A Beautiful Friendship

Several of my recent tweets (@davearlingtontx) featured the National Board of Medical Examiners or NBME. I have been fortunate in my professional career at the Federation of State Medical Boards (FSMB) to have spent two decades working with colleagues at the NBME on our jointly-sponsored program, the United States Medical Licensing Examination® (USMLE®).

In thinking about the FSMB-NBME relationship I am reminded of the last line from the movie Casablanca. As Humphrey Bogart and Claude Rains stroll across a misty airport tarmac, Bogie says “Louis, I think this is the beginning of a beautiful friendship.”

FSMB and NBME joint mtg in 1990

And while I don’t suppose any of the key figures from the earliest days of either organization said it quite so starkly, surviving evidence strongly suggests that friendship and mutual respect characterized the relationship then and now. This manifested itself with the FSMB’s early support of the NBME and the launch of its certifying examination in 1916 and later when the Federation turned to the National Board in the 1960s when the two collaborated on a national examination specifically for medical licensure, the Federation Licensing Examination or FLEX. Personal connections were at the heart of the relationship with a key figure in both organization’s early years, Walter Bierring, serving on governance of both executive boards; and this deepened with “cross pollination” that witnessed nearly three dozen individuals serving on the governance of both organizations. Today, the relationship centers especially around the deep workings of the two organizations around the USMLE. (A more detailed account of the FSMB-NBME relationship appeared in the Journal of Medical Regulation, vol. 100, no. 4, 2014, pp. 17-20 at http://jmr.fsmb.org/archives/)

I share all this because of an observation I remember hearing from a former President at the NBME. Reflecting on the close working relationship of the two organizations spanning so many decades, he marveled at how unique this felt, particularly as such a relationship seemed wholly unimaginable in the for-profit world. I think he was right. In a for-profit environment of bottom line revenues, shareholder returns and cutthroat competition, this kind of relationship simply doesn’t exist—and if it did, it wouldn’t last. One party would eventually seek to leverage a temporary or strategic advantage in the relationship to force either a merger or an ouster of the other party. One of the beauties of the FSMB-NBME relationship in support of the USMLE is the common use of pronouns like “us,” “our” and “we” by staff at both organizations working on the program.

In a way, this speaks to the fundamentally different nature of not-for-profit organizations (NPOs)—with their explicit mission usually pertaining to a specific societal benefit—which manifests an organizational culture more amenable to the kind of collaborative endeavor and relationship such as that between FSMB and NBME. This relationship has benefited medical regulators for more nearly fifty years.

In the early to mid-1960s, two trends in the functioning of state medical boards shifted in noticeably opposite directions. At that time, physician discipline assumed an increasingly prominent position in the work of state medical boards—one requiring not only a paradigm shift in medical regulators’ views of their own role but also a marked increase in the direct resources (both staff, time and intellectual focus) directed to this function. At the same time, medical boards’ recognized that the science of assessment had outstripped their capacity to develop and deliver sufficiently high quality examinations for medical license based upon the limited expertise and resources available to most boards.

This recognition led directly to the creation of the FLEX, the first large-scale, formal collaborative endeavor between the FSMB and the NBME. The relationship that deepened over time between the two organizations in their efforts on FLEX and later USMLE provided a direct benefit to the medical regulatory community. The involvement of the FSMB in this relationship meant that the priorities and interests of the medical regulatory community featured directly and prominently in the national programs for the assessment of physicians. The involvement of the NBME in this relationship brought professional and technical expertise to one of the most visible and fundamental elements in the medical regulatory process.  The success of this relationship through these assessment programs allowed medical boards to more effectively meet public expectations demanding greater accountability and transparency in their disciplinary function while simultaneously improving the boards’ collective role in assessment.

It is worth noting that success was never guaranteed. I have personally heard anecdotes from long-tenured staff at the NBME about tensions that periodically arose between medical educators and medical regulators working on various committees supporting the FLEX and later USMLE. These anecdotes date to activities that occurred twenty and sometimes thirty years ago when strong personalities tackling potentially divisive issues might have led some to wonder about the viability of the long-term working relationship between FSMB and NBME. The relationship survived (and thrives today) due in part to the alignment of the mission, vision and values of the two organizations. But just as important are human relationships tying the two organizations together. The glue that preserved these working relationships were the staff at the two organizations and the commitment of senior leadership and governance to nurture an effective long-term relationship.

We may think in generalized terms of organizations and boards but it is individuals that comprise these entities. These broader relationships flourish or suffer depending upon the inter-personal element that exists at the level of individuals from two different organizations working collaboratively. The ultimate success in fostering trust and mutual respect in the organizations’ working relationship stems directly from the daily activities of colleagues working toward a shared purpose serving both organizations’ mission and, in doing so, the interests of medical regulation and society at large.

So here’s to my colleagues past and present who have created and maintained this unique, vital relationship: Hank, Don, Jim, Peter, Gerry, Kate, Amy, Susan, Frances, Janet, Suzanne, Debbie, Michael, Shelley, Randy, John and so many others.

The views expressed in this blog are solely those of the author and not that of the FSMB

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