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APPENDIX G Nutrition Science Content of National Board Examinations The National Board of Medical Examiners (NBME), an independent nonprofit enterprise based in Philadelphia, develops and administers qualifying examinations "of such high quality that legal agencies governing the practice of medicine within each state may at their discretion grant a license without further examination to those who have completed successfully the examinations of the National Board and have met such other requirements as the National Board may establish for certification of its Diplomates" (NBME, 1985~. These examinations, offered for more than half a century by the National Board, represent the more traveled of the two major avenues leading to medical licensure. Indeed, during the past few decades, more than three-fourths of the students graduating from the U.~. medical schools used the National Board certification as their pathway to profes- sional licensure. National Board certification is now accepted as quali- fication by the medical licensing authorities of all states and territories other than Louisiana, Texas, and the Virgin Islands. The Canadian provinces of Alberta and Ontario also accept the National Board examinations in lieu of local licensing mechanisms. The National Board examinations are also used by some of the U.S. medical schools "as an external evaluation of the progress of their students" (NBME, 1985~. NATIONAL BOARD TEST CONTENT ._ Part I of the National Board examination contains multiple choice questions in seven major disciplines: 0 anatomy (gross anatomy, cell biology, histology, human development, central nervous system, special senses) 127

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128 NUTRITION SCIENCE CONTENT OF NATIONAL BOARD EXAMINATIONS (cont.) behavioral sciences (behavioral biology, individual behavior, interpersonal and social behavior, culture and society) ~ biochemistry (energy metabolism, metabolic pathways, properties and function of major cell constituents, inte- grated and correlative biochemistry, biochemical aspects of genetics and molecular biology) microbiology (microbial structure, cell metabolism, microbial and molecular genetics, immunology, bacterial pathogens, virology, medical mycology, medical parasi- tology) pathology (general pathology, systemic pathology, clinical pathology) pharmacology (general principles; central, periph- eral, and autonomic nervous systems; autacoids; cardio- vascular and respiratory systems; fluids and electrolytes vitamins; chemotherapeutic agents; intoxicants) ~ physiology (organ physiology, neurophysiology, cel- lular physiology) Part II of the examinations is devoted to the clinical sciences. It contains multiple choice questions in medicine obstetrics and gynecology pediatrics preventive medicine and public health psychiatry surgery The National Board examinations, therefore, represent a comprehensive and diligently selected set of questions

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129 NUTRITION SCIENCE CONTENT OF NATIONAL BOARD EXAMINATIONS (cont.) designed to reflect the measurable content of under- graduate medical education in U.S. medical schools. The scores obtained in all subjects or disciplines accordingly provide a means by which faculties may, in their discre- tion, judge the effectiveness of the teaching of the sub- ject under consideration. Members of the committee assessed approximately 6,000 questions from Parts I and II of examinations given in 1980, 1982, and 1984. The nutrition-related questions were identified and then assigned to one or another of the core curriculum categories previously proposed by the committee (Chapter 5~. Analyses of student performance on each of these questions (for 1980 and 1982) were also made available to committee representatives. In the tables that follow, P is used to designate the percentage of correct responses to a particular question and R is used to designate the discrimination value--an index that represents how well high-scoring examinees perform on a particular question when compared with low-scoring examinees. The higher the R value, the more discriminat- ing the question. FINDINGS Table G-1 summarizes the distribution of and the examinees' performance on the nutrition-related questions identified in Part I of the 1980, 1982, and 1984 examina- tions. There was a small drop (from 4% to 3%) in the number of items that test knowledge in nutrition. The number of such questions diminished from 42 in 1980 to 25 in 1984. Questions concerning nutrition were found in all disciplines except microbiology. The average percent- age of correct responses to these nutrition items for all disciplines combined ranged from 61.5% to 63.8%--in approximately the same range found for the entire examination for those years (i.e., 63% to 67%~. Table G-2 summarizes the distribution of and the exami- nees' performance on nutrition-related questions from Part II of the 1980, 1982, and 1984 examinations. The percent- age of the total number of questions identified as

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130 NUTRITION SCIENCE CONTENT OF NATIONAL BOARD EXAMINATIONS (cont.) TABLE G-1. Nutrition-Related Questions on Part I of the 1980, 1982, and 1984 National Board Examinations: Distribution and Performance - 1980 Discipline Na fib pc Rd Anatomy 6 4 46.2 23 3 +10.3e +4.2 1982 1984 % P R N % 3 70.S 22.8 2 _6.9 +5.2 P R Behavioral 6 4 74.8 26 3 2 57.7 25.3 1 1 science +10.1 +5.4 +14 +5.8 Biochemistry 16 12 5 3 29.8 10 7 59.1 25.9 6 4 _5.5 +3.5 +9.1 +2.0_ _ Pathology 4 3 73.5 29.5 5 3 72.8 27.4 4 3 _15.1 +5.5 +7.2 +5.6_ _ Pharmacology 6 4 59.5 26.5 6 4 59.8 24.3 3 2 +12.9 +7.5 +10.2 +6.2 Physiology 4 3 75.3 29.3 4 3 67.3 35.0 9 6 _15.0 +7.0 +2.4 +2.5_ _ Microbiology 0 0 - - 0 0 - - 0 0 Average for all disciplines 4 61.5 28.0 3 63.8 26.5 combined +4.0 +2.1 +3.8 +1.6 aNumber of nutrition-related questions. bPercentage of nutrition-related questions among total ques- tions for discipline. CAverage percentage of correct responses to all the nutrition- related questions in each discipline. dDiscrimination value: An index that represents how well high- scoring examinees perform on the particular question compared with low-scoring examinees. e+Standard error of the mean.

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131 NUTRITION SCIENCE CONTENT OF NATIONAL BOARD EXAMINATIONS (cont.) TABLE G-2. Nutrition-Related Questions on Part II of the 1980, 1982, and 1984 National Board Examinations: Distribution and Performance 1980 _ 1982 1984 Discipline N % P Rd N % P R N _ Preventive medicine, public health (PMPH) 8 5 73.9 35.8 5 3 62.9 19.4 1 1 +lO.le +4.5 +9.5 +6.6 _ _ _ _ Pediatrics 14 9 58.5 22.4 18 12 51.9 22.3 13 9 +6.3 +2.4 +5.8 +2.3 _ _ _ _ Psychiatry 3 2 74.3 17.7 3 2 74.0 26.0 6 4 +9.7 +14 +20.6 +8.5 _ _ _ _ Medicine 4 3 83.0 31.3 2 1 63 31.5 4 3 +5.7 +3.8 Surgery 4 3 80.8 30.0 4 3 74.0 20.5 +6.0 +5.9 +14.7 +6.5 Obstetrics and gynecology 2 7 65.5 10.0 2 1 74.5 30.0 1 1 Average for all disciplines 4 68.8 29.4 4 59.1 23.0 3 combined +3.8 +2.5 +4.1 +4.7 aNumber of nutrition-related questions. bPercentage of nutrition-related questions among total ques tions for discipline. CAverage percentage of correct responses to all the nutrition- related questions in each discipline. dDiscrimination value: An index that represents how well high- scoring examinees perform on the particular question compared with low-scoring examinees. e+Standard error of the mean.

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132 NUTRITION SCIENCE CONTENT OF NATIONAL BOARD EXAMINATIONS (cont.) containing a nutrition component dropped again slightly, from 4% to 3%. The total number of nutrition-related questions varied from 22 to 29 per year. Table G-3 summarizes the average percentage of correct responses to all questions and the discrimination values by year and scientific discipline for Parts I and Part II of the three examinations reviewed. No significant per- centage trends are apparent for the years studied nor were there substantive departures from these indices in the values representing performance in nutrition-related questions. Ninety-eight nutrition-related questions were identi- fied in Part I, and 94 in Part II of the three examina- tions that were reviewed by the committee. In Table G-4 these 192 nutrition-related questions are assigned to the core curriculum categories. The percentages of the total questions assigned to each topic are given. SUMMARY OF FINDINGS Approximately 3% to 4% of all questions in Parts I and II of the 1980, 1982, and 1984 National Board examinations test the students' knowledge in the nutrition sciences. The greatest concentration of nutrition-related questions in Part I of the examinations is in the biochemistry sec- tion (varying from 7% to 12% of all questions) and in the physiology section (6%~. In Part II the greatest concen- tration is invariably found in pediatrics. The average percentage of correct responses indicate that there is no difference in performance on nutrition- related test items when compared to all test questions on the examinations reviewed by the committee. The R values indicate that questions on nutrition reflect about the same level of discrimination as all test items in both Parts I and II of the examinations reviewed. Approximately 12% of the 1982 nutrition-related ques- tions address obesity and undernutrition or starvation. The following core concepts are also well represented: lipids and essential fatty acids, vitamins and minerals,

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133 NUTRITION SCIENCE CONTENT OF NATIONAL BOARD EXAMINATIONS (cont.) TABLE G-3. Average Percentage of Correct Responses and Discrimination Values by Discipline for Parts I and II of the 1980, 1982, and 1984 National Board Examinations Discipline _80 1982 pa Anatomy Behavioral science 63 66 Rb 30 23 1984 p R P 65 69 31 26 68 65 33 26 Biochemistry 59 33 64 35 70 35 Pathology 64 27 63 28 63 29 Pharmacology 62 29 64 31 68 32 Physiology 65 31 67 30 73 29 Microbiology _ 30 62 28 67 31_ Average 63 29 65 30 67 31 PART II Discipline 1380 I95 ~1984 P R P R P R Anatomy 63 30 65 31 68 33 Preventive medi cine, public 66 31 65 28 68 30 health Pediatrics 67 28 63 26 64 26 Psychiatry 67 25 66 26 65 26 Medicine 65 32 67 30 65 28 Surgery 65 28 63 25 66 27 Obstetrics and gynecology 64 28 66 26 63 24 Average 66 28 65 27 65 27 aAverage percentage of correct responses to all questions in each discipline. bDiscrimination value: An index that represents how well high-scoring examinees perform on the particular question compared with low-scoring examinees.

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134 NUTRITION SCIENCE CONTENT OF NATIONAL BOARD EXAMINATIONS (cont.) TABLE G-4. Questions on 1980, 1982, and 1984 National Board Examinations Related to Nutrition Core Curriculuma Core Curriculum Topic Nb %C Energy balance General concepts Excess: obesity Deficiency: undernutrition and starvation Specific nutritional factors (requirements, sources, deficiency excess interaction) General principles of recommended dietary allowances (RDAs) Protein Carbohydrate Lipids - Essential Fatty Acids Vitamins and minerals, including: Vitamin D Calcium, phosphorus Iron Vitamin B12' folate Vitamin A Trace minerals Nutrient interaction with other factors (e.g., genetic, other nutrients, drugs) Nutrition in the life cycle Pregnancy and lactation Early infant feeding Adolescence Aging Nutritional assessment Protein/energy malnutrition 22 23 16 15 7 7 11 4 o 1 7 2.6 11.5 12.0 0.5 3.6 2.6 8.3 7.8 3.6 3.6 5.7 2.1 0.5 3.6 13 6.7 18 9.4 1.0 2 o o o

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135 NUTRITION SCIENCE CONTENT: OF NATIONAL BOARD EXAMINATIONS (cont.) TABLE G-4 (cont.) Core Curriculum Topic _ Nb %C The role of nutrition in disease prevention and treatment Atherosclerosis and cardiovascular disease 8 4.2 Hypertension/sodium O Renal disease 2 1.0 G.I. disease/malabsorption 5 2.6 Liver disease/alcoholism 6 3.0 Food intolerance: allergy O Cancer O Diabetes/hypoglycemia 5 2.6 Surgery, stress, burns 1 0.5 Dental caries 3 1.6 Parenteral and enteral nutrition O Immune response O Nutrition and central nervous system 1 0.5 Osteoporosis O Dietary practices Cultural and ethnic variation Prudent diet Vegetarianism Food faddism: popular diets Megavitamins Others 2 2 o o 1 0.5 1.0 1.0 Anatomy and embryology 2 1.0 "Core curriculum concepts as defined by the Committee on Nutrition in Medical Education (see Chapter 5~. bThe number of nutrition-related questions identified by core concept in both Parts I and II of the 1980, 1982, and 1984 examinations. (Total number identified = 192.) CPercentage of all 192 questions related to this core concept.

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136 NUTRITION SCIENCE CONTENT OF NATIONAL BOARD EXAMINATIONS (cont.) iron, nutrition in pregnancy and lactation, and early in- fant feeding. No test questions were found on the following subjects recommended as core concepts by the committee: vitamin A metabolism, nutrition in the aged, food intolerances and allergies, nutrition in cancer patients, parenteral and enteral nutrition, the role of nutrition in the immune response, osteoporosis, and food fads and popular diets. REFERENCE National Board of Medical Examiners. 1985. Bulletin of Information and Description of National Board Examina- tions. National Board of Medical Examiners, Philadelphia, Pennsylvania.