Policies of U.S. medical schools on the use of the NBME Part I and Part II examinations

The study reported here provides information on National Board of Medical Examiners (NBME) examination policies from all U.S. medical schools (n = 67) that require students to pass the examination. Most of these schools have similar policies on use of a 380 total score as the passing level for the NBME Part I examination, allowing three attempts to pass the examination, interrupting a student's progress into the clinical curriculum upon failure of the examination, officially providing time for preparation for taking the test, and requiring students to pass the Part II examination.     

Student performance on the NBME Part II subtest and subject examination in obstetrics-gynecology

Clerkship directors in obstetrics-gynecology often use the National Board of Medical Examiners (NBME) norms to evaluate third-year medical students' performance on the NBME obstetrics-gynecology subject examination. A comparison of the scores of 342 students at the Medical College of Georgia School of Medicine showed that the students performed significantly better on the NBME subject examination than on the Part II subtest in obstetrics-gynecology. These results concur with the findings of the NBME, which advises directors wishing to adjust the criterion group norms to determine the average difference observed in a school's performance on the two examinations and to use that difference or some portion of it in their interpretation of percentile scores on the subject examination. Additional analyses revealed that a single, linear weight may inappropriately adjust these scores, that student performance on the Part II subtest depends on specialty choice (obstetrics-gynecology versus all others), and that time and sequence of the clerkship were unrelated to the students' performance on the two examinations.     

Performance on NBME Part I examination in relation to policies regarding use of test

From 1971 to 1983, a number of administrative decisions were made at the University of Oklahoma College of Medicine regarding the National Board of Medical Examiners (NBME) Part I examination. Students' performance on this examination was found to be associated with administrative decisions that required (a) a passing score for promotion, (b) the student to take the examination, and (c) the student to take an integrated basic sciences review course. A modest improvement in student performance was noted when passage of the examination was made mandatory. The introduction of a review course into the curriculum effected a major upward change in scores that has persisted despite the removal of all requirements to pass, or even take, the Part I NBME examination.     

Effect of two preclinical curricula on NBME Part I examination performance

The Michigan State University College of Human Medicine conducts two preclinical medical education programs. In Track I (lecture-based), students attend classes 24 hours per week, and lecture time totals 908 hours over a 50-week period. In Track II (problem-based), students attend classes only 12 hours per week, and lecture time totals 112 hours over the same 50-week period. Institution of the Part I examination of the National Board of Medical Examiners (NBME) as a graduation requirement provided an opportunity to compare the performances of students in both tracks. When students from each track with similar Science Problems subtest scores on the Medical College Admission Test were compared, no significant differences were observed in the students' total scores or pass rate on the NBME examination. However, there were significant differences in scores on the microbiology subtest of the NBME examination, with the Track I students achieving higher scores. The 1984 report of the Project Panel on the General Professional Education of the Physician and College Preparation for Medicine of the Association of American Medical Colleges stressed the need to examine critically and consider reducing the scheduled instructional and lecture hours in preclinical medical education programs. In the study reported here, the authors demonstrated that reduction of scheduled instructional time, when replaced by a guided problem-solving program, is not detrimental to students' performance on the NBME Part I examination.     

External examinations for internal evaluation: the National Board Part I Test as a case

The appropriateness of the Part I examination of the National Board of Medical Examiners to evaluate second-year curricular performance of students at Case Western Reserve School of Medicine was examined. Review of the June 1974 examination by 37 faculty members revealed that 85% of the items reflected the content of the second-year curriculum and that 60% could be answered from information provided in the second-year teaching. Two-thirds of the items were related to the content of the first-year curriculum, and half could be answered on the basis of first-year material. The school's faculty used the study data in making policy-changing decisions.     

A model for predicting performance on the NBME Part I examination

Multiple regression analyses were employed to determine the relationships between achievement variables as predictors of the performance on Part I of the National Board of Medical Examiners examinations (NBME-I) of 366 medical students. The students' examination score averages in first- and second-year basic science courses were sequentially added to a composite Medical College Admission Test (MCAT) score to investigate the increases in prediction accuracy. Four prediction equations were cross validated on two subsequent medical school classes. While the multiple correlation between the predicted NBME-I score and the actual score significantly increased as first- and second-year course examination scores were added to the equations, the overall accuracy in predicting passing or failing did not substantially increase. The most useful equation employed a combination of the MCAT score and the first semester anatomy course examination score. The NBME-I predictions were given by letter to the 1984 and 1985 students approximately a year before they were to take the NBME-I examination so that students at risk of failure could undertake remedial study.     

Effects of curriculum and format changes in a medical pharmacology course, 1983 to 1987

During the past five years, the medical pharmacology course at the University of Arkansas College of Medicine has changed from a poorly attended course in which students depended on "canned notes" (from a note-taking and note-distribution system organized among themselves) and had bad rapport with faculty members to a course in which attendance is high, the canned-notes system has been abandoned, and faculty-student interactions are generally pleasant. These changes in student behavior occurred during a period in which the pharmacology faculty implemented changes that anticipated the recommendations of the Panel on the General Professional Education of the Physician and College Preparation for Medicine of the Association of American Medical Colleges. These changes included encouraging independent learning, reduced lecture time, and increased problem-solving. The students' performance on the Part I examination of the National Board of Medical Examiners did not change during this period of curriculum revision.     

Relationship between past academic performance and results of specialty in-training examinations

In this study, the authors review the records of 63 graduates of Northwestern University Medical School who were residents in its graduate medical education programs of anesthesia and orthopedic surgery. They examine the relationship among college grades, medical school performance, and the results of assessment by annual, nationwide, medical specialty in-training examinations. For the anesthesia group, the best predictors of in-training examination performance were the Medical College Admission Test (MCAT) Verbal Ability score, the college grade-point average for nonscience subjects, and the MCAT Science, General Information, and Quantitative Ability scores. For the orthopedic group, the best predictors were the MCAT Verbal Ability score, the college grade-point average in nonscience subjects, the MCAT Science score, and the National Board of Medical Examiners Part I and Part II examination scores. The previous academic records for the 63 residents contained little to presage results in the in-training examination. The correlation obtained between nonscience college subjects and the in-training examination results was negative.     

Predicting academic performance at a predominantly black medical school

A study was conducted by the authors that examined the validity of the Medical College Admission Test (MCAT), undergraduate grade-point average (GPA), and "competitiveness" of undergraduate college in predicting the performance of students at a predominantly black college of medicine. The performance measures used in the analysis consisted of course grades in all four years of medical school and scores on both Part I and Part II of the National Board of Medical Examiners (NBME) examinations. The predictive validities of the MCAT scores and undergraduate GPAs were found to be similar to those revealed in earlier studies conducted at predominantly white schools. Two exceptions to these similarities were found. First, the MCAT scores at the black school had a somewhat lower validity in predicting NBME examination scores than was the case at the other schools. Second, of the six MCAT subtest scores, Skills Analysis: Reading had the highest correlation with first-year grades, in contrast to results at the other schools. No differences between men and women were found in the validity of MCAT scores and the GPA. The competitiveness of the undergraduate college attended was found to contribute significantly to the prediction of all measures of medical school performance.     

Correlates of clinical performance during medical school.

Many efforts have been made to define the complex factors related to successful clinical performance and to determine relationships among them. This study was an attempt to increase the understanding of cognitive and noncognitive attributes of clinical performance. Intercorrelations among overall clinical performance ratings, quarterly comprehensive examination scores, total scores on the Part II examination of the National Board of Medical Examiners, and overall grade-point average were computed for a graduating class of medical students. Aspects of clinical performance pertaining to information, concepts, skills, ingenuity, and conscientiousness were found to correlate with academic achievement as measured by grades and cognitive tests; however, such a correlation was not found for other aspects pertaining to attitude, peer relations, maturity, patient rapport, and integrity.     

Using ratings of resident competence to evaluate NBME examination passing standards

The passing standards of the National Board of Medical Examiners (NBME) examinations were empirically evaluated by analyzing the distributions of examination scores received by 1,994 graduates of one medical school in relation to the clinical competence ratings given to the graduates by their first-year residency directors. A significant association was found between the NBME examination scores and ratings in the cognitive areas of clinical competence. The graduates who scored 420 or less on the NBME Part I or the Part II examination received significantly lower medical knowledge ratings than did the total group of graduates. A similar analysis of NBME Part III examination scores was less clear-cut but also suggested that a score of 420 or less could identify those graduates at significant risk of receiving low knowledge ratings. When low ratings were used as an outcome measure, analysis showed that the NBME Part II examination was not sensitive in detecting such graduates. Based on these data, the authors do not propose changes in the passing standards for the NBME examinations but recommend that these standards continue to be reassessed and further measures be taken to strengthen the internal evaluation methods in medical schools.     

Preclinical curriculum characteristics and institutional performance on NBME. Part I

A study was conducted that analyzed the relationship between various characteristics of the preclinical curriculum and institutional performance on the Part I examination of the National Board of Medical Examiners (NBME) at a sample of 85 U.S. medical schools. Total scheduled hours per week was the single curriculum characteristic having a positive and significant relationship with institutional NBME examination performance. However, when the data were controlled by medical school selectivity in admissions and institutional policy on the taking of the examination, total scheduled hours per week failed to make a significant contribution to the prediction of performance. The results were viewed as failing to provide support and justification for intense preclinical curriculum loads on the basis that this would enhance NBME examination performance. The authors conclude that simple comparisons of schools on the basis of mean NBME examination performance are meaningless unless the entering abilities of students and school policies on the examination are taken into account. The authors also suggest that those schools that prescribe heavy and intense preclinical curriculum loads should reexamine those policies in light of recommendations of the Project Panel on the General Professional Education of the Physician and College Preparation for Medicine.     

A comparison of medical students' performances in independent study and traditional programs

Medical students at Ohio State University may study the basic medical sciences in an independent study program or in a conventional lecture-discussion program. In a study involving more than 2,000 students over a 10-year period, students pursuing the independent study program and students in the more traditional program performed similarly on Part I of the National Board of Medical Examiners (NBME) examinations and in their required clerkships. However, differences were identified in some content areas and resulted in curricular changes.     

The use of Part I National Board scores in the selection of residents in ophthalmology and otolaryngology

A survey of ophthalmology and otolaryngology residency program directors was conducted to determine the extent to which National Board of Medical Examiners (NBME) Part I scores are used in selection of residents in these highly competitive specialty fields. Results from 218 completed questionnaires representing nearly 90% of all US ophthalmology and otolaryngology/head and neck surgery programs were analyzed. More than three fourths indicated that Part I NBME scores were used in selecting residents; more than half of the programs used these scores as a means to determine whom to interview. The direct use of NBME scores in the residency application process is widespread; however, such use of NBME scores is not consistent with the purposes of the National Board. The preeminent role of the faculty in the evaluation of medical students and in the assessment of their clinical competence needs emphasis.     

Students' certainty during course test-taking and performance on clerkships and board exams

Psychometric aspects of multiple-choice tests were investigated using a confidence-weighted scoring technique. The contributions of two indices, overconfidence and underconfidence, in the prediction of subsequent academic performance of examinees were studied. A total of 444 sophomore students (entering classes of 1982 and 1983) in one medical school were asked to indicate their confidence, on a 5-point scale (100, 75, 50, 25, and 0), in the correctness of their responses to each multiple-choice item on an Introduction to Clinical Medicine examination. Examinations were scored in two ways: in the conventional way, using the total number of correct responses, and by a confidence-weighted technique based on the level of certainty indicated for each response by the examinee. Only the conventional score determined the grade; the confidence-weighted score was calculated for the purely experimental purposes of this study. Overconfidence and underconfidence indices were also calculated by using the indicated levels of certainty. Improvements in the psychometrics of the examinations were observed when confidence-weighted scoring was used. In multiple-regression models, the confidence-weighted scores and indices of over- and underconfidence contributed significantly to predicting scores of the students studied on Parts I and II of the National Board of Medical Examiners examinations, whereas the conventional score did not contribute to the prediction of Part II scores. Significant differences on junior clerkship examinations and ratings were observed between those who were highly overconfident and those who were slightly overconfident. The highly overconfident students also estimated higher future incomes than did those who were slightly overconfident.     

Predictive validity of the MCAT for students with two sets of scores

Addressed in the study reported here is the question of which set of scores for those students who retake the Medical College Admission Test (MCAT) yields a better predictive validity. The sample was comprised of 304 students who retook the MCAT prior to entering Jefferson Medical College between 1978 and 1981. Five sets of MCAT scores were considered as predictors in the study: earlier, later, higher, and lower sets of MCAT scores and the average of the earlier and later scores for each MCAT subtest. Twenty-five criteria were used, including grades earned in the freshman and sophomore years and scores on the subtests of Part I and Part II of the examinations of the National Board of Medical Examiners. Correlational techniques, such as bivariate and multiple correlation analyses and canonical correlation followed by redundancy analysis were utilized. The magnitude of redundancy indices indicated that the set of MCAT scores in which the earlier and later scores were averaged was the best predictor, followed by the earlier, lower, higher, and later sets of MCAT scores. The implications of these findings for the admissions process and for validity studies are discussed.     

Effectiveness of an international health elective as measured by NBME Part II.

A total of 434 third- and fourth- year medical students from 80 U.S. medical schools participate between 1968 and 1974 in Yugoslav or Israeli international fellowship programs sponsored by the Association of American Medical Colleges and the U.S. Public Health Service. Subsequently, the scores of these fellowship student on Part II of the examinations of the National Board of Medical Examiners (NBME) were compared with the scores of rejected applicants and with the national average to determine the cognitive impact of the fellowship experience on the participants. The results show that the international fellows scored significantly higher than the rejected applicants and the national average in only the preventive medicine/public health portion of the examination. The conclusion is drawn that the fellowship programs enhanced the participants' knowledge of preventive medicine and public health.     

Predictors of success in an anesthesiology residency

The selection of residents in medical specialty programs is a difficult task facing all selection committees. The present authors examined factors that contribute to successful residency performance by 26 anesthesiology residents in order to assist the program's selection committee in developing selection criteria. The best predictor of a resident's academic average in the anesthesiology program was the number of years the resident had spent in other specialties. Comparison of the residents' scores on the Anesthesiology In-Training Examination (ITE) and their scores on Part I of the examinations of the National Board of Medical Examiners (NBME) showed a statistically significant negative correlation. The higher that residents scored on the NBME Part I examination, the lower they scored on the ITE. No significant correlations were found between the residents' ITE scores and undergraduate grade-point average or nonacademic variables such as the residents' age or parents' level of education. The residents' composite grade-point average (GPA) for the residency and their interview scores had a strong positive relationship significant at the 0.06 level.     

Evaluating student performance in a decentralized basic science program.

The results of the evaluation of the basic science curriculum in a regionalized medical education program in the states of Washington, Alaska, Montana, and Idaho (WAMI) are presented and discussed. The hypothesis that students taking the first quarter of basic science at universities remote from the Unversity of Washington School of Medicine (UWSM) will be no different in academic performance from those who remain at the UWSM is tested. The variables considered were student performance on (a) common tests in Anatomy/Histology, Biochemistry, Mechanisms of Physiology, and Epidemiology; (b) subsequent course work at the UWSM; and (c) the mini-tests and Part I of the examinations of the National Board of Medical Examiners. The developement of the common tests is described. Analysis of variance indicates that the null hypothesis cannot be rejected at the .05 level.     

Determining geriatric content in a medical school curriculum

Geriatric content in a medical school curriculum was assayed by surveying faculty course directors and students about course content, by conducting an independent review of course content, and by analyzing the content of course examinations. The students' assessments of geriatric content were found to be not valid. Considerable variability was found in the amount of geriatric content within courses, and review of course examinations was found to be the most valid review method. Pharmacology and second-year psychiatry courses were shown to have the most coverage of geriatrics, while microbiology, biochemistry, and neuroanatomy courses were shown to have the least coverage of geriatric items. The geriatric items in the course examinations correlated strongly (r = .71) with the National Board of Medical Examiners Part I and Part II examinations; because of this correlation, the investigators felt the study findings may be generalizable outside the one medical school. It would appear that geriatric content within the medical school curriculum is low; however, the results of the review methods indicate that disagreement exists over the degree of deficiency. The authors conclude that examination review offers an expeditious method to determine the relative emphasis placed upon geriatrics material within specific courses.