Performance on the radiology component of a critical clinical skills examination

RATIONALE AND OBJECTIVES: Clinical competence certification is now required in some specialties in medicine. A Comprehensive Clinical Assessment (CCA) was created to test mastery of critical skills by students at the end of the 3rd year of medical school. METHODS: The CCA is a series of stations that test skills the faculty consider important for all medical students (eg, breast examination, electrocardiogram reading, chest pain assessment, ophthalmology photographs). The radiology station was designed to evaluate imaging skills believed to be taught and learned in the core 3rd-year rotations. RESULTS: External measures (National Board Examinations, grade point average, and overall score) of clinical performance of the 608 medical students who completed the CCA examination between 1991 and 1993 were found to be correlated with the radiology station scores. CONCLUSION: The radiology station in the CCA examination is a reproducible measure of clinical performance.     

The role of the American Board of Professional Psychology in professional mobility.

This article describes the role of certification by the American Board of Professional Psychology (ABPP) in easing the process by which psychologists move beyond their original jurisdictional boundaries to practice psychology. Meeting the requirements for licensure or certification in the various jurisdictions can be a difficult task because these requirements vary considerably from jurisdiction to jurisdiction. Other mechanisms that are available to facilitate this process include the Certificate of Professional Qualification in Psychology issued by the Association of State and Provincial Psychology Boards and certification by the National Register of Health Service Providers in Psychology. The ABPP certificate/diploma has been regarded by many state psychological associations and state boards of psychology as an appropriate way in which to recognize psychologists who are eligible for licensure/certification in a jurisdiction because of the examination requirements for board certification. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Emergency medicine career change: associations with performances in medical school and in the first postgraduate year and with indebtedness

OBJECTIVE: Emergency medicine has been identified as the specialty that has gained the most young physicians who have changed their careers. To identify factors that may have contributed to such career changes, the authors compared the characteristics of three groups of physicians trained at their medical school: those who chose and stayed in emergency medicine, those who migrated into emergency medicine from other specialties, and those who moved out of emergency medicine. METHODS: A prospective longitudinal study was conducted. The sample consisted of physicians who chose emergency medicine as their careers at graduation and stayed in the specialty (n = 24), those who migrated from other specialties into emergency medicine (n = 51), and those who moved out of emergency medicine (n = 10). This sample was obtained from a total of 2,173 graduates of Jefferson Medical College between 1978 and 1987. The three groups of physicians were compared according to their academic performances both during medical school and after graduation. The dependent variables were freshmen and sophomore grade point averages (GPAs), written clinical examination scores, scores on National Board of Medical Examiners examination (Parts I, II, and III), and residency program directors' ratings. Age and indebtedness at medical school graduation and board certification status also were examined. RESULTS: Those physicians who stayed in emergency medicine and those who migrated from other specialties into emergency medicine had similar measures of academic performance, but both of these groups had higher academic performance measures and higher board certification rates than did the physicians who moved out of emergency medicine. Those who stayed in emergency medicine had the highest mean debt in the senior year of medical school. CONCLUSIONS: High academic performance and high indebtedness are factors associated with choosing or staying in the specialty of emergency medicine.     

Ensuring reliability of outcome measures in multicenter clinical trials of treatments for acute ischemic stroke. The program developed for the Trial of Org 10172 in Acute Stroke Treatment (TOAST)

BACKGROUND AND PURPOSE: Ensuring the reliability and validity of outcome measures used in clinical trials is essential to the success of the trial. The Trial of Org 10172 in Acute Stroke Treatment (TOAST) is a multicenter clinical trial that is recruiting patients with acute ischemic stroke seen at medical centers across the United States. METHODS: This paper describes an approach to train physicians to use three clinical measures: the National Institutes of Health (NIH) Stroke Scale, a supplemental motor examination, and the Glasgow Outcome Scale. The program included education, certification, remediation when needed, monitoring, and reliability assessment. The goal was to ensure that interrater assessments were as equivalent to one another as possible. RESULTS: Of the first 95 clinicians who began the certification process, 75 passed during the first evaluation. Eighteen of the other physicians were able to complete the process after remediation. The intraclass correlations of both the NIH Stroke Scale and supplemental motor examination exceeded 0.95. The kappa values for the Glasgow Outcome Scale were 0.61 and 0.62 for the first and second ratings of the videotape, respectively. CONCLUSIONS: Our experience suggests that a program that includes educational and certification processes can be performed as part of the design of a multicenter clinical trial. The method of providing educational and testing videotapes to each site so that physicians can be trained and certified is an effective, inexpensive, and practical approach for enhancing and certifying the expertise of the large number of physicians involved in a multicenter study.     

Pilot study of explicit grading criteria in the American Board of Psychiatry and Neurology. Part II. Examination

OBJECTIVE: The purpose of this study was to identify specific competencies that differentiated passing from failing performance on the American Board of Psychiatry and Neurology Part II oral board certification examination. METHOD: A total of 363 candidates were rated in 18 areas of competence defined by behavioral criteria. Data were analyzed to determine which areas best discriminated between passing and failing candidates. RESULTS: In both parts of the examination, the ability to develop a comprehensive treatment plan was most influential. After that, specific interview and observational skills discriminated best. Failing candidates had most difficulty detecting and following informational and affective cues in their interview of a patient and presenting a biopsychosocial formulation and comprehensive treatment plan. CONCLUSIONS: Specific candidate competencies related to passing and failing performances can be identified and assessed by a rating scale of observable behaviors on the board certification examination in psychiatry.     

A comparison of sonographic examinations for trauma performed by surgeons and radiologists

BACKGROUND: It has been demonstrated that surgeons and surgery residents, trained in the focused abdominal sonographic examination, are able to accurately and reliably evaluate trauma patients. Despite this, radiologists have objected to surgeon-performed sonography for several reasons. We set out to compare the accuracy of sonographic examinations performed by surgery residents and radiologists. METHODS: A retrospective review of medical records of all trauma patients who received focused ultrasound examinations from January 1, 1995, through June 30, 1996, at one of two American College of Surgeons-verified Level I trauma centers in the same city was undertaken. Ultrasound examinations were performed by surgery residents at trauma center A (TCA) and by radiologists or radiology residents at trauma center B (TCB). Findings for each patient were compared with the results of computed tomography, diagnostic peritoneal lavage, operative exploration, or observation. Sensitivity, specificity, accuracy, positive predictive value, and negative predictive value were calculated for each group of patients. Comparison of patient charges for the trauma ultrasound examinations at each of the trauma centers was also made. RESULTS: Patient populations at the two centers were similar except that the mean Injury Severity Score at TCB was higher than at TCA (11.74 vs. 9.6). Sensitivity, specificity, accuracy, or negative predictive value were not significantly different between the two cohorts. A significantly lower positive predictive value for examinations performed by surgery residents was noted and attributed to a lower threshold of the surgery residents to confirm their findings by computed tomography. Billing data revealed that the average charge for trauma sonography by radiologists (TCB) was $406.30. At TCA, trauma sonography did not generate a specific charge; however, a $20.00 sum was added to the trauma activation fee to cover ultrasound machine maintenance and supplies. CONCLUSION: Focused ultrasound examination in the trauma suite can be as safely and accurately performed by surgery residents as by radiologists and radiology residents and should be a routine part of the initial trauma evaluation process.     

The adequacy of medical school education in musculoskeletal medicine

A basic familiarity with musculoskeletal disorders is essential for all medical school graduates. The purpose of the current study was to test a group of recent medical school graduates on basic topics in musculoskeletal medicine in order to assess the adequacy of their preparation in this area. A basic-competency examination in musculoskeletal medicine was developed and validated. The examination was sent to all 157 chairpersons of orthopaedic residency programs in the United States, who were asked to rate each question for importance and to suggest a passing score. To assess the criterion validity, the examination was administered to eight chief residents in orthopaedic surgery. The study population comprised all eighty-five residents who were in their first postgraduate year at our institution; the examination was administered on their first day of residency. One hundred and twenty-four (81 per cent) of the 154 orthopaedic residency-program chairpersons who received the survey responded to it. The chairpersons rated twenty-four of the twenty-five questions as at least important. The mean passing score (and standard deviation) that they recommended for the assessment of basic competency was 73.1 +/- 6.8 per cent. The mean score for the eight orthopaedic chief residents was 98.5 +/- 1.07 per cent, and that for the eighty-five residents in their first postgraduate year was 59.6 +/- 12 per cent. Seventy (82 per cent) of the eighty-five residents failed to demonstrate basic competency on the examination according to the chairpersons' criterion. The residents who had taken an elective course in orthopaedic surgery in medical school scored higher on the examination (mean score, 68.4 per cent) than did those who had taken only a required course in orthopaedic surgery (mean score, 57.9 per cent) and those who had taken no rotation in orthopaedic surgery (mean score, 55.9 per cent) (p = 0.005 and p = 0.001, respectively). In summary, seventy (82 per cent) of eighty-five medical school graduates failed a valid musculoskeletal competency examination. We therefore believe that medical school preparation in musculoskeletal medicine is inadequate.     

Advanced practice nursing certification: where do we go from here?

Certification requirements for advanced practice nurses (APNs) vary between APN specialties and the certification agencies. This variability perpetuates confusion for APNs, the health care system, and the public. Recommendations are made for the certification of APNs: (1) standardization of the certification process for APNs, (2) consistency in the requirement for graduate level education for all APNs, (3) regulation requiring certification for practice in all states, and (4) nurse practitioner (NP) program accreditation or preaccreditation for eligibility to take the certification examination. To support these recommendations, two questions are considered: Where are we now in certification? Where do we need to go?     

Performance on the internal medicine second-year residency in-training examination predicts the outcome of the ABIM certifying examination

For 223 residents from eight teaching hospitals, the results of the second-year in-training examination and the first-sitting certifying examination of the American Board of Internal Medicine were highly correlated. The results of the in-training examination can serve residents as an important measure of their preparedness for certification and can be useful in identifying the need for more intensive self-study strategies during the subsequent one and a half years.     

Are stereotaxic breast biopsies adequate?

BACKGROUND: Stereotaxic core breast biopsy (SCBB) has been proposed as a cost-effective and reliable method of evaluating mammographic lesions. This study evaluates an initial experience with SCBB and assesses the adequacy of the biopsy specimens obtained. METHODS: Two hundred forty-one SCBB were performed on 221 patients during 13 months by four radiologists. Mammograms were assigned a suspicion index on a scale of 1 to 5. One pathologist performed a blinded retrospective review of all SCBB specimens and assigned an adequacy score based on the quality and amount of the tissue present. RESULTS: The majority of SCBB were ordered by general surgeons (67%). A suspicion index score of 3 was assigned to 74% of lesion specimens. Twelve percent of specimens were malignant. Overall SCBB adequacy (score > or = 2) was 77%. Adequacy was present in 74% of benign biopsy specimens as compared with 100% of malignant specimens (p < 0.005). Only 62% of specimens reported as benign without specific features were adequate. There were no differences in adequacy between individual radiologists or during the study period. CONCLUSIONS: SCBB is largely used by surgeons to assess indeterminate mammographic lesions. One of four benign specimens was inadequate. Benign SCBB specimens must be interpreted with caution.     

The national occupational therapy practice analysis: findings and implications for competence

OBJECTIVE: This article reports some of the findings from a national study of occupational therapy practice conducted by the National Board for Certification in Occupational Therapy (NBCOT) as part of its fiduciary responsibility to ensure that its entry-level certification examination is formulated on the basis of current practice. METHOD: The NBCOT developed a survey with input from approximately 200 occupational therapy leaders and then used it to solicit information about current practice from 4,000 occupational therapists and 3,000 occupational therapy assistants. The sample included geographical location, experience level, and practice area distributions. RESULTS: Approximately 50% of the sample responded to the survey. Data indicate similarities and differences in occupational therapist and occupational therapy assistant practice (e.g., occupational therapists spend more time conducting evaluations, planning interventions, and supervising, whereas occupational therapy assistants spend more time providing interventions), an increased emphasis on population-based services (e.g., serving a business or industry rather than an individual worker), and an emphasis on occupation as a core knowledge base for practice. From a continuing competency perspective, the data can be useful to the profession; we can plan continuing education to address topics that practitioners have indicated are critical to their practice. CONCLUSION: The findings will be useful for revising the entry-level certification examination and may guide thinking about the parameters of continuing competence because the responses represent a cross-section of the profession.     

Results of the National Dental Examining Board of Canada written examination and implications for certification

In 1994, following a request from the ten Provincial Licensing Authorities, the National Dental Examining Board of Canada (NDEB) implemented significant changes to the certification process for dentists seeking a license to practice in Canada. Prior to 1994, graduates of accredited Canadian dental programs were certified without further examination while graduates of United States and other international programs (non-Canadian, non-U.S.) were required to complete successfully a written and three-phase clinical certification examination. Changes implemented in 1994 required graduates of accredited Canadian programs to take both a Written and Objective Structured Clinical Examination (OSCE) Examination. The analysis of the results of the Written Examination for all candidates over the 1994-1996 period supports the following conclusions. There was no meaningful difference in performance of graduates across the ten Canadian dental programs; there was a small difference between the performance of graduates of Canadian and U.S. programs; and Canadian and U.S. graduates performed significantly better than graduates of other international programs. This level of candidate performance and changes to the respective accreditation processes supported the formal agreement providing reciprocal recognition of dental accreditation in Canada and the United States. As of January 1, 1997, graduates of dental programs in Canada and the United States are required to take the same certification examination while international graduates are required to complete a different certification process. These changes to the certification process were ratified by all ten Provincial Licensing Authorities, therefore maintaining a system of national portability for dental licensure in Canada that does not require preclinical or clinical board examinations for graduates of accredited North American dental programs.     

The routine use of radiography and arterial blood gases in the evaluation of blunt trauma in children

STUDY OBJECTIVE: To evaluate the usefulness of routine radiographs and arterial blood gases in children with blunt trauma. DESIGN: Retrospective chart review. TYPE OF PARTICIPANTS: Ninety patients who met triage criteria for our trauma team evaluation and who were less than 15 years old were evaluated. Patients with a Glasgow Coma Scale score (GCS) of 15 (lie, mild to moderately injured children) were the focus of this study. METHODS: Children seen from May 1991 through August 1992 had charts reviewed systematically and within 24 hours of emergency department evaluation. Standard radiologic evaluation, including cervical-spine, chest, and pelvic radiographs, as well as arterial blood gas analysis, were obtained. The severity of injury was graded according to the Modified Injury Severity Scale. RESULTS: The mean age of patients was 6.4 years, and the injuries observed were exclusively extremity fractures. The correlation between physical examination findings and radiologic evaluation was assessed. Forty-three patients had an abnormal physical examination (ie, gross deformity, limitation of motion, or pain), and 26 had a fracture identified on radiograph. Forty-seven patients had a normal physical examination and none had a fracture identified on radiograph (P < .001; sensitivity of positive signs and symptoms, 100%; false-negative findings, 0%). Four patients with abnormal blood gases are described. No patient had any vascular or solid organ injury identified. CONCLUSION: In children with a GCS score of 15, selected radiologic and laboratory tests based on clinical findings are recommended. Careful observation and repeat examinations by trained clinicians can select a group of children at low risk for occult injury.     

The protein kinase N (PKN) gene PRKCL1/Prkcl1 maps to human chromosome 19p12-p13.1 and mouse chromosome 8 with close linkage to the myodystrophy (myd) mutation

OBJECTIVE: This study was performed to evaluate the frequency of postdeglutitive aspiration in lateral hypopharyngeal pouches and to correlate postdeglutitive aspiration to pouch size and dynamics. MATERIALS AND METHODS: Two radiologists retrospectively analyzed 325 videofluorography examinations of patients swallowing. The 325 patients were 22-81 years old, 173 men and 152 women. Patients who had undergone surgery of the hypopharynx were excluded from the study. All pouches found on videofluorography were classified into grade I, II, or III. Because iodinated contrast agent had been used initially, patients who had no or minimal aspiration underwent a second imaging examination using high-density barium. RESULTS: Of the 325 patients, 118 had lateral hypopharyngeal pouches: 77 bilateral and 41 unilateral. Postdeglutitive aspiration was diagnosed in 14 (56%) of the 25 grade III pouches and in two (3%) ot the 58 grade II pouches. Aspiration was not seen in any of the 112 grade I pouches. CONCLUSION: The prevalence of postdeglutitive aspiration is high in patients who have grade III pouches. To date, no appropriate conservative treatment has been described; however, in severe cases surgery is warranted.     

A breast density index for digital mammograms based on radiologists' ranking

The purpose of this study was to develop and evaluate a computerized method of calculating a breast density index (BDI) from digitized mammograms that was designed specifically to model radiologists' perception of breast density. A set of 153 pairs of digitized mammograms (cranio-caudal, CC, and mediolateral oblique, MLO, views) were acquired and preprocessed to reduce detector biases. The sets of mammograms were ordered on an ordinal scale (a scale based only on relative rank-ordering) by two radiologists, and a cardinal (an absolute numerical score) BDI value was calculated from the ordinal ranks. The images were also assigned cardinal BDI values by the radiologists in a subsequent session. Six mathematical features (including fractal dimension and others) were calculated from the digital mammograms, and were used in conjunction with single value decomposition and multiple linear regression to calculate a computerized BDI. The linear correlation coefficient between different ordinal ranking sessions were as follows: intraradiologist intraprojection (CC/CC): r = 0.978; intraradiologist interprojection (CC/MLO): r = 0.960; and interradiologist intraprojection (CC/CC): r = 0.968. A separate breast density index was derived from three separate ordinal rankings by one radiologist (two with CC views, one with the MLO view). The computer derived BDI had a correlation coefficient (r) of 0.907 with the radiologists' ordinal BDI. A comparison between radiologists using a cardinal scoring system (which is closest to how radiologists actually evaluate breast density) showed r = 0.914. A breast density index calculated by a computer but modeled after radiologist perception of breast density may be valuable in objectively measuring breast density. Such a metric may prove valuable in numerous areas, including breast cancer risk assessment and in evaluating screening techniques specifically designed to improve imaging of the dense breast.     

Radiation dose and diagnosticity of barium enema examinations by radiographers and radiologists: a comparative study

With the current emphasis on the extension of the role of the radiographer, radiographers in some hospitals now undertake some of the procedures traditionally performed by radiologists. In the present study, dose-area product (DAP) measurements for over 1000 barium enema examinations performed by radiologists and radiographers were analysed and compared to ascertain whether there were significant differences in the radiation dose to the patient, depending on the category of staff performing the examination. All examinations were reported by a radiologist. The radiologist's reports were analysed against the known outcomes to compare the diagnosticity of the examination when carried out by the two categories of staff. The study shows that although radiographers are able to produce consistent diagnostic results, there is an increase in patient dose due to extra films taken for reporting, which may be difficult to justify. Measures for reducing the dose from this component of the examination were explored.     

A case of bleeding from the Dieulafoy lesion of the jejunum

Little information is available regarding the practice of nurses who hold two perianesthesia certification credentials (CPAN/CAPA) and their motivation in achieving a dual certification distinction. Achievement of certification in both areas of perianesthesia nursing is a significant accomplishment. Nurses with dual certification are a valuable asset to the profession, their employer, and the perianesthesia patient. The characteristics of this unique group were surveyed by the American Board of Perianesthesia Nursing Certification, Inc. The findings have implications for nurse managers, educators, and perianesthesia colleagues.     

A remote conference system for image diagnosis on the World-Wide Web

OBJECTIVE: The World-Wide Web on the Internet enables an exchange of multimedia information among remote desktop computers. Therefore, a teleradiology system using the Web would allow remote consultation with expert radiologists. Our objective was to establish a Web-based prototype system for image interpretation. CONCLUSION: Our system allows a physician to transmit clinically useful images to an expert radiologist at a different location, who can see them on a Web browser and discuss diagnoses with the physician.     

The first certifying examination in pediatric rheumatology

OBJECTIVE: On May 12, 1992, the first certifying examination in pediatric rheumatology was administered by the American Board of Pediatrics to 94 candidates. We describe the certifying process and the characteristics of the examinees. METHODS: The Sub-board of Pediatric Rheumatology developed an examination consisting of 235 multiple choice items covering a broad range of topics pertinent to the subspecialty. Applicants with a current certificate in general pediatrics and a current medical license were admitted through one of 3 pathways requiring 2 years of fellowship training or equivalent practice experience. RESULTS: Sixty-three percent of the candidates had completed at least 2 years of fellowship training. The total group average score was 76% correct. Eighty-five percent of the examinees passed the examination. CONCLUSION: The 80 candidates who were certified received time limited certificates that may be renewed by a recertification process to begin in 1999. A second certifying examination was offered in 1994 and a third in 1996. Requirements for future certifying examinations will include 3 years of full time fellowship training and verification of meaningful accomplishment in research.     

Development of the human fetal visceral pleura. An ultrastructural study

OBJECTIVE: To develop a method to predict long-term outcome after head injury and determine if outcome can be accurately predicted 24 hours after injury. DESIGN: A retrospective review was performed on a study cohort of 672 head-injured patients admitted in coma (Glascow Coma Scale score < or = 8) who remained comatose for at least 6 hours, survived more than 24 hours, and had 6-month outcome data available. Stepwise logistic regression analysis was used to determine which clinical variables predicted 6-month outcome. Statistically significant clinical predictors were combined into a single examination variable (MPX score), which reflected a rank-ordering of examinations from worst to best, which was then further weighted by patient age. The relation between 6-month outcome and MPX score at admission and 24 hours was plotted and analyzed. MEASUREMENT AND MAIN RESULTS: Age, best motor score, and pupillary reactivity at admission and 24 hours were significant predictors of outcome; extraocular motility was predictive at 24 hours only. Age was the most important independent predictor, followed by best motor score, pupillary reactivity, and extraocular motility. Combining these predictors into MPX score resulted in a set of graphs that reliably predicted long-term outcome. The 24-hour MPX data were better predictors of 6-month outcome and were more specific in predicting negative outcomes than admission data. CONCLUSIONS: The method is simple to use, relying on bedside neurologic examination and a single graph, but appears to predict long-term outcome accurately as early as 24 hours after head injury. If validated on other large series of patients, this method could provide an objective and practical basis for terminating care in patients unlikely to survive a head injury.