed from congressional jurisdiction, to avoid capricious cuts, and administered by physicians and health care economists. These funds would be placed in, dare I say it, a "lockbox", prohibited from being decreased on a yearly basis, but increased instead by cost-of-living adjustments. In addition to establishing acceptable fees for service provided by their members, each college of physicians or superiors would create an encounter form with each reimbursable service. Time spent in non-face-to-face patient care could be logged into the system and reimbursed once appropriate documentary codes were entered into the system. Assessment of performance would be obtained by educating patients as to each college's expectations for interactions, and assessing patients' feedback. Physicians would be issued report cards, based on a number of performance indices, and both professional and economic incentives could be created, if desired. In summary, in order to be able to provide enough high-quality primary care physicians for the next century, we must alter the way we are educating them and paying them. While we want to continue to recruit genius doctors with super-high IQ's to be our medical and clinical scientists, our society is best served by having A-/B+ students with high emotional quotients become our primary care physicians. These clinicians would be granted an extraordinary privilege: that of the responsibility of caring for the life and well-being of another. Each college of physicians or superiors needs to create a national system of record keeping, so that our practitioners know at what level the bar is being set. There can be no questions about what the expectations are. By revitalizing medical education, we will select physicians more likely to be intellectually and emotionally gratified by primary care. We can restore the thrill of making diagnoses to clinicians and away from radiologists, and return our primary care physicians to the patient and away from the computer. They would be clinicians, not paper-pushers, and primary care medicine will be a calling, not a default position. Finally, in a nation so economically and intellectually rich as ours, we must create a climate where someone paying a large amount of money for several years of post- collegiate education who provides excellent care to his or her patients receives a wage commensurate with their peers. If we don't make primary care medicine intellectually exciting and financially acceptable, then our Ivory Towers will rest on faulty foundations.
Jeffrey D. Fisher, M.D. 311 East 72nd Street New York, NY 10021
1. Sox, H.C. Leaving (Internal) Medicine [Editorial]. Annals of Internal Medicine 2006; 144: 57-58
2. Fred, H.L. Hyposkillia "“ Deficiency of Clinical Skills [Editorial]. Texas heart Institute Journal 2005; 32: 255-257
3. Forbes. November 28, 2005; p. 122
Lucian L. Leape
Harvard School of Public Health
March 14, 2006
Response to Letters to the editor
To the editor:
We agree with Dr. Kuhn that much more attention needs to be paid to assessing medical students and residents for their suitability and fitness to practice medicine, and that failure to do so is a breach of the fiduciary responsibility of schools and hospitals. These are issues that the AAMC and specialty boards should address.
However, his dismissal of the need for additional testing is diametrically opposed to the strong, and we think laudable, initiative by all of the specialty boards to develop much more rigorous and effective assessment of physician performance. Although we are sensitive to the fact that rural practice clearly has unique accountability issues, the ability of physicians to learn and maintain personal standards is not one of them. There is neither an ethical nor practical justification for accepting lower standards for physicians in rural areas.
We disagree that our estimate that at least one third of physician will need help at some time in their career is not justified by the data we present. Indeed, the finding that performance problems are not confined to a small fringe of practitioners is a central point of our paper. Sadly, most compromised doctors do continue to practice, often with dire consequences for their patients, which is what we seek to remedy.
The diametrically opposed views of Doctor Gold and Ms. Frost-Pineda who advocate for pre-employment and random drug testing of physicians and those of Doctor Donohoe who raises associated "ethical, legal, and policy questions" illustrate the controversial nature of this issue, which clearly warrants further study and testing.
Doctors Gifford, Crausman, and McIntyre make the important point that not all physicians participate in hospital credentialing processes. However, it is a good place to start improvements because a mechanism and a requirement already exist. If we can develop effective early identification and assessment practices for physician performance in hospitals, they should be adaptable to office, clinic, and ambulatory surgical settings.
While we applaud their call for expanding licensing boards support to remediation programs, and agree they should set standards, we do not share their enthusiasm for having state boards actually perform the credentialing process, or for having insurers and managed care plans play a role in reviewing physician performance. We, and we believe the overwhelming majority of physicians, view these as the profession's responsibility.
Lucian L. Leape John A. Fromson
Joseph O. Boggi
June 7, 2006
Who cares about this?
Let's get to the heart of the matter. Medicine is run by corporations or large federal institutions. There is next to no interest in improving the prevailing rate of malpractice, and no effective program to address it. If payments were made for all of the Medical Malpractice, we would have to pay the patients for the privilege of working in Medicine.(1)
As with all large entities, the only real incentive is to suppress. That is most evident in the treatment of folks with mental illness who have never hurt a patient. As an example folks with ADHD cannot get hospital privileges. At the recent ACP meeting, I asked the expert what to do about a prospective doctor with ADHD. He told me not to tell anyone that the candidate has ADHD. He went on to say that any specific question requesting direct information about a mental illness is illegal and hence the question should be answered as if there was no history of ADHD. Really. That assumes a stable patient of course.
As a member of the ACP with ADHD, I cannot disgree with that advice, I am not sure if it is legal however. Who knows?
As I return to practice, I have encountered the IPE. I have this to say about the IPE. There is no transparency of testing at the IPE. If you can take a 60 question per minute test you will do fine, they won't tell you about the rate in advance. It goes on.
In general, I am a big proponent of ongoing testing of doctors. I think that random doctors should be run through the IPE on a yearly basis so that all of them go in a ten year period.
My path to the IPE started when I actually tried to fire federal civilian employee physician from a protected class of individuals. That is not an easy thing to do. There is no whistleblower protection, and if you call the JCAHO that is the very first thing that they told you. It is even harder if you have ADHD. Honor, family name, and the fear of God almost always give way to the pressure of the corporation or the Federal Institution to toe the line.
You see, Medical Malpractice can become rare. I am sure. Tolerance of folks who are paying attention but appear distracted can become part of our culture. In general changes like these take two generations.
Before Medical Malpractice becomes rare, more of it will have to be revealed. Perish the thought. Before folks with Mental illness can be tolerated many reforms need to be instilled. The first of which is that standards of medical practice have to apply to licensure of doctors, and their discipline. That is not currently the case.
Will this ever change? Articles like this at least talk about the issue. Much more than talk needs to be done. We just have to look to Dr. Deming and use his tenets for good and not politics.(2) A little fear of God, consideration of honor, and concern about your good family name will start to bring the meaning of Medicine back to us all.
Joseph O. Boggi D.O. MACP
1.Brennan et al. Incidence of adverse events and negligence in Hospitalized Patients. NEJM 324: 370-376
2. Crospby, Phillip Quality is still free Oct 1,1995.
June 14, 2006
Every once in awhile doing the right thing brings a positive response. To that end, I am writing to give precise details about the difficulties with the IPE. Thanks to those who encouraged me to do this.
1. The multiple choice question tests. I was given three of these. I was told that all of them would cover Internal Medicine by the Director of the IPE. Indeed that is not the case at all. The tests titled Mechanisms of disease and Pharmacotherapeutics are best described as Step 3 tests. You may remember that includes OB, Surgery, Psych, IM, Peds, and Prevent Med. While IM covers many of these you don't ever go into a test without clear knowledge of the test material. Every test given by the NBME, NBOME, or ABIM and such gives extremely clear information about the nature of the testing. To do any less is abhorent to the concept of standardized testing.
2. Two of the tests noted above were given at a rate of 60 MCQ's per hour. I inquired about this rate on multiple occasions. I was never given an answer, and hence practiced at the standard rate of 48-50 questions. This is the rate for every other test given by these organizations.
3. The Computer Case Simulations. The standard is to take these tests on a computer that is at least 733 MHZ. I practiced on an 850MHZ unit. Frankly, practice is not the correct word. I tried to simulated about a hundred patients, I tried to harm the computer patients to see what it took to do it in cyberspace, I looked up almost all of the thousands of orders, and generally "took the program apart and put it back together again."
These tests are designed to last about 8 mintues. ( Source, the President of the NBOME ) There was no possible way to get these tests finished properly on the computer provided. I was told just as I hit start that the computer would my much slower. After the testing, the director of the IPE noted that they would look into getting another computer. Yes, there are about 40 standard computers in the testing center. One is reserved for the IPE.
The computer used makes you go at least two times as fast and probably three times as fast as the standard computer. The director noted to me that I must have computer difficulties. I was pretty astonished to hear that assertion.
If you have ever taken the CCS you know that the longer it takes you to treat the sicker folks get. Also, if you are rushing, while you don't make mistakes per se, you are not as smooth. You try to make the computer go faster and so on.
The bottom line is that at the very least you have to get an opportunity to practice at the tested computer speed. The most intereting thing was that the IPE later backed down from the assertion that I had difficulty with the computer. That was my major complaint, until number four that is.
4. In my experience almost every official examination I have had, and every examiner has laughed at the precepts of medicine. The one examiner who played it straight was relieved of his duty in the army. His boss, the Chief of Psychiatry at Walter Reed Army Medical Center was also relieved. I never met that man. May God Bless him and his family. The Major General who did that later spoke to the ACP about ethics.
Examiners pretty much walk in literally laighing at me. When you speak to folks who are at the top of the profession, you get a knowing nod. This type of thing is common place. Yes, this particular examiner had a persistent smirk on his face and laughed at least five times. This examiner would raise his voice, all the while maintaining that smirk on his face. He was enjoying tweaking his examinee.
The only answer to this activity, save a little concern for honor, family name and fear of God, is an audio tape. Better yet a video tape.
There is no room here to go into the minute details. Suffice it to say, that every official meeting of this sort needs to be taped. This is a disgrace to the practice of Medicine. A complete disgrace. Whenever a transcript was generated it has been altered, every single one. In regard to the CCS, I can and expect to speak for 30 minutes to an hour on each topic of the CCS in front of a serious examiner.
I let down my guard, this was the NBME. As the examiner walked in, I told him that I had been looking forward to this for a long time.
Now, you may be surprised to hear that I was told that I did pretty well on the testing. I reject that notion. I've never given my patients pretty good care. Pretty well did not get us into Medicine. I can honestly say that I was more ready for the testing than when I took and passed my ABIM Boards on the first try years ago. Anyone in my position cannot drive through a "stop sign" let alone do pretty well on a test. I have places to go and people who are helping me. I cannot get there with a test result that is pretty good, whatever that means. I studied almost everything available.
Back in the day, you took a class, studied your butt off and got an A. There can be no exception to that, and at this level it is highly irregular to say the least.
So, the IPE needs to tell folks what is on the test, tell them how many questions are on the test, give them an opportunity to test on a standard computer, and before an examiner who is taped. These are pretty standard things, that the IPE and the NBME are currently completely rejecting to the dishonor of the NBME in general.
The NBME is not four people. The NBME stands for the very best. Even their receptionists understand this problem. Why can't the IPE and the NBME.
Finally, take a look at some of the things that make you a disruptive doctor on the article above. Two of them regard telling patients about their poor care. There should be 650000 letters from Physicians complaining about that. How sick is that?
Leape LL, Fromson JA. Problem Doctors: Is There a System-Level Solution?. Ann Intern Med. ;144:107–115. doi: 10.7326/0003-4819-144-2-200601170-00008
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