[The new medical licensing regulations (ÄApprO) : Status and expected challenges]

BackgroundThe amendment to the medical licensing regulations (ÄApprO) was decided at the federal level in the version of the "Master Plan for Medical Studies 2020" passed in 2017. In addition to the organizational effort involved in redesigning the curricular teaching, the expected costs associated with the implementation of the new licensing regulations due to the necessary additional time and, therefore, personnel expenditure are of particular importance. Taking into account the different forms of study and the 20% scope for study-design provided to the individual faculties, the process of transferring the teaching content to the new modules confronts us with an enormous organizational challenge.Significance of O&UDiseases of the musculoskeletal system are of particular medical, social and economic importance. Therefore, the training of future physicians in the field of orthopedics and traumatology must be taken into account. The visibility of the field of orthopedics and traumatology must not be lost with the introduction of the new medical licensing regulations (ÄApprO).ImplementationThe implementation of the new medical licensing regulations at German universities will be costly and necessitates an increased number of staff. However, there is a great opportunity to position orthopedics and traumatology as a "central player" in the modular, interdisciplinary and interprofessional course landscape. It is, therefore, important to take on concrete responsibility for the design of the new teaching programs and to bring in our specialist and interdisciplinary skills wherever sensible and possible.

Medical Students' Reflections on the Recent Changes to the USMLE Step Exams

The United States Medical Licensing Examination (USMLE) consists of Step 1, Step 2 Clinical Knowledge, Step 2 Clinical Skills, and Step 3. To be licensed to practice medicine in the United States, medical students must pass all parts of the USMLE. However, in addition to that pass/fail grade, students are currently given a numerical score for Step 1, Step 2 Clinical Knowledge, and Step 3. Residency program directors have come to use the Step 1 score to efficiently screen a growing number of residency applicants. As a result, a deleterious environment in undergraduate medical education has been created, given the importance of Step 1 to medical students matching to their preferred residency program. It was announced in February 2020 that the score-reporting protocol for Step 1 would be changed from a 3-digit numerical score to pass/fail only, beginning no earlier than January 1, 2022. This decision will undoubtedly impact medical students, medical schools, and residency program directors. Here, the authors discuss the impact that the change to Step 1 scoring will have on these key stakeholder groups, from their perspective as students at MD-granting medical schools in the United States. They also call attention to outstanding issues with the USMLE that must be addressed to improve undergraduate medical education for all stakeholders, and they offer advice for further improvements to the residency application process.

Admissions Is Not Enough: The Racial Achievement Gap in Medical Education

The achievement gap is a disparity in academic and standardized test performance that exists between White and underrepresented minority (URM) students that begins as early as preschool and worsens as students progress through the educational system. Medical education is not immune to this inequality. URM medical students are more likely to experience delayed graduation and course failure, even after accounting for science grade point average and Medical College Admission Test performance. Moreover, URM students are more likely to earn lower scores on licensing examinations, which can have a significant impact on their career trajectory, including specialty choice and residency competitiveness. After the release of preliminary recommendations from the Invitational Conference on USMLE Scoring (InCUS) and public commentary on these recommendations, the National Board of Medical Examiners and Federation of State Medical Boards announced that the United States Medical Licensing Examination (USMLE) Step 1 would transition from a 3-digit numeric score to pass/fail scoring. Given that another of InCUS's recommendations was to "minimize racial demographic differences that exist in USMLE performance," it is paramount to consider the impact of this scoring change on URM medical students specifically. Holistic admissions are a step in the right direction of acknowledging that URM students often travel a further distance to reach medical school. However, when residency programs emphasize USMLE performance (or any standardized test score) despite persistent test score gaps, medical education contributes to the disproportionate harm URM students face and bolsters segregation across medical specialties. This Perspective provides a brief explanation of the achievement gap, its psychological consequences, and its consequences in medical education; discusses the potential effect of the Step 1 scoring change on URM medical students; and provides a review of strategies to redress this disparity.

An Investigation of the Relationship Between COMLEX-USA Licensure Examination Performance and State Licensing Board Disciplinary Actions

PURPOSE

Passing the Comprehensive Osteopathic Medical Licensing Examination of the United States (COMLEX-USA) serves as a licensing requirement, yet there is limited understanding between this high-stakes exam and performance outcomes. This study examined the relationship between COMLEX-USA scores and disciplinary actions received by osteopathic physicians.

METHOD

Data for osteopathic physicians (N = 26,383) who graduated from medical school between 2004 and 2013 were analyzed using multinomial logistic regression to assess the relationship between COMLEX-USA scores and placement into one of 3 disciplinary action categories relative to no action received, controlling for years in practice and gender.

RESULTS

Less than 1% of physicians in this study (n = 187) had a disciplinary action(s). Controlling for all COMLEX-USA levels, years in practice, and gender, higher Level 3 scores were associated with significant decreased odds for all action categories: revoked licensed (odds ratio [OR] = 0.51, 95% confidence interval [CI] 0.36, 0.72; P < .001), imposed limitations to practice (OR = 0.59, 95% CI 0.41, 0.84; P < .01), and other action imposed (OR = 0.48, 95% CI 0.33, 0.69; P < .001), relative to not receiving an action. In these same models, higher Level 2 Performance Evaluation Biomedical/Biomechanical Domain scores decreased the odds for an action that revoked a license (OR = 0.75, 95% CI 0.58, 0.98; P < .05) and imposed limitations to practice (OR = 0.64, 95% CI 0.49, 0.84; P < .001).

CONCLUSIONS

These findings provide evidence that the COMLEX-USA delivers useful information regarding the likelihood of a practitioner receiving state board disciplinary actions.

Breaking the boundaries of professional regulation: medical licensing, foreign influence, and the consolidation of homeopathy in Mexico

As doctors sought state support to regulate professional training and practice after Independence, Mexicans also developed different attitudes toward foreign ideas, influences, and professionals. Leveraging the allure of the foreign among Mexicans, homeopaths strategically used work, products, and organizations from abroad to establish their practices and fight changing professional policies in the country that threatened homeopathic institutions. Homeopaths inhabited the blurry and shifting boundary between professional and lay medical practice during the early Republican period, the Porfiriato, and the post-revolutionary era, and used the ambivalent feelings about medical licensing, and foreign influence in Mexican society to consolidate their position.

[Defending entitlement: struggles and fate of the practice of homeopathy in Colombia (1905-1950)]

This article analyzes the practice and professional status of Colombian homeopaths in the twentieth century, based on applications for licenses in the "Teguas" series in the Archivo General de la Nación. Within the historical context of the practice of medicine in Colombia, it studies homeopathic practice within the framework of the debate between licensed and permitted medicine. In that context, the field of homeopathy was subordinate to university medicine and homeopaths were a group of practitioners who were neither homogeneous nor organized, but characterized by their shared struggle to become "entitled" to practice, and their advocacy of professional status through constant litigation against official reprimands.

Permission without Direction: Gross Negligence Manslaughter and Erasure following Bawa-Garba

This article explores when a doctor convicted of gross negligence manslaughter would be erased from the medical register. The General Medical Council (GMC) sanctions guidance avoids directing the Medical Practitioners Tribunal (MPT) about erasure following gross negligence manslaughter and rulings at the High Court and Court of Appeal argue against any presumption of erasure after a doctor is convicted of gross negligence manslaughter. The Court of Appeal in Bawa-Garba ruled that the sanctions guidance should not be taken to guide the MPT towards erasure after "serious harm to others either deliberately or through incompetence", but merely permits erasure in those circumstances. This approach is consistent with the rest of the sanctions guidance which allows the MPT wide discretion and defends that MPT's case-by- case approach. This promotes decision-making behind closed doors, diminishes the Sanctions Guidance, and makes it difficult to predict when a doctor will be erased after gross negligence manslaughter.

Mandated State Medical Licensing Board Disclosures Regarding Resident Performance

BACKGROUND

State medical licensing boards ask program directors (PDs) to complete verification of training (VOT) forms for licensure. While residency programs use Accreditation Council for Graduate Medical Education core competencies, there is no uniform process or set of metrics that licensing boards use to ascertain if academic competency was achieved.

OBJECTIVE

We determined the performance metrics PDs are required to disclose on state licensing VOT forms.

METHODS

VOT forms for allopathic medical licensing boards for all 50 states, Washington, DC, and 5 US territories were obtained via online search and reviewed. Questions were categorized by disciplinary action (investigated, disciplined, placed on probation, expelled, terminated); documents placed on file; resident actions (leave of absence, request for transfer, unexcused absences); and non-disciplinary actions (remediation, partial or no credit, non-renewal, non-promotion, extra training required). Three individuals reviewed all forms independently, compared results, and jointly resolved discrepancies. A fourth independent reviewer confirmed all results.

RESULTS

Most states and territories (45 of 56) accept the Federation Credentials Verification Service (FCVS), but 33 states have their own VOT forms. Ten states require FCVS use. Most states ask questions regarding probation (43), disciplinary action (41), and investigation (37). Thirty-four states and territories ask about documents placed on file, 36 ask about resident actions, and 7 ask about non-disciplinary actions. Eight states' VOT forms ask no questions regarding resident performance.

CONCLUSIONS

Among the states and territories, there is great variability in VOT forms required for allopathic physicians. These forms focus on disciplinary actions and do not ask questions PDs use to assess resident performance.

Serious Ethical Violations in Medicine: A Statistical and Ethical Analysis of 280 Cases in the United States From 2008-2016

Serious ethical violations in medicine, such as sexual abuse, criminal prescribing of opioids, and unnecessary surgeries, directly harm patients and undermine trust in the profession of medicine. We review the literature on violations in medicine and present an analysis of 280 cases. Nearly all cases involved repeated instances (97%) of intentional wrongdoing (99%), by males (95%) in nonacademic medical settings (95%), with oversight problems (89%) and a selfish motive such as financial gain or sex (90%). More than half of cases involved a wrongdoer with a suspected personality disorder or substance use disorder (51%). Despite clear patterns, no factors provide readily observable red flags, making prevention difficult. Early identification and intervention in cases requires significant policy shifts that prioritize the safety of patients over physician interests in privacy, fair processes, and proportionate disciplinary actions. We explore a series of 10 questions regarding policy, oversight, discipline, and education options. Satisfactory answers to these questions will require input from diverse stakeholders to help society negotiate effective and ethically balanced solutions.

Analysis of the French national evaluation of radiology residents

PURPOSE

In France, a national evaluation is given annually to radiology residents. The aim of this study was to perform both a docimological analysis of the quality of the questionnaire and a statistical analysis of the results.

MATERIALS AND METHODS

This retrospective study, which included French radiology residents from Year 1 to Year 5 of residency, was performed from 2015 to 2017 across 25 medical universities in France. Both qualitative and quantitative docimological analyses were performed as assessed by the Cronbach alpha coefficient, the difficulty of question (PDI), and the coefficient of discrimination (Rir). Results to the questionnaire were compared between years of residency.

RESULTS

The results of the analysis confirmed the quality of the questionnaire (Cronbach alpha coefficient=0.71, mean [PDI=0.40]) though the majority of questions could be answered by memory rather than cognitive ability. The mean Rir was 0.02, indicating that students could not be certified using only the questionnaire. The results measuring resident level of knowledge were moderate, with mean results ranging from 9.2/20 at the first year to 11.3/20 at the fifth year of residency (P<0.001). There were no significant differences in results obtained between the third, fourth, and fifth year of residency but results were significantly different among university hospitals.

CONCLUSION

Even if close interactions exist between learning and pedagogic environment, our results suggest that it may be useful to further develop an evaluation process in relation with pedagogic instructions in order to provide more optimal training.

Medical Licensure Questions About Mental Illness and Compliance with the Americans With Disabilities Act

Substantial numbers of medical students and physicians live with some form of mental illness. Over the years, many medical licensure boards have asked physician medical licensure applicants with Doctor of Medicine (MD) degrees intrusive questions about whether they have any psychiatric history. This has discouraged many who need psychiatric treatment from seeking it because of fear of the questions. Gradually, court decisions and the United States Department of Justice have established that such questions violate the Americans with Disabilities Act (ADA). The 2014 Louisiana Supreme Court Settlement Agreement set definite limits on law licensure mental health questions, followed by a least one licensing body revising its physician licensure questions to be consistent with ADA standards. In this article we examine the current medical licensure questions from each state and the District of Columbia about the mental health of applicants and discuss their validity under ADA standards. Our original investigation of these questions found that the majority still ask questions that are unlikely to meet ADA standards. The judicial and Department of Justice developments, however, may compel them to abandon these questions. If not, legal action will enforce ADA compliance. This change will significantly benefit applicants who need psychiatric treatment.

The Transmutation of Deference in Medicine: An Ethico-Legal Perspective

This article critically considers the question of whether an increase in legal recognition of patient autonomy culminating in the decision of the Supreme Court in Montgomery v Lanarkshire Health Board in 2015 has led to the death of deference to doctors, not only within the courts and healthcare regulatory arenas in England and Wales but also in the consulting room and the health care system more broadly. We argue that deference has not been eradicated, but that the types of deference paid to doctors and to the medical profession have changed. In addition, whilst traditionally deference was extended towards the medical profession, increasing instances of deference being shown to other parties in the healthcare setting can be identified, allowing wider debate or recognition of the complexity of understandings, interests and aims of all those involved. Finally, we note instances in which deference to the medical profession has become more hidden.

Visions and reality: the idea of competence-oriented assessment for German medical students is not yet realised in licensing examinations

Objective: Competence orientation, often based on the CanMEDS model, has become an important goal for modern curricula in medical education. The National Competence Based Catalogue of Learning Objectives for Undergraduate Medical Education (NKLM) has been adopted in Germany. However, it is currently unknown whether the vision of competence orientation has also reached the licensing examination procedures. Methods: Therefore, a prospective, descriptive, single-centre, exemplary study design was applied to evaluate 4051 questions/tasks (from 28 examiners at 7 two-day licensing oral-practical exams) for undergraduate medical students at the University of Ulm. The oral and practical questions/tasks as well as the real bedside assessment were assigned to specific competence roles (NKLM section I), categories (NKLM section II) and taxonomy levels of learning domains. Results: Numerous questions/tasks were set per candidate (day 1/2: 70±24/86±19 questions) in the licensing oral-practical exam. Competence roles beyond the "medical expert" were scarcely considered. Furthermore, practical and communication skills at the bedside were hardly addressed (less than 3/15 min). Strikingly, there was a significant predominance of questions with a low-level taxonomy. Conclusions: The data indicate a misalignment of competence-oriented frameworks and the "real world" licensing practical-oral medical exam, which needs improvement in both evaluation and education processes.

"I would never want to have a mental health diagnosis on my record": A survey of female physicians on mental health diagnosis, treatment, and reporting

INTRODUCTION

Physicians have high rates of suicide and depression. Most state medical boards require disclosure of mental health problems on physician licensing applications, which has been theorized to increase stigma about mental health and prevent help-seeking among physicians.

METHODS

We surveyed a convenience sample of female physician-parents on a closed Facebook group. The anonymous 24-question survey asked about mental health history and treatment, perceptions of stigma, opinions about state licensing questions on mental health, and personal experiences with reporting.

RESULTS

2106 women responded, representing all 50 states and the District of Columbia. Most respondents were aged 30-59. Almost 50% of women believed that they had met the criteria for mental illness but had not sought treatment. Key reasons for avoiding care included a belief they could manage independently, limited time, fear of reporting to a medical licensing board, and the belief that diagnosis was embarrassing or shameful. Only 6% of physicians with formal diagnosis or treatment of mental illness had disclosed to their state.

CONCLUSIONS

Women physicians report substantial and persistent fear regarding stigma which inhibits both treatment and disclosure. Licensing questions, particularly those asking about a diagnosis or treatment rather than functional impairment may contribute to treatment reluctance.

Popular Medicine and Empirics in Greece, 1900-1950: An Oral History Approach

Western literature has focused on medical plurality but also on the pervasive existence of quacks who managed to survive from at least the eighteenth to the twentieth century. Focal points of their practices have been their efforts at enrichment and their extensive advertising. In Greece, empirical, untrained healers in the first half of the twentieth century do not fit in with this picture. They did not ask for payment, although they did accept 'gifts'; they did not advertise their practice; and they had fixed places of residence. Licensed physicians did not undertake a concerted attack against them, as happened in the West against the quacks, and neither did the state. In this paper, it is argued that both the protection offered by their localities to resident popular healers and the healers' lack of demand for monetary payment were jointly responsible for the lack of prosecutions of popular healers. Moreover, the linking of popular medicine with ancient traditions, as put forward by influential folklore studies, also reduced the likelihood of an aggressive discourse against the popular healers. Although the Greek situation in the early twentieth century contrasts with the historiography on quacks, it is much more in line with that on wise women and cunning-folk. It is thus the identification of these groups of healers in Greece and elsewhere, mostly through the use of oral histories but also through folklore studies, that reveals a different story from that of the aggressive discourse of medical men against quacks.

Legal and ethical aspects of telemedicine

There are many issues of concern regarding the legal and ethical aspects of telemedicine. These include the responsibilities and potential liabilities of the health professional, the duty to maintain the confidentiality and privacy of patient records, and the jurisdictional problems associated with cross-border consultations. There is also the issue of reimbursement for care provided using a telemedicine service. Telemedicine allows the transmission of health information across the borders of nation states. Cross-border telemedicine services have begun, particularly in specialties such as teleradiology, but questions of jurisdiction and registration have yet to be answered definitively. While this may be true of many of the legal and ethical aspects of telemedicine generally, it is also the case that health-care professionals who undertake telemedicine in a prudent manner will minimize the possibility of medicolegal complications.

The 19th Century Origins of Facial Cosmetic Surgery and John H. Woodbury

John H. Woodbury was an incredibly entrepreneurial, self-trained dermatologist who, between 1870 and 1909, built an empire of cosmetic surgery institutes in 6 states, with 25 physician/surgeon employees and an advertising budget of $150,000/year (1892 data). Under his management, his surgeons, and perhaps Woodbury himself, performed multiple facial cosmetic surgeries, including early versions of browlifts, frown excisions, lower facelifts, mid-face lifts, rhinoplasties, double-chin reductions, and dimple creation. In addition, Woodbury developed a proprietary soap and cosmetic line, which he sold to Jergens for $212,500 in 1901 (retaining a 10% royalty). Woodbury's story has been unknown until now because this nonacademic concentrated his publishing in articles and advertisements in lay magazines. Woodbury's life ended in bankruptcy, litigation, and suicide when the corporate practice of medicine and advertising were made illegal. In his legal proceedings, Woodbury conceded that he was not a doctor, although he went by the title. Regardless, his surgical innovations are of major historical significance, as these cosmetic procedures are the first of their kind to be noted in the lay or academic press and predate, by years and even decades, the previously earliest known cosmetic surgeries in the United States.

Refusal to grant provisional General Medical Council registration to U.K. medical graduates

In the last five years, 2010-2014, there have been 17 instances when an application for provisional registration by a U.K. medical graduate was refused by the General Medical Council because the Registrar considered that the applicant's fitness to practise was impaired. While this number is small, the fact that this can happen is largely unappreciated by medical students and their teachers, the prevailing false assumption being that passing finals and graduation is the final hurdle before taking up a Foundation Programme post. It is a poorly recognised fact that just because a university fitness to practise committee has concluded that a student is fit to practise there is no guarantee that the General Medical Council will come to the same decision. This paper explains the reasons for these refusals and makes suggestions for students and medical schools.

Three controversies over item disclosure in medical licensure examinations

In response to views on public's right to know, there is growing attention to item disclosure - release of items, answer keys, and performance data to the public - in medical licensure examinations and their potential impact on the test's ability to measure competence and select qualified candidates. Recent debates on this issue have sparked legislative action internationally, including South Korea, with prior discussions among North American countries dating over three decades. The purpose of this study is to identify and analyze three issues associated with item disclosure in medical licensure examinations - 1) fairness and validity, 2) impact on passing levels, and 3) utility of item disclosure - by synthesizing existing literature in relation to standards in testing. Historically, the controversy over item disclosure has centered on fairness and validity. Proponents of item disclosure stress test takers' right to know, while opponents argue from a validity perspective. Item disclosure may bias item characteristics, such as difficulty and discrimination, and has consequences on setting passing levels. To date, there has been limited research on the utility of item disclosure for large scale testing. These issues requires ongoing and careful consideration.

Big push for tort reform this legislative session

These are just a few of the things we'll see this year, but it doesn't come close to being an exhaustive list. We anticipate having our yearly discussions over the worthiness of state's motorcycle helmet law. We'll find ourselves advocating for stricter texting-while-operating laws and seat belt enforcement. The insurance companies will probably get an earful over narrow networks and prior authorization. Telemedicine will likely come up; as will the pharmaceutical industry and their numerous endeavors. We'll have to watch some public health groups who will attempt to offer solutions to their own issues for their select set of patients. We're the only state without a Prescription Drug Monitoring Program (PDMP), so that will be in play Plus, the chiropractors, optometrists, midwives, etc., never seem to go away And on and on and on... Be sure to read MSMA's weekly Legislative Report during the 2015 session. It will keep you in the loop on all the above and then some. And don't forget to volunteer as the MSMA Physician of the Day at the Capitol. It's not difficult, and the legislators love seeing one their physicians from back home. Look for a sign-up sheet on the MSMA website soon. If you have any questions about our advocacy efforts on your behalf, feel free to give me a call anytime at 573-636-5151, or email jhowell@msma.org.

Accountability: the challenge for medical and nursing regulators

Little has been written about how regulatory bodies define and demonstrate accountability. This paper describes a substudy of a research project on accountability in healthcare. The aim was to increase understanding of how regulatory bodies perceive and demonstrate accountability to their stakeholders. Twenty-two semi-structured interviews were conducted with provincial/territorial CEOs from the two largest health professional regulatory bodies in Canada: medicine and nursing. The regulators indicated that accountability was essential to their mandates and provided the foundation for regulatory frameworks. However, they did not offer a common definition of accountability. They agreed that they were accountable to three constituencies: the public, government and their members. Regulators noted that protecting the public and meeting the demands of the government and their members creates tension. They were also concerned about maintaining independence in the regulatory role.