We are there for the good of the patient, not for the good of the protocol, not for the good of the medical director, and not for the good of the company.

- Rogue Medic

Gaming the National Registry Exam – Part II

In the comments to Gaming the National Registry Exam – Part I, Chy Miller writes –

Certification and/or licensure (doctor, nurse, medic, etc.) testing never has validity in the viewfinder of those successful but is the cornerstone of public trust and the essential gate keeper of those who don’t possess your abilities. Change the public’s need for “something” that communicates trust as well as the lack of ability in people and you’ll change the need for “dogma deficiency detectors” forever.

I have no interest in changing the opinion of the public. I am interested in changing the opinion of the people who work in EMS and in emergency medicine – people who should know better.

Working on public opinion is just the tail trying to wag the dog.

Good luck! If that doesn’t work out for you, maybe you could build a new and improved NR model.

I would tear it down and start anew.

 

Assess understanding.

 

This is not easy or cheap, but it is much better than the NR lottery.

The problem is that we are too interested in avoiding the appearance of any possibility of an evaluator being in a position to make a subjective decision. This is ridiculous.

Discrimination is what they are supposed to do – based on the understanding of the candidate, not based on gender, race, religion, or anything else that is not related to the understanding of patient care.

We need instructors who understand the material they are supposedly teaching. If the instructors truly understand the material and they understand how to assess for understanding among the students, then what is required is to evaluate that understanding.

“Don’t be a cynic and disconsolate preacher. Don’t bewail and moan. Omit the negative propositions. Challenge us with incessant affirmatives. Don’t waste yourself in rejection, or bark against the bad, but chant the beauty of the good.” – Ralph Waldo Emerson

Don’t be a cynic like the people who claim that our instructors cannot be trusted to evaluate understanding?

Don’t be a cynic like the people who feel that the instructors should be hired, even though they believe that the instructors are not trustworthy?

Don’t be a cynic like the people who complain that our patients require the cheapest preparation possible?

Don’t be a cynic like the people who complain that evaluating understanding is just too expensive?

I have never been really good at going along to get along.

All that is necessary for the triumph of evil is that good men do nothing.[1]

If I do nothing, I do nothing to stop the use of this failed model for screening out the incompetent. I do not think that Ralph Waldo Emerson would encourage me to remain silent.

For example, in a speech at Harvard University, Ralph Waldo Emerson had this to say –

If the colleges were better, if they had any monopoly of it, nay, if they really had it, had the power of imparting valuable thought, creative principles, truths which become powers, thoughts which become talents, — if they could cause that a mind not profound should become profound, — we should all rush to their gates: instead of contriving inducements to draw students, you would need to set police at the gates to keep order in the in-rushing multitude.[2]

Hardly chanting the beauty of the good to his alma mater.

He continued with –


On the contrary, every generosity of thought is suspect and gets a bad name. And all the youth come out decrepit citizens; not a prophet, not a poet, not a daimon, but is gagged and stifled or driven away. All that is sought in the instruction is drill; tutors, not inspirers.[2]

Emerson was not averse to criticizing those he felt were not educating well.

Would Emerson be as critical of what I write?

Speak what you think now in hard words, and to-morrow speak what to-morrow thinks in hard words again, though it contradict every thing you said to-day.[3]

Emerson might notice that what I write is far from cynical. I notice that the comment did not include any claim that what I wrote is inaccurate, only that I did not put a smiling face on the first part of a multi-part article. On other subjects, I do Challenge us with incessant affirmatives. I avoid the hobgoblin of the incessant.

– `Ah, so you shall be sure to be misunderstood.’ –[3]

Then perhaps I should strengthen my criticism.

No, if I have nothing nice to say, I should remain silent./

Qui tacet consentire videtur[4]

I would not recommend baiting one’s breath, awaiting my silence.

If we cannot trust our instructors to competently assess understanding, then we need better instructors.

We definitely need better people to hire our instructors. If those doing the hiring think the instructors are inadequate, why are these bureaucrats hiring them to instruct?

Are those hiring the inadequate instructors the same bureaucrats enshrining our lethal treatments as Standards Of Care? Is this something that should not be addressed harshly?

I do not give consent.

Footnotes:

[1] Edmund Burke
Wikiquote
Quote page
Disputed

Disputed

All that is necessary for the triumph of evil is that good men do nothing.

This is probably the most quoted statement attributed to Burke, and an extraordinary number of variants of it exist, but all without any definite original source. These very extensively used remarks may be based on a paraphrase of some of Burke’s ideas, but he is not known to have ever declared them in so succinct a manner in any of his writings. They may have been adapted from these lines of Burke’s in his Thoughts on the Cause of Present Discontents (1770): “When bad men combine, the good must associate; else they will fall one by one, an unpitied sacrifice in a contemptible struggle.”

This purported quote bears a resemblance to the narrated theme of Sergei Bondarchuk‘s Soviet film adaptation of Leo Tolstoy‘s book “War and Peace”, in which the narrator declares “All that is necessary for evil to triumph is for good men to do nothing”, although since the original is in Russian various translations to English are possible.
More research done on this matter is available at these two links: Burkequote & Burkequote2 — as the information at these links indicate, there are many variants of this statement, probably because there is no clearly definitive original by Burke.

[2] The Celebration of Intellect
Ralph Waldo Emerson
Harvard University
1870
Speech

[3] Self-Reliance
Ralph Waldo Emerson
1841
Essay

[4] The Horror of Qui Tacet Consentire Videtur
WordPunk
Posted on October 2, 2008
by David W. Boles
Article

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Comments

  1. I’m honored to be Rogue Medics featured guest for the day and as my twins daughters would say; “touché Dad! We’ve been schooled!”

    I don’t disagree with what you have to say and your perception to remark “I notice that the comment did not include any claim that what I wrote is inaccurate, only that I did not put a smiling face on the first part of a multi-part article” is precise.

    I do agree with what you are saying, in fact I am one who in my own state challenges the manner in which we conduct practical skills testing every chance I get. Practical exams happen to be the first on a long list of things needing changed, which include written exam processes as well.

    Targeting instructor trust from bureaucratic advantage points, demonstrating solid programmatic processes for those who educate, and improving operational agency trust to ensure one’s ability through mentor and credentialing programs are beginning points in changing how we “certify” a person to work in this profession. I think you and I are fairly close in our thoughts on this.

    My issue, your hunch, with Part I is not what you said but how you said it. You’re a passionate and skilled writer with sound EMS experience who has an audience larger than what you probably even comprehend. In my opinion, Part I was an attempt at an impassioned plea for change for current practices that missed the mark. It sounded more like an angry, discontented rant from a burned out medic who is just using his/her ability to blog as an avenue to whine and bemoan the very profession he/she is part of. It sounded like you were calling the bombs to drop on your own troops just to prove your spotters are wrong.

    Also, I would contend that your perspective, based upon your writing, of the National Registry is smug and based in ignorance. I can’t help but believe from what you write that you have no kind of personal relationship with the systematic processes the men and women leading the National Registry implore to provide the best indicator of skill and ability possible. Remember, the NR didn’t create the NEED for an exam, we in EMS did. Beating up the NR for providing what our profession requested, and failed to produce on our own, is unnecessary and counter-productive. Plus, the people at the NR care about doing the right thing for the profession and the patient just as much as you think you do.

    But then again maybe that is your MO and if so, maybe it’s me who needs the change most. Maybe if that was/is your intention then maybe I just need to find a different blog to read, after-all, it is your blog.

    My sarcasm about the public, and it was sarcasm, probably overshadowed what I was truly trying to communicate. For that I apologize. Meaningful dialogue, that isn’t so quick to force a reader to choose sides, serves this argument, our patients and our profession way better, in my humble opinion.

    Chy

    • Chy Miller,

      Targeting instructor trust from bureaucratic advantage points, demonstrating solid programmatic processes for those who educate, and improving operational agency trust to ensure one’s ability through mentor and credentialing programs are beginning points in changing how we “certify” a person to work in this profession. I think you and I are fairly close in our thoughts on this.

      I agree.

      My issue, your hunch, with Part I is not what you said but how you said it. You’re a passionate and skilled writer with sound EMS experience who has an audience larger than what you probably even comprehend. In my opinion, Part I was an attempt at an impassioned plea for change for current practices that missed the mark. It sounded more like an angry, discontented rant from a burned out medic who is just using his/her ability to blog as an avenue to whine and bemoan the very profession he/she is part of. It sounded like you were calling the bombs to drop on your own troops just to prove your spotters are wrong.

      It’s not what I say, but the way that I say it.

      In other words, you agree. You just want a more politically correct version. Then rewrite it with all of the affirmations that you think are necessary to convince the bureaucrats.

      That is not what I am good at, but that does not mean that your way of doing things is better, it is only more superficially polite.

      Also, I would contend that your perspective, based upon your writing, of the National Registry is smug and based in ignorance.

      Please make me less smug and less ignorant. Oh, wait. That seems to be just your demonstration of smugness and ignorance.

      Are you pretending to read my mind? I am not superstitious, so I do not believe in mind-reading or any other paranormal stuff that you appear to think is better than asking questions to figure out what I mean.

      Please continue with your diagnosis.

      I can’t help but believe from what you write that you have no kind of personal relationship with the systematic processes the men and women leading the National Registry implore to provide the best indicator of skill and ability possible.

      What word did you intend to use where you placed implore?

      A personal relationship with the systemic processes?

      That is much too touchy-feely for me. I implore you to stop making me giggle.

      The NR test is not remotely the best indicator of skill and ability possible.

      No multiple guess test or structured dance with occasional vocal sections could be. It does not matter how much the NR people care, or how many affirmations they use, the concept is fatally flawed.

      Remember, the NR didn’t create the NEED for an exam, we in EMS did. Beating up the NR for providing what our profession requested, and failed to produce on our own, is unnecessary and counter-productive.

      I criticize everyone who is foolish enough to think that this kind of test is anything other than a joke.

      Plus, the people at the NR care about doing the right thing for the profession and the patient just as much as you think you do.

      How do you determine what they care about or what I think I care about?

      Do you really assume that you know what others think without asking? Are you really that blind?

      But then again maybe that is your MO and if so, maybe it’s me who needs the change most. Maybe if that was/is your intention then maybe I just need to find a different blog to read, after-all, it is your blog.

      I do not intend to switch to your passive-aggressive/concern troll style of attack. Well, maybe I will use it occasionally, but it can lead to a saccharine overdose.

      My sarcasm about the public, and it was sarcasm, probably overshadowed what I was truly trying to communicate. For that I apologize. Meaningful dialogue, that isn’t so quick to force a reader to choose sides, serves this argument, our patients and our profession way better, in my humble opinion.

      Chy

      This is what you are like when you are humble. I’d hate to see what you are like when your abandon your tremendous humility.

      Kind of funny that you started with this, but then appear to contradict everything you write –

      I do agree with what you are saying, in fact I am one who in my own state challenges the manner in which we conduct practical skills testing every chance I get. Practical exams happen to be the first on a long list of things needing changed, which include written exam processes as well.

      .

  2. Well having one point we agree upon is a start. Don’t let me hold up your movement any longer. I’m sure others are waiting just as anxious as I am to hear your original Part II.

  3. At the risk of butting into a private argument… :-)

    Rogue,

    Obviously you don’t need to have a “smiling face” on your blog posts; a dose of harsh reality is necessary sometimes. However, there is a line between being brutally honest and being deliberately ( and maybe gratuitously) insulting. Chy obviously thinks you crossed it here. God knows I’ve crossed it enough myself in the past; and so I can see when others are at or over that line. Bits about how the NR writers “can’t think clearly” tends to cross the line.

    Also, what would you replace it with? I think the opinion that the NR testing process doesn’t work well is universal; what we need to discuss is what to replace it with. I’ve seen comments about using simulators in full-blown scenarios and about making the clinical and field internships the only requirement. Are there other options that haven’t been mentioned that I’m too obtuse to recognize?

    Finally,

    I have no interest in changing the opinion of the public. I am interested in changing the opinion of the people who work in EMS and in emergency medicine – people who should know better.
    Working on public opinion is just the tail trying to wag the dog.

    Ideally, that would be true, but the requirements for practicing paramedicine are defined by laws; and laws are made by (mostly) non-medical people.

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