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However, the complex, proprietary systems for delivering the simulation have posed challenges in integrating them with the vendor s test delivery systems The software environment for simulations is much more complex resulting in various computer network performance problems and examinee problems during test administration On the positive side, the simulation provides unique information about examinees, information that is judged to be important by content experts and is shown to be valuable in assessing the competencies considered important for licensure
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The long journey from concept to implementation is remarkable, but the results appear to make the journey worthwhile As Christopher Columbus said, Here the people could stand it no longer and complained of the long voyage; but the Admiral cheered them as best he could, holding out good hope of the advantages they would have (Christopher Columbus: Journal of the First Voyage, 10 October 1492) The journey provided a number of important lessons First, measures are more dif cult to create than methods While the technology of computer-based testing is always the rst topic of conversation, experience at the NBME has proved over and over that the technologic problems are far less daunting than the measurement problems The most recalcitrant problems throughout the developmental history of the simulation project were the extraction of meaningful measures from the plethora of observational data The simulation model was conceptually complete by the late 1970s Many re nements have been made, updating the model to take advantage of emerging technology Virtual disks in random access memory (in 1984), analog videodisk (in 1985), digital audio and video (in 1994), object-oriented programming (in 1993) these are examples of the changes made technologically However, the basic logical structure of the system has been stable for many years Appearances have changed, but the basic structure of the simulation engine has not The dumb terminal of 1978, completely character based and requiring input of coded numbers from a printed index, has given way to the networked personal computer running under Microsoft1 Windows1 and exploiting its graphical interface It can include full motion segments as part of the patient introduction, free text entry on a mock order sheet, and iconic representation of time and location However, scoring research has continued throughout the developmental timeline, and the research has not been just the incremental exploitation of technology, but has required repeated creative approaches to solve speci c recalcitrant problems In particular, scoring and simulation design must proceed hand in hand, each informing the other The major approaches to scoring have built less upon one another than upon the weaknesses discovered with the predecessor scoring method Initial scoring approaches adapted PMP scoring systems As with PMPs, this system rewarded thoroughness rather
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than ef ciency, and often scored good novices higher than highly competent experts The Rasch partial credit model allowed better use of information gathered about timing and sequencing of actions and depended on item dif culty to weight the various actions Separate categories for very risky actions were segregated from actions that were allowed to compensate for one another The latter represented a conceptual shift toward combining quantitative data with qualitative information in scoring, the rst step toward a rulebased, case-logical approach The most signi cant step forward in scoring strategy was the move to capturing and replicating expert judgments about global case management This approach has increased the precision with which the computer-generated scores can replicate the judgments of experts about the performances Second, test delivery is more technologically demanding than test development Throughout the history of the NBME s CBT projects, applying technology to the task of test method development has been easy In fact, we have had to work hard to keep up with rapidly evolving technology in selecting tools to solve our unique problems It has always seemed that, just as we squeezed a technology to solve a problem, a new technology emerged that solved the problem without contortions It is very easy to forget the requirements for successful delivery of a technology-based test Whether testing a few hundred or tens of thousands, the logistical challenge of providing a suitable testing environment with standardized test conditions is immense It is easy to buy a few of the latest PCs or peripheral devices for a development environment, and tempting to do so to allow the latest and best tools to be applied to solving problems However, cost becomes signi cant when it is scaled up to a delivery system A home PC cost $3400 in December 1994 By October 1995, the exact same computer cost $2400, but, of course, it was no longer state of the art By 2002, it was not possible to buy the same computer, except at a junk sale Providing state of the art and updating it frequently is likely to make a delivery system economically nonviable NBME experience indicates that computer-based testing should target well de ned, standard technology that is available economically Only in this manner is it likely that large-scale test administration systems will be available at a defensible cost The software for delivering this test was usable in the late 1980s, but no system for secure computer delivery of tests existed While such systems exist today, and new approaches using Internet technology offer alternative delivery vehicles, the constraints of the capacity of available testing networks place new demands on tests that have historically been administered simultaneously to large numbers of examinees To make a technology-based testing program work, a test sponsor needs not only expertise in testing, but also equivalent expertise in technology, at both hardware and software system development levels In addition, the effective design, construction, nancing, marketing, and management of a technologybased delivery system is mandatory Anyone wishing to sponsor a computerbased testing program must either develop or acquire these competencies
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