In the Public Trust Charles Hazzard, DO First President of the National Board In the Public Trust: The National Board of Osteopathic Medical Examiners 1934-2009

Betty Burnett, PhD Copyright 2010©National Board of Osteopathic Medical Examiners All rights reserved. No portion of this book may be reproduced, stored in an electronic retrieval system, or transmitted in any form or by any means—electronic, mechanical, photocopy, recording, or any other—without the prior permission of the National Board of Osteopathic Medical Examiners, Chicago, Illinois.

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PRINTED IN THE UNITED STATES OF AMERICA CONTENTS

N at i o n a l B o a r d o f O s t e o pat h i c Medical Examiners

Foreword vii History 1 The Examinations 53 NBOME: The People 75 Appendix 99 Fredrick G. Meoli, DO, FACOS First Full-Time President and CEO of the NBOME 2002-2009; President of the NBOME, 1999-2001 Foreword

here is something sacred about the relationship between and patient. The basis of the relationship lies in the implicit trust T placed in the physician by the patient. That trust stems from the be- lief that the physician is competent to practice , and thus the public has come to inherently rely on jurisdictional regulatory agencies, licensing examinations, certifying boards, and hospitals to assure them that the physician is competent.

Prior to 1900, there was no regulation and Surgeons which sought to create a or licensure of in the United universal examination with high stan- States. The twentieth century ushered dards acceptable to all jurisdictions and in the regulation of physicians, but to the osteopathic medical profession. judgments regarding their competence This examination would be used to as- were largely made by the use of proxy sess physicians seeking to practice osteo- measures, such as a graduation certificate pathic medicine. from a medical school. At first voluntary, but later required for After 1920, states began to create graduation from all osteopathic medical medical practice acts and individual schools by the AOA’s Commission on state examinations for medical licensure. Osteopathic College Accreditation, an It was in this milieu that, in 1934, men of examination for physician candidates like mind had the vision to recognize the was developed which would ultimately need to create an examination sequence be accepted in every state in the United to evaluate the physician’s knowledge, States in recognition of the practitioner’s skill and behavioral sets to competently ability to practice the art and of practice osteopathic medicine. osteopathic medicine. They established the National Board The National Board of Examiners for of Examiners for Osteopathic Physicians Osteopathic Physicians and Surgeons

vii promoted the concept that osteopathic examination. The 1940s introduced live medicine offered a unique approach to patient clinical examinations in the hospi- both health and disease that must be pre- tal setting. The 1950s brought identity and served and promoted as a means to pro- reorganization. The 1960s were character- vide the public with a valuable addition ized by the introduction of objective test- to available traditional medicine. With the ing formats and wider acceptance across assistance of the American Osteopathic the country. The 1970s brought advances Association, a cadre of dedicated and in testing, scoring, and test administra- committed professionals, the board de- tion. Some state medical boards sought veloped the forerunner of what would be- assistance in building their own exami- come the National Board of Osteopathic nations for licensure. The 1980s ushered Medical Examiners and the COMLEX-USA in sophisticated item banking, electronic osteopathic medical licensure examina- scoring, and test refinement. The 1990s tion sequence of today. fostered significant research, the intro- Although the name evolved from duction of COMLEX-USA, and organiza- the National Board of Examiners for tional changes arising from a series of im- Osteopathic Physicians and Surgeons portant board meetings and retreats. In to the National Board of Osteopathic 1995, the last diplomate status was award- Medical Examiners, the mission of the ed. Today it is no longer necessary. board has always remained to provide as- The new millennium would provide surance to the public that all candidates a period of unprecedented growth and who successfully complete the osteopath- expansion. It was in this decade that the ic licensure sequence have met the min- NBOME established two venues of opera- imum requirements of knowledge and tion, introduced computer-based testing, skill to practice osteopathic medicine. and began clinical skills evaluation. Its ex- During its seventy-five years, the aminations for licensure became accepted NBOME has faced many obstacles and in all fifty states of the United States and challenges that make the history of the many international jurisdictions. organization compelling to study in order Thus, the twenty-first century has re- to comprehend the scope of osteopathic quired more of the physician. Highly so- medical licensure. Each decade brought phisticated testing for licensure and spe- significant change and special character- cialty certification more closely resemble istics to the National Board of Osteopathic the actual clinical environment in which Medical Examiners. Many of the changes the physician works. These tests require are revealed in the symbolism reflected the physician to show, rather than tell, in the great seals of the board. The 1930s that he or she is competent. The physi- brought initial organization and an essay cian must now demonstrate a clear com-

viii mitment to life-long learning and must Osteopathic Medicine.” It has continued possess the requisite clinical skills and to apply the organization’s values of qual- knowledge to assure the public that the ity, security, safety, commitment, and ac- medical professional they are selecting countability to create, preserve, and pro- can and will meet their needs, as well as mote competency in osteopathic medical those of society at large. licensure through its examination sys- The pages that follow chronicle the tems and service to the public and the milestones and benchmarks that have profession. made the NBOME the respected organi- The NBOME looks forward to meeting zation that it is today in both the domestic the challenges of the next seventy-five and international regulatory and medical years with the same basic tenets: to sup- educational arenas. It has steadfastly ad- port general access to quality medical care hered to its mission, “To provide for the and to enhance the osteopathic medical public welfare a means to assess compe- profession. tency in the health disciplines relevant to ~ Frederick G. Meoli, DO December 2009

ix For all the men and women who fought for the right to unrestricted medical practice and licensure and the recognition of the osteopathic medical profession

 In the Public Trust

“Frequently there is more Danger from the Physician than from the Distemper.” Dr. William Douglass, 1753

As early as 1649, colonists in the state of Early in the nation’s history, formal Massachusetts petitioned for a law to reg- education in the colonies was spotty and ulate “Chururgeons, Midwives, Physitines or the best known physicians were educated others imployed at any time about the bodyes in Europe. Although the first American of men, women or children, for preservation medical school was founded in 1765, only of life, or health.” Finding safe, honest, and a handful of students attended. A much dependable health care has been on the greater number of physicians and sur- minds of Americans since then. geons learned their trade through appren- Developing a system to regulate health ticeship, as did . care, which now seems routine, was a In the late eighteenth century, medi- long, complex process filled with ques- cal societies in New York and New Jersey tions that were debated for years. Who created a system of informal regulation, was to be licensed? Physicians only? What using the power of ostracism to keep doc- about midwives, botanists (apothecaries tors in line. Apprentices were required or pharmacists), or phrenologists? How to pass a test before they could go out could anyone prove an untried physician on their own, while graduates of a medi- or surgeon was qualified? Should there be cal school, no matter how inexperienced, a written test, oral test, or clinical test or were not. Anyone disciplined for unpro- all three? Would a university or college fessional conduct could simply cross a degree be required or was apprenticeship state line and open a new practice. training sufficient? During the era of Andrew Jackson’s And, perhaps the most important influence, roughly 1830 to 1850, fron- question of all: Who should be in charge— tier democracy spread and profession- the government, the public or the medi- als —especially doctors, lawyers, and cal profession itself? bankers—were seen as elitist. It was a

 time of expanding public education, and study in a medical school. In response Americans felt they were knowledgeable to the AMA lobbying efforts, state laws enough to judge the quality of their medi- to monitor licensing proliferated, but cal care themselves. State medical licens- each was written in accordance with the ing laws were repealed. When A. T. Still, politics in the state and there were no MD, DO, founder of the American osteo- uniform standards. To obtain a license, pathic medical profession, was growing a short interview might be required or a up, there were no regulations regarding comprehensive examination. Some states the licensure of physicians anywhere in allowed a diploma to be equivalent to a the United States. license. Examiners might be bureaucrats, In 1847 a group of physicians founded college professors, or physicians. In 1891, the American Medical Association (AMA) the National Confederation of State Medi- to fight this trend. They wanted to raise cal Examining and Licensing Boards (now the status of their profession, which was the Federation of State Medical Boards, then lower than that of many tradesmen. FSMB) formed in an attempt to bring or- To do so, they needed to set standards. der from the chaos. But even in 1874, when Dr. Still devel- oped his new method of health care , the medical profession was disorganized and A New Profession its status low. Few doctors were formally trained and most offered eclectic treat- A year later, in 1892, the first class of the ment regimens, rather than scientifically American School of (ASO) based ones. , water cures, met for instruction in Kirksville, Missouri. Grahamism, Christian Science, mesmer- In accordance with the school’s charter, ism (hypnosis), and magnetism were some Dr. Still could have called graduates of the alternatives to allopathic medicine Medical Doctors, but chose instead the at the time osteopathy was founded. designation Diplomat in Osteopathy, In its continuing effort to professional- DO (Later, Doctor of Osteopathy). He ize the practice of medicine, the AMA in insisted that his doctors were different 1883 began to advocate for graduation from “regular” MD physicians and from medical school plus hospital train- surgeons through their emphasis on the ing as necessary before applying for a well-being of the whole person and the license to practice. Apprenticeship would belief that the body had the inherent no longer be acceptable. Furthermore, ability to heal itself. He saw physicians they wanted every medical student to as facilitators, rather than dictators of have a degree from an accredited college healing. or university before being accepted for In 1897, a few years after DOs had be-

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gun practicing in various locations across Osteopathic Association began a vigorous the United States, a group of students campaign for licensure, they faced a long, at ASO founded the American Associa- hard-fought battle, filled with contentious tion for the Advancement of Osteopathy politics, galling misinformation and dis- (AAAO) with the goal of organizing the appointment, with just enough victories profession and promoting its system to keep them going. No matter that scores

“The reasons for the organization are many, are obvious, are strong; and personal protection is the least of these. No; the members of this organization have laid upon them a heavier responsibility, a greater duty, than the so-called “first law of nature,” self-preservation. The primary objects of the organization are, in the broadest sense, to work toward and attain all things that will truly tend to the “advancement of Osteopathy,” and the rounding of it into its destined proportions as the eternal truth and vital principle of therapeutic science.”

—Daniel B. McAuley, DO First AAAO President, 1897 of holistic health care. The name was of well-reasoned letters to the editor changed to the American Osteopathic were sent to newspapers, that numbers Association (AOA) in 1901. of patients who had been restored to From the first, perhaps fearing a loss health (including some politicians) of income, most MDs disdained osteo- testified before legislators, it was the pathy. As its popularity grew, the AMA anti-osteopath vitriol that grabbed the at both national and state levels actively headlines. In 1914, The New York Times fought its spread, calling it a dangerous editorialized, “The bills which . . . the cult. Ignorance about the profession was osteopathists have urged through the endemic. “These osteopaths,” a New York Legislature are examples of the mischief senator said in 1902, “rub backs and de- which the leaders of half-baked cults sire to have their rubbing legalized.” In may do in exposing the health of the the same year, the Illinois Medical Jour- community to its worst dangers.” nal called osteopathic physicians “med- By 1900, licensure was necessary to ical malefactors,” pirates, and publicity practice medicine in every state. The pro- hounds, chasing after money and not pur- cess of licensure was structured to mea- suing genuine health care. sure minimal competency in order to pro- When members of the American tect patients from ignorance, ineptitude,

 and fraud. Licensure did not guarantee up of medical practitioners from the same good doctors, merely adequate ones. Once discipline (MDs, DOs, or homeopathic licensed, a medical practitioner could physicians); a composite of MDs, DOs, “diagnose, treat, operate, or prescribe for and homeopaths; a board consisting of any human disease, injury, deformity, or MDs only (usually state medical society physical condition,” but some states gave members); public health officials and only partial rights to osteopathic physi- department administrators; or any other combination with which state legislators could be persuaded to agree. Medical Nineteenth-Century society boards routinely failed DOs; many Ailments composite ones did as well, depending on the makeup of the board. The ideal situation would have DO candidates Ague apply for licensure from a board made Apoplexy Dengue up solely of osteopathic physicians, but Bad Blood Diphtheria this occurred in only a handful of states and required intensive lobbying. Blackwater Dropsy Fever Childbed Fever Scarlet Fever Organizational Cholera Typhoid Beginnings Consumption Yellow Fever

Three early ASO graduates cham- pioned that course and developed the cians, limiting their scope of treatment. standards for osteopathic licensure, In many states DOs couldn’t operate or independence, and integrity: Arthur G. prescribe medications. Full licensure was Hildreth, DO (1894), Charles Hazzard, often required for signing death certifi- DO (1898) and Asa Willard, DO (1900). cates, so a DO might have to call on an Each served as president of the AOA and MD to give a cause for the death of a pa- each had a deep loyalty to the profession. tient. Besides wanting equal rights, DOs They never flagged in their insistence on wanted the respect that would come with the need for self-regulation. being recognized as a competent medical A graduate of Northwestern Univer- professional. sity, Hildreth was in the first ASO class In the early years of the twentieth of students to receive the DO degree. He century, a licensing board could be made was a close associate of the Still family, on

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the faculty of ASO, and a founder of the Arthur G. Hildreth-Still Sanitarium in Macon, Mis- Hildreth, souri. In 1910, while president of the AOA, Hildreth sounded a call for self-monitor- DO ing at the AOA annual convention. “I have always claimed,” he said, “that the only just kind of safeguard to the public, or the practice of medicine, lies in each school of medicine having its own Board of Exam- iners who should pass upon all applicants to practice in their own particular schools; for who can there be so well qualified to know?” Or, he might have added, as de- sirous of keeping professional standards sectarians should be prohibited from see- high and practices free from arbitrary ing patients. Medical schools, societies, limitations. and boards accepted his philosophy and At that time, the AMA required phy- with the power of their numbers, creat- sicians to attend medical school in order ed a single method for health care in the to be licensed; apprenticeship was no United States. Not surprisingly, it was longer acceptable. In many states an MD “regular” or traditional medicine. diploma was all that was necessary to be Within ten years of the , licensed, no examination was required. most of the medical school diploma mills In response, “diploma mills”—medical had closed, but the report had alerted schools without requirements, testing public officials to the alleged dangers or occasionally, even faculty—appeared from fringe practitioners. Throughout throughout the nation. The AMA became the 1920s, the police in major cities were concerned about the number of bogus busy with raids on suspected political doctors and asked , an radicals, raids on speakeasies, and raids educator, to evaluate these schools and on unlicensed physicians. It’s a “War on the overall state of American medicine. Quacks” declared The New York Times. The Flexner Report, issued in 1910, Some osteopathic physicians were caught had far-reaching consequences. Flexner in the net, along with hypnotists, homeo- felt that only scientific medicine should paths, “Eddyists” (Christian Science prac- be allowed in the United States, no mat- titioners), and chiropractors. ter what patients wanted. He labeled In 1920, the year of the Red Scare, a everyone who wasn’t AMA-approved a furor over suspected Bolsheviks, a Wis- “medical sectarian” and insisted that these consin MD came up with another way to

 Asa keep DOs away from patients. He pushed Willard, DO the state legislature to enact a new crite- rion for medical licensure. His plan was 1876-1959 the “Basic Science Law” and required all would-be practitioners of the healing art Willard was to pass an examination covering , born in Frederick physiology, chemistry, bacteriology, and County, hygiene before they were allowed to take Maryland. a licensing exam. Questions were not to include medicine or healing techniques, After attend- but were strictly about “basic science.” ing Missouri State Normal School Furthermore, no one could take the test (now Truman State University) in until reaching the age of twenty-one. In Kirksville, he entered the American effect, this mandated a pre-med educa- School of Osteopathy, where he was tion. Schools of osteopathy at that time taught directly by Dr. Still. He did not require or desire students to have graduated in 1900 and moved to a pre-med education. The California Missoula, Montana, to open a prac- Medical Association editorialized in its journal that basic science legislation prob- tice. His chief role was that of gadfly ably wouldn’t stop the spread of cultish and tireless promoter of full rights medicine but might at least make the cults for osteopathic physicians. He served raise their educational standards. as president of the AOA in 1925 and Basic Science legislation moved legislative chairman thereafter. His through the states between 1925 and columns in the JAOA were written 1935. In seventeen states and the District in a folksy style with an incisive in- of Columbia, DOs were required to pass tellect that feasted on statistics and basic science examinations before taking a licensure exam. AOA activists were able political machinations. He didn’t to hold the line there. (Ironically, they know how to be dull. A founder of later incorporated “basic science” into the National Board of Examiners their own exams and the Medical College for Osteopathic Physicians and Admission Test, MCAT, is now required Surgeons, he was its first secre- by all osteopathic school applicants.) tary-treasurer. In his spare time, Feisty Dr. Williard, from his home in he was an elder in his Presbyterian Missoula, Montana, did everything he church, a Mason, and a Rotarian. could to fight basic science laws and “B.S. boards,” as he called them. In all-caps

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he announced to the Philadelphia AOA Charles convention in 1930, “IT IS THOSE FACTS Hazzard, THAT ARE MOST USABLE TO US IN OUR WORK THAT WE NEED TO HAVE TAUGHT.” DO Not, presumably, the periodic table and 1871-1938 the scientific name for table salt. More than anything else, basic sci- A native ence legislation galvanized the cause of of Peoria, DOs and became the impetus to create a national board of osteopathic exam- Illinois, Hazzard graduated from iners. Dr. Willard supplied the passion Northwestern University and en- and Dr. Hazzard the logic for establish- rolled in the first class at American ing examinations not dependent on AMA School of Osteopathy in Kirksville in graders. In a 1932 Journal of the American 1892. After a short stint in a Chicago Osteopathic Association (JAOA) article titled office, Dr. Hazzard was hired by “Professional Independence is Vital,” Dr. the “old doctor” to teach histol- Willard wrote, “. . . just in so far as so- ogy at ASO. Eventually he became called ‘regular’ medicine is allowed to dominate the regulation of osteopathic a professor of histology and pathol- practice is that practice held back.” And fur- ogy, taught the principles and prac- ther, “Independence in regulation is the tice of osteopathy, and served as the vital factor essential to the maintenance chief of clinics. He was the author of of our professional integrity and our nu- the widely used The Principles of merical expansion.” Osteopathy and The Practice of What Dr. Willard didn’t want, as he Osteopathy. Hazzard was elected explained in 1930, were “tests applied by AOA president in 1903, the same men who have an entirely different view- point of the healing art and who regard an year he moved to New York to be- entirely different set of facts as the most gin a private practice. For many usable for its practice.” He was afraid that years he was treasurer of the A. T. “the prejudice of allopaths doing the mea- Still Research Institute. Beginning suring will result in actual discrimination in 1923, he became a member of the against these new osteopath graduates. New York State Board of Medical That has occurred, and not infrequently.” Examiners. In 1934 he was named Looking to his own profession, he added, the first president of the NBEOPS. “If we were dominant on medical boards perhaps we would average no better in

 John E. our treatment of our competitors – unless Rogers, DO possibly our experiences in being discrim- inated against and unjustly deprived of 1884-1950 rights might serve to increase our average charity and determination to be just.” Born in Scales Dr. Willard insisted to the 1932 AOA Mound, convention, “With independent regula- Illinois, John tion and the natural numerical expansion it allows, we will ultimately get every Rogers took right for ourselves and those to come. If a BA from we lose the vision we have shown in the Lenox College and an MA from past, yield to expediency, and accept un- Northwestern University. Before limited privileges at the expense of inde- becoming a DO, he worked as an pendence, we will take care of the present, athletic director and loved sports but there will be no future.” He pointed out that the basic science all his life. After he graduated requirement had seriously curtailed the from Des Moines-Still College of expansion of osteopathic medicine. “For Osteopathy, he practiced primarily instance, in the two years the District of in Oshkosh, Wisconsin. An early Columbia has had its Basic Science Board, president of the AOA, he later be- no DO has hurdled [it] to get the unlim- came president of the A. T. Still ited privileges offered.” The most telling argument for independent examiners was Research Institute. He served on that more than fifty percent of osteopathic the NBEOPS board from its in- graduates appearing before mixed boards ception to his death. Deeply com- failed the examination. The osteopathic mitted to higher standards for os- boards failed six percent of their own ap- teopathic education, he was chair plicants, exactly the same percent that MD of the Bureau of Professional boards failed their own applicants. He Education and Colleges. Dr. summed it up: “Our graduates cannot get licenses to practice.” Rogers raised pedigreed Scots ter- The AOA membership was convinced. riers and had his own radio pro- In 1934, the organization agreed to form gram called “The Kennel Hour.” a National Board of Examiners for His son, Richard C. Rogers, was Osteopathic Physicians and Surgeons also an osteopathic physician. (NBEOPS). The board was made up of fifteen members who would serve for

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three-year terms. Charles Hazzard, DO, W. Curtis author of the classic The Principles of Brigham, DO Osteopathy, and the seventh president of AOA, was chosen to lead it. W. Curtis 1881-1962 Brigham, DO, a well-known Los Angeles surgeon was vice-president; Asa Willard, A native of DO, was named secretary-treasurer; and Moscow, Idaho, John E. Rogers, DO, president of the A.T. Dr. Brigham Still Research Institute, became chairman was very of the committee on examination. He would take over the presidency of the much an or- AOA in 1937. Other board members were ganization man after he moved Samuel V. Robuck, DO, first president of to Los Angeles. A fellow and the American Osteopathic Foundation; founder of the American College Edward A. Ward, DO; and Chester D. of Osteopathic Surgeons and a Swope, DO, who was awarded an AOA founder of Monte Sano Hospital, Distinguished Service Certificate in 1934 he was also a founding member of for his work in public relations for the organization. the National Board of Osteopathic The NBEOPS board members, nomi- Examiners and a trustee of the nated by the AOA, were a mixture of out- AOA. Dr. Brigham served as chief standing professors, administrators, and of staff at Monte Sano for more prominent clinicians. The new organiza- than twenty years while writing tion had two major tasks—to prepare a extensively on surgical techniques. test for osteopathic graduates and to get the test results approved by state boards He also taught , both in Los for licensure. The latter was much more Angeles and Denver. He and his difficult than the former. wife, Eleanor G. Brigham, DO, of- Dr. Edward A. Ward reported to the ten made the society news of the AOA annual convention at the Cleveland Los Angeles Times for their ac- Hotel in 1935: “The possession of a license tivities and especially for their to practice one’s profession in a state, ter- ritory, or other division of the United work with Revolutionary War ge- States should be considered a property nealogy. Their two children were right, and the legal protection surround- both DOs, Dr. Fleda Brigham ing the instrument recording that right and Dr. Crichton Brigham. properly and justly rests upon the legis-

 lature.” Although an attorney general or limit, he should bring along work to busy a state health board might grant a license, himself during the rest of the period.” there was a constant shift in the personnel Parts I and II of the examination in- of both state examining boards and the cluded essay questions covering five ar- staffs of attorneys general. The recogni- eas: anatomy (histology, embryology); tion of a national osteopathic examina- physiology; physiological chemistry; gen- tion by state legislators would have more eral pathology; and bacteriology (para- substantial value and protect the holder sitology, immunology). The questions throughout his or her lifetime. were written to test knowledge only, not At that time, forty states and territories clinical skills. Part III, the clinical test, was recognized the MD’s National Board of scheduled to be given during the AOA Medical Examiners certificates. It seemed annual convention, when a panel of DOs logical that the same states would recog- would be coming together. nize certificates from the National Board Twenty-eight-year-old Margaret of Examiners for Osteopathic Physicians Barnes, a graduate of Wellesley College and Surgeons as well. But it was not easy and ASO, took the first test. Forty-year-old to convince legislatures, primarily be- George S. Rothmeyer from Philadelphia cause of the vociferous opposition from College of Osteopathy took the second. the lobbying arm of the AMA. He later became an examiner for NBE- OPS. Barnes was given the Distinguished Testing Begins Award in Pediatrics in 1951. On July 23

In announcing the time for the first test—February 3 and 4, 1936—Dr. Rogers added, “The certificates of this board at the present time are of an honorary nature only since there are no laws as yet to give them legal force.” Applications were available from Dr. Asa Willard for a $5 registration fee and an application fee of $15. Each of the five exams was to last two hours, during which time no one could leave. Dr. Rogers ended the announcement with a note of optimism: Margaret Barnes, DO, took the first “If one has reason to believe that he can NBEOPS examination in 1936. write the examination before the time

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1936, the results were authorized and both equivalent to a license. Board members passed. Those who passed the examina- had to familiarize themselves with the tion were awarded a DNB (Diplomat of exact requirements for licensure in each the National Board). It was more a mark state and learn the art of politics. of prestige and professional proficiency Vice-president W. Curtis Brigham, than a practical means of obtaining medi- DO, took over the board presidency cal licensure, and few applicants were when Dr. Hazzard died suddenly of a 1930s

Parked in front of a stucco bungalow ($3,800, half the annual salary of a DO) is a two-door Buick with a rumble seat ($825). The owners have eaten a healthy breakfast of eggs (18¢/doz,), bacon (38¢/lb.) and white toast (sliced, 8¢/loaf). From their Crosley radio comes news of the shooting of bank robbers Bonnie and Clyde in Louisiana, followed by “Mood Indigo” by Duke Ellington. willing to submit themselves to a grueling heart attack in 1938. Dr. Brigham’s atten- two-day test for a mark of prestige. tion was diverted from politics by World Dr. Hazzard explained the rationale War II. During the war years, 1941-1945, for NBEOPS to the Association of Colleges the AOA was absorbed not only in home of Osteopathy convention at the Waldorf- front activities, but also in the fight to get Astoria in July 1936. The “difficulties, in- DOs into the U. S. Army Medical Corps. conveniences, and expense” of having to Despite the passage of several Congres- take state board examinations with dif- sional acts which seemed to give officer ferent requirements could at last be over- status to DOs, they were given ratings as come by having one national examination technicians and assigned jobs as order- with the highest standards possible. He lies or pharmacists’ mates in the Medical concluded, “A certificate issued by such a Service Corps. DOs who applied for com- national board should be recognized and missions were turned down. As Georgia honored under the laws of all States, so Warner Walter writes in The First School that, once having established his stand- of Osteopathic Medicine, “The surgeon gen- ing, a physician could practice where he eral, bowing to his medical colleagues of would.” “Should be” did not equal “will the AMA, refused to recognize osteopaths be.” State osteopathic associations were as physicians or surgeons.” This was a called upon to try to convince their leg- blow to the AOA and a step backward in islators to accept a NBEOPS certificate as the licensing crusade. DOs would not be

11 recognized as medical officers until 1966, sion following the war changed the urban- when Secretary of Defense Robert McNa- rural dynamics of the nation. Now a new mara ordered it so. nirvana, suburbia, became the center of Another setback during the 1940s the American dream. Many MD physi- came when the Wassermann blood test cians moved into suburban offices where for syphilis became mandatory in most they found lucrative practices. Specialty states for those seeking a marriage license. clinics proliferated and the all-purpose DOs were prevented from administering family doctors became scarce. DOs for 1940s

In a brand-new suburb is a barely landscaped brick house ($6,200, financed with his VA loan and the money she saved working in the small arms plant during the war). In the garage sits a luxurious Hudson ($2,380); in the basement are a wringer washer and a mangle. The children reluctantly swallow a spoonful of cod liver oil with their orange juice before they run to school, bringing toothbrushes and bars of soap for the displaced children of Europe.

this simple test in states where they were the most part, chose small and mid-sized not fully licensed and had to appeal to the towns to set up practices as family doctors, courts to determine if they were indeed but many of them, too, began to specialize physicians who could draw blood, which and seek practices in or near large cities. was consider an “operation.” By the mid-1950s, many of the old threats Hostility from MDs toward DOs had to health—polio, diphtheria, whooping not abated by the mid-forties. An article cough, tuberculosis—had disappeared or appeared in Science in 1946 claiming that were greatly diminished. It seemed that osteopathic institutions are perpetuating modern medicine would someday cure “a fraud upon a gullible public.” Cyrus every disease. N. Ray, DO, a former member of the T. T. Spence, DO, served as president Texas State Board of Medical Examiners of NBEOPS from 1944 to 1948. During replied charitably, “We believe that the his tenure, in 1947, live patients in os- great majority of the allopathic profession teopathic hospitals were used for Part III are just as scientific, just as honest, and examinations. Osteopathic hospitals had just as faithful and hard working as the been built throughout the nation to keep practitioners of the osteopathic school of pace with the growing profession begin- medicine.” ning in the late nineteenth century. By The baby boom and economic expan- 1945, there were 260 such hospitals. The

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great majority of new DOs interned at Samuel V. osteopathic hospitals, primarily because Robuck, DO allopathic hospitals wouldn’t accept them. 1886-1976 In 1945, the American Osteopathic Hospi- tal Association began to review hospitals Born in Sterling, objectively in order to ensure that osteo- pathic students were receiving training Colorado, S. V. in facilities that provided a high quality Robuck stud- of patient care. ied finance and S. V. Robuck, DO, followed Spence. accounting at Walter E. Bailey, DO, of St. Louis served Denver University before begin- as vice-president, and Paul van Buren ning his medical career. He was Allen, DO, of Indianapolis, secretary-trea- the first president of the American surer. Robuck, on the faculty at Chicago Osteopathic Foundation when it was College of Osteopathy, had summed up his philosophy of competition between formed in 1929 and was a founding osteopathy and traditional medicine in an member of the NBEOPS, as well as article in the JAOA in 1923. “Let us not fall the American College of Osteopathic into the error that we may so easily,” he Internists. He served on the faculty wrote, “that of consoling ourselves that of Chicago College of Osteopathic on an average we are as good diagnosti- Medicine and on the staff of Chicago cians as are our medical brothers. That Osteopathic Hospital for more is not the yardstick by which to measure. than forty years and received a Our standard must be a new one—that of the needs of the hour and of humanity.” “Physician Emeritus” award from Eugene Oliveri, DO, stated in his 2009 Sigma Sigma Phi. He enjoyed fish- A. T. Still Memorial Lecture that Dr. Ro- ing and pheasant hunting. In 1946, buck “argued passionately before the AOA he and Dr. T.T. Spence, then presi- Board to continue giving the third part of dent of the National Board, appealed the exam sequence during the to the AOA Board to give NBEOPS year.” He felt this was a way of ensuring more control over its membership and protecting the public. He wanted DOs selection, allowing educators and to be fully evaluated during a period of monitored and unmonitored training be- members of DO licensing boards to cause it would offer “a true reassurance participate. Dr. Robuck served as to both the public and licensing boards president of the NBEOPS 1948-1963. that competencies during all phases

13 and periods of osteopathic education to give a perfect score because time and training in patient care were being constraints limited the depth of answers. assessed by a distinctively osteopathic Furthermore, essay questions could seem examination.” The AOA thought this re- ambiguous and, while facts might be striction would hurt those DOs who went correctly recited, the interpretation could into practice without internship, as many be off. In that case, should the applicant states did not then require internship for receive half credit, one-quarter credit, or licensure. no credit? Such decisions were almost entirely subjective. In 1953, the board began a study of Expansion how best to change the testing procedure. By 1958, they were convinced of the ad- vantages of an objective examination. At The boards of the 1950s made several that time, only sixteen states plus Wash- administrative changes. In 1951, the ington, D.C. and the territory of Hawaii organization was incorporated in the had accorded recognition to NBEOPS dip- state of Illinois as the National Board of lomats in lieu of a state examination. After Examiners for Osteopathic Physicians twenty years of offering the test, there and Surgeons (NBEOPS), confirming were only 263 National Board diplomats. itself as a legal entity. As the board Something was preventing the program expanded its efforts, its fifteen volunteer from going forward. members juggled practices, students, At their July 1958 board meeting, families, and a hundred other interests. NBEOPS members voted to go with Spencer Bradford, DO, later described multiple-choice exams. The decision that period as “a modest scale of initiated a staggering amount of work operations.” (A board member in 1973 from board members, consultants, and noted that each member wore six hats of educators. Multiple-choice examinations responsibility on the board in addition required a greater number of questions. to twelve they wore in other capacities.) The board also wanted an equitable As the number of applicants for representation of the various teaching NBEOPS examinations grew, it became approaches, with coverage of both obvious that grading essay questions academic and clinical material. Questions was too time-consuming and not really had to be succinct and clear, with no fair. Facile writers had an advantage over ambiguity. There was the danger of students who might know as much but reductionism: complicated processes who found expository writing difficult. might be made too simplified for the Graders found it virtually impossible sake of clarity. In addition to testing

14 IN THE PUBLIC TRUST

facts, the board wanted to ensure that istician, as well as a DO, laid the ground- the osteopathic principles of autonomy, work. Preliminary evaluations showed beneficence, non-malfeasance, fidelity, that the new format was successful and justice, and utility were implicit in the from that point on, numerical analysis questions. They debated whether there became a major focus of NBEOPS. should be separate questions on osteo- A shortage of U.S. doctors in the late

1950s A new Ford Fairlane ($2,013) sits in the driveway of a suburban ranch house ($14,300, with slab patio). Tonight the family will laugh their way through Milton Berle’s Texaco Hour on their Philco television set after having a TV dinner. The baby’s last-week earache was treated with a shot of penicillin and baby aspirin, and he is sleeping soundly now. In the morning the family will take the Eisenhower Interstate system as far west as it goes (gasoline is 21¢/gal.) and stay at a fancy Howard Johnsons Motel. pathy or if osteopathic principles and 1950s opened the doors to practitioners— practices could be woven into such short MDs, not DOs—trained overseas. Eventu- questions. ally the Educational Council of Foreign Board members were assigned spe- Medical Graduates (ECFMG) would be cific subjects in a discipline. They then formed to test their competence. A 1957 contacted clinicians and academics for editorial in JAOA warned of “A Clear suggestions and found consultants to and Present Danger, the Disappearing review, criticize, and revise questions DO.” More DOs were graduating than for clarity and significance. Thousands ever before, but the proportion of DOs of questions were gathered, along with to the general public was diminishing. In four or five possible answers for each. 1955, there was one DO for every 13,500 Hundreds were thrown out immediately. Americans and as the population grew, Then began the long process of culling, DOs would be even more in the minor- editing, and deciding. The final result was ity. An obvious solution was to build and a product of the entire board, almost of staff more colleges of osteopathy, but the entire profession. this raised questions about the nature of The next step was to use a statistical osteopathy vs. “the medical monopoly.” evaluation of the testing procedure. Dr. Is the insistence on separateness simply Price Thomas, a mathematician and stat- feeding a feud between medical factions,

15 Price a “continuing cultist deviation”or, is os- Thomas, DO teopathy a genuine contribution to the healing arts that should refuse to merge 1920-1972 with the majority? Certainly osteopathy was becoming more medical and more Price Thomas scientific. was born in “Science” was a magic word after the Oklahoma City USSR launched its Sputnik satellite in and attended 1957. The U.S. space program gathered William Jewell College in Liberty, the best engineering brains in the nation Mo. He graduated from Kirksville to compete with the Russians. Medicine, College of Osteopathic Medicine too, became more scientific, less intui- tive, and more evidence-based. Biologists with a DO in 1943 and received a called the “an engineering BS from Northwest Missouri State marvel.” Over the decade of the 1960s, College shortly thereafter. He prac- organ management took precedence over ticed family medicine in Weoka, a holistic view of health care. A dialysis Okla. for a year before entering the machine could replace failing kidneys Navy where he served as a clini- and an artificial heart held out hope for cian because DOs were not con- heart patients. Within a few more years, sidered physicians. In 1946, he transplanted live organs offered a better practiced in Ashland Ore., while quality of life than artificial ones. he took training in the new sci- Pharmaceuticals became synonymous ence of electronics. He joined the with quality of life during the sixties, and it quickly became evident that DOs would faculty of KCOM in 1949 as an in- have to be able to distinguish between structor in physiology and served diazepam, chlordiazepoxide and dozens as chair of the department from more new wonder drugs. Pharmacology 1960 until his death in 1972. became an increasingly important part of His many scientific publications the National Board examinations, replac- earned him honors. He is cred- ing “therapeutics.” New DOs had to know ited with bringing the National the side effects of corticosteroids and the Board into the electronic age with benefits and drawbacks of L-Dopa, broad the use of computerized testing spectrum antibiotics, birth control pills, procedures. He was also a private and silicon implants. pilot and a ham radio operator. Americans hoped that one’s life could be managed completely with chemicals.

16 IN THE PUBLIC TRUST

But at the same time, pesticides, herbi- Beginning in 1961, it began a campaign cides, chemical fertilizers, and industrial that culminated in a state referendum that pollutants were pouring into the nation’s was intended to make DOs disappear by waterways and asbestos fibers and ciga- offering them MD status. Eighty-six per- rette smoke were damaging lungs. Exam- cent of the two thousand DOs in the state iners had to be aware of environmental paid $65 to take on the new initials and issues that affected health. the College of Osteopathic Physicians and In 1961, the NBEOPS incorporated in Surgeons became the California College Indiana, the home of the Indianapolis office of Medicine, awarding the MD degree of Paul van B. Allen, DO, then secretary- only. The AOA refused to recognize the treasurer. It voted in constitutional unearned degrees and a strong remnant 1960s In a split-level house, the sound of the Beatles comes from a large rec room, somewhat muffled by the shag carpeting. The family has been thrilled by the space program, shocked by assassinations, outraged by a lack of civil rights for citizens, and confused by an endless war and a “drug culture.” The son dreams of owning a Pontiac Firebird Transam ($4,366) while flipping burgers at McDonald’s; the daughter wants to join the Peace Corps and eventually become a physician, working to eradicate small pox world-wide. amendments which altered the structure of determined DOs fought the legislation of the board and allowed for full-time, until 1974, when the California Supreme paid personnel. There were adjustments, Court ruled that the licensing of DOs as too, in composing and administering the DOs must be resumed. examinations. The NBEOPS widened its focus from California was one of the first states to state licensing boards to looking at os- welcome DOs, with full licensure granted teopathic educational institutions. A new in 1901 via an osteopathic licensing board. need within the profession was emerging, The state and county osteopathic orga- “for an evaluating agency that would offer nizations grew as the state’s population the various osteopathic colleges the op- burgeoned during the 1920s and 1930s, portunity to compare their programs to but AMA organizations were never happy a nationwide standard,” as Dr. Spencer coexisting with a “cult.” Rather than fight Bradford wrote. Using an outside exami- this popular profession, the California nation agency to test college programs Medical Association decided to absorb it. was considered and rejected because the

17 Spencer G. colleges. Board members visited colleges Bradford, and formed ties with educators. The DO College of Osteopathic Medicine and Surgery in Des Moines and Chicago College of Osteopathy requested that NBEOPS provide examinations for all their students. Osteopathic educators were Dr. Bradford involved in the process of generating received his questions. DO from NBEOPS President Spencer G. Brad- Philadelphia College of Osteopathy ford, DO, oversaw the new structure. The in 1942 and joined the Department board hired Carl W. Cohoon, an Illinois of Physiology as an instructor educator, as executive director in 1964. The board moved its headquarters to in 1943 while maintaining a pri- Kirksville for a time, but that proved in- vate practice. His love was re- efficient and they returned to the Chicago search and he used the facilities area, first in Park Ridge and then in Des at nearby Temple University. In Plaines. 1963, he was named chairman of A 1969 report by Dr. Bradford de- Physiology and Pharmacology at scribed the testing procedure at that time: two sets of examinations were given to PCOM and received a major grant pre-doctoral students: Part I tested know- from NIH. He served as president ledge of the basic and was given of NBEOPS from 1963 to 1976. at the end of the student’s second year; Part II covered clinical subjects and was board felt that the unique qualities of given at the end of the fourth year. osteopathic required Candidates failing one or more sub- special examinations. Only someone jects in any examination were permitted thoroughly versed in osteopathic prin- re-examination in those subjects. Subse- ciples could test how well they were be- quent failures required that the candidate ing taught. take additional work in the subject before In 1963, the AOA adopted a statement taking it again. No more than two re-ex- of educational standards for osteopathic aminations were allowed. For Part III, the colleges with its first goal “to develop oral and practical exam, “the respective the distinctive osteopathic contribution directors of medical education are chief to medicine.” This initiated a closer examiners, and the candidate is tested relationship between NBEOPS and the by a series of associate examiners, using

18 IN THE PUBLIC TRUST

actual teaching cases in the hospitals.” be kept in the offices of all physicians. Professional statistical evaluators Whenever a quick answer to a medical from the University of Iowa were hired problem was needed, a physician could to analyze the questions used and all simply consult a data base. By 1979, an possible answers to each question. They osteopathic physician urged JAOA read- judged the tests accurate and fair. ers to invest in a 16K microcomputer for As the quality of National Board ex- less than $1,000. Software was then being aminations improved, state recognition developed for assessing the growth of expanded. By 1969, thirty-five states the skeletal system and there were other accepted the NBEOPS test as a basis for possibilities as well. licensure. More than twenty states had Computer technology would change been added since multiple-choice test- almost every aspect of health care over ing began. In 1966, the state of Florida the next thirty years; the Internet would asked the NBEOPS to develop a licensing transform it even more. Complex infor- examination for its own use. mation could be collected and analyzed In the early 1970s, the board began to in minutes. Other technology, such as investigate the emerging computer tech- electron microscopy and digital imag- nology. Computerized scoring of NBEOPS ing used in conjunction with computers, tests through the University of Iowa had opened up research into genetics, viruses, begun in 1971. In 1973, the cost of rent- and cells. To critics, medicine seemed to ing a computer was described in a board be becoming subatomic and the whole meeting as “outlandish,” especially since person was being overlooked in the haste it would be needed only for storing ex- to find the smallest element of life. amination questions. Office management quickly became Instead of renting space, the board dependent on computers for billing and asked Cohoon to look into the purchase inventory. Medical personnel had to be of a PDP-8 computer. The PDP-8, the best certain accurate medical records were selling computer in the world in 1973, was kept, as medical malpractice suits in- described as the model-T of the computer creased geometrically in the seventies. industry because it was the first computer Medical jurisprudence and medical ethics to be mass produced at a relatively low became increasingly important in practice, cost. Could it be used enough to justify its as well as in theory, and were addressed cost? Board members were doubtful. in NBEOPS exams. Computers were not just for engineers, The year 1974 was the centennial of visionaries argued. They could be useful the founding of osteopathic medicine in every line of work. Experts predicted and time for stock-taking. Much of the that by 1980, computer terminals would first hundred years had been taken up

19 with politics and the fight for the right to well. Many doctors gave up their private practice medicine without restriction. In practices and joined corporate medicine, the annual A. T. Still Memorial Lecture such as Kaiser Permanente, to avoid them. that year, Edward P. Crowell , DO, spoke Misdiagnosis was the greatest cause of of his hopes for the next hundred years. lawsuits, ironically in part because doc- Traditional medicine, he said, focuses on tors were so successful they didn’t have disease and dysfunction after they oc- time to do a full “H and P” (history and

1970s Protest is out and hospitality is in. Suburban cul de sacs (average house price, $21,000) host block parties, where residents debate buying a waterbed or a microwave oven while listening to Pink Floyd or Barbra Streisand on an 8-track stereo. The Vietnam War is over, ex-president Richard Nixon has left D.C., “Gunsmoke” is on television and Ford Motor Co. has come out with a sharp-looking Pinto for less than $2,000. Scientists are experimenting with in vitro fertilization; organ transplants are routine. Alarmists, concerned about the connection between toxic chemicals and cancer, find that few are listening. Science has taken us to the moon. It can do anything. cur. Osteopathic medicine should speak physical examination), leaving the ba- out loudly for preventive medicine. “The sics to assistants. To protect themselves, public is entitled to reap the benefits of doctors ordered an increasing number of 100 years of osteopathic experience and objective tests, not trusting intuitive or biomedical research. They are entitled to “hands-on” medicine. Hospitals required more than just the palliation of disease. doctors and other medical personnel to They are entitled to more than episodic define their scope of practice in detail be- care. They are entitled to health mainte- fore receiving privileges, and they were nance by the application of all preventive not allowed to exceed their scope of prac- measures now available.” tice on threat of censure or expulsion. Few patients wanted to listen to lec- In 1976, Marion E. Coy, DO, past presi- tures on prevention; they wanted a quick dent of the AOA, took over the presidency fix. Increasingly, medicine was focusing of NBEOPS from Spencer Bradford, DO. not only on curing and managing disease, Dr. Coy believed in the positive values of but also on defense against attack. As the change and hoped “to establish policies number of malpractice suits soared, liabil- and programs [that] will anticipate even ity insurance premiums skyrocketed as further change.” He issued a report in

20 IN THE PUBLIC TRUST

1976 reaffirming the organization’s goals Marion E. of licensure. At that time, the NBEOPS Coy, DO certificate was accepted by professional licensing boards in forty-three states plus 1910-2001 the District of Columbia in lieu of their own examinations. Acceptance was not total or unrestricted in all those states, but Born in it was getting closer. Reciprocity of licen- Mattoon, sure among states was common. During those years, the National Ill., Dr. Coy Board entered into agreements with the earned a BS American Osteopathic Board of General from Eureka College in 1932 and Practitioners (the current AOBFP) for the a DO from Kirksville College of preparation and administration of their Osteopathic Medicine in 1938, in- certification examinations and with vari- terning at the Laughlin Hospital ous osteopathic state licensure boards for there. He practiced family medicine assistance with their examinations. With the first goal almost achieved, and anesthesiology for 34 years be- the organization turned to its second fore moving to Fort Worth, Texas, purpose: “To provide recognized colleges where he joined the faculty of Texas of osteopathy, through its examinations, College of Osteopathic Medicine with the means for impartial, extramural as administrative dean and its first evaluation of the effectiveness of their president, when the school changed educational programs.” As educational programs became more sophisticated, from private to state-supported. He methods of testing for evaluation had to was also professor of osteopathic keep pace. philosophy, principles and prac- Early in the 1970s, U.S. Surgeon Gen- tice. He served on the NBEOPS for eral, Jesse L. Steinfeld, MD, claimed that twenty years and was president education in the health sciences was in 1976-1980. He held many posi- ferment. “It is undergoing its most far- reaching changes since publication of the tions in the AOA as well, includ- Flexner Report in 1910,” he said. He was ing the presidency, 1970-1971. not referring to affirmative action and equality of access, which were frequently in the news, but to methods of teaching. Students were encouraged to use

21 audiovisual and computerized aids to nation with both a college of allopathic control the pace of their education. It was medicine and a college of osteopathic thought that professors would become medicine. less important as each student became The Comprehensive Health Man- “a class of one,” using films, slides, tapes, power Act of 1971 appropriated millions and programmed instruction. of dollars for construction and capitation NBEOPS President Spencer Bradford grants for osteopathic colleges, as well as DO, was an enthusiastic proponent of this for all other health care training facilities. approach to education at PCOM until he While the growth was enthusiastically concluded that videos were no substitute welcomed, provision had to be made for for a hands-on laboratory experience. ensuring that it was quality growth. The Courses in all medical schools came NBEOPS continually evaluated its test- under close scrutiny for relevance. Top- ing procedure for students, depending ics were melded and compressed. Some heavily on its advisory panel of expert medical schools experimented with three- consultants. year curricula, and others accepted provi- While osteopathic education was bur- sional students after high school without geoning in the 1970s and 1980s, osteopathic pre-med courses. hospitals were shrinking. Most osteopath- Internship training was changing, too, ic hospitals were small, with less than as the American Board of Family Practice 150 beds, and many of them found the merged the traditional internship into a high cost of new equipment staggering. new three-year training pro- When insurance companies and Medicare gram. Two-thirds of new DOs chose family reduced the number of days they would medicine and interned in osteopathic hos- cover for illness or surgery, hospital in- pitals, but most new MDs sought out spe- come dropped precipitously. Patients cialties and subspecialties that required were lured away from small facilities long periods of residency training. to large regional medical centers by the promise of state-of-the-art technology and well-known specialists. Competing with GROWTH hospitals, free-standing clinics offered out-patient surgery and emergency care. Between 1968 and 1980, the number It seemed wise for small hospitals to con- of osteopathic schools rose from five solidate resources, and many osteopathic to fifteen and the number of students and allopathic hospitals merged. enrolling jumped 84 percent. In 1969, Insurance coverage for health care be- Michigan State University became the came ever more complex, with stacks of first state-supported university in the paperwork required for each procedure.

22 IN THE PUBLIC TRUST

What were the differences in the types of a major concern of osteopathic medicine managed care—HMOs, PPOs, Medicare and consequently appeared on examina- and Medicaid? This was information that tions, with “overnutrition,” poor nutri- DOs needed to understand, and conse- tion, cigarette smoking, alcoholism, and quently it was incorporated into their ex- drug abuse receiving special attention. aminations, along with other non-medi- HIV�/��������AIDS overshadowed all other public cal information new doctors needed to health issues in the 1980s. The disease survive. was defined and named in 1982, but for Osteopathic physicians had always years afterward the public was unsure practiced holistic medicine without calling about how easily it might spread. The it such. They believed that mind, body, great number of symptoms and unusual spirit, and social milieu were wrapped up course of the disease made it difficult together in the whole person. In the late to treat. U.S. Surgeon General C. Ever- seventies and early eighties, as a reaction ett Koop, MD, predicted in 1986 that by to atomistic medicine, “holistic” became 2000, AIDS would be the number one killer a buzz word. Often it meant “alternative” in the U.S. In fact, it didn’t even make and included crystal diagnosis, Rolfing, the top fifteen because of powerful drug Native American practices, acupuncture, cocktails, meticulous health care, and the and a host of other therapies. Bookstores increased use of condoms during sexual and health food stores were flooded with intercourse. do-it-yourself manuals which implied As the population aged and deadly that the people were better off taking infectious diseases waned, learning how care of themselves than going to qualified to manage the complex issues of late physicians. This was not what Dr. Still life became important to family doctors. had had in mind when he advocated for Diabetes, Parkinsons, heart disease and a new kind of health care, one that looked stroke, COPD, dementia, loss and grief at the unity of the body. were the plagues of old age, just as diph- Part of osteopathy’s holistic approach theria, whooping cough, “summer com- was to consider the entire environment. A plaint” (diarrhea), mumps and measles 1980 editorial in the JAOA declared, “The had once been the plagues of youth. impact of our environment and some of Four presidents served the National its toxic elements cry out for further in- Board during the 1980s: Lester Eisenberg, vestigation. The relationship of vitamins DO (1980-85); Thomas F. Santucci, Jr., DO and hormones to our well-being and to (1985-87); Robert E. Mancini, DO,����� PhD the treatment of disease also should be (1987-89); and Eugene Mochan, DO,���� PhD thoroughly investigated.” (1989-91). In 1986, the organization re- The broad subject of public health was incorporated in Indiana as the National

23 Board of Osteopathic Medical Examiners, time when . . . great leaders, thinkers, and Inc. (NBOME). doers all got together to propel the Na- Two years earlier, the U.S. Department tional Board into a future of monumental of Health and Human Services awarded changes and technological advances. . . It the National Board a grant to develop was a time of reorganization and a new a competency-based standard for their sense of urgency.” It was also a time when exams. The board hired Joseph F. Smoley, achievement followed achievement al- PhD, as its executive director. He had ex- most faster than they could be absorbed. perience in evaluating tests that measured knowledge and ability. His two major research tasks were: first, to construct test New Directions development procedures for measure- ment and second, to develop and refine Dr. Santucci brought to the board theoretical approaches to measurement. of the mid-�������������������������1980s�������������������� a new vision of the Analysis of the effectiveness of any examinations. At that time, tests were educational process is time-consuming used to measure knowledge of the and expensive, but it was absolutely basic sciences, the very philosophy necessary if the NBOME was to convince that Dr. Asa Willard had fought anyone of the efficacy of its examinations. against. Dr. Santucci pushed for clinical Sohrob Shahabi, PhD, was hired as di- applicability. He stressed correct test rector of testing and Linjun Shen, PhD, item writing formats, encouraged clarity as psychometrician. They proved to be of language and the accuracy of graphic both brilliant and willing to work long images. He also aggressively recruited hours. Eventually, additional technical panels of experts to oversee the writing staff joined them, employees who were of test questions and promoted the not merely computer literate but com- careful analysis of psychometric data, puter intimate, ensuring that test results constantly reminding board members of would be charted and graphed scientifi- the need for efficiency and quality in the cally. Some were specialists in security, examinations and their grading. and the NBOME adopted tight security By �������������������������������1991���������������������������, diplomat status was being measures to ensure that examination ma- awarded to approximately 1,300 osteo- terials were handled appropriately prior pathic physicians each year. Some 20,000 to and during the administration of the diplomat certificates had been awarded examination. by then and forty-eight states accepted The board of the late 1980s and through those who completed the NBOME exams the 1990s was extraordinarily involved in successfully, without further testing. its work. As Dr. Oliveri wrote, “It was a Dr. Mochan explained in a 1991 arti-

24 IN THE PUBLIC TRUST

cle in The DO that preparing each part of Lester the examination took about one year. All Eisenberg, together, 600 osteopathic physicians and DO PhD scientists participated in the process. About ninety-five percent of theNBOME consultants were experts in their field and affiliated with an osteopathic medical A graduate of school or . The majority the Philadelphia of test reviewers were board certified and College of considered content experts in their field. Osteopathic All questions were evaluated by the Medicine, Dr. Eisenberg chose ob- Test Construction Committees (TCCs) and stetrics and gynecology for his spe- experts from specific disciplines. A draft of the examination was then submitted cialty. In 1970, President Richard to the Test Review Committee (TRC) for Nixon invited him to participate further scrutiny. The questions had to be in the White House Conference challenging, but not esoteric. They also on Children and Youth. Associate had to be free from ambiguity and con- editor of Maternal and Child cisely written. After passing this hurdle, Health, he was also medical di- the questions went back to the chairs of the individual TCCs, who were respon- rector and director of medical sible for producing the final version of education at Lancaster (Penn.) the examination. Osteopathic Hospital, and chair- It was important for DOs to under- man of the OB-Gyn Department stand the process of preparing exami- of PCOM. He served as president nations because, beginning in 1989, MD of the National Board from 1980 to credentialing groups began promoting 1985 and was largely responsible “a single pathway to licensure.” In 1992, the Federation of State Medical Boards for securing a major grant from the (FSMB) was made up of sixteen states with Department of Health and Human separate boards for DOs and MDs, twenty- Services to develop competency- eight states with composite boards (MDs based standards in examinations. predominating), and six states plus the District of Columbia with MD boards only. The FSMB and the National Board of Medical Examiners (NBME) partnered to produce the U.S. Medical Licensing

25 Thomas F. Far from convinced, the AOA reiter- Santucci, ated the reasons for keeping MD and D��O Jr., DO examinations separate. No examination prepared by MDs could include osteo- pathic principles and practices because they weren’t taught to them. For the pro- The Santuccis, fession to maintain its identity and to father and test the candidates’ full scope of practice, son, both re- it needed its own examination. Robert ceived the Mancini, DO, PhD, then president of the NBOME, attended FSMB–NBME merger Distinguished Service Award meetings as an invited observer. from the American College of In July 1991, outgoing NBOME Presi- Osteopathic Pediatricians, both dent Eugene Mochan, DO, PhD, speaking practiced in New Jersey, and both for new President John Fernandes, DO, served on the National Board. Dr. addressed the Trustees of the AOA to Santucci, Jr., received the DO from discuss four areas of concern impinging on the threatened “single pathway” and PCOM and became nationally rec- indicated that some friction was building ognized as an outstanding pediatric up between the FSMB and the NBOME. Dr. pulmonologist. He was president Mochan made the following points: of the National Board from 1985 “First of all, a number of questions, to 1987 and is credited with bring- over the past years, had been raised con- ing new energy to the board, mod- cerning the quality of the National Board ernizing its structure and attitude, examinations. Comments were made re- garding the psychometric validity, secu- and changing the discipline-based rity, the uniqueness of our examinations, test to a more clinically based test. et cetera, and I am very proud to report to you that the NBOME has approached these criticisms in a very constructive and Examination (USMLE), eliminating the enthusiastic way. I also know our exam- FLEX examinatio��������������������������������n��������������������� formerly produced by inations can favorably compare to any the FSMB in 1986.� The USMLE was touted other examining group in the country.” as the definitive medical licensure exami- The second area that he addressed nation, and it was suggested that it was was related to not having global input the only test for medical licensure that from the medical community in general. states needed. “In response to this,” he said, “we have

26 IN THE PUBLIC TRUST

now introduced our plan to expand our in an AOA-approved hospital. Board of Directors to include members The fourth area of concern Dr. Mo- of the osteopathic community—includ- chan described was much more difficult ing osteopathic state board examiners, to address. Throughout the late eighties, AACOM representatives, and represen- a need for independence had been grow- tatives from the AOA. ing among board members. The NBOME “The third issue raised is that the had been criticized by various legislative NBOME has been criticized in many re- examining groups for having a conflict spects related to the restrictions of our of interest in that it was not autonomous, Part III examination . . . in that not all and did not function independently of

1980s House prices rise above $50,000, but so do salaries (about $25,000/year is average). A Pontiac Grand AM can be bought for less than $10,000. Rust Belt residents watch manufacturing go south, and the Sun Belt welcomes snowbirds. President Ronald Reagan brings deregulation to government. The “me generation” invests in money markets, self- actualization, marriage enrichment, and divorce recovery. With so many women working, fast food threatens to end home cooking. Families rent video tapes of popular movies for a dollar or tape episodes of “Dallas” or “The Cosby Show” on their VCRs. Europeans and Americans rejoice as the Berlin Wall comes down—the Cold War is finally over.

DOs were eligible to take this examination the AOA. While the AOA was the politi- if they had not completed an AOA-ap- cal arm of the osteopathic profession, the proved internship.“ NBOME was the assessment arm with the The NBOME cooperated with the AOA goal of protecting the public from physi- to pass a resolution permitting DOs who cians unqualified to practice. Objectivity completed AOA�-approved or American was paramount in achieving this goal. Council on Graduate Medical Education The NBOME could not allow itself to be (ACGME)-approved internship to take Part influenced by political pressure of any III of the NBOME examination. This step kind, no matter how benign. The public opened the field to DOs who wanted to needed assurances that the development, intern in a specific geographic area where administration, and scoring of examina- there was no AOA-approved facility or to tions had both integrity and security. obtain training in a specialty not offered Board members had also been long

27 Robert E. Bradford, then President of the NBEOPS, Mancini, and Dr. Robuck both argued before the AOA the NBEOPS should have more con- DO, PhD trol over the election of its members in order to assure the best quality in testing. In 1947, Dr. Robuck, assuming the presi- dency after Dr. Bradford, insisted that Dr. Mancini, Part III, a live-patient assessment, should a noted sci- be conducted during the internship at the hospital where the candidate was training. entist in By 1951, the AOA agreed that the Part III and pharmacol- examination should be conducted during ogy, received the Distinguished the internship, but insisted that the AOA Andrology Award in 1977. Over continue to approve members appointed his scholarly life, he authored or to the Board of the NBEOPS. The concept co-authored more than 180 scien- of clinical skills assessment would subse- tific articles. He served as presi- quently arise as the COMLEX-USA Level 2 PE some forty years later. dent of the NBOME 1987-1989 Ultimately, a task force made up of the executive committees of the AOA and chafing under the conditions that the the NBOME was scheduled to meet to re- AOA had set in 1934, that new members solve this issue, but the issue could not be of the National Board must be approved brought to resolution. Instead, the NBOME (if not appointed, as in the early days) by amended several of its by-laws, allow- the AOA before they could serve and that ing decisions to be made, especially on amendments to its charter had to be ap- board members, without approval of the proved by the AOA as well. The AOA’s ra- AOA. On October 1, 1991, the AOA sent tionale was that it was the representative the by-laws back to NBOME with the nota- association of the profession as a whole tion “proposed amendment denied” on and had to serve the educational needs page after page. Some of the less sensitive of the profession in all other areas, such amendments were adopted. as accreditation of colleges and hospitals, The NBOME board members wanted approval of educational programs, and to reach out beyond the confines of the specialty certification. NBOME was but profession, and to bring in state officials one of its non-practice affiliates. who were not members of the AOA when A similar circumstance arose in 1946 appropriate. Although the AOA had nev- and was resolved in 1951. In this case, Dr. er rejected a proposed candidate for the

28 IN THE PUBLIC TRUST

National Board, getting their approval Eugene seemed to be a formality that was no long- Mochan, er necessary. The NBOME board members, after years of experience, knew the kind DO, PhD of board members they wanted. In October 1991, without conferring Dr. Mochan with the AOA, the NBOME decided on is an academ- a course of action, understanding that it ic physician might have serious repercussions. Under with dozens President John Fernandes, DO, the board of outstand- merged the NBOME, an Illinois corpora- ing scholarly tion, and NBEOPS, an Indiana corporation, then inactive. The articles of incorporation publications to his credit. He re- for the new entity terminated the rights ceived a PhD in biochemistry from accorded to the AOA when the National the State University of New York Board was originally formed in 1934. at Buffalo and served as an NIH- AOA leadership reacted immediately, funded postdoctoral research fellow believing that the merger was a means at the University of Pennsylvania. of unilaterally severing the NBOME’s ties He earned his medical degree at with the AOA. Those ties, in the eyes of PCOM and completed his clinical AOA trustees, were essential to the unity of the profession. The NBOME must be training at UMDNJ-SOM. He was accountable to the profession, not merely president of the NBOME 1989- to itself. 1991 and presented the AOA trust- After fruitless attempts at dialogue, ees with the reasons for NBOME’s and upon the advice of counsel, the AOA dissatisfaction with AOA limita- filed suit against the NBOME, asserting tions. He currently serves as the that the purported merger was invalid. They insisted the issue was a matter associate dean for primary care and of governance and nothing more. The continuing education at PCOM, NBOME resisted this suit and a court hear- as well as director of the Centers ing was scheduled. In 1992, the Indiana of Evidence-Based Practice and Supreme Court ruled for the AOA, and Community Outreach. He has re- the NBOME dropped its plans for forming ceived numerous awards for his a new corporation. As Dr. Oliveri later dedication to community health. wrote, the move for independence on the part of the NBOME was “well-intentioned

29 but ill-advised” and incurred huge legal As Dr.Meoli explained in the Journal of fees that threatened to set back the work Medical Licensure and Discipline (2007), in of the organization. the early 1990s NBOME board members Presidents during the 1990s were realized “that patients present clinically John Fernandes, DO (1991-1993); Bruce to the physician with problems, not just Gilfillian, DO (1993-1995); John P. Bru- with a set of organs or a series of disci- no DO (1995-1997); Gerald Osborn DO plines. The patient must also be viewed (1997-1999); and Frederick Meoli, DO in the context of his or her psychosocial (1999-2001). milieu. Physicians must address these During Dr. Gilfillian’s tenure, the problems by properly and appropriately

1990s Empty nesters, still-young at 55, move to condos ($150,000) overlooking a golf course. Medical costs skyrocket as medically savvy patients ask for MRIs, CT scans, ultrasound, noninvasive surgery—laparoscopic, arthroscopic, and laser—and plastic surgery. Americans are health-conscious and youth-obsessed; nonetheless, obesity is commonplace. The World Wide Web reaches into homes, offices, and libraries as the information highway becomes the road to success, but the gap between professionals and minimally skilled workers widens. The world awaits the 21st century with trepi- dation, fearing catastrophe, but clocks and calendars roll over without a blip. board began a tradition of retreats. The applying certain tasks, knowledge and first, held in July 1993, came to be known the clinical skills to address the patient’s as Snowbird. The results were primar- complaint or health-based issues.” ily practical—forging mission and vision In the summer of 1993, a large group statements, rearranging the committee of academicians and practicing physicians structure, and preparing a budget—but representing a variety of specialties met it was also a time to think creatively and to discuss these issues. Knowing that a discuss new ideas. One idea that emerged test of memorized information was no from Snowbird was the trade-name COM- longer relevant, the NBOME sought a way LEX-USA for the Comprehensive Osteo- to evaluate the ability to use information pathic Medical Licensing Examination wisely in a clinical setting. The licensing of the United States of America, which examination, they thought, should mirror would change the way tests were admin- the setting where diagnosis and manage- istered and evaluated. ment decisions on patient care were made,

30 IN THE PUBLIC TRUST

taking into account the context of the real- John J. life demands of physicians and surgeons, Fernandes, including costs and ethics. It was almost impossible for one DO, MBA individual to memorize the vast amount of medical knowledge available by the mid-nineties anyway. Most doctors, like most engineers and attorneys, had come to rely on computers as an extra brain. Dr. Fernandes, Doctors had to know how to access the information they needed, process it a pathologist quickly, and use it. At every stage of their by training, is a graduate of the education they learned how to relate facts Chicago College of Osteopathy to events. How could the ability to use and the J. L. Kellogg School of information for the benefit of patients be Management at Northwestern best evaluated? University. He served as dean of There was agreement among the CCOM at , participants that the new examination should test “a comprehensive style where he was also chair of its of medicine that emphasizes how the Pathology Department. He was on structural harmony of the body affects the faculty at PCOM and TCOM. efforts to prevent and treat illness.” It Most recently, he was presi- should emphasize primary care medicine dent and dean of Oklahoma State and osteopathic principles and practice University’s Center for Health throughout, and it should emphasize life- long learning. This was a new concept in Sciences in Tulsa. He was presi- testing, to test the process of education dent of NBOME 1991-1993, when rather than simply the result, and it took the NBOME began to forge a years to develop into the full COMLEX- new relationship with the AOA. USA examinations. In 1995 and 1996, after the AOA and the NBOME had mended their differences, the Josiah Macy Foundation, which supports programs that improve health care, sponsored two conferences. The first looked at the history of osteopathic medicine, its present status, and its future.

31 Bruce John P. Gilfillian, Bruno, DO DO, MBA

Dr. Bruno Born in graduated from Hackensack, Philadelphia New Jersey, Dr. College of Gilfillian took a BS in zoology from Osteopathic Medicine in 1969. the University of Pennsylvania, He was one of the first DOs to ob- and a DO from PCOM. He in- tain an MBA degree and moved terned at Doctors Hospital in from clinical practice to teach- Columbus, Ohio, specializing ing to administration. At the re- in pediatrics. He joined the fac- quest of President Fernandes, Dr. ulty of the University of North Bruno became an item writer and Texas Health Science Center- Part III reviewer for the NBOME. Texas College of Osteopathy, While serving as NBOME presi- where he was a professor of pedi- dent, 1995-1997, he was instru- atrics for more than thirty years, mental in settling the legal dis- inspiring students with his zeal pute with the AOA. The present for osteopathic medicine. During NBOME committee structure was the years 1993-1995, he served devised while he was president, as president of the NBOME. and he played a significant role in the development of COMLEX- USA, Levels 2 and 3. He is now vice president for medical affairs at St. Luke’s Emergency Hospital in Allentown, Pennsylvania.

32 IN THE PUBLIC TRUST

The second brought MDs and DOs together Gerald to discuss ways they could cooperate. A Osborn, key issue was licensure, with most MDs arguing for the USMLE as a practical DO, MPh “single pathway.” The DOs in attendance explained their philosophy of keeping Emergent care examinations for DOs separate from those for a child- of MDs, although a few DOs were open to hood asthma the idea of using the USMLE as well as a attack by a NBOME examination. David Richards, DO, noted that passing the USMLE protects DO was Dr. osteopathic medical students, “so they’re Osborn’s introduction to osteo- not excluded [from practicing medicine] pathic medicine. Dr. Osborn for the wrong reasons,” i.e., political ones. earned his DO degree from Benjamin Cohen, DO, from the University KCOM. He completed his psy- of North Texas Health Science Center said he encouraged students to take the USMLE, chiatry residency at Michigan in addition to the NBOME examination, State University, where he began because the USMLE may give them access his academic career. He earned a to competitive graduate medical training MPhil degree at the University programs. of Cambridge and is a distin- Other areas discussed where MDs and DOs would work together in the years guished fellow in the American ahead were managed care and the growth College of Neuropsychiatrists and of enormous, for-profit corporate health- American Psychiatric Association. care systems. Small rural hospitals and His work with the NBOME be- private practices had all but disappeared gan in 1986; he served as presi- by the mid-nineties, unable to compete with the giants, and administrators dent 1997-99. He was instru- without medical training seemed to be mental in the development and in charge of telling physicians how to implementation of COMLEX- practice medicine. USA. He is widely published and After the second Macy conference, the is presently the associate dean for NBOME, the FSMB, and the NBME agreed to keep talking with each other on issues Community and International of common interest. By then, COMLEX- Medicine at LMU-DCOM, as USA had made its successful debut: Level well as being clinically active.

33 Frederick member in 1988, serving at every G. Meoli, level within the organization, in- DO, FACOS cluding as president 1999-2001. In 2002, the NBOME was reor- Frederick G. ganized, and Dr. Meoli became its Meoli, a New first full-time president and CEO, York City a position he held until his retire- native, re- ment in 2009. During this time ceived his DO he oversaw the great growth of the from the City College organization. One of the many is- of Osteopathy and Surgery in sues he worked for is the interna- 1968 and completed his residen- tional recognition of the NBOME . cy in general surgery at the John 3 in 1995, Level 2 in 1997, and Level 1 F. Kennedy Memorial Hospital in 1998. The pass/fail standard used in New Jersey. A board-certi- reflected the minimal level of competency fied surgeon, he taught at both the that should be exhibited by a candidate Philadelphia College of Osteopathic seeking licensure. (Details can be found in Medicine and the University of “The Examinations” section.) In 1998, the Medicine and Dentistry of New FSMB challenged the validity of COMLEX- Jersey School of Osteopathic USA as a pathway to licensure and asked for documentation to prove its worth. It Medicine. He was the chair of also asked for documentation on the the Department of Surgery at validity of USMLE. UMDNJ-SOM for sixteen years. A special committee on licensure, Dr. Meoli’s interest in medicine chaired by Allen Schumacher, MD, was began with a bout of severe tonsil- created in 1999 within FSMB, and had both litis at age ten, when he decided DO and MD members. Dr. Schumacher to do all it took to get on the other had served as Federation president. The side of that needle. Inspired by his committee was to determine the “rigor” and validity of both the USMLE and the example, his brother Christopher COMLEX-USA. The NBOME asked Ben- and son Frederick are both DOs, jamin Wright, PhD, head of the MESA and both osteopathic radiologists. Institute at the University of Chicago, to Dr. Meoli became a NBOME board evaluate the COMLEX-USA. After an ex- tensive review and analysis, Dr. Wright

34 IN THE PUBLIC TRUST

published a report that stated that COM- more, the FSMB psychometric consultant, LEX-USA was one of the best examinations Stephen Sirici, PhD, from the University he had evaluated in his thirty years of ex- of Massachusetts, stated, “I rate the evi- perience. Over twenty additional studies dence supporting the validity of score- were conducted under the direction of Dr. based inferences for the COMLEX-USA Linjun Shen and others and reviewed.. as exemplary.” He thought it definitely Strong support for COMLEX-USA came achieved its intended purpose of exam- from the AOA, the American Association ining osteopathic candidates for medical of Colleges of Osteopathic Medicine (AA- licensure. COM), and the American Association of The results of the comparison and Dr. Osteopathic Examiners (AAOE). Sirici’s report were included in the final In April 2001 Dr. Eugene Oliveri, pres- report of the Special Committee on Li- ident of the AOA and a member of the censure and were submitted to the FSMB NBOME board of directors, was invited House of Delegates, which then passed to give the annual Galusha Memorial Resolution 01-03 recognizing that the Lecture to the FSMB House of Delegates. USMLE and COMLEX-USA were valid ex- It was the first time that a DO had been aminations for medical licensure for MDs asked to do so. Dr. Oliveri used the op- and DOs respectively. Following adoption portunity to praise COMLEX-USA, and of this resolution, in May 2001, the Com- to offer an outstretched hand in friend- mittee on Medical Licensure Examina- ship to MDs. Together, he counseled, the tion Systems (CMLES) was created with two professions could work on a single members from the FSMB, NBME, and the examination system that contained two NBOME to attempt to develop models for distinct and separate examinations—one a licensure system. for DOs and one for MDs. The NBOME, NBME, and FSMB Three months later, representatives continued to meet to work toward a from the NBME, NBOME, and FSMB met in common licensure system until 2003, New York to discuss barriers and strate- when meetings ceased, as no practicable gies to sharing common item pools and plan had emerged. During these a uniform licensure pathway with com- proceedings, the AOA and the AAOE mon standards. This meeting, chaired played an important supportive role by George Barrett, MD, a member of in the NBOME’s efforts to preserve the the FSMB and a radiologist from North identity of the osteopathic profession with Carolina, ultimately led to a side-by-side regard to medical licensure. The AOA was comparison of COMLEX-USA and USMLE particularly helpful through the efforts of in January 2001, conducted at the NBME its Bureau for State Government Affairs headquarters in Philadelphia. Further- and through the support of a number

35 Thomas of AOA presidents, including Anthony Cavalieri, Minisalle, DO; Daryl Beehler, DO; Eugene Oliveri, DO; Donald Krpan, DO; George DO, FACOI Thomas, DO; James Zini, DO; and AOA Executive Director, John Crosby, JD. AOA Dr. Cavalieri be- staffers, such as Michael Maille, and gan advocating Linda Mascheri, were crucial players over for quality care the six-year period when relations were for older adults cordial but challenging with the FSMB. Although these organizations worked in the mid- cooperatively and collaboratively, they 1980s and was founding director of could not come up with a workable system the Center for Aging, now the New or plan, and, due to the fact that both the Jersey Institute for Successful Aging, NBME and the NBOME were in the process and its chair of the Department of of performing a comprehensive review Medicine. Nationally known in of their entire examination sequences, the field of geriatrics, he has a spe- the work of CMLES was discontinued in cial interest in medical ethics and 2008. Because the AAOE had a voice at the end-of-life issues and sees commu- FSMB, their efforts in support of the con- nity service as a part of education. cept of maintaining the identity of the His publication credits include more osteopathic profession through licensure than ninety scholarly articles, ab- for osteopathic physicians as osteopath- stracts, and book chapters. He has ic physicians was extremely helpful at held dozens of leadership positions the political and state regulatory levels. within and without the profession. AAOE members Robert Foster, DO; Tho- He was the chairman of the NBOME mas Pickard, DO; Susan Rose, DO; R. Rus- 2001-2002. Currently he is the dean sell Thomas, Jr., DO; Timothy Kowalski, DO; and countless others were instrumen- of the University of Medicine and tal in the NBOME’s success in maintaining Dentistry of New Jersey School of the osteopathic pathway. The executive Osteopathic Medicine. Dr. Cavalieri director of the AAOE and current NBOME was also president of the American board member, Gary Clark, gave sage College of Osteopathic Internists. advice based on his broad experience in the regulatory arena. His ability to work within the “political and regulatory en- vironment” helped achieve success over

36 IN THE PUBLIC TRUST

the long haul. Boyd R. “The FSMB periodically raises issues Buser, DO, regarding the quality of medical licen- sure examinations, as well it should, in FACOFP the interest of public safety,” Dr. Meoli wrote in 2009. “However, relations with A native of the FSMB have attained a different level Iowa, Dr. Buser today. There is interest in collaboration earned his DO and cooperation.” degree from The FSMB and the AOA have assisted the Des Moines the NBOME in attaining international rec- University, College of Osteopathic ognition through the International Asso- ciation of Medical Regulatory Authori- Medicine in 1981 and went into ties (IAMRA) and the Osteopathic Inter- family practice at Kennebunkport, national Alliance (OIA). Further, NBOME Maine. While at the New England and AOA representatives were asked to College of Osteopathic Medicine, participate in the 2009 Search Commit- he received dozens of profession- tee for a new FSMB President and CEO by al awards, including Educator of the then-FSMB chair, Regina M. Benjamin, the Year. He is the first DO to be MD. Dr. Benjamin, a member of the Ala- bama Medical Board and director of the elected to an editorial panel of the Bayou DeBatrie Clinic, was recently nom- AMA. His interests are world-wide inated by President Barack Obama to the and he has participated in a num- post of U. S. Surgeon General. ber of World Health Organization Individual effort, such as exhibited initiatives and is active in the by Kim Edward LeBlanc, MD, PhD, that Osteopathic International Alliance. resulted from the challenges raised by the During his tenure as chairman of FSMB also helped the relationship grow NBOME, 2003-2005, the PE was im- stronger. Working with the AOA and NBOME, Dr. LeBlanc took the initiative plemented. He currently serves as to have COMLEX-USA recognized within vice president and dean of Pikeville the State of Louisiana for the licensure of College School of Osteopathic osteopathic physicians, and was instru- Medicine in Kentucky, where he mental in having the Louisiana Practice also holds the rank of professor of Act revised to permit full practice rights Osteopathic Principles and Practice. to DOs in that state in 2005. Louisiana was the last state to do so, making COMLEX-

37 Sheryl A. William F. Bushman, Ranieri, DO DO

When Sheryl Bushman was five years old, her baby Dr. Ranieri’s sister died of a interest in diaphragmatic medicine be- hernia. Watching her mother gan early, and by high school, he grieve, Bushman made a vow had decided on a career in psy- that she would grow up and be a chiatry. As an army medical of- doctor so no more babies would ficer, he worked in the Psychiatric die and no more mothers weep. Service at Ireland Army Hospital By a wonderful coincidence, in Fort Knox, Kentucky. He re- when Bushman was in OB-Gyn ceived his DO from PCOM. An in- residency in Detroit, an ultrasound terest in depression and anxiety picked up another diaphragmatic led to his co-authoring twenty-one hernia in a fetus. She directed the articles in a variety of journals. woman to a hospital in San Diego, Dr. Ranieri founded the Depart- where an in utero operation fixed ment of Psychiatry at UMDNJ- the hernia and the baby was born SOM in 1983 and served as healthy. Dr. Bushman received chair until 2003, when he be- her DO in 1984 from the Texas came an associate dean for clini- College of Osteopathic Medicine cal affairs until his retirement in and practiced in Kansas City for 2007. In 1989, Dr. Ranieri was five years before moving to St. Louis elected president of the American and then to Fort Scott, Kansas. College of Neuropsychiatrists. Her professional career has been He served as a member of the balanced between medical practice American Osteopathic Board of and medical administration. Among Neurology and Psychiatry 1986- the highlights of her life are medical 1996, when he became the ex- mission trips to Vietnam and Haiti. ecutive director. His involvement She served as the first woman with the NBOME began in 1991. chair of NBOME, 2005-2007. He was elected chair in 2007.

38 IN THE PUBLIC TRUST

USA recognized in all fifty states. John “It may be safely said,” Dr. Meoli con- Thornburg, tinued, “that relations with the FSMB and its new leadership under Martin Crane, DO, PhD MD, the current FSMB chair and former member of the Massachusetts Medical Board, have evolved from the trials, tribu- lations, challenges and confrontations of the period from 1998 through 2004. This has resulted in a mutual respect for both Dr. Thornburg organizations, a desire to work coopera- is professor tively, and has furthered the mission and of pharmacology and toxicology vision of both organizations to protect and family and community medi- the American public by helping to ensure cine at Michigan State University quality medical care and the ease of ac- College of Osteopathic Medicine, cess to the healthcare system.” from which he graduated in 1976. In 2002, the NBOME changed its or- ganizational structure to reflect its grow- He is presently vice-chair of the ing complexity and hired its first full-time board of directors of the NBOME, president and CEO, Frederick G. Meoli, and will assume the role of chair DO, FACOS, a long-time NBOME board in December 2009. He has a member. He functioned in these capaci- more than twenty-year history ties of the expanding organization until with the NBOME. Initially, he his retirement in 2009. During his ten- ure, he and his management team led the served on the pharmacology Test NBOME through a period of unprecented Construction Committee, first as growth and international recognition. a member and later as chair. Dr. The leadership of the board remained a Thornburg was the first coordi- voluntary position, with Thomas Cava- nator of Level 1 COMLEX-USA. lieri, DO, serving as chair from 2002 to Subsequently, he served as chair 2003. The twenty-one board members by of product committee and was then included DOs and representatives of the AOA, AACOM, and AAOE. Two lay elected to the board of directors members, Fred Wilson, a vice president and to the executive committee. of Proctor & Gamble, and Gary Clark, ex- ecutive director of the Oklahoma Board of Osteopathic Examiners, were added.

39 Today, four standing board commit- degrees were not osteopathic physicians tees meet throughout the year: finance, and surgeons, nor were they recognized nominations, liaison, and standards and as DOs by the AOA. Canadian DOs, on assurances. The operational committees the other hand, have frequently been of the NBOME include communications members of the AOA. Three Canadians and consumer affairs, research, emerging have served as president of the American technologies, Americans with Disabili- Academy of Osteopathy. ties (ADA) test accommodations review, In 2005, the NBOME became an as- clinical skills testing advisory, and prod- sociate member of the International As- uct. The liaison committee encourages a sociation of Medical Regulatory Authori- free exchange of ideas from all tiers of ties (IAMRA) and part of the IAMRA Fast constituents having an interest in the Track Work Group. In 2006, New Zealand medical licensure field. Members of this accepted all DOs who had passed COM- committee include representatives from LEX-USA and obtained a license in any the AOA, the FSMB, AACOM and AAOE, U.S. state. More than fifty nations license student associations, and other profes- DOs on an individual basis today. The sional groups. NBOME is currently working with the A major accomplishment during the Osteopathic International Alliance (OIA) late 1990s and early 2000s was the de- to obtain further recognition. velopment and implementation of the In the mid-1990s, the Institute of Med- COMLEX-Level 2-Performance Evalua- icine (IOM) began an in-depth study of the tion. Years of research came to fruition safety and quality of medical care. Their with the opening of NBOME’s National first report, To Err Is Human, was issued Center for Clinical Skills Testing (NCCST) in 1999. It brought public attention to in Conshohocken, Pennsylvania, under the deaths and maimings of thousands the leadership of John R. Gimpel, DO, of Americans each year from medical MEd. A history of the process leading to errors. The media focused on patient that achievement is on page 45. safety along with quality medical care, The province of Ontario, Canada, and patients called for reform. The next accepted COMLEX-USA in 2005, several IOM report, Crossing the Quality Chasm years after the NBOME began working in 2001, described broader quality issues with the Medical Council of Canada. The and defined six aims or areas of compe- certification of foreign-trained osteopaths tency. Medical care should be was an issue that had come up from time 1) safe to time. Institutions in England, Australia, 2) effective and New Zealand granted degrees in 3) patient-centered osteopathy, but the recipients of these 4) timely

40 IN THE PUBLIC TRUST

5) efficient The NBOME was invited to partici- 6) equitable pate in the Physician Accountability for In 2005-2006, the NBOME formed a Physician Competence (PAPC) Summits task force to study the competency issue sponsored by the FSMB beginning in 2006. as it might apply to licensure. Their ef- The NBOME has been active in this effort forts resulted in the publication of “The to assure physician competence from an Seven Core Osteopathic Competencies; academic, clinical, and economic perspec- Considerations for Osteopathic Medical tive.

2000s The terrorist attacks on 9/11/01 change much in American life, as security trumps individual liberty. President George W. Bush sends troops to Afghanistan and Iraq in retaliation. The family minivan ($18,000 equipped with GPS and drop-down TV) may be traded it for a more fuel-efficient Prius ($20,000) as Americans try to be less dependent on Mideast oil. Hurricane Katrina strikes New Orleans making global warming seem real. In 2008, after the stock market collapses and financial institutions fail, the nation’s first bi-racial president, Barrack Obama, is elected.

Licensure and the Practice of Osteopathic While remaining a nonprofit corpora- Medicine” in September 2006. The task tion, the NBOME began to offer a variety force defined physician competence as of services and products in the mid-2000s. “suitable or sufficient knowledge, skill, Between 2005 and 2006, after years of work experience, values and behavior.” The by Dr. Shen and his team, COMLEX-USA seven competencies identified were: was converted to computer-based testing 1) osteopathic philosophy and treat- (CBT) and examinees were liberated from ment pencil and paper testing. It was logical 2) medical knowledge to continue to expand this expertise and 3) osteopathic patient care knowledge. 4) interpersonal and communication As part of the goal of life-long learn- skills ing, COMVEX-USA, in computerized for- 5) professionalism mat, was developed to evaluate current 6) practice-based learning and im- osteopathic medical knowledge. Its full provement name, Comprehensive Osteopathic Medi- 7) systems-based practice. cal Variable-Purpose Examination, indi-

41 cates that it is an examination designed based format. The NBOME works with to meet the needs of physicians who ex- the American College of Osteopathic Sur- perience significant change during their geons (ACOS) in scoring and analyzing its practice life-time. It focuses on applying “in-service” examination and assists the knowledge in patient evaluation, diag- American College of Family Physicians nostic technologies, and case manage- (ACOFP) in creating their “in-service” ex- ment. The examination is appropriate for amination as well. DOs who have passed the USMLE and The NBOME offers a number of no- are moving their practice to a state that cost services to DO candidates, osteopath- requires osteopathic examinations, or ic colleges, and the osteopathic profes- DOs who want to be reinstated after an sion, among them, educational programs, interruption in a clinical career, or expe- faculty development, and item-writing rienced DOs who need to demonstrate workshops. Examinations are also pro- basic osteopathic medical competency for vided to colleges of osteopathic medicine some reason. to assist in the assessment of students’ Phase 1 of COMS��AE, the Comprehen- knowledge of certain subjects and disci- sive Osteopathic Medical Self Assessment plines. Other services are psychometric Examination, was launched in the spring analysis, proctoring, item banking, CBT of 2008, followed by Phase 2 and Phase conversion of written examinations, and 3. COMSAE resembles COMLEX-USA and seminars in test construction for review allows medical students to evaluate how committees. well they are learning the material in their Repeatedly during the past seventy- course work. While the results of self-as- five years, members of the National Board sessment modules are not 100 percent of Osteopathic Medical Examiners have predictive of future COMLEX-USA per- shown a commitment to the integrity of formance, the correlation is indeed very their profession. From Dr. Asa Willard’s high. The NBOME has worked with other impassioned stand for self-regulation to specialty groups to assist with high- and Dr. Frederick Meoli’s successful efforts medium-stakes testing as part of physi- for the world-wide acceptance, respect, cian credentialing. In 2008, the NBOME and appreciation of the NBOME mission, assisted the American Osteopathic Board the line of osteopathic physicians and of Emergency Medicine (AOBEM) with surgeons has kept moving forward. Not the conversion of their certifying exami- discouraged by opposition, in fact often nation into computer-based format. In turning opposition into support through 2009, it helped the AOBEM introduce its determination, the men and women of re-certifying examination in computer- the NBOME have shown their pride in

42 IN THE PUBLIC TRUST

and affection for a profession that aims safe, competent osteopathic health care to preserve the public trust by promoting for all people.

(Above) Offices of the NBOME at 2700 River Road in Des Plaines, Illinois

(Right) Home of the NBOME Chicago corporate offices today.

At these two facilities, the research, development, and implementation of COMLEX-

43 National Center for Clinical Skills Testing offices in Conshohocken, Pennsylvania.

Ribbon-cutting for the new fa- cility in 2004. Left to right: The Hon. Connie Williams, assem- blywoman; Dr. Boyd Buser, Dr. John Gimpel; Dr. Sheryl Bushman; Dr. Frederick G. Meoli.

44 IN THE PUBLIC TRUST

Creation of the National Center for Clinical Skills Testing and Comlex-USA Level 2-Performance Evaluation (PE)

In 1995, NBOME President John P. force, including Dennis Dowling, DO, Bruno, DO, appointed John R. Gimpel, chair of the Department of Osteopathic DO, a new member of the board, as chair Manipulative Medicine at NYCOM An- of NBOME’s Task Force on Performance thony Errichetti, PhD, Director of Stan- Testing, with the charge to investigate dardized Patient Training at PCOM; Mi- the possibility of adding a clinical skills chael Warner, DO, family physician in examination to COMLEX-USA. The Medi- Johnstown, Penn.; NBOME president-elect cal Council of Canada (MCC) had intro- Gerald Osborn, DO, Chair of Psychiatry at duced its Qualifying Examination Part II MSCOM; and NBOME’s Director of Test- in 1991, which included a multi-station ing Linjun Shen, PhD. Joining the team in objective structured clinical examina- the early years were consultants Michael tion (OSCE), and the National Board of Curtis and Jack Boulet, PhD, both Canadi- Medical Examiners (NBME) had begun ans and both with extensive experience in pilot testing models in preparation of clinical skills testing from the ECFMG. Dr. including a clinical skills examination in Boulet served as consultant for psycho- the USMLE pathway. The Educational metrics throughout the eight-year period Council of Foreign Medical Graduates of research, development and pilot testing (ECFMG) was planning to introduce the of what would become the COMLEX-USA first national, high-stakes standardized Level 2 Performance Evaluation (Level patient-based clinical skills examination 2-PE). for international physicians in the United Dr. Osborn and Dr. Gimpel visited States in 1998. and observed the MCC’s Part II OSCE in In his capacity as director of the Skills Toronto, Canada, in 1998. During NBOME Program, Dr. Gimpel recruited a talented retreats in 1998 and 2000, members debat- group of national experts in medical edu- ed and deliberated about the enormous cation and assessment to form the task projected obstacles—financial, logistical,

45 John R. and political—that faced the NBOME in Gimpel regard to adding a clinical skills examina- tion to COMLEX-USA. DO, MEd Meanwhile, Dr. Gimpel, Dr. Errichetti, and Dr. Boulet outlined a road map for “Students value the development of an osteopathically what you test, distinctive clinical skills assessment. The not just what task force developed a blueprint for the you teach,” Level 2-PE examination and reported reg- is one of Dr. ularly to NBOME. After assembling a case Gimpel’s core beliefs. After gradu- development committee with representa- ating from the Philadelphia College tives from numerous osteopathic medical of Osteopathic Medicine (PCOM), colleges and state medical boards, the trio brought a demonstration troupe of stan- Dr. Gimpel taught physical di- dardized patients to the NBOME board agnosis and clinical skills testing retreat at the Samoset Hotel in Rockport, using standardized patients. He Maine, in 2000. joined the NBOME board in 1995 At this retreat, with the foresight of to assist with clinical skills test- outgoing President Osborn and incom- ing in COMLEX-USA. Dr. Gimpel ing president Frederick G. Meoli, DO, has published widely in the area of each board member completed a mock high-stakes assessment and medi- two-station OSCE in which he or she en- cal education and has authored countered two standardized patients and several articles and textbook chap- were faced with the task of evaluating and ters on family medicine. In 2004, treating the patient. The board was sold! Shortly thereafter, developing a clinical Dr. Gimpel became NBOME’s first skills examination to augment the current full-time vice president for Clinical COMLEX-USA series was made the top Skills Testing (CST). In 2009 he priority for NBOME, despite the lingering became NBOME’s second full- uncertainty relative to the political and time president and CEO. When financial feasibility. he is not attending to NBOME The addition of an assessment of os- business, Dr. Gimpel can regu- teopathic diagnosis and OMT by trained larly be found coaching one of his osteopathic physicians was a key compo- three children on the golf course. nent of the initial pilot testing of the new PE examination. Led by Dr. Dowling, with considerable input from the Educational

46 IN THE PUBLIC TRUST

Council on Osteopathic Principles (ECOP) Dennis of the American Association of Colleges Dowling, DO of Osteopathic Medicine (AACOM), scor- ing rubrics and rater training processes were developed, piloted and validated Dr. Dowling in numerous studies and field trials from was on the task 1999-2004, partnering with a number of force that led osteopathic colleges. Logistical aspects of to the NCCST. the new 12-station Level 2-PE model were fine-tuned. A number of peer-reviewed articles were published in the Journal of the American Osteopathic Association, and the about the ability to finance the $2-3 mil- development of the Level-2-PE attracted lion investment needed for the launching significant attention from the Federation of Level 2-PE. It posed enormous finan- of State Medical Boards, as well as inter- cial risk and would double the NBOME’s national regulation, testing, and licensure entire budget. It became clear that part- communities. nering with osteopathic medical schools The landscape seemed ready for a final was not going to be the preferred delivery decision about implementation of clinical model for the new examination. While skills examinations into the COMLEX-USA other models were still being evaluated, and USMLE examinations in 2003. At the the NBOME was faced with the need to annual House of Delegates meeting of make a final decision about an imple- the American Medical Association (AMA) mentation model. The 2003 AOA House in June 2003, a resolution was adopted of Delegates Resolution seemed like a that opposed the addition of a national mandate for moving forward, but some clinical skills examination to the USMLE significant decisions needed to be made examination. The objection seemed to first. Former chair Dr. Frederick G. Meoli be primarily centered around financial had recently returned to the NBOME, hav- concerns for medical students. Just one ing been named the first full-time presi- month later, in July 2003, the House of dent and CEO of the organization. The Delegates of the American Osteopathic new chair, Thomas Cavalieri, DO, chair Association (AOA) adopted a resolution of Internal Medicine at the University of in support of the addition of a clinical Medicine and Dentistry of New Jersey, skills examination to COMLEX-USA, citing and chair-elect Boyd Buser, DO, associate the protection of the public as the prime dean for Clinical Affairs at the University concern. of New England College of Osteopathic The NBOME Board was still skeptical Medicine, worked with Dr. Meoli and Dr.

47 Gimpel to organize proposals and for- National Center for Clinical Skills Testing mulate the key questions for the NBOME was identified at 101 West Elm Street in in the late summer and early fall of 2003. Conshohocken, Pennsylvania, at the very Decisions were made to build the NBOME border of Philadelphia. The NBOME ap- National Center for Clinical Skills Testing proved a plan outlined by President Meoli in the Greater Philadelphia region, since to borrow some of the financial resourc- the number of examinees would make es necessary to lease and fully equip the testing at multiple sites impractical and a NCCST, while limiting the overall need majority of osteopathic medical students for upfront capital by negotiating a lease in their fourth year of clinical rotations, for the new site. the likely candidate pool, were training Tireless efforts by NBOME staff, in- within several hundred miles of Philadel- cluding new Managing Director Laurie phia. Proximity to the expertise needed to Kerns, Administrative Assistant Taunya implement the Level 2-PE examination in Cossetti, a growing staff of NBOME per- 2004, including professionals in testing sonnel in the new NCCST, and a number and standardized patient trainers, and of key partners, including Anurag Singh also the ECFMG and NBME headquarters, of the EMS clinical skills software com- were also significant reasons to set up pany, allowed for the historic signing the shop in Philadelphia, since the NBOME lease on December 23, 2003. Site construc- staff were collaborating closely with their tion of the NCCST began in late January colleagues at the ECFMG and NBME on is- 2004. Installation of all of the technology sues relating to examination development and hiring the staff was finished by June and implementation. 2004. Standardized patients were hired Having led the task force (now called and trained, and pilot testing was carried the Performance Testing Committee) and on in July and August. The NBOME host- the Case Development Committee in an ed a grand opening of the facility in early eight-year process of research and de- September and on September 23, 2004, the velopment on a part-time basis and as first COMLEX-USA Level 2-Performance a consultant, Dr. Gimpel decided to join Evaluation examination was adminis- NBOME full-time as vice president for tered to twelve student candidates. Clinical Skills Testing. Board member The NBOME initiated an electronic John Becher, DO, accepted the appoint- registration system for candidate schedul- ment as the first chair of the Clinical Skills ing through the efforts of Joseph Smoley, Testing Advisory Committee (CSTAC), PhD, vice president for administration which replaced the Performance Testing and COO, and hired its first full-time Committee and directed oversight of Director of Information Systems, Oracle- this new examination. A site for the new expert David Kreines, JD, in 2004. The

48 IN THE PUBLIC TRUST

NBOME was the first to implement a web- ing the organization and the staff on the based secure portal for the physician scor- verisimilitude of the standardized patient ing of the written post-encounter SOAP portrayals and the professionalism of the notes and the videotape performances of staff. Managing Director Crystal Wilson, candidates using osteopathic patient as- MEd, joined the staff in its second year sessment and treatment. Osteopathic phy- of operation, and the team grew signifi- sician raters from all around the country cantly over the ensuing years as the num- were trained to score thousands of SOAP ber of candidates tested increased from notes and videotape performances, and a 2,900 annually to almost 4,000 in 2008- system was designed so that the scoring 2009. William Roberts, EdD, was hired in and rater calibration could be done for 2006 as the director for Psychometrics and timely candidate scoring. Research for Clinical Skills Testing and in The NBOME received widespread ac- 2008, Erik Langenau, DO, was hired as claim for the success of Level 2-PE. In part vice president for Clinical Skills Testing, due to regular publications in peer-re- replacing Dr. Gimpel, who went on to viewed journals and dozens of presenta- become the dean at the New England tions at prominent national and interna- College of Osteopathic Medicine. tional meetings, coupled with a number In 2009, the NCCST doubled its testing of innovations in testing that were being space and capacity, adding a second clini- emulated by other testing organizations, cal skills testing pod in order to provide the NBOME was recognized for excellence greater flexibility in testing candidates. when the Federation of State Medical The Level 2-PE staff, including almost Boards (FSMB) issued its Meritorious thirty full-time employees, several hun- Service Award to Dr. Gimpel in 2007. dred physician examiners and standard- The NCCST quickly became a very ized patients, and another hundred or so busy place, with 12-24 candidates, 14-28 physician volunteers on committees that standardized patients, and testing and support the examination, are poised to administration staff arriving despite continue to develop the Level 2-PE ex- snow, hail or rain to deliver the Level 2- amination and improve the NBOME’s PE examination, offering double shifts ability to protect the public by providing and weekend administrations at the the means to assess the competencies for Conshohocken facility. Candidate feed- osteopathic medicine and related health back about the Level 2-PE examination care professions. remained uniformly positive, commend-

49 The NBOME’s Future

Setting the pace for osteopathic executive officer, four vice-presidents, and medical licensure and competency fifty full-time staff positions. This growth assessment has provided the NBOME has positioned the NBOME to implement with many challenges and opportunities. these ambitious strategic goals. Expanded The NBOME is prepared to face those of relationships with other organizations the future in order to meet its mission of in delivering relevant assessment tools, protecting the public. such as or in-training The NBOME board of directors set a examinations and COMAT subject exami- new direction for the organization in 2008, nations, are likely to increase as NBOME when it approved an innovative strategic attempts to realize the vision of its board plan. This plan outlined five major goals to become “the testing organization for for the organization: the osteopathic profession.” 1. Preeminence in the arena of domes- As part of assuring that its signature tic and international testing of the COMLEX-USA examination series osteopathic and relevant health care remained current in meeting the needs professions of the state medical licensing boards and 2. Leadership and collaboration in other secondary constituents in protecting the fields of osteopathic education, the public, the NBOME commissioned a medical regulation and research comprehensive review of its COMLEX- 3. Innovation and excellence in product USA examination series in 2007. This lines and services process originated from discussions of 4. Creation of a strong and sustainable continuous quality improvement at an technological infrastructure for the NBOME board retreat in 2006. development, administration, pro- This review included extensive input motion and delivery of products from the many stakeholders, including and services state medical board representatives, 5. Promotion of an efficient and effec- representatives from schools of osteopathic tive organizational structure medicine and graduate medical education Over the past decade, the NBOME has programs, physicians in private practice, evolved from a structure of having an students, residents, and other content executive director and fifteen full-time and testing experts. Numerous NBOME employees to a complex organization committees, subcommittees, and task featuring two corporate locations, a forces met to evaluate the content, format, full-time physician president and chief and consequences of the COMLEX-USA

50 IN THE PUBLIC TRUST

series and to devise a plan for assuring of several assessments of competen- that it will continue to elevate the breadth cies, including osteopathic medical and quality of assessment to meet the knowledge and clinical skills, but expectations of the profession and the the decision point would occur public. immediately prior to entry into One critical committee was the graduate medical education, which Blueprint Audit Committee, chaired is considered supervised medical by board member Fredrick Schaller, practice. This is the time when medi- D.O. Another was the Committee on cal licenses are typically granted for Competency Assessment, led by former practice in the supervised setting of NBOME President Eugene Mochan, DO, a residency training program. PhD. This latter committee had published 3. The second decision point would be “The Core Osteopathic Competencies: made in postgraduate training and Consideration for Medical Licensure and prior to the entry into unsupervised the Practice of Osteopathic Medicine” or independent practice. It may con- in 2007, and an updated version, “The sist of several separate assessments Fundamental Osteopathic Competencies” of competencies. in 2009. This document addressed the core 4.The revised COMLEX-USA series osteopathic medical competencies and will adopt a general competencies how the competencies might be evaluated schema with osteopathic principles from a licensure perspective. and practices integrated throughout Upon recommendation from NBOME’s all assessment tools and each of the Product Committee, chaired by board six core competencies. member Deborah Pierce, DO, and board 5. Assessment of the application of chair William Ranieri, DO, who also biomedical sciences to clinical pres- chaired NBOME’s In-depth Assessment entations will be expanded across Committee, the board of the NBOME the examination series, as will the voted in 2009 to move forward with plans ability to evaluate and use best evi- to further study and implement a future dence and appropriate information design for COMLEX-USA which would resources to address clinical pres- be delivered in a competency-based, two entations. decision point model. This model would It was recognized by the board that incorporate the following: additional research would be necessary 1. Two decision points rather than the in the upcoming five to ten years in order current three decision point model to implement these changes to COMLEX- (COMLEX-USA Level 1, 2, & 3). USA, and to do so in a fashion that gives 2. The first decision point may consist consideration to secondary users and

51 indeed all constituents of the NBOME. state medical boards in determining the The NBOME’s mission to protect the competence of practicing physicians. public, and the validity and reliability Meeting challenges in osteopathic of the NBOME’s assessments will remain medical licensure and educational paramount. assessment and doing so with innovation, An additional consideration of con- a sense of purpose, and dedication have siderable interest at this time to the been the hallmark of the exciting first Federation of State Medical Boards (FSMB) seventy-five years of theNBOME history. is the issue of maintenance of licensure and Continuing to meet these challenges career long competence. The NBOME has and to strive to continually improve its joined efforts led by the FSMB to explore products and services, in the interest of pilot testing of additional assessment the health of the public, will remain the tools and processes that might assist NBOME’s opportunity for the future.

“Almost every phase of society, nearly every section of the country, and certainly quite, if not all, the ills to which flesh is heir, were represented. . . . One thing they possessed in common, and that was a beaming countenance that indicated confidence, an expectancy, if not already a realization of a bettered condition.”

Quoted in The DOs by Norman Gevitz describing the infirmary at American School of Osteopathy in 1896.

52 The Examinations

“To protect the public by providing the means to as- sess competencies for osteo- pathic medicine and related health care professions.”

53 “When I joined the NBOME, I was immediately caught up with this desire to improve the quality of the examination. During my over twenty years with the NBOME, I have seen the level of the examination dramati- cally change and improve to match the challenges of the twenty-first cen- tury. Along the way, I have met an extraordinary group of people who are dedicating their time to produce examinations that assure the gen- eral populace that our osteopathic physicians are competent to meet their medical needs.”

William F. Ranieri, DO Chair, 2009

54 IN THE PUBLIC TRUST

To Protect The Public

The first examinations put together tions for its examination and in 1961, es- by the National Board of Examiners for say questions were dropped. Multiple- Osteopathic Physicians and Surgeons choice tests allowed for faster grading, (NBEOPS) in the late 1930s, were made but required a new way of thinking and up of questions that tested knowledge of more work for test preparers. The choices science, medicine, and osteopathic prin- given had to be logical and close to the ciples. They were similar to all universi- correct answer; otherwise the test would ty examinations at the time, requiring an be too easy and meaningless. Examiners essay answer that was graded on coher- began to be concerned with the best way ence as well as correct facts. Part I tested to measure the validity of their tests and the academic knowledge of second-year looked to the growing science of statistical students; Part II tested the knowledge of analysis. In 1971, computerized scoring those finishing up their academic educa- was introduced. tion; and Part III tested the clinical eval- After 1960, questions about social uations of interns after a year of experi- problems, such as drug and alcohol abuse ence. and sexually transmitted diseases, appear Over the next seventy-five years, on tests, as well as (briefly) the best way test questions reflected the evolution of to test for radiation sickness. Medical medical knowledge and osteopathic tech- jurisprudence and medical ethics became niques and the changing social milieu of important. Beginning around 1970, the United States. The greatest changes familiarity with diagnostic equipment in medicine in the twentieth century was increasingly significant, and more came after 1950 with the expanding use attention was paid to psychological of pharmaceuticals which required in- problems, such as depression and anxiety. depth knowledge of biochemistry and In the 1980s, questions about HMOs, the physiology. Surgical techniques changed fees-for-services system and record- radically beginning about 1975 with the keeping were added development of open heart surgery, mi- Gradually the examinations moved crosurgery, arthroscopic surgery, trans- from testing rote knowledge to testing the plants, and the use of the laser. ability to diagnose and treat disease. The In the late 1950s, the National Board first series of objective type examinations began developing multiple-choice ques- was subject- and discipline-based. Part

55 1 covered the basic science subjects failed. This was no longer possible of physiology, pathology, anatomy, after Dr. Santucci revamped the testing pharmacology and osteopathic principles. procedure. As the number of candidates Part 2 covered the medical disciplines of for the DO degree increased, test security medicine, surgery, pediatrics, obstetrics became a crucial issue. The AOA auxiliary and gynecology, and osteopathic prin- provided proctors for the examinations ciples. Part 3 was similarly discipline- in the 1980s and 1990s, supervising the based, but more clinically oriented. In the administration of Parts I and II, which 1980s and early 1990s, the movement in were then held at the various osteopathic medical education was toward a “systems- colleges. In the 1990s, the NBOME con- based” approach, where basic sciences tracted with a third party, Applied and clinical disciplines were integrated Measurement Professionals (AMP) to and applied to human organ systems. oversee the examinations. Medical students were taught to approach The development of COMLEX-USA the cardiovascular or the gastrointestinal and its subsequent evolution was a ma- system from a multidisciplinary approach jor event in the NBOME’s history and a bringing to bear the anatomy, physiology, turning point for osteopathic medicine. pathology and clinical correlations of each Following a board retreat in 1990, a com- organ system. This systems approach mittee under the leadership of Michael became the forerunner of the problem- Clearfield, DO, was charged to develop based and case-based approaches of the a new paradigm for the osteopathic li- 1990s and early 2000s. censure examinations. The committee Questions about OMT were in a came up with a unique bi-dimensional separate section in the early years, but blueprint that would form the basis of as the tests evolved, OMT and OPP the licensure examination sequence for were integrated into test questions and the NBOME for the next fifteen years. As osteopathic principles were evident a result of the foresight of this commit- throughout. Thomas Santucci, Jr., DO, tee and the board of directors, the new was a major advocate for developing a examination sequence would be intro- clinically based test and one that could duced into Level 3 in 1995 and the entire be measured statistically for validity. In sequence would be fully implemented by 1987, the NBOME began to use electronic 1998. For the past ten years, board mem- scoring and perform analysis within the ber and staff have presented information organization. Before then, scoring was about COMLEX-USA to osteopathic medi- provided by the University of Iowa. cal colleges and state licensing boards. Before 1985, candidates were allowed Getting their message out has become a to retake the parts of the tests they had major focus.

56 COMLEX-USA: a New Paradigm in Testing and Evaluation

Rreprinted with consent from JAOA, The Journal of the American Osteopathic Association, 100 (2), February 2000, 105-111. Contents © 2000 by the American Osteopathic Association

Gerald G. Osborn, DO; Frederick G. Meoli, DO; Boyd R. Buser, DO; Michael R. Clearfield, DO; John P. Bruno, DO; Laura Sumner Truax

From the beginning, the intention of are the underpinning of medical decision the COMLEX-USA sequence was to use making. the actual practice patterns of osteopathic By beginning with Level 3, the team primary care physicians as an overlay [for steered the preceding two levels to be- the examination blueprint]. come more clinically relevant and per- Working in reverse manner, the team mitted the fundamentals of biomedical determined the preceding knowledge and science to be applied to clinical situations clinical decision-making elements that an and settings. osteopathic physician must have to make The examination outline is organized clinical decisions independently. Begin- along the integration of two major axes ning with Level 3, the test committee or dimensions of patient encounters and determined by consensus the degree of physician knowledge and skill. Both of sophistication and knowledge discrimina- these dimensions are uniform and con- tion the candidate should possess. sistent through all levels of the COMLEX- Then, using a pattern of high-impact/ USA sequence, as the same grid was used high-frequency patient encounters, the to compose the examination. The first NBOME committee members decided axis (Dimension I) is modeled after a which skills and information a practic- problem-oriented approach to patient ing osteopathic physician would need to care. On this axis, patient encounters are make decisions about a patient. From this broadly collapsed into the homeostatic clinical starting point, the construction categories or capabilities, and clinical team determined the knowledge blocks of signs and symptoms. understanding and bio-mechanisms that The second axis, Dimension II, con-

57 tains six components and considers this allows NBOME to not only provide a clear expanding knowledge that an examinee level of assessment, but to allow for ef- would bring to the situations of Dimen- ficiency of item use. The following test sion I. . . . items provide examples of how test items At Level 1, the examination outline are practically revised. reinforces the clinical relevance of the first two years of osteopathic medical school At Level 1, the test item focuses on by placing the knowledge and under- the basic biological defects caused by a standing of biological, behavioral, bio- vitamin B12 deficiency: mechanical mechanism, and osteopathic A 70-year-old man presents with ane­ manipulative techniques in a clinically mia. The red cell indices indicate hyper­ oriented setting. Approximately 80% of chromia, macrocytosis, and hyperseg­ the items from Dimension II address ba- mented neutrophils. The underlying ab­ sic science concepts underlying disease normality best explaining the anemia is: mechanisms. Integrated throughout is an emphasis on ambulatory care and stages (A) abnormal ß-globulin synthesis of the life cycle that represent the scope of resulting in ineffective erythro­ patients seen in typical primary care set- poiesis tings. Additionally, the examination grid (B) failure of erythropoietin secret­ was constructed to be flexible to accom- ing function of the kidney modate the constant changes in medical (C) G-6-PD deficiency causing dam­ knowledge and practice. age to cells via oxidative stress Using the identical outline, Level 2 (D) impairment of DNA synthesis emphasizes the evolving area of clinical secondary to vitamin B12 defi­ knowledge examinees possess as their ciency medical education is completed, with the (E) impairment of RNA synthesis majority of examination items focusing secondary to iron deficiency on clinical application to the patient en- counters of Dimension I. Level 3 stresses Answer D is correct. The distractors the management knowledge osteopathic are a variety of physiologic findings asso­ physicians should utilize to practice in- ciated with anemias. The answer suggests dependent, unsupervised care. a specific abnormality for 12B . The use of the same outline for all The same item presented in Level 2 three levels allows test construction teams focuses on the diagnostic skills a fourth- to modify examination questions to ap- year osteopathic medical student would propriately assess examinee knowledge bring to the same problem: across all three examination levels. This

58 IN THE PUBLIC TRUST

A 70-year-old man presents with ane­ priate treatment. The answer highlights mia. The red cell indices indicate hyper­ a common abnormality that can be im­ chromia and macrocytosis. The abnor­ proved with treatment when caused by mality suggesting B12 deficiency is: a B12 deficiency. Each of the three examples are cate­ (A) generalized lymphadenopathy gorized in the same way under Dimen­ (B) hepatosplenomegaly sion I, yet the physician knowledge that (C) scleral icterus each example demonstrates is classified (D) increased reticulocyte count uniquely under Dimension II-Level 1 il- (E) hypersegmented neutrophils on lustrates the scientific understanding of peripheral smear basic mechanisms, Level 2 stresses clinical assessment, and Level 3 presents the item Answer E is correct. The distractors with a case-management orientation. are a variety of laboratory and physical Application of osteopathic principles findings associated with anemia. The an- is interwoven throughout the entire ex- swer suggests a specific abnormality seen amination at all three COMLEX-USA se- with B12 deficiency. quence levels, with a significant number The item as used in Level 3 assess- of test items having clear osteopathic ori- ment of the treatment and management entation. An example of this integration skill expected of a resident osteopathic is seen in the application of structural physician: and palpatory diagnosis and osteopathic A 70-year-old man presents with ane­ manipulative techniques in the diagnosis mia. The red cell indices indicate hyper­ and management of patients. chromia, hypersegmented neutrophils, In Level 1, knowledge of basic osteo­ and macrocytosis. The most likely clinical pathic concepts and biomechanical prin­ benefit from the correction of the cause of ciples are examined as illustrated in the the anemia is: following test item:

(A) improvement in dementia A 24-year-old man with thoracic back (B) improved renal function pain has acute tissue texture changes in (C) improved respiratory function the right midthoracic paraspinal tissues. (D) reversal of jaundice Palpatory examination reveals posterior (E) reversal of splenomegaly transverse process of T7 on the right side that become more prominent when the Answer A is correct. The sequelae of thoracic spine is extended. Which of the anemia can result in a variety of abnor­ following is true regarding this somatic malities that can be reversed with appro­ dysfunction?

59 (A) flexion motion is restricted other sites. (B) left sidebending is restricted In Level 3, where unsupervised pa- (C) motion between T6 and T7 is ab- tient care is emphasized, osteopathic normal manipulative treatment (OMT) in patient (D) motion restriction is maintained by management is highlighted: long restrictor muscles (E) rotation toward the right is re­ A 35-year-old man presents with right stricted lower back pain that began after moving furniture at home. Neurologic exami­ Answer B is correct. The student must nation is normal. A diagnosis of lower understand the physiologic motion char­ back strain of mechanical origin is made. acteristics of the thoracic vertebral column Structural findings include hypertonicity and the proper terminology for describing of the left psoas muscle. Correct position abnormalities of motion in this region. of this patient for direct muscle energy In Level 2, the integration of structural treatment of this dysfunction includes: findings in the differential diagnosis is one aspect of the osteopathic examina- (A) patient supine, trunk sidebent left tion: (B) patient prone, left hip extended (C) patient seated, trunk rotated right A 44-year-old woman with a com- (D) patient supine, right hip and knee plaint of vague abdominal pain has tissue flexed texture changes in the right paraspinal (E) patient prone, lumbar spine hyper- tissues at the T8-T9 level. The most likely extended viscerosomatic relationship is with which of the following organs? The correct response is B. To choose the correct answer the student must have (A) colon knowledge of the anatomy and the func­ (B) gallbladder tion of the psoas muscle and an under­ (C) ovary standing of basic muscle energy treatment (D) spleen principles. (E) stomach While the above examples focus on The correct response is B. The visceral the diagnosis and management of pa- afferent nerves from the gallbladder en- tient care using osteopathic manipula- ter the spinal cord in the T8-T9 region on tive techniques, the osteopathic medical the right side. The distractors are organs focus is evident throughout the COMLEX- whose visceral afferents enter the cord at USA sequence in the tendency of the test

60 IN THE PUBLIC TRUST

items to emphasize the body’s capacity criterion for generalized anxiety disor­ for self-regulation and repair and the cor­ der (Diagnostic and Statistical Manual of responding interrelationship of bodily Mental Disorders, American Psychiatric structure and function. Osteopathic inte­ Association, 1994). Her musculoskeletal gration is further achieved by other inter­ findings are corroborative to the other disciplinary items that reflect the signif­ generalized anxiety disorder features icance of musculoskeletal findings, as with which she presents. shown in the following test item: Osteopathic integration is even fur­ ther achieved by test items that challenge A 26-year-old woman is observed examinees to consider OMT along with pacing in the waiting room prior to a conventional management issues. The new-employee physical examination. She following item illustrates this feature: startles as the physician enters the exam room and appears much more concerned A 53-year-old woman with rheuma­ than seems appropriate to the situation. toid arthritis of 13 years’ duration, stable The physician tactfully comments about on a maintenance dose of a nonsteroidal her demeanor, and she replies, “Oh, anti-inflammatory drug NSAID( ), returns I’ve always been like this and even get for a follow-up visit. She now complains teased because I worry about everything of a four- to five-week history of increas- constantly.” She admits to problems con­ ing dorsal neck pain, and dyesthesias in- centrating and also to having difficulty volving both hands and occasionally her falling asleep even when fatigued. Phys­ arms. Her exam reveals chronic rheuma- ical examination is within normal limits toid arthritis deformities. Evaluation of except for mild tachycardia and high her neck reveals restricted range of mo- levels of tension bilaterally in her mas­ tion with tenderness in the upper cervical seter, temporalis, and trapezius muscle area more pronounced on the right. Rou- groups. Her presentation is most con­ tine lab is normal. Which of the following sistent with: should be done next?

(A) agitated depression (A) change to a different NSAID (B) hypochondriasis( (B) begin methotrexate (C) somatization disorder (C) begin oral steroids (D) generalized anxiety disorder (D) direct action OMT to the upper cer- (E) obsessive-compulsive disorder vical spine (E) cervical spine x-ray in flexion The correct answer is D. Increased muscle tension is a DSM-IV diagnostic The correct answer is E. The first

61 concern is to rule out cervical spine sub­ [permits] medical students to take the ex- luxation and myelopathy. Direct action aminations out of order. manipulation is contraindicated, and Primary areas of ongoing research are more extensive treatment of the rheuma­ the refinement of examination reliability toid arthritis would probably be of no and validity. The extent to which the benefit or could possibly transiently mask examination is reliable is the degree to the symptoms placing the patient at high­ which the examination yields the same er risk. This question illustrates further results on multiple administrations. Reli­ that examinees must consider the indi­ ability asks, “Is the examination a tool cations and contraindications of adjunc­ that will provide a stable, dependable tive OMT as they should with any other measurement for different groups of can- therapeutic modality. didates over different periods of time?” COMLEX-USA is a sequential process: The COMLEX-USA sequence performs at each level must be successfully completed a [reliability coefficient] . . . of 0.85 and before moving on to the next level. Levels higher on a value range of 0 to 1, which l, 2, and 3 are each two-day, multiple- is considered a high coefficient value for choice tests administered twice annually. multiple choice examinations. Each day of testing is divided into two The validity question asks, “Does four-hour sessions consisting of approxi- the examination measure what we say mately 200 examination items with the it is measuring?” The COMLEX-USA con­ range of topics randomly ordered. Vir- struction and review committees regu­ tually all osteopathic medical schools re- larly ask faculty members and adminis­ quire their students to sit for Levels 1 and trators to give feedback on examination 2 of COMLEX-USA and the vast majority items. Items are routinely submitted to of osteopathic medical graduates in both those in the fields of osteopathic medical AOA-approved and ACGME PGY-l pro- education for feedback about the items’ grams sit for Level 3 of COMLEX-USA. perceived appropriateness. Candidates The COMLEX-USA examination is likewise are surveyed after taking the appropriate for U.S. osteopathic medi- examination to learn their opinions on cal students and graduates and closely whether the examination reflected their follows the general progression of osteo­ expectations and whether it represented pathic medical education and training of an appropriate relationship to their medi- the 19 osteopathic medical schools in the cal education and training experiences. United States, and it is consistent with a The development of COMLEX-USA model of osteopathic practice. Because included the adoption of new pass/fail of the integrated sequential nature of the standards to reflect the profession’s vi- examination, there is no mechanism that sion and expectations of minimum com-

62 IN THE PUBLIC TRUST

petency to practice osteopathic medicine is to affirmatively offer to each osteo- within the current and emerging health- pathic medical college the opportunity for care system. Standard setting is achieved faculty to review the examination under by a method generally accepted for high- secure conditions. Since the 1998 cycle stakes examinations. The new standards of COMLEX-USA, osteopathic faculty are are content-based and are, therefore, in- asked to fill out a standard survey instru- dependent of performances of specific ment after reviewing the examination. examinee groups. Over 80 percent of those faculty members These new standards were set by rated the quality of the items, connection carefully selecting committees of experts to osteopathic education, and the balance within osteopathic medical education. For of the examination content as “good” or Levels 1 and 2, the selection of committee “excellent.” NBOME will continue to sur- members began with a review of nomina- vey formally and systematically a wide tions from the osteopathic medical schools sample of osteopathic educators. There and leaders within osteopathic graduate are also plans to expand the survey to col­ medical education. Final selection was de- lect the opinions and impressions of os- signed so each discipline would be repre- teopathic practitioners in the field who are sented. The committees also represented not actively involved in education. This the widest possible cross-section of those “field test” of the examination style and faculty having good professional repu- content will provide an added dimension tations and seasoned understanding of to our ongoing assessment of validity. osteopathic medical practice. The process As a component of a continuous quali­ of standard setting involves all committee ty improvement strategy, NBOME is en- members reviewing each item used in the gaged in a study to examine the construct examination. Each member then makes validity of the novel design features of an independent judgment about the per­ COMLEX-USA. A uniform content speci- centage of borderline candidates who fication across all three levels is a unique would answer each of the aggregated per- feature not shared by any other licens- centage correct for the total exam. NBOME ing examination process. This new design policy requires reexamination of pass/fail provides a method to raise the standard standards for each level of COMLEX-USA of the quality of licensing examinations. every 3 years. It does this by addressing the critical is- In the past, NBOME’s policy has been sues of both continuity and differentiation to accommodate an osteopathic school’s that are characteristic of progressive pro- request to have their faculty review the fessional education and training, which actual COMLEX-USA examination materi- are comprised within each level of the als and booklets. The new NBOME policy examination. These complex issues of

63 continuity and differentiation have never sure the degree of competency expected before been empirically formulated. The according to the respective point in the purpose of the COMLEX-USA Construct educational/training process. The Con­ Validity Project is to examine whether struct Validity Project will specifically the outcomes of the novel features realize examine if each higher sequential level the goals of the uniform test specification demonstrates a difficulty increment over design. its lower-level counterparts. It will mea­ An inherent assumption of the COM- sure the extent to which these increments LEX-USA design is that the three exam­ are reasonably spaced. It will also address inations together define the minimum if the pass/fail standards of the three lev- competencies to practice osteopathic els are meaningfully spaced. medicine in an independent, unsuper­ Continuous refinement and quality vised setting. Each exam level has its improvement is an ongoing process for own emphasis in both areas of breadth this new examination paradigm. and depth. Each level is intended to mea­

64 IN THE PUBLIC TRUST

A distinct licensure examination, addressing the critical differences in educational philosophy, is a principal component of [our] survival. I also believe that it is in the interest of the public health and safety that all states assure that candidates for a license to practice osteopathic medicine have taken and passed an examination that has assessed their knowledge and skill in the areas relevant to their scope of practice. For osteopathic medicine, the only examination series meeting that standard is the COMLEX-USA. Boyd R. Buser, DO NBOME chair, 2003-2005

Comlex-USA Today

The article reprinted from the JAOA In 2009, students from the twenty-six gives a sense of the history of the develop- U.S. osteopathic medical schools use COM- ment of the COMLEX-USA examination LEX-USA to measure their knowledge and and the procedures used to create the test diagnostic abilities. Each COMLEX-USA items. It also explains how the examina- test item goes through five independent tion sequence addresses the maturation of committee reviews and is pre-tested be- the osteopathic medical candidate. Since fore it is used in an actual examination. the article’s publication in 2000, many New items are scrutinized by the staff things have changed. Most notable is that to ensure proper coding, grammar, and the COMLEX-USA is in administered in a context. The graphics are checked for ac- computerized format, the clinical skills curacy. All “clean test items” are then examination component has been incor- surveyed by the New Item Review Com- porated into the sequence, and the va- mittee. Those that pass are sent to the Ap- lidity argument has been clearly settled. proved Item Review Committee for their The CBT examination is now offered na- approval. A third committee analyzes and tionally at professional test centers more approves items selected for pre-testing. than forty times per Level per year as a The results are subject to statistical analy- day-long test. The Level 2 PE is given all sis. Items passing this hurdle are sent to year around at the NCCST. the Examination Review Committee and

65 if approved, put into the item bank for the psychometric quality of COMLEX CBT use. and gave it high marks. They considered The computer based testing (CBT) NBOME’s CBT setup one of the most in- format was introduced in July 2005 after novation systems in the nation. Approxi- years of work by Dr. Linjun Shen and his mately 12,000 candidates take the COM- team. Level 2 was implemented first in July LEX-USA series annually and to each of 2005. This component of CBT COMLEX- them, the questions are new. USA was labeled Level 2 CE (cognitive To be certain that NBOME examina- evaluation) to identify and distinguish tions are valid to measure the competency it from the clinical skills performance of DOs seeking licensure, psychometric component of Level 2, which followed techniques are used. The NBOME routine- in September 2005. Either of the Level 2 ly conducts internal audits to ensure the components (CE or PE) could be taken in high psychometric quality of its products. any order. Level 1 was introduced last to It also invites external auditing by na- complete the conversion of the COMLEX- tional experts. Over the years, the NBOME USA sequence in May 2006. has continued to conduct research to as- As has always been the case, a can- sure that the content, construct, and psy- didate must successfully complete Level chometric accuracy and integrity of the 1 before Level 2. Level 1 and both com- NBOME examinations. The literature is ponents of Level 2 must be completed in replete with articles reflecting this con- order to take Level 3 in the CBT format. tinued effort. The NBOME has invested The most difficult problem was mak- heavily to ensure that the examinations ing the examinations secure, despite offer- are secure, and that a great deal of pro- ing them on-line multiple times each year. fessional effort is spent in maintaining To keep candidates from memorizing the and improving the quality, currency and questions and giving them to others, it applicability of the examinations used for was thought that multiple test forms with osteopathic medical licensure. completely different items were needed. The NBOME continues to work to as- As each examination uses 400 questions, sure the security, quality, integrity, cur- the number of available test items re- rency, and applicability of its osteopathic quired would be daunting. No solution licensure examination sequence. Visit the to this problem was available in the litera- NBOME website at www.nbome.org for ture, but on sudden inspiration, Dr. Shen the most up-to-date, complete and accu- came up with an idea that worked. rate information regarding the NBOME Four years after CBT was launched, a and the COMLEX-USA examination se- group of national testing experts reviewed quence.

66 IN THE PUBLIC TRUST

NBOME Testing Linjun Professionals Shen, PhD Dozens of people—board members, staff, and consultants—worked on Linjun Shen COMLEX-USA. It was a team effort in joined the much the same way that the launch of a NBOME as a space shuttle is. Years were spent on the psychometri- project, thinking, discussing, composing, cian in 1990 being disappointed, and thinking, when a gradu- discussing, and composing again until success was achieved. ate student. He graduated from Among the staff members, no one the Measurement, Evaluation, and put more time and effort into developing Statistical Analysis (MESA) pro- COMLEX-USA than Dr. Linjun Shen, vice gram of the University of Chicago president for research and cognitive in 1994 with a PhD degree. In testing. It was his skill in implementing 1998, he completed a master of ideas that made the project a reality. Dr. Joe Smoley, vice president for public health degree (MPH) em- administration, oversaw the whole phasizing epidemiology from the process, which culminated in the University of Illinois at Chicago. imple-mentation of the delivery of Dr. Shen’s role with the NBOME COMLEX-USA at over 320 professional gradually evolved into program test sites nationwide, on-line electronic development and management registration, electronic item banking, a uniqe website, and improved of testing. He has been involved telecommunications. He was assisted in all NBOME written examina- by David Kreines and Michael Kastler, tions for the past twenty years and both IT specialists. spearheaded computer-based test- Among other professional staff mem- ing. He believes that osteopathic bers today, Dr. Erik Langenau, as vice licensing programs have the ca- president for Clinical Skills Testing, is in charge of Level 2-Performance Evalu- pability to break new ground in ation. Crystal Wilson, MEd, serves as the field of licensure and certifica- managing director of the National Center tion and his technological creativ- for Clinical Skills Testing. ity continues to lead the way.

67 Joseph Erik Smoley, PhD Langenau, DO Joseph Smoley began employ- After growing up ment at the in rural Michigan, National Board Erik Langenau of Examiners received his DO for Osteopathic in January 1985 after complet- from New York ing his PhD in Educational College of Osteopathic Medicine. Psychology and Research Methods After completing his internship, pedi- at Loyola University of Chicago. atric residency and chief residency at Up to that time, his experience had Maimonides Infants and Children’s all been in the area of assessment. Hospital of Brooklyn, he continued Shortly after his arrival, Thomas F. as a pediatric hospitalist, outpatient Santucci, Jr., DO, began the task of re- preceptor, associate program direc- vamping the entire test development tor for the institution’s allopathic pe- process. This included a new name, the diatric residency program, and pro- National Board of Osteopathic Medical gram director for the osteopathic pe- Examiners (NBOME) with addi- diatric residency program. As an tional staff, committees and resources educator, he enjoyed the opportunity to implement a strategic plan. The to develop and administer resident- first five-year plan was sketched out level Objective Structured Clinical in many iterations on cloth napkins or table cloths thanks to the La Famiglia Examinations (OSCEs) for forma- restaurant in Philadelphia. These last tive assessments. As his interest in twenty years for Dr. Smoley have been OSCEs and clinical skills assessment filled with the challenges and oppor- grew, he relocated to Conshohocken tunities necessary to promote a high to assume the role as NBOME’s vice standard of educational assessment. president for Clinical Skills Testing. The next decades promise no less.

68 IN THE PUBLIC TRUST

Part III

Information about the early clinical purpose of assessing a candidate’s clinical examinations is sketchy. The first ones competence as an osteopathic physician were given once a year, beginning in 1936, and surgeon. It was given by a panel of during the summer AOA conventions. By associate examiners under the supervision 1947, Part III was given annually at the Los of a director of medical education or a chief Angeles and Philadelphia colleges using examiner and member of the board. live patients. In 1968, NBEOPS President, Although Part III reflected greater Dr. Spencer Bradford reported,“After application of knowledge in the clinical considerable study, a new Part III format setting, by 1986 it was no longer practicable was developed, retaining the practical to continue to use actual patients as part quality but administering the test at the of the testing sequence because of privacy, site of the candidate’s internship. The liability, and test standardization issues. respective directors of medical education Patient comfort was also taken into con- serve as chief examiners and the sideration. With the discontinuation of candidate is tested by a series of associate Part III as a clinical assessment program, examiners, using actual teaching cases in NBOME decided to use the more objective the hospital. . . . Careful analysis of the multiple-choice type examination. results by the Part III Committee showed From 1986 until the 2004 introduction that the examinations had served the of the clinical skills assessment program desired purpose quite well. In addition, using standardized patients, Part III did most participating institutions felt that not evaluate hands-on clinical skills. It was the procedure had been helpful to the an objective-type examination in paper- intern training program.” and-pencil format until the introduction A 1976 report gives a few more clues of the computer-based (CBT) version of about the history of Part III. The first half COMLEX-USA Level 3 in 2005. then consisted of a written examination With the advent of computerized with live patient evaluations and a medical testing, the NBOME was able to use new record review. It was given annually graphics, audio-visual test items, and at an AOA-approved hospital during a interactive test items that more closely rotating internship. A director of medical resemble the clinical situation as it education was in charge of administering may appear in actual practice without the test. utilizing real patients. This form of test The second part of Part III was an item, facilitated by CBT technology, oral and practical examination for the helps to augment the assessment of the

69 clinical competence of the candidate. COMLEX-Level 2-PE is is based on Ongoing research continues to explore the use of twelve stations to objectively the possibilities for testing and training assess a candidate’s clinical ability. Four- offered by these emerging technologies teen minutes are permitted for the clinical and will permit a better assessment of the encounter with the SP. The candidate has competence of candidate in the future. an additional nine minutes to record the In 2004, the NBOME decided to place significant aspects of the encounter in a the clinical skills assessment program SOAP note, which should propose a dif- into Level 2 of COMLEX-USA. There ferential diagnosis and develop a plan of was the belief that all candidates must action to address the case. Each candidate demonstrate certain requisite clinical is also evaluated on OMT skills. SPs, using skills prior to entry into graduate medical prescribed checklists, score each clinical education programs. Therefore, the encounter, while the OMT performance is COMLEX-USA Level 2 PE is aimed at the assessed by osteopathic physicians from assessment clinical skills of a candidate videos. A separate cadre of DO examiners about to enter into supervised medical rate each SOAP note. care. A more detailed description of the The examination typically takes seven PE program is found on page 45. and a half hours to administer, includ- The use of Standardized Patients ing an extensive orientation program (SPs) was introduced into the Level 2-PE that precedes each examination. All can- clinical examination in September 2004 didates are tested at the NBOME National after nearly eight years of research, field Center for Clinical Skills Testing in Con- and pilot testing. SPs are lay persons shohocken, Pa., a state-of-the-art facility. trained to portray patients with various Score fidelity is assured by rigorous qual- diseases and conditions that are likely ity control measures. to be encountered by the osteopathic In the Biomedical/Biomechanical Do- physician or surgeon. Through the use of main of the examination, the candidate is SPs, history-taking, physical examination, evaluated on data gathering (history and and interpersonal and communication physical diagnosis), osteopathic manipu- skills can be assessed. Going beyond lative skills, and the ability to formulate medical knowledge, the Performance and write a SOAP note. The Humanistic Evaluation (COMLEX-PE) measures the Domain requires that the candidate es- candidate’s attitude, behavior, procedural tablish the doctor-patient relationship, skill, and ability to create a rapport with a demonstrate professionalism, and show patient, a skill critical in primary care. the ability to communicate.

70 IN THE PUBLIC TRUST

COMLEX-USA Timeline

1989 Taskforce developed 2001 FSMB passed resolution blueprint for COMLEX-USA 01-03 indicating COMLEX- USA valid for licensing osteopathic physicians 1990-1994 Ongoing research and development Special Committee on 2004 COMLEX-Level 2 PE Licensure, Sirici-Wright administered September 23, review, CMLES 2004 2005 COMLEX-USA converted to 1995 COMLEX-USA introduced CBT - Level 2 and 3 with Level 3 COMLEX accepted in Ontario, Canada, for initial registry Louisiana accepted COMLEX- 1997 COMLEX-USA Level 2 USA; DOs given full practice introduced rights

2006 COMLEX-USA accepted for 1998 COMLEX-USA Level 1 registry in New Zealand introduced AOBEM contracted with NBOME to deliver CBT 1998 FSMB challenged COMLEX- certifying examinations USA validity NBOME converted AOBEM certifying examination to 1999-2001 Special Committee on CBT format Licensure; Sirici-Wright reviews; CMLES formed

71 Item Writers and Case Authors of the Year 2008

Item writers are essential to the development of the COMLEX-USA examination. They contribute a great deal of time and energy to writing, reviewing and editing examination materials. In 2008, special recognition was given to the following contributors for their extraordinary service:

LEVEL 1 Charles Pavia, PhD, NYCOM������������� of NYIT

LEVEL 2-CE: Carmine D’Amico, DO, LECOM�����

LEVEL 2-PE Bruce Bates, DO, UNECOM

LEVEL 2-PE Gautam Desai, DO, UHS/COM

LEVEL 3 Theodore Spevack, DO, FACOEP, FACEP

LEVEL 3 Timothy J. Hogan, DO

HP/DP James L. Fleming, DO, MPH, FAOCPM Medical Director, Phoenix Fire Department Health Center

OPP Alexander Nicholas, DO, FAAO, PCOM

72 IN THE PUBLIC TRUST

Coordinators

Level coordinators and vice-coordinators are in charge of everything from recruiting the item writers and physician examiners, editing submitted questions, verifying source materials, and reviewing the final product. They oversee the work of the NBOME examination committees. Level 1 Coordinator: John Goudreau, DO, PhD – MSUCOM Vice-Coordinator: James Rechtien, DO, PhD – MSUCOM Level 2 Coordinator: Michael Geria, DO, FACOOG – UMDNJ-SOM Vice-Coordinator: Rocco Crescenzo, DO, FACOI Level 3 Coordinator: Roberta Wattleworth, DO, MHA, MPH, FACOFP – DMU-COM Vice-Coordinator: Peter Gulick, DO, FACOI, FACP, FIDSA – MSUCOM HP-DP/HCD Coordinator: H. Timothy Dombrowski, DO, FACOI – UMDNJ-SOM Vice-Coordinator: James Foy, DO, FACOP – TCOM-CA OPP Coordinator: Karen Snider, DO – ATSU/KCOM Vice-Coordinator: Mark Sandhouse, DO – NSU-COM OMM for PE Examination Coordinator: Dennis Dowling, DO Case Development and SP Training for PE Examination Coordinator: Jeanne M. Sandella DO SOAP Note Scoring for PE Examination Coordinator: Laurie A. Gallagher, DO Advanced Test Items Coordinator: Wolfgang Gilliar, DO, FAAPMR Vice-Coordinator: Robert Hasty, DO, FACOI

73 “During the years that the responsibility of osteopathic education has been placed more or less upon my shoulders as chairman of the Bureau of Professional Education and Colleges, I have grown in the belief that we have a certain dignity to uphold and that we must continue to build the thought of osteopathy as a complete therapy.”

John E. Rogers, DO, 1937 Founding Board Member NBEOPS

74 NBOME: The People

75 “The single most impressive thing about the NBOME is the people. They are a group of dedicated, committed individuals who give freely of the time, expertise, and effort for the greater good of the organization and not for their own personal gain. They often learn more about each other, and about how to improve medical education and testing in the process.”

Frederick G. Meoli, DO, 2009

76 IN THE PUBLIC TRUST

The NBOME is governed by a board of directors consisting of twenty members. Most members are DOs, with the exception of two lay members who represent the gener- al public. The AOA, the AAOE, and the AACOM each have one DO representative. Directors are elected to the board based on experience and expertise in the clinical and basic science disciplines, medical education and assessment, or medical or regulatory administrative experience reflective of the needs of the public and society at large.

Front row: John Becher, DO; John Thornburg, DO, PhD; William Ranieri, DO; Sheryl Bushman, DO; Janice Knebl, DO; William Anderson, DO; Eugene Oliveri, DO. Middle row: George Thomas, DO; Dana Shaffer, DO; Gary Clark; Brian Fulton, DO; Gary Slick, DO; Deborah Pierce, DO. Back row: John Gimpel, DO; Craig Lenz, DO; Michael Murphy,DO; Stephen Shannon, DO; Carman Ciervo, DO.

Not pictured: Wayne Carlsen, DO; Frederic Wilson; Frederick Schaller, DO.

77 The organizational structure in 1935 seems as simple as the Model T. The operation of the National Board was completely volunteer without office space or a home base. Communication among member was primarily by mail, with the occasional long-distance telephone call. Meetings were held in conjunc- tion with the AOA annual meeting.

78 IN THE PUBLIC TRUST

National Board of Osteopathic Medical Examiners, Inc. Organizational Chart NATIONAL BOARD OF OS(2008)TEOPATHIC MEDICAL EXAMINERS, INC. ORGANIZATIONAL CHART (2008)

Board of Directors (Chair/Vice Chair – Elected by Board)

Executive Committee Chair Secretary/Treasurer (Chair/V/Ch, Sec/Tres, 2 At-Lg) (Elected by Board) Board Committees

President - CEO Finance Committee (Sec/Tres)

Nominating (App’d by Chair) (Sec/Tres) VP Human VP for Operations/ VP for Clinical Skills VP for Cognitive NBOME Committees Examination Liaison Resources/CFO COO Testing (PE) Testing Coordinators (Est by Board)

Standards and Director of Finance & Candidate Services Managing Director Senior Test Product Level 1 Assurances Committee Human Services Coordinator Development IS Coordinators and Specialists Research Level 2 Personnel/HR Help Desk Staff Control Room Standards for Quality Reporting Reception Operators Acct’g/Finance Administrative Staff Test Assurance for COMLEX- Development Membership Level 3 USA Level 2-PE – Sub Director of Associate Director Assistants Committee Information Services for ADA CE SP Trainers IS Associate – Chicago SP’s Editor IS Associate CST Marketing & OMM/OPP Public Assoc Director of Director for Publication Relations Data Services Psychometrics & Specialists COMVEX Research - CST Administrative Staff Multimedia Publication & Research Assoc. Website Development COMAT Coordinator Director of OMM CSTAC Assessment Other Multimedia Item Specialist Emerging Coordinator of DR/PT Technologies Communications Assessment. Psychometrician Associate

Physician Research Examiners Associates

Physician Trainers

Case Development Committee

In 2009, the board’s organizational structure is complex. and far-reaching. Members work on their portfolios consistently and are in frequent communi- cation with each other, their committee members, and the staff through email, cellphones, meetings, and retreats. The large staff is also in constant motion, traveling to conferences, presenting educational programs, and creating in- novations in testing.

79 NBOME Committees

ADA Review Creates and administers policy for the accommodation of Americans with Disabilities Act. Chair: Jeb Magan, DO

Blueprint Audit Ensures that the content and format of COMLEX-USA is consistent Committee with the mission of the NBOME to protect the public. Chair: Frederick Schaller, DO

Competency Reviews COMLEX-USA to ensure that the core physician competencies are addressed. Chair: Eugene Mochan, DO, PhD

Consumer Affairs and Develops and recommends strategies to improve relationships with Relations existing agencies, jurisdictions, association, clients and the public.: Chair, Gary Clark

Clinical Skills Testing Assures the NBOME that the Clinical Skills component of COMLEX- Advisory Committee USA is current, accurate, valid, reliable and innovative. Chair: John (CSTAC) Becher, DO

Emerging Technologies Explores, evaluates, tests, and recommends implementation of new and existing technologies through the Product Committee. Co- Chairs: Jeanne Sandella, DO, and Rocco Crescenzo, DO

Finance / Audit Addresses the financial matters of the NBOME. Chair: Janice Knebl, DO

In-depth Assessment Assures the NBOME that the content and format of COMLEX-USA is consistent with NBOME’s mission. Chairs: William Ranieri, DO, John Thornburg, DO, PhD

Liaison Provides a forum for a free exchange of ideas between stakeholder groups and the NBOME. Chair: John Thornburg, DO, PhD

Product Prepares and recommends new products that will meet the needs of the profession and updates ones in use. Chair: Deborah Pierce, DO, MS

Research Stimulates, encourages, and supports intramural and extramural research. Chair: Thomas Hardie, EdD, RN

Standards & Assurances Assures that all products and procedures used by the NBOME meet acceptable industry standards. Chair: Thomas Cavalieri, DO

80 IN THE PUBLIC TRUST

A Few Good MEMBERS

William Anderson, DO first president of the Albany Movement, which worked to register African- American voters and devised ways to end racial segregation, getting the attention of Dr. Martin Luther King, Jr. Dr. Anderson is a member of Physicians for Social Responsibility. He writes: “As one of the newest members of the National Board of Osteopathic Medical Examiners, I am constantly challenged and rewarded as I learn more and more about how this outstanding organization works. I am proud to be a part of a process that assures the public that only the well- qualified physicians will be recommended for licensure. “The long hours and days of deliberation on how to make the Dr. Anderson is best-known for his examinations credible and valid are civil rights work and as the first African- rewarded by producing examinations that American president of the AOA, 1994- can withstand the most critical scrutiny 95. He was born in Americus, Georgia and analysis and meet the objectives and in 1927, and attended the Des Moines mission of the NBOME. College of Osteopathic Medicine. He “The very competent staff of the served as associate dean of the Kirksville NBOME makes it the finest testing College of Osteopathic Medicine and a organization in the country. Working clinical professor of osteopathic surgery with them is a pleasure, and their efforts at Michigan State University’s College to continually improve serve as a stimulus of Osteopathic Medicine, yet when he and challenge to me as well as the other returned to Albany, Georgia, in 1957, board members.” he was prevented from treating patients Six of Dr. Anderson’s children and because of segregationist policies. He grandchildren have become DOs. responded by becoming the founder and

81 John W. Becher, DO

ber of the advisory group on continued competence of licensed physicians of the Federation of State Medical Boards. Dr. Becher became involved with the NBOME over ten years ago as an item writer for COMLEX-USA. He has been a COMLEX-USA Level 2 coordinator, chair of the Level 2 examination review com- mittee, the PE case development com- mittee, chair of clinical skills testing advisory committee, a member of the product committee, and a member of the executive committee. As chair of the clinical skills testing advisory commit- tee (CSTAC) he was instrumental in de- veloping policy and procedures for the Dr. Becher is professor and chairman clinical skills examination. He was a pio- of the department of emergency medi- neer in his efforts to convert the Ameri- cine at the Philadelphia College of Os- can Board of Emergency Medicine into teopathic Medicine. He is also the chair a nationally administered, computer- of emergency services at the AtlantiCare based certifying examination. Working Regional Medical Center in Atlantic City, with the NBOME, he was able to develop New Jersey. He is a member of the board and implement the new examination of trustees of the American Osteopathic and in 2009, introduced the recertifying Association and treasurer of the Ameri- examination in that specialty in the same can Osteopathic Board of Emergency format. Dr. Becher’s participation in the Medicine. Dr. Becher formerly was the Physician Alliance for Physician Com- program director for the PCOM/Albert petence is evidence of his passion for im- Einstein emergency medicine residency proving medical education and promot- in Philadelphia. He has been president ing physician competence. His broad of the Pennsylvania Osteopathic Medical experience makes him a valued and con- Association and the Pennsylvania Trau- tributing member of the NBOME. ma Systems Foundation. He is a mem-

82 IN THE PUBLIC TRUST

Gary Clark, Administrator

Licensure, Enforcement and Regulation (CLEAR). He was a founding member and a past president of Administrators in Medicine (AIM), the organization of executive directors of the state licensing boards. He served three different times on the board of directors of the Federa- tion of State Medical Boards (FSMB), and in this position was a strong voice for NBOME. For the past several years he has been the volunteer executive director of the American Association of Osteopathic Examiners (AAOE). In 2007, he was elect- ed to the National Board of Osteopathic Medical Examiners as a public member, currently serves on a number of commit- Following graduation from Quincy tees, and is highly regarded for his abil- University in 1967, Clark went to Jeffer- ity to get things done. Now retired, he son City, Mo. as a pharmaceutical rep- enjoys reading and writing fiction and resentative. In 1975, he began work for cooking Tuscan and Provencal, with a the Missouri State Board of Healing Arts special interest in seafood dishes, from as executive director and in 1990 he be- land-locked Jefferson City, Missouri. came executive director of the Oklaho- ma Board of Osteopathic Examiners. He retired from that position in 2007. For more than thirty years, Clark has been active at both at the state and national levels with organizations asso- ciated with licensure and professional discipline. He served on the board of di- rectors and as president of the Council of State Governments’ Clearinghouse on

83 Eugene Oliveri, DO, MACOI, FACG, FACOS

osteopathy before he made the move. The minute he walked into Kansas City School of Osteopathy, Oliveri felt he belonged there, and after more than forty years of practicing and teaching internal medicine, he is even more enthusiastic about the profession. Medical mission trips have taken him to China, Russia, Cuba, and Italy and these have strengthened his commitment to a healthy public. A strong advocate for COMLEX-USA, Dr. Oliveri served three terms on the NBOME and was president of the AOA in 1999-2000. He joined the faculty of Gene Oliveri was born in Brooklyn, MSU-COM in 2000 and is presently as- N.Y., in a neighborhood that taught him sistant to the dean and professor of in- what “multi-ethnic” means. He became ternal medicine there. He delivered the a child-entrepreneur, de-livering ice at Galusha Address at the FSMB in 2000 the age of ten. and the A. T. Still Memorial Lecture to After a two-year stint in the U.S. the AOA in 2009. Army, where he became interested One of Dr. Oliveri’s four children, in public health, Oliveri returned to Dr. Lisa Jean Oliveri, followed in his Brooklyn College for pre-med work, footsteps and has a practice of gastero- intending to go to his family’s native enterology. Italy for medical school. A professor suggested he look into U.S. schools of

84 IN THE PUBLIC TRUST

Frederick Schaller, DO, FACOI

University Nevada, and also directs the internal medicine residency at Val- ley Hospital. He has served NBOME for eighteen years, the AOA COPT twelve years, and the ACOI twenty-four years (including as its president in 2005). Over the years with NBOME on many different committees and as a member of the board, Dr. Schaller has observed and assisted the organization in the con- tinuing development of valid, effective and respected examinations which meet the national mandate. He notes the re- markable flexibility, innovation, creativ- ity and adherence to strict standards of quality and validity which mark the After completing his osteopathic activities of NBOME. Development of medical training at Michigan State Uni- the Performance Examination, the intro- versity College of Osteopathic Medicine duction of new testing modalities, and in 1977, Dr. Schaller entered a general the restructuring of the testing blueprint practice in the mountains of Pennsylva- in line with the AOA core competencies nia. Three years later he returned to an all demonstrate the adaptability and ef- Internal Medicine residency and Cardi- fectiveness of the organization. ology at UMDNJ-NJSOM. He served eleven years there on the faculty, followed by sixteen years at Texas Col- lege of Osteopathic Medicine. In Texas he founded the Cardiology Fellowship at Plaza Medical Center. He now serves as professor and vice dean of Touro

85 Jim Award from the Florida Osteopathic Andriole, DO Medical Association. He is past presi- dent, and a current member of the Florida Osteopathic Medical Board. Dr. Andriole re- ceived his DO de- gree from PCOM in 1984. While practic- Wayne ing in Pennsylva- Carlsen, nia, he sustained a traumatic spinal cord injury that resulted DO, FACOI in paraplegia. As a result, he founded Disability Consultants USA, Inc., and Dr. Carlsen is is a longtime volunteer for the National the chair of the Sports Center for the Disabled in Colo- Geriatric Medicine rado. Dr. Andriole has a passion for flying and Gerontology around the United States and the Carib- Department at bean in his personal aircraft designed Ohio University College of Osteopathic with hand controls, accompanied by his Medicine (OUCOM), where he has been dog Bravo. Until recently, he provided a faculty member since 1993. He also medical care to impoverished villages in serves as the medical director for the Central America. He flew a transatlantic Medi Home Health Care Agency and is flight in a single-engine aircraft, inspiring the director for the Geriatrics Cost Center people with spinal cord injuries through- for University Medical Associates. He out Europe. received the Dean’s Award in 2004 from He is the current president of the OUCOM, where he serves on the college’s American Association of Osteopathic promotion and tenure committee, the Examiners (AAOE) and was appointed Institutional Review Board, and is the to the NBOME board of directors in 2009. medical director for community health He is the current treasurer of the FSMB programs. Dr. Carlsen is a 1986 graduate and was recently appointed to the Bu- of UMDNJ-SOM. reau of International Osteopathic Medical In 1989, Dr. Carlsen became an Education and Affairs. He is a delegate item writer for NBOME and has served to the International Association of Medi- on various examination construction cal Regulatory Authorities. Dr. Andriole, committees. He was a level coordinator who now resides in Tallahassee, Florida, for Level 3 in the 1990s and a member of received the Presidential Achievement the HPDP/HCD Examination Construction

86 IN THE PUBLIC TRUST

Committee for several years. He currently for six yearsTest Construction Committee serves on NBOME’s finance committee. for six years and is now a member of Dr, Carlsen has served on the NBOME NBOME’s finance committee. He has Board since 2005. been responsible for development of test construction for the ACOFP, bringing Carman A. NBOME and ACOFP together to work on Ciervo, DO, the project. Dr. Ciervo was elected to the NBOME Board in 2007. FACOFP

Dr. Ciervo is chair Brian of the Department Fulton, DO of Family Medicine at UMDNJ-SOM as well as chief Dr. Fulton is a con- of service for family practice in the sulting psychiatrist Kennedy Health System-University at the Plains Area Medical Center. A graduate of PCOM, he Mental Health Cen- completed his family medicine residency ter in Cherokee, at UMDNJ-SOM, where he also served as Iowa, a position he chief resident. has held since 1981. A native of Washing- Dr. Ciervo serves on many committees ton, Iowa, he completed his DO degree for and is president of the New Jersey at the College of Osteopathic Medicine chapter of the American College of and Surgery in Des Moines, Iowa, in 1975, Osteopathic Family Physicians (ACOFP). then completed a rotating internship at He is a fellow in the national ACOFP, and Cranston General Hospital in Rhode Is- vice chair of that organization’s CEE. He land. After serving as a general medical has received several awards, including officer in the U.S. Navy 1976-78, he com- the UMDNJ-SOM Excellence in Teaching pleted his psychiatry residency at Chero- Award. He has authored and co-authored kee Mental Health Hospital in Iowa. He numerous articles, abstracts, and lectures went on to serve there in several capaci- on a variety of topics affecting family ties, including site training director and practice. He sits on numerous advisory staff psychiatrist, throughout the 1980s boards, including those related to the and 1990s. He also had a private practice proper prescribing of antibiotics and in psychiatry in Sioux City, Iowa, and was appropriate treatment of allergic rhinitis. a consulting psychiatrist at Hope Haven Dr. Ciervo served as Level 3 Coordinator in Rock Valley, Iowa. He is board certified

87 from the American Board of Psychiatry the University of New England College and Neurology as well as the American of Osteopathic Medicine and Gold Foun- Osteopathic Board of Psychiatry and Neu- dation Humanism in Aging Leadership rology. He joined the NBOME Board of Award. Directors in 2005. Dr. Knebl began her service to the NBOME as an item writer in the late 1980s, Janice A. becoming a Level 2 Test Review Com- Knebl, DO, mittee participant and chair during the 1990s. She was appointed to the NBOME MBA, FACOI, Board of Directors in 1999, elected to the FACP, CMD executive committee in 2003, and has served as secretary-treasurer since 2005. Dr. Knebl complet- Dr. Knebl has enjoyed participating in ed her osteopathic local, statewide, and national organiza- medical education tions that promote health and quality of at PCOM in 1982. life for older adults. She has a passion for She received the Dallas Southwest Dis- osteopathic medical education and for tinguished Endowed Chair in Clinical positively influencing the future practice Geriatrics in 2003 and has been chief of of American medicine. the Division of Geriatric Medicine within the Department of Medicine at UNTHSC- Craig TCOM since 1988. Lenz, DO, Dr. Knebl has received several distin- guished awards for excellence in teaching, FAODME including the 2004 James Pattee Award Dr. Lenz is profes- for Excellence in Education, the Ameri- sor of Emergency can Medical Director’s Foundation teach- Medicine/Family ing award, the TCOM M.L. Coleman DO Medicine/OMM Award for Excellence in Clinical Teaching, and senior associ- and the Golden Apple Award for Clini- ate dean at Lincoln cal Teaching. She also has received the Memorial University DeBusk College of distinguished Internist of the Year Award Osteopathic Medicine. He graduated from the ACOI. Most recently she partici- from PCOM in 1978. He completed his in- pated in the Drexel University Hedwig ternship at John F. Kennedy Memorial in Van Ameringen Executive Leadership in Stratford, New Jersey. Dr. Lenz is a mem- Academic Medicine (ELAM) Program and ber of the board of trustees for Southwest is now an ELUM. In 2008, she received Virginia Graduate Medical Education

88 IN THE PUBLIC TRUST

Consortium and a member of the advi- Carey University College of Osteopathic sory board of Middlesboro ARH Hospital. Medicine in Mississippi. After graduating He was a founder of the AHEC Program from Kirksville College of Osteopathic at UNECOM, and a dean at COMP. He also Medicine in 1973, Dr. Murphy joined the serves the AOA as Osteopathic College U.S. Navy, completing his internship Accreditor and team chair for COCA. He and residency at Camp Pendleton Naval is also an OPTI Accreditor and Internship Hospital in California. He continued an Program Inspector. Dr. Lenz has served active career with the military, where his on the NBOME board since 2001. assignments took him to major military He writes, “I was so proud to be a part hospitals throughout the United States of NBOME when I was first asked to write and to Guantanamo Bay in Cuba. He re- items over twenty years ago. The quality tired as captain in the Medical Corps in of the organization and the dedication of 1999 then began an academic career in its leadership has continued to evolve to osteopathic medicine. meet the complex set of challenges for an Dr. Murphy received the KCOM Spe- organization responsible for the pathway cial Recognition Award and was the to licensure. Linda, my wife of 36 years, recipient of numerous military service and I are proud of our three children: awards. He currently serves as Trustee- Laurie, who is a DO; Craig Jr., who just Region 3 for the AODME. He has also started his first year at LMU-DCOM; and served on various AOA committees and Andrew, who does pharmaceutical re- is a member of the AOA Board of Trust- search. My deepest hope is that by being ees. Dr. Murphy was selected to serve a part of NBOME, I have given back to the on the first Standard Setting Committee profession that gave me the chance to be for COMLEX-USA Level 2-PE in 2005. He an osteopathic physician.” has been a member of the NBOME Board of Directors since 2005. Michael Deborah Kenneth Pierce, Murphy, DO, DO, MS FACOFP, FAODME Dr. Pierce is the associate residen- Dr. Murphy is cy director for the vice president and emergency medi- dean of William cine residency pro-

89 gram at Medical Center positions on that board, and the board in Philadelphia and is a board-certified of the American Association of Osteo- emergency physician. She has worked pathic Examiners, where he is currently with the NBOME for fourteen years, start- vice president. In 2008, he was elected ing with the organization as an item writ- the AAOE representative to the NBOME er for COMLEX-Level 2, was on the item board of directors. In addition, he serves and test review committees for Level 2, on the NBOME ADA subcommittee, the and served three-year stints each as vice consumer affairs and product commit- coordinator and coordinator for Level 2. tees. She has been on the board for the past four years. She is chairman of the prod- Stephen C. uct committee, serves on the membership Shannon, committee and the committee for new in- novations and advancing technologies. DO, MPH Dr. Shannon has Dana been president of Shaffer, DO the American As- sociation of Colleg- es of Osteopathic After completing Medicine (AACOM) undergraduate since January 2006. Before that, he served medical education as vice president for health services and in 1985 at PCOM, dean of the University of New England Dana Shaffer com- College of Osteopathic Medicine. Dr. pleted a rotating Shannon graduated from UNECOM in osteopathic internship at Des Moines 1986 and went on to receive his master’s General Hospital. For the next twenty-two of public health degree in 1990 from Har- years, he practiced the complete spectrum vard University School of Public Health. of rural family medicine, including OMM, He is board certified in preventive medi- OB, and ER, as well as both inpatient and cine and osteopathic family practice. outpatient medicine in Exira, Iowa. He has been a member of the NBOME Dr. Shaffer serves as the senior associ- Board since 2000, when he was selected ate dean of clinical affairs at Des Moines as the representative of the AACOM. Over University College of Osteopathic Medi- the years, he has witnessed tremendous cine in Des Moines, Iowa. Over his ca- development in the NBOME, with the tran- reer, he has served on the Iowa Board of sition to a full-time president, implemen- Medicine and has held several leadership tation of the computer-based examination

90 IN THE PUBLIC TRUST

and performance evaluations, and the University. He has served the osteopathic strides taken in evaluation and research profession as president of the ACOI, chair to improve the quality and standardiza- and executive director of the AOBIM, and tion of testing in the osteopathic medical chair of the Bureau of Osteopathic Spe- profession. He is tremendously gratified cialists of the AOA. to have the opportunity to participate Dr. Slick has served the NBOME in with this organization as it looks back on numerous capacities since 1978, includ- seventy-five years of accomplishments, ing item writer in physiology for Level 1 and he looks forward to implementing and item writer in internal medicine for changes that will maintain and enhance Level 2 and 3, Test Construction Commit- its leadership in coming decades. tee member in interdisciplinary medicine, and final reviewer ofCOMLEX-USA Level 1 examinations. He was chair of the Test Construction Committee in physiology, Gary L. and served on the committees for emerg- Slick, DO, ing technologies. He has been an NBOME board member since 2005. MA, MACOI George Dr. Slick is a grad- Thomas, uate of the of DO, Medicine and Bio- FACOFP sciences and re- ceived his master’s degree from the Uni- Dr. Thomas prac- versity of Kansas. He served as chair of tices medicine the Department of Internal Medicine at at Euclid Family Midwestern University-COM for twenty- Practice-Meridia one years. He then became vice president Medical Group in Euclid, Ohio. Having for academic affairs at Oklahoma State graduated from Kirksville College of Os- University Center for Health Sciences and teopathic Medicine in 1972, he completed now serves as associate dean for graduate his internship at Charles Still Hospital in medical education and director of medi- Jefferson City, Missouri. He is a recipient cal education at the OSU Medical Center. of many honors, including the Trustees Dr. Slick has received numerous awards, Award and the Distinguished Service including Educator of the Year from the Award of the Ohio Osteopathic Asso- graduating class of 2000 at Midwestern ciation (OOA). Dr. Thomas has served in

91 many capacities for the Cleveland Acad- and Gamble Pharmaceuticals in Mason, emy of Osteopathic Medicine, the OOA, Ohio. He worked closely with the AOA and the AOA, where he served as presi- through the AOA Foundation, and was dent for 2004-’05. He has represented the instrumental in establishing a scholarship AOA with many associations and organi- fund to help students meet the costs and zations, including the National Commit- challenges of the COMLEX-USA Level 2 tee of Quality Assurance, the Ambulatory PE examination. Quality Association, and United Health Being disabled himself he acted as an Group Practicing Physicians Advisory advocate for the handicapped in testing. Committee. He was the first public member selected Dr. Thomas writes, “During the to serve on the Board of Directors of the FSMB/NBME attack on the credibility and NBOME, and served the NBOME for near- validity of the COMLEX-USA exam and ly six years. NBOME, it was Dr. Fred Meoli’s calm- ing personality and strength along with Board members profiled elsewhere: the professional integrity of the validity Sheryl Bushman, DO studies of Linjun Shen, PhD, that blunted John Gimpel, DO, MEd, (until appoint- the attack and fortified theNBOME in the ed president in July 2009) eyes of the medical community.” He has William Ranieri, DO served on the NBOME board of directors John Thornburg, DO, PhD as the AOA representative since 2008. In Memoriam: Frederic A Special Mention Wilson Over the years, the families of the NBOME board members, the NBOME staff, and our committee chairs have support- The NBOME mourn ed us in innumerable ways. They have the irreplaceable hosted dinners, provided moral support, loss of Mr. Fred- offered innovative ideas and perspectives eric Wilson, who and have been there to take the displaced passed away on frustrations that come from an organiza- October 11, 2009, tion that strives to be the best that it can after a long ill- be. They have served as ambassadors, ness. Mr. Wilson emissaries, and advocates for the public, worked in the Professional and Scien- the students, and the NBOME itself. We tific Relations Department for Procter are very grateful and appreciative.

92 IN THE PUBLIC TRUST Staff nbome Staff Perspectives from some of the longest-serving NBOME staff members:

Sydney L. organization over the last two decades Steele, JD, as it developed its preeminent comput- er-based and performance-evaluation General COMLEX-USA examinations now being Counsel administered throughout the United Sydney Steele, States and elsewhere. was retained as le- gal counsel in 1993 and has served Shirley the NBOME as its Bodett, general counsel since that time. He is licensed to practice law in Indiana (the Senior state of incorporation of the NBOME) and Testing in all the federal courts, including the U. Consultant S. Supreme Court. He graduated from Purdue University and attended law Shirley Bodett school at Indiana University, graduat- thought the job as ing in 1964 with a doctorate of jurispru- the NBOME office dence. He serves as an officer or board manager would be member for numerous national and lo- only temporary, until she became a full- cal legal and civic organizations. time orchestra manager. Twenty-five As general counsel of the NBOME, years later, she is still with the NBOME Mr. Steele witnessed and participated and glad she stayed. When she first in dramatic changes in the organization. came to work, the NBEOPS was housed His first significant task was to negotiate in a three-room one-story office build- the settlement with the AOA following ing with no air-conditioning. On warm the legal disputes in the early 1990s. A days, staff opened the windows and had successful agreement was reached that to make sure papers didn’t fly too far. recognized the legitimate interests of They had no computers, only two giant the both the AOA and NBOME; this ac- word processors. Test items were kept cord continues to benefit the osteopathic on file cards and word processor floppy medical profession and the public. He disks—about fifty items to a disk. Ms. also has witnessed the growth of the Bodett joined a two-person staff; soon

93 afterward, two more administrative as- USA. A few years later, the group was sistants were hired. An annual item- building the National Center for Clinical writing-and-review meeting was held Skills Testing to administer the COMLEX- for small groups of physicians to review USA Level 2-PE. Even nine years ago, the new items in each discipline. Those items NBOME had great aspirations for the fu- were transferred to file cards, which ture, and over the years, Ms. Cossetti has were stored and used to compile ex- helped those objectives come to fruition ams. In addition to the multiple-choice while carrying out the NBOME’s mission Part III examination, interns also had to “To Protect the Public.” do “live patient evaluations.” In 1987, She writes, “I am honored to say a new president, Dr. Thomas Santucci, that I contribute to an organization that made substantial changes to the exam makes a difference, an organization that development process and the structure takes pride in its contributions to soci- of the board. From that point on, chang- ety, and an organization whose board es have progressed at lightning speed, to and employees work hard every day the point where the NBOME now is fully to support its mission, while striving to in the computer age and employs many reach the vision of becoming the testing times over the number of employees it organization for the entire osteopathic once did in its production of high-quali- profession. The past seventy-five years ty, reliable testing instruments that have of accomplishments are evidentiary of been lauded by testing experts. what the NBOME can do, and how it can make a difference. I am looking forward to being a part of this family for years to Taunya come as NBOME pioneers for osteopathic Cossetti, medicine into the twenty-first century.” Executive Assistant to the President

Taunya Cossetti first became familiar with NBOME nine years ago, having accepted a position to assist with a research study for a po- tential clinical skills exam for COMLEX-

94 IN THE PUBLIC TRUST

David C. It soon became apparent that a single Kreines, system would not handle the volume of work and additional functions that were Associate required, so the group purchased its first Director “server” computer. Since this system for Data was compatible with the database man- agement system, all the programming Services continued to work, and the NBOME en- tered the computer age. As computerized systems began to prove themselves, the David Kreines became director of infor- work of the testing department was also mation systems for the NBOME in 2005, moved from the processor to a server and now serves as associate director for and then to a new item banking system, data services. He started working with which was custom designed and built on the NBOME in 1987 as a contractor at a the NBOME’s newly acquired network of time when the NBOME did not even own PCs. This system replaced the existing a computer; a word processing unit was system by the mid-1990s. Through the the closest thing the organization had. 1990s and into the 2000s, those systems Mr. Kreines helped to develop a basic were expanded and tuned, but the basic system for registering candidates, track- architecture continued to function. The ing scores and record keeping, and he database management system turned programmed the first in-house optical out to be a critical component and is in scanner for processing answer sheets. use at NBOME today in a more modern The system initially ran on a single com- version. Mr. Kreines has been integral to puter using a database management sys- the way the organization has grown in tem. That system closely mirrored the the computer era to keep pace with the existing paper applications and forms, needs of the profession, the candidates, and essentially computerized the manu- and the public. al processes used in the office.

95 75th Anniversary Staff of the NBOME

The NBOME is deeply indebted to and greatly appreciates all the staff members who have provided the energy and effort that has been needed to make the NBOME the strong professional organization it is today and the even stronger organization it will become.

Listed below are those on the active employee roster for the year of the 75th anni- versary, 2009 who have not been cited elsewhere.

Chicago Office Conshohocken Office

Mirela Bonica, Client Service Rep Adam Benjamin, Control Rm Operator Ashley Bronersky, Test Associate Caitlin Dyer, Coord for QA Julie Burgett, Sr. Test Specialist Gregory Folk, IT Services Coord Henryka Chmura, Financial Asst. Laurie Gallagher, DO, Physician Trainer Richard Conner, IT Services Coord Robert Hendricks, SP Trainer Tracey Gates, Client Services Rep Wayne Hibschman, SP Trainer Kathy Green, Sr. Text Specialist Timothy Koltonuk, Control Rm Operator Dee Grimes, VP, HR/CFO Kristie Lang, Admin Asst/ PT Judy Hibbert, Clerical Associate Rachel Maxwell, Admin Asst Michael Kastler, Director, IS Donald Montrey, SP Trainer Feiming Li, Psychometrician Kathleen Natter, Exam Administrator Zhonghe Lu, Test Media Specialist Cara Ondik, Admin Asst/ EA Peter Lu, Sr. Test Specialist Gina Pugliano, Research Assoc Jaquelyn Miller, Receptionist William Roberts, EdD, Dir for Psycho- Regina Oryszczak, Dir., Finance/HR metrics Candice Pernell, Test Associate Jeanne Sandella, DO, Assoc. Dir for Case Rochelle Teague, Client Service Rep Dev/Training Yi Wang, Sr. Research Associate Joseph Schwartz, Exam Administrator Margaret Wong, Client Services Mngr Mia Solomon, PhD, Coord for Dr-PT Communication Assessment Margot Young, SP Trainer Amy Zeltner, Asst Dir

96 IN THE PUBLIC TRUST

Supporting the Community

During the early years of its formation, care, and several of its board members the National Board was primarily are involved in encouraging new doctors concerned with recognition, acceptance, to choose rural medicine. and the development of a quality universal At the professional level, the NBOME examination for medical licensure. As participates in and/or supports almost the organization became established, all organizations involving osteopathic the National Board extended its area of physicians, such as AODME and the concern. NBOME people today are aware various bureaus of the AOA. The NBOME that they are part of a larger community, is a strong supporter of the National beyond hospital, college, or office. The Alliance for Physician Competence, which board and staff feel that fostering a sense produced a document titled The Guide to of community is important at all levels, Good Medical Practice-USA. international, national, and local. The NBOME has reached out inter- In Chicago, the NBOME supported nationally in many ways, by supporting the KABOOM program in cooperation efforts to improve medical facilities in with the AOA. The program provides third world countries, through medical playgrounds and parks for children in missions, and by participating in distressed neighborhoods. organizations such as the Osteopathic In Conshohocken, the NBOME International Alliance (OIA) and the staff participate in the “Walk to Cure International Association of Regulatory Diabetes,” which includes a walk along Authorities (IAMRA), which addresses Philadelphia’s West River Drive to support issues of medical workforce shortages, juvenile diabetes research. The staff also physician portability, quality medical strongly supports local efforts for breast care, and better access to medical care. cancer awareness and attentiveness to the The profiles of board members, health problems connected with being although packed with organizations and overweight. educational institutions, do not show the The NBOME contributed to a com- scope of their involvement with the world. munity health care initiative in Fort Scott, Several go on mission trips, bringing Kansas, and to the Bayou la Batre Rural their expertise to areas in need. Others Health Clinic in Alabama which had volunteer in their churches, in sports been damaged by both fire and hurricane activities for children, or in programs for Katrina. The NBOME, like the AOA, has the elderly. Their definition of “the public a long-standing interest in rural health trust” includes everyone in need.

97 “I believe most osteopaths . . . are trying to do something to make it pos- sible for humanity to enjoy the wonderful healing powers of this new sci- ence. We do not all have the same ideas as to detail in accomplishing the desired results, but we are all justified in expecting cooperation.”

Samuel V. Robuck, DO, 1923

98 Appendix

99 NBOME Timeline

1934 Chartered as the National Board of Examiners for Osteopathic Physician and Surgeons (NBEOPS) 1935 Elected first president, Charles Hazzard,DO 1936 Administered the first examination and issued the first Diplomat Certificates 1946 NBEOPS challenged AOA on membership selection 1947 Part III of the examination involved live patients 1951 Incorporated in Illinois as the National Board of Examiners for Osteopathic Physicians and Surgeons (NBEOPS), AOA approved conducting Part 3 in hospital setting 1961 Multiple choice examination introduced 1966 Developed licensing exam for the Osteopathic Medical Board of Florida 1975 Developed licensing examination for California and Michigan 1981 Developed licensing examination for Pennsylvania 1984 Received grant from the U.S. Department of Health and Human Services to develop competency- based standards 1985 Developed licensing examinations for Tennessee and West Virginia 1986 Incorporated in Indiana as the National Board of Osteopathic Medical Examiners (NBOME) 1986 Discontinued live patient examinations for Part III 1987 Internalized electronic scoring and analysis 1990 AOA rejected NBOME bid for internal controls 1991 NBOME settled third party rights issue with AOA 1993 NBOME and AOA reconciled 1993 New committee structure instituted for NBOME; retreats began 2002 First full-time president/CEO appointed 2004 NCCST opened its doors for Level 2-PE examinations 2004 NBOME admitted as associate member to IAMRA

2005 NBOME became a participant in PAPC and a partner in OIA

2006 NBOME published competency report

2007 NBOME contracts with AOBEM to provide CBT certifying examination

2008 COMSAE released, AOBEM converted to CBT format

2009 Second NBOME president/CEO appointed, AOBEM recertifying examination converted to CBT format

100 IN THE PUBLIC TRUST

Brief Summary of Osteopathic Medical History in Canada

1898 First osteopathic physician established practice in Canada (New Brunswick). 1901 Ontario Osteopathic Association chartered. 1923 Western Canada Osteopathic Association chartered. 1926 Canadian Osteopathic Association chartered. 1926 Osteopathic physicians in Ontario relegated to practice under the “Drugless Practitioners Act,” intended to be a “temporary measure.” 200 in practice in Ontario. 1970 Osteopathic physicians granted full practice rights in the province of Quebec. 1991 Medicine Act (Bill 55) incorporated osteopathic physicians; those sections re- lating to osteopathic physician registry not proclaimed into law. 1992 Medical Council of Canada recognized graduates of AOA-accredited schools as eligible to write their examinations (Medical Council of Canada Evaluating Examination, Medical Council of Canada Qualifying Examination). 2003 College of Family Physicians of Canada recognized graduates of AOA-accred- ited osteopathic medical schools as eligible to write their family practice certi- fication exams (Certificant College of Family Physicians of Canada). 2003 College of Physicians and Surgeons of Ontario extended full practice rights to American-trained osteopathic physicians. 2005 Royal College of Physicians of Canada recognized graduates of AOA-accred- ited osteopathic medical schools as eligible to write specialty certification ex- aminations (Fellow Royal College of Physicians Canada/Fellow Royal College of Surgeons Canada). 2009-2010 COMLEX-USA recognized by the College of Physicians and Surgeons of Alberta (anticipated with new Health Professions Act) late 2009 or 2010. COMLEX-USA recognized by the College of Physicians and Surgeons of British Columbia as of June 2009. Defacto recognition of COMLEX-USA by College des Medicins du Quebec as they accept DO qualifications with the addition of one year post-graduate training in Quebec. Defacto recognition of COMLEX-USA by New Brunswick through reciprocity with Maine.

101 NBOME Presidents

Charles Hazzard, DO 1935-1939 Chairs of the Board W. Curtis Brigham, DO 1939-1944 Thomas Cavalieri, DO, 2001-2003 T. T. Spence, DO 1944-1948 Boyd Buser, DO 2003-2005 Sheryl Bushman, DO, 2005-2007 Samuel V. Robuck, DO 1948-1963 William Ranieri, DO 2007-2009 Spencer G. Bradford, DO 1963-1976

Marion E. Coy, DO 1976-1980 President / CEO (full-time) Lester Eisenberg, DO 1980-1985 Frederick G. Meoli, DO 2002-2009 Thomas F Santucci, Jr., DO 1985-1987 John R. Gimpel, DO , MEd 2009- Robert E. Mancini, DO, 1987-1989 Eugene Mochan, DO 1989-1991 John J. Fernandes, DO 1991-1993 Bruce Gilfillian, DO 1993-1995 John P. Bruno, DO, 1995-1997 Gerald Osborn, DO 1997-1999 Frederick G. Meoli, DO 1999-2001

102 IN THE PUBLIC TRUST

The National Board Seals

The first seal, adopted in 1951, was used to imprint each diplomate certificate and other official documents. The use of the likeness of the founder of osteopathic medicine, A. T. Still, MD, DO, indicates the respect the board and the osteopathic profession had for him. National Board of Examiners of Osteopathic Physicians and Surgeons was inscribed in the outer ring.

The seal created in 1985 displays the new name of the organization, National Board of Osteopathic Medical Examiners (spelled out in the periphery), and its new direction. The book in the lower left portion symbolizes osteopathic medical knowledge and education. The caduceus represents the importance of the NBOME’s relations with all stakeholders within the osteopathic profession. The closed double ring of the inner circle represents a commitment to quality, excellence, and the protection of the public. The year 1934 indicates the date of the original charter.

The seal to commemorate its 75th anniversary, adopted in 2009, displays both a commitment to change and a respect for the past. The name of the organization is again in the periphery with “since 1934” just below the “75th Anniversary” notation. The single inner circular line continues to represent the dedication to the organization’s values of quality, integrity, accountability, professional commitment, and public safety. The book in the upper half of the inner circle defines the importance of osteopathic medical knowledge and education to the practice of osteopathic medicine. The most notable features in the new seal are the hands placed at the bottom of the inner circle. This symbol carries many meanings, including the laying on of the hands for diagnosis, treatment and healing; the timely use of manual medicine; and the use of hands to save and preserve life.

103 The Osteopathic Medical Profession Today

Since 1980, the percentage of DOs in the and Kansas City University of Medicine total U.S. physician population has risen and Biosciences College of Osteopathic from four percent to seven percent. The Medicine. The first class to convene at osteopathic medical student population American School of Osteopathy in 1892-93 continues to increase. Since 2003, five new included a few women. By 2007, women osteopathic medical schools and three new accounted for fifty percent of the total branch campuses have opened, bringing enrollment in osteopathic medical schools. the number to twenty-seven. There are By race and ethnicity, 70 percent of DOs currently eighteen accredited osteopathic are white, non-hispanic; 17.1 percent are post-doctoral training institutions (OPTIs) Asian; 3.5 percent are African-American; in the U.S. 3.7 percent are Hispanic; and 0.7 percent The total enrollment in osteopathic are Native American. medical schools was just under 17,000 Osteopathic physicians and surgeons in 2008-09. In 1935, only 459 students are licensed to practice medicine with full graduated from osteopathic medical privileges in every state in the union and schools; in 2008, the number was 3,364. The in several nations in the world. There is largest college of osteopathic medicine in no longer a question of qualification in 2009 is New York College of Osteopathic part due to the sustained effort of the Medicine of New York Institute of National Board of Osteopathic Medical Technology, followed by Philadelphia Examiners. College of Osteopathic Medicine (PCOM)

104 IN THE PUBLIC TRUST

Glossary of Commonly Used Orgainzational Terms

AACOM: American Association of Col- BOS: Bureau of Osteopathic Specialists leges of Osteopathic Medicine CBT: Computer Based Testing AAMC: American Association of Medi- CE: COMLEX-USA CE (Cognitive cal Colleges Evaluation) AAO: American Academy of Osteopathy CME: Continuing Medical Education AAOE: American Association of Osteo- COCA: Commission on Osteopathic pathic Examiners College Accreditation ABMS: American Board of Medical Spe- COM’s: Colleges of Osteopathic Medi- cialties cine ACGME: American Council on Graduate COMAT: Comprehensive Osteopathic Medical Education Medical Achievement Test ACOI: American College of Osteopathic COMLEX: Comprehensive Osteopathic Internists Medical Licensing Examination ACOEP: American College of Osteopath- COMSAE: Comprehensive Osteopathic ic Emergency Physicians Medical Self Assessment Examination ACOFP: American College of Osteopath- COMVEX: Comprehensive Osteopathic ic Family Physicians Medical Variable-Purpose Examina- ACOOG: American College of Osteo- tion pathic Obstetricians and Gynecolo- COPT: Council on Osteopathic Post- gists Doctoral Training ACOS: American College of Osteopathic COSGP: Council of Osteopathic Student Surgeons Government Presidents AIM: Administrators in Medicine CST: Clinical Skills Testing AOA: American Osteopathic Association ERAS Electronic Residency Application AODME: Association of Osteopathic Di- Service rectors and Medical Educators ERC: Exam Review Committee AOF: American Osteopathic Foundation FSMB: Federation of State Medical AOSED: Association of Osteopathic State Boards of the United States Executive Directors ECFMG: Educational Council of For- ASPE: Association of Standardized Pa- eign Medical Graduates tient Educators ECOP: Educational Council on Osteo- BOI: Bulletin of Information pathic Principles

105 GME: Graduate Medical Educator USMLE: United States Medical Licensing HPDP/HCD: Health Promotion Disease Examination Prevention/Health Care Delivery UGME: Undergraduate Medical Educa- IAMRA: International Association of tion Medical Regulatory Authorities IMG: International Medical Graduate Colleges of Osteopathic Medicine LCME: Liaison Committee on Medical Education ATSU/KCOM - Missouri MCC: Medical Council of Canada ATSU/SOMA - Arizona MOC: Maintenance of Certification AZCOM/Midwestern - Arizona MOL: Maintenance of Licensure CCOM/Midwestern -Illinois NAOF: National Association of Osteo- DMU/COM - Iowa pathic Foundations GA/PCOM - Georgia NBME: National Board of Medical Exam- KSUMB/COM - Missouri iners LECOM - Pennsylvania NBOME: National Board of Osteopathic LECOM/Bradenton - Florida Medical Examiners LMU-DCOM - Tennessee NOMA: National Osteopathic Medical MSUCOM - Michigan Association NSUCOM/COM - Florida OIA: Osteopathic International Alliance NYCOM/NYIT - New York OMERI: Osteopathic Medical Education OUCOM - Ohio Research Institute OSUCOM - Oklahoma PE: COMLEX-USA PE (Performance PCOM - Pennsylvania Evaluation) PCSOM - Kentucky PAPC: Physician Accountability for Phy- PNWU-COM - Washington sician Competence (committee of the RVUCOM - Colorado FSMB) TOUROCOM - New York PLAS: Post-Licensure Assessment Sys- TUCOM - California tem (provided by the FSMB) TUNCOM - Nevada SGA: State Government Affairs UNECOM - Maine SOM: School of Osteopathic Medicine UMDNJ-SOM - New Jersey SOMA: Student Osteopathic Medical As- UNTHSC/TCOM - Texas sociation VCOM - Virginia SOME: Society of Medical Educators Western U/COMP - California SPEX: Special Purpose Examination WVSOM - West Virginia (provided by the FSMB) WCUCOM - Mississippi

106 IN THE PUBLIC TRUST

Credits and Acknowledgments

The Still National Osteopathic Museum and National Center for Osteopathic History at Kirksville, Mo., is a fascinating place to those with an interest in medical history. Under the direction of curator Debra Loguda Summers, the collection of historical material from throughout the world has grown extensively. Barbara Magers, curatorial research assistant at the Still Museum archives, was of invaluable help in assembling material for this book. I can’t imagine what we would have done without her. Ida Sorci at the AOA archives also helped with the research. Taunya Cossetti’s help was crucial in the last days before publication. I am indebted to Dr. Frederick G. Meoli, who acted as a very welcome and tireless editor-in-chief for the project. His first-hand knowledge of every phase of the NBOME’s complex growth over the past twenty years was extremely valuable. He led the organization to places that Dr. Charles Hazard and Dr. Asa Willard could not have begun to imagine in those early years of struggle for recognition, but most certainly would applaud. -Betty Burnett

The following photographs are courtesy of the Still National Osteopathic Museum Archives: p. 5, A.G. Hildreth, DO; p. 6, Asa Willard, DO; p. 7, Charles Hazard, DO; p. 8, John Rogers, DO; p. 9, W. Curtis Brigham, DO; p. 13, Samuel V. Robuck, DO; p. 16, Price Thomas, DO; p. 18, Spencer G. Bradford, DO; p. 21, Marion E. Coy, DO; p. 25, Lester Eisenberg, DO; p. 26. Thomas F. Santucci, DO; p. 28, Robert E. Mancini, DO. The photo on p.82 of Dr. John W. Becher is courtesy Philadelphia College of Osteopathic Medicine and John Shetron Photography.

About the Author Historian Betty Burnett, PhD, is the author of numerous books for both adults and young people. Most involve social history. Her middle-school book on the U.S. Army’s Delta Force won a VOYA award given by the American Library Association. A Connecticut native, she now lives in St. Louis, Missouri.

107 Selected Bibliography

Books Gevitz, Norman. The D.O.’s: Osteopathic Medicine in America, Johns Hopkins Press, 1982 Shyrock, Richard H. Medical Licensing in America 1650-1965. Johns Hopkins Press, 1967 Sirica, Coimbra M., ed. Osteopathic Medicine: Past, Present, and Future: a conference sponsored by the Josiah Macy, Jr., Foundation, 1995 Sirica, Coimbra M., ed., Current Challenges to M.D.s and D.O.s: a conference sponsored by the Josiah Macy, Jr., Foundation, 1996 Walter, Georgia Warner. The First School of Osteopathic Medicine. Thomas Jefferson University Press at Northeast Missouri State University, 1992

Articles

“A Basic Science Law—Would it better conditions in California?” California and Western Medicine, October 1929, 285-86 “A New Method of Medical Licensure,” California and Western Medicine, October 1927. 525 Balbis, Robert. “Gerald G. Osborn Receives Award from American Psychiatric Association,” www.com.msu.edu Beal, Myron C., DO. “Osteopathic Basics,” JAOA 81, March 1980, 456. Bradford, Spencer G., DO. “The evolution and functions of the National Board of Examiners for Osteopathic Physicians and Surgeons,” JAOA, 22(16), 566-67, January 1968. Coy, Marion. “The National Board of Examiners for Osteopathic Physicians and Surgeons, Inc.” JAOA 76, September 1975, 94-97 Crowell, Edward P., DO. “Andrew Taylor Still Memorial Lecture: Osteopathic medicine – a second century challenge,” JAOA 74, 280 Feinstein, A. Archie, DO., “Changing times for interns,” JAOA, February 1985, Fischer, Ralph L., D.O., “Osteopathy—Fifty Years Later,” JAOA 50 (10), June 1951, 509-514. Gimpel, John, DO. “Getting ‘Beyond the Barriers’ in Reforming Osteopathic Medical Education,” JAOA 107 (7), July 2007, 270-275.

108 IN THE PUBLIC TRUST

Gimpel, John, DO. “Standardized Patients and Mechanical Simuators in Teaching and Assessment at Colleges of Osteopathic Medicine.” JAOA 107 (12), December 2007 Hazzard, Charles, DO. “National Board of Examiners for Osteopathic Physicians and Surgeons,” The Journal of Osteopathy, December, 1935. ------, January, 1936 ------, March 1936 ------, May 1936 Korr, Irvin M., Ph.D. “Medical education: The resistance to change,” JAOA 88 (8), 1022-1026. Letters to the Editor, Science 103 (265) “Medical Malefactors,” Illinois Medical Journal, March 1902, 456-67 Melnick, Donald, MD et al, “Medical Licensing Examinations in the United States,” Journal of Dental Education, May 2002, 595-596 Meoli, Frederick G., DO, et al. “National Board of Osteopathic Medical Examiners in the 21st Century,” JAOA 100 (11), November 2000, 703-706. Meoli, Frederick G., DO. “The Comprehensive Osteopathic Medical Licensure Examination: A paradigm for assessing the skill and knowledge of osteopathic physicians.” Journal of Medical Licensure and Discipline 93 (1), 2007, 25-35. Mochan, Eugene, DO. “National board looks to future.” The DO, November 1991. Moore, Robert C., DO. “The Progress of a Profession,” JAOA 55 (12), August, 1956, 723-724 “National Board adopts multiple choice examination,” JAOA, October 1958, 125-26 Northrup, George W. DO. Editorials in JAOA, 1965-1980 NBOME Annual Report 2008 Oliveri, Eugene, DO. [unpublished] Andrew Taylor, Still Memorial Lecture, July 2009 Osborn, Gerald G., DO et al. “The Comprehensive Osteopathic Medical Licensing Examination, COMLEX-USA: a new paradigm in testing and evaluation.” JAOA 100 (2), February 2000, 105-111 Robuck, S. V., DO., “Developing Good Internists is Osteopathy’s Best Need and Greatest Opportunity,” The Osteopathic Physician, XLIII (5), March 1923, May 1923 Rogers, John E. DO. “Osteopathy and the Future,” JAOA 36 (1), September 1936, 1-2 Sodeman, William A. “Osteopathy and Medicine,” JAMA 209 (1), July 7, 1969. 85-89

109 Steinfeld, Jesse L., MD. “Changing patterns in medical education in the seventies,” JAOA 71, January 1972, 423-426 Tilley, J. Peter D.O., “Quality in predoctoral osteopathic education,” JAOA 86 (11), November 1986, 719-721. Wainer, Harold D.O., “Current uses of the computer in medicine,” JAOA Wilkins, Frederick, D. O., “Education leading to osteopathic certification,” JAOA 86 (11), November 1986, 727-730. Willard, Asa, D.O., “Professional Independence is Vital,” The Journal of Osteopathy 30 (5), May 1932, 269-270 ------“Education and the Colleges.” The Journal of Osteopathy 37 (11), 1930C ATSU/ KCOM (Kirksville) 16, 21, 33 73, 89, 91

The NBOME display at the 2008 annual meeting of the FSMB in San Antonio celebrated 75 years of dedication, commitment and innovation in osteopathic medical licensure testing and its efforts to earn the public trust. The booth was hosted by John Thornburg, DO, PhD, (right) vice-chair of the NBOME, and Joseph Smoley, PhD, vice-president for administration/COO.

110 Index

111 Allen, Paul van B., 13,17 Apprenticeship, medical, 2 , 23 A. T. Still Research Institute, 9 Allopaths, 7 American Association for the Advance- Bailey, Walter E.. DO, 13 ment of Osteopathy (AAAO), 3 Barnes, Margaret, DO, 10–11 American Association of Colleges of Os- Barrett, George MD, 35 teopathic Medicine (AACOM), 27 Basic Science legislation, 6-8 PE examination input, 47 Bates, Bruce, DO, 72 American Association of Osteopathic Ex- Becher, John W. DO, 82 aminers (AAOE), 37 Beehler, Daryl, DO, 36 American Board of Family Practice, 22 Benjamin, Regina M., MD, MBA,39 American College of Osteopathic Surgeons Biomedical/Biomechanical Domain, 70 (ACOS), 42 Blueprint Audit Committee, 51 American Council on Graduate Medical Board certification, 50 Education (ACGME) Boards, medical, internship approval, 27 acceptance by, 17, 39 PGY-1 programs, 62 fail rates of, 8 American Medical Association (AMA), 2, Bodett, Shirley, 93–94 3, 5, 7, 8, 17, 47 Boulet, Jack, PhD, 45–46 American Measurement Professionals Bradford, Spencer G., DO, 18, 22, 69 (AMP), 56 Brigham, W. Curtis, DO, 9 American Osteopathic Association (AOA), Bruno, John P., DO, MBA, 32, 45 3, 4,5, 7, 8, 9, 10, 11, 1, 13, 14, 15, 17, 18, Bureau for State Government Affairs, 36 19, 23, 26,27-31, 33, 35, 36,37, 39,`47, 56 Buser, Boyd R., DO, 37, 47–48 American Osteopathic Association Auxil- Bushman, Sheryl, DO, 38 iary (AOAA), 56 American Osteopathic Board of Emergen- California College of Medicine, 17 cy Medicine (AOBEM), 42 California Supreme Court, ruling of, 17 American Osteopathic Board of Family Canada, osteopathic medical history, 101 Practice (AOBFP), 21 Carlsen, Wayne, DO, 86 American Osteopathic Board of General Case Development Committee, 48 Practitioners, 21 Cavalieri, Thomas. DO, 36, 40, 47-48 American Osteopathic Foundation, 9 Chicago College of Osteopathy, 13 American School of Osteopathy (ASO), 2, Chiropractors, 5 4, 6, 7, 8, 10, 52, 104 Ciervo, Carman A., DO, 87 Americans with Disabilities Act (ADA), 40 Clark, Gary, 37, 40, 83 Anderson, William, DO, 81 Clean test items, 66 Andriole, Jim, DO, 86 Clearfield, Michael, DO, 56

112 IN THE PUBLIC TRUST

Clinically based test, 56 Comprehensive Health Manpower Act of Clinical Skills Testing Advisory Commit- 1971, 22 tee (CSTAC), Performance Testing Com- Comprehensive Osteopathic Medical Li- mittee, 48 censing Examination (COMLEX-USA), Cohen, Benjamin, DO, 33–34 28-29 Cohoon, Carl W., 18, 19 Biomedical/Biomechanical Domain, 70 College of Osteopathic Physicians and Sur- candidates tested, number of, 66 geons (California), 17 CBT, psychometric quality, 66 Colleges of Osteopathic Medicine (COMs) clean test items, review, 66 ATSU/KCOM (Kirksville) 16, 21, 33, 73, competency-based model, 51 89, 91 Construct Validity Project, 64 CCOM-Midwestern (Chicago), 13 18, 31, continuous quality improvement, 63 91 coordinators, 73 DMU-COM (Des Moines), 18, 37, 73, 81, debut, 34–35 87 design, 65 KSUMB (Kansas City), 34, 72, 84, 91 104 study/implementation, 51 LECOM (Erie), 72 development, 56, 62–63 LMU-DCOM (Tennessee), 33, 88, 89 dimensions, 57–61 MSUCOM (Michigan) 33, 39, 45, 73 81 85 evolution, 56 NSUCOM, (Florida) 22, 73 external audits, 66 NYCOM (New York), 45, 68, 72, 104 Examination Review Committee, 66 OUCOM (Ohio), 86 field test, 63 OSUCOM (Oklahoma), 31, 91 Humanistic Domain, 70 PCOM (Philadelphia), 10, 18, 22, 25, 26, Item/case writers, 72 29,31, 32, 34, 38, 46, 72, 82, 86, 87, 88, Level 1, 58, 66, 71 90, 104 Level 2, 60, 70, 71 PCSOM (Kentucky), 73 Level 2 CE, 65, 66, 71 TUCOM (California), 73 Level 2, clinical skills assessment pro- TUNCOM (Nevada), 85 gram, 70 UNECOM (Maine), 37, 72, 89, 90 Level 2 Performance Evaluation (PE), 40, UMDNJ-SOM (New Jersey), 29, 34, 36, 45 46 38, 47, 73, 85, 86, 87, 88 pilot studies, 47 UNTHSC/TCOM (Texas), 32, 33, 38, 85 Standardized Patients (SPs), 70 WCUCOM (Mississippi), 89 Level 3, 57, 71, 61-62 Comprehensive Osteopathic Medical Level 3 CBT version, 69, 71Levels (COM- Achievement Test (COMAT), 50 LEX-USA), 57–62 Committee on Medical Licensure Exami- New Item Review Committee, 66 nation Systems (CMLES), 36–37 Ontario, Province of, acceptance, 40

113 Part III, history, 69 D’Amico, Carmine, DO, 72 Part III Committee, 69 Desai, Gautam, DO, 72 pass/fail standards, adoption, 62–63 Diplomate in Osteopathy DO, 2 quality, 35 Diplomate of the National Board (DNB), 11 recognition, 39 District of Columbia, 8 reliability/validity, 62 Distinguished Service Certificate, 9 score-based inferences, 35 D.O., The, 25 sequence, performance, 62 Doctor of Osteopathy DO, 2-4 sequential testing process, 62 competency measurement, 66 series, review, 50–51 state acceptance, 17 series, revision, 51 Dowling, Dennis, DO, 45, 47 standard, pass/fail, setting of, 63

status, 66 Eddyists, 5 testing/evaluation paradigm, 57 timeline, 71 Educational Council of Foreign Medical Comprehensive Osteopathic Medical Li- Graduates (ECFMG), 15-16 censing Examination Performance Eval- patient-based clinical skills examination, uation (COMLEX-PE), 70 45 Comprehensive Osteopathic Medical Self Educational Council on Osteopathic Prin- Assessment Examination (COMSAE), 42 ciples (ECOP), 47 Comprehensive Osteopathic Medical Vari- Eisenberg, Lester, DO, 25 able-Purpose Examination (COMVEX- Errichetti, Anthony, PhD, 45–46 USA), 42 Examination, essay, 10, 14 Computer-based testing (CBT), 42, 66 Examination Review Committee, 66 Construct Validity Project (COMLEX- USA), 64 Federation of State Medical Boards Continuous improvement strategy, 63 (FSMB), 2, 26, 34-35, 52 Core osteopathic competencies, 41 AAOE, impact, 37 Competence, physician, 41 licensure, 26 Cossetti, Taunya, 48, 94 Fernandes, John J., DO, 29–31 Coy, Marion E. DO, 21 Fleming, James L., DO, 72 Crane, Martin, MD, 39 Flexner Report, 5, 22 Credits, 107 Florida Osteopathic Board, 86 Crosby, John, JD, 36 Foster, Robert, DO, 37 Crossing the Quality Chasm (IOM), 41 Fulton, Brian, DO, 87–88 Crowell, Edward P., DO, 20 Curtis, Michael, 45 Galusha Memorial Lecture, 35 Gilfillian, Bruce DO, 30–32

114 IN THE PUBLIC TRUST

Gimpel, John R., DO, MEd, 40, 45, 46, 49 Kowalski, Timothy, DO, 37 Kreines, David C., 49, 67, 95 Hazzard, Charles, DO, 4, 7, 9, 11 Krpan, Donald DO, 36 Principles of Osteopathy, The, 9 Health care, insurance coverage, 23 Langenau, Erik, PhD, 49, 67, 68 High-impact/high-frequency patient en- LeBlanc, Kim Edward, MD, PhD, 39 counters, 57 Lenz, Craig, DO, 88–89 Hildreth, Arthur G., DO, 4–5 Licensing boards, 4 Hildreth-Still Sanitarium, 5 Licensure, 3-4, 36 Hogan, Timothy J., DO, 72 Life-long learning, 64 Holistic medicine, 23 Louisiana Practice Act, 39 Homeopaths, 2, 5 Humanistic Domain, 70 Maille, Michael, 36 Mancini, Robert E., DO, PhD, 24, 28 Illinois Medical Journal, 3 Mascheri, Linda, 36 Indiana Supreme Court, ruling of, 30 Massachusetts Medical Board, 39 In-service examination, ACOS, 42 Maternal Child and Health, 25 Institute of Medicine (IOM) McAuley, Daniel B., DO, 3 Crossing the Quality Chasm, 41 McNamara, Robert, 12 To Err is Human, 41 Medical Council of Canada (MCC) International Association of Medical Regu- Part II OSCE, 45–46 latory Authorities (IAMRA), 37-38, 40-41 Qualifying Examination Part II, 45 In-training examinations, 50 Meoli, Frederick G., DO, 30–31, 34, 40, 43, 46, 47 Journal of American Osteopathic Association Meritorious Service Award, 49 (JAOA), 7, 13, 15, 23, 45, 47, 56 MESA Institute (see University of Chicago) Journal of Medical Licensure and Discipline Minisalle, Anthony DO, 36 (JMLD), 30 Mochan, Eugene DO, 24–25, 27–29, 51 Josiah Macy Foundation, 33 Multiple choice questions, 14, 15, 55 conference, agreements, 34–35 Murphy, Michael K., DO, 89 second conference, 34 National Board of Examiners for Osteo- Kastler, Michael, 67 pathic Physicians and Surgeons Kerns, Laurie, 48 (NBEOPS), 4-9, 14-24, 34-35 Knebl, Janice A., DO, 87 American Osteopathic Board of General Knowledge blocks, 57 Practitioners, 21 Koop, C. Everett, MD, 23 certificates, 10-11

115 examinations, 14, 33, 55 testing professionals, 67 FSMB/AOA assistance, 37–38 timeline, 100 Part 1, 18, 55, 56 National Center for Clinical Skills Test Part 2, 18, 55, 56 ing (NCCST), 40, 45-49, 67 Part 3, 28, 55, 69 National Confederation of State Medical Part III Committee, 69 Examining and Licensing Boards, 2 Testing, 10-14 New Item Review Committee, 66 National Board of Medical Examiners Nicholas, Alexander, DO, 72 (NBME), 26 certificates, recognition, 10 Objective Structured Clinical Examination discussions, 34–35 (OSCE), 45 pilot testing models, 45 two-station OSCE, completion, 46 National Board of Osteopathic Medical Oklahoma Osteopathic Board, 40 Examiners (NBOME) Oliveri, Eugene DO, 13–14, 24, 30, 36, 84 board of directors, 77 Galusha Memorial Lecture, 35 by-laws, 29 candidate scheduling, electronic regis- OMT, 46–47, 56, 70 tration system initiation, 48–49 Osborn, Gerald, DO, MPhil, 30, 33, 45, 46 committees, 80 Osteopathic competencies, 41 community support, 97 Osteopathic diagnosis, assessment, 46–47 computerized testing, 69–70 Osteopathic education, 22–23 governance, 77 Osteopathic International Alliance (OIA), IAMRA membership, 40–41 37, 39 In-depth Assessment Committee, 51 Osteopathic medical history (Canada), 101 legal perspectives, 93 Osteopathic medical licensure National Board seals, 103 challenges, 52 NCCST, construction, 48 considerations, 41 operational committees, 40 Osteopathic medical profession, status, 104 organizational chart, 79 Osteopathic medical schools, 104, 107 organizational structure, 78 Osteopathic postdoctoral training institu- PAPC participation, 42 tions (OPTIs), 104 Product Committee, 51 Osteopathic principles, 59 proposals, organization, 47–48 re-incorporation, 24 Pass/fail standards, adoption, 62–63 services of, 43 Patient-based clinical skills examination, staff, 93–96 ECFMG, 45 strategic plan, 50 Pavia, Charles, DO, 72 Task Force on Performance Testing, 45 Performance Testing Committee, 48

116 IN THE PUBLIC TRUST

PGY-1 programs (ACGME), 62 Special Committee on Licensure, 35–36 Pharmaceuticals, impact, 16–17 Spence, T. T., DO, 12–13 Physician Accountability for Physician Spevack, Theodore, DO, 72 Competence (PAPC), 42 Standardized Patients (SPs), 70 Pickard, Thomas, DO, 37 Steele, Sydney L., JD, 93 Pierce, Deborah, DO, 51, 89-90 Steinfeld, Jesse L. MD, 22 Principles of Osteopathy, The. 9 Still, Andrew Taylor, MD, DO, 1–2 Public safety/protection, 37, 39, 50 Swope, Chester D., DO, 9

Qualifying Examination Part II, (MCC), 45 Test Construction Committees (TCCs), 25 Quality improvement strategy, 63 Test Review Committee (TRC), 25 Thomas, George, DO, 36, 91-92 Ranieri, William F., DO, 38, 51 Thomas, Jr., R. Russell, DO, 37 Ray, Dyrus N., DO, 12 Thomas, Price. DO, 15, 16 Resolution 01-03, passage, 35–36 Thornburg, John, DO, PhD, 39, 110 Richards, David, DO, 33–34 Two-station OSCE, completion, 46 Roberts, Bill, EdD, 49 Robuck, Samuel V. DO, 9, 13,28 University of Chicago, MESA Institute, 34 Rogers, John E., DO, 8, 9 University of Iowa, 19 Rose, Susan, DO, 37 U. S. Department of Health and Human Rothmeyer, George S., DO,10–11 Services, 24 U. S. Army Medical Corp, 11 Santucci, Jr., Thomas F. DO, 28, 58, 93 U.S. Medical Licensing Examination Schaller, Fredrick, DO, 51, 85 (USMLE), 26, 33, 42 Schumacher, Allen, MD, 35 Shahabi, Sohrob, PhD, 24 Validity question, 62 Shaffer, Dana, DO, 90 Shannon, Stephen, DO, 90–91 Ward, Edward A., DO, 9–10 Shen, Linjun, PhD. 24, 35, 42, 45, 66, 67 Warner, Michael, DO, 45 Single pathway, 33 Willard, Asa, DO, 4, 6, 10, 24, 43 Sirici, Stephen, PhD, 35 Wilson, Crystal, MEd, 49, 67 Slick, Gary, DO, 91 Wilson, Frederic, 40, 92 Smoley, Joseph F., PhD, 24, 67, 68, 110 Wright, Benjamin, PhD, 35 Snowbird retreat, 30–31 Zini, James DO, 36 SOAP notes, 70

117 “The possession of a license to practice one’s profession in a state, territory, or other division of the United States should be considered a property right, and the legal protection surrounding the instrument recording that right properly and justly rest upon legislative authority.” Charles Hazzard, DO, 1935 “With independent regulation . . . we will ultimately get every right for our- selves and those to come.” Asa Willard, DO, 1932

118