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vestigating hypothermia treatment in bacterial meningitis should include more precise inclusion criteria such as objective intracranial pressure status. Marko Kutleša, MD, PhD Dragan Lepur, MD, PhD Bruno Baršić, MD, PhD Author Affiliations: Department of Intensive Care Medicine and Neuroinfectology, University Hospital for Infectious Diseases “Dr Fran Mihaljević,” Zagreb, Croatia. Corresponding Author: Marko Kutleša, MD, PhD, University Hospital for Infectious Diseases “Dr Fran Mihaljević,” Mirogojska 8, Zagreb 10000, Croatia ([email protected]). Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. 1. Mourvillier B, Tubach F, van de Beek D, et al. Induced hypothermia in severe bacterial meningitis: a randomized clinical trial. JAMA. 2013;310(20):2174-2183. 2. Irazuzta JE, Pretzlaff R, Rowin M, Milam K, Zemlan FP, Zingarelli B. Hypothermia as an adjunctive treatment for severe bacterial meningitis. Brain Res. 2000;881(1):88-97. 3. Lepur D, Kutleša M, Baršić B. Induced hypothermia in adult community-acquired bacterial meningitis—more than just a possibility? J Infect. 2011;62(2):172-177.

In Reply Therapeutic hypothermia always includes an induction phase and a maintenance phase.1 In our study, induction was obtained by infusion of cold saline. This technique was proven to be safe in several types of cerebral injuries.2 Because all centers did not use the same hypothermia technique, we tried to obtain a uniform and quick induction phase in the hypothermia group. Moreover, there are no data in the literature supporting a restrictive fluid policy for bacterial meningitis.3 Although we do not have fluid data for the control group, we found no association between the amount of fluid and mortality (t test P = .34) in the hypothermia group. We agree with Drs Pirracchio and Journois that there was an imbalance between groups concerning septic shock. Nevertheless, futility analysis showed that there was a very low probability of demonstrating any beneficial effect of therapeutic hypothermia. We believe that the results of our study do not support that mild hypothermia is associated with better neurological outcome. We disagree that higher mortality may affect only the proportion of patients with a GOS score of 5. When we compared the proportion of patients with GOS scores of 4 and 5 with those with a GOS score of 3 in each group, we found no beneficial effect of therapeutic hypothermia (odds ratio, 1.90 [95% CI, 0.56-6.91], P = .38). A higher number of patients died because life support was withdrawn due to poor neurological outcome in the hypothermia group. Dr Kutleša and colleagues point out the low recruitment at each participating center. Enrolling the 49 centers took 14 months, so some centers were active during a shorter period than the total inclusion period. Among the 49 centers, only 34 actively enrolled patients, with a median of 1 patient per center. Bacterial meningitis is a rare disease4 and only the most severe patients met all of the inclusion criteria. We agree that 1358

the inclusion rate was low, but it was homogenous among all active centers, excluding selection bias. The duration of the disease is almost impossible to assess because timing of the infection is unknown. Nevertheless, once patients were referred to the hospital, we found no significant difference in time from door to first dose of antibiotics. Knaus chronic health status score and McCabe classification were also similar in the 2 groups. We acknowledge that the chosen duration (48 hours) of therapeutic hypothermia was arbitrary. This period corresponds to the maximum inflammatory response into the cerebrospinal fluid. Monitoring intracranial pressure could have helped to guide the hypothermia duration. Nevertheless, the use of this technique could have precluded external validation of the results because most hospitals do not measure intracranial pressure. Moreover, inserting a device to measure intracranial pressure could have delayed the onset of therapeutic hypothermia at a time when cerebral inflammation is maximal. Bruno Mourvillier, MD Michel Wolff, MD Author Affiliations: Réanimation Médicale et Infectieuse, Groupe Hospitalier Bichat-Claude Bernard, Paris, France. Corresponding Author: Bruno Mourvillier, MD, Réanimation Médicale et Infectieuse, Groupe Hospitalier Bichat-Claude Bernard, 46 Rue Henri Huchard, 75018 Paris, France ([email protected]). Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. 1. Nielsen N, Wetterslev J, Cronberg T, et al; TTM Trial Investigators. Targeted temperature management at 33°C versus 36°C after cardiac arrest. N Engl J Med. 2013;369(23):2197-2206. 2. Polderman KH, Rijnsburger ER, Peerdeman SM, Girbes AR. Induction of hypothermia in patients with various types of neurologic injury with use of large volumes of ice-cold intravenous fluid. Crit Care Med. 2005;33(12):2744-2751. 3. Maconochie I, Baumer H, Stewart ME. Fluid therapy for acute bacterial meningitis. Cochrane Database Syst Rev. 2008;(1):CD004786. 4. Thigpen MC, Whitney CG, Messonnier NE, et al; Emerging Infections Programs Network. Bacterial meningitis in the United States, 1998-2007. N Engl J Med. 2011;364(21):2016-2025.

Basic Science Content in the USMLE Step 1 To the Editor When discussing changes to the United States Medical Licensing Examination (USMLE) Step 1, Dr Haist and colleagues1 concluded that “many medical students prepared for Step 1 with a ‘binge and purge’ mentality; because students failed to recognize the value of the basic sciences in medical practice, many memorized information for shortterm retention.” Haist et al1 used this position as a rationale for “planned changes to emphasize basic sciences throughout [the] USMLE.” The Viewpoint neglected to consider the alternative hypothesis that students take a binge and purge mentality not because they fail to recognize the value of basic science in medicine, but because they believe the focus of Step 1 is on clinically irrelevant minutiae that have little value in patient care. For instance, Step 1 commonly tests students on their ability to analyze various bacterial growth plates and media to de-

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duce what species of bacteria are present. Although this skill set may have been relevant in the past, most clinicians today likely cannot remember the last time they saw a blood agar plate. A recent meta-analysis2 showing that Step 1 scores are not associated with clinical skills acquisition provides additional evidence of the mismatch between the subject matter of Step 1 and actual clinical practice. Because students may believe that much of the material on Step 1 is irrelevant to modern medical practice rather than fundamental basic science knowledge, it is no surprise they may have a binge and purge mentality, instead choosing to spend their time on other educational pursuits, such as research or additional rotations. The fact that students do not take a similar approach to the more clinically focused Step 2 and 3 examinations further supports this notion. Although basic science certainly has an important role in patient care, testing future physicians on knowledge that seems clinically irrelevant fails to achieve the aim of ensuring that medical students can “apply foundational science in patient care.” The goal of enhancing the assessment of practice-related competencies with the USMLE is an important one. However, as these examinations evolve, continuous evaluation of whether the proposed changes move toward this goal is necessary. Before components of Step 1 are added to the other USMLE examinations, this content should first be updated to ensure that it is truly related to foundational science for patient care. John S. Barbieri, BA Author Affiliation: Perelman School of Medicine at the University of Pennsylvania, Philadelphia. Corresponding Author: John S. Barbieri, BA, Perelman School of Medicine at the University of Pennsylvania, 3450 Hamilton Walk, Philadelphia, PA 19104 ([email protected]). Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. 1. Haist SA, Katsufrakis PJ, Dillon GF. The evolution of the United States Medical Licensing Examination (USMLE): enhancing assessment of practice-related competencies. JAMA. 2013;310(21):2245-2246. 2. McGaghie WC, Cohen ER, Wayne DB. Are United States Medical Licensing Exam Step 1 and 2 scores valid measures for postgraduate medical residency selection decisions? Acad Med. 2011;86(1):48-52.

In Reply We concur with Mr Barbieri regarding the importance of assessment being relevant to the profession for which the assessment is being used to judge competence. This is one principle of good test development. Initially one defines what is being measured; Step 1 assesses understanding and ability to apply important concepts of the sciences basic to the practice of medicine.1 Ensuring the relevance of test content is important. Two ways to ensure relevance are through practice analysis and by the carefully designed use of expert opinion. Practice analyses have helped guide many of the plans for changes to the USMLE. The USMLE program also relies on experts to develop questions.

A volunteer faculty representing 110 accredited US allopathic medical schools, along with representatives from other institutions, including the US Food and Drug Administration and the US Centers for Disease Control and Prevention, participates in the USMLE program. In 2013, there were 337 volunteers generating and reviewing the questions and approving the USMLE examinations to guarantee the questions and examinations are pertinent to the practice of medicine. Questions are generated and approved by test development committees. The majority of the members of these committees, including those for Step 1, are clinical faculty. Questions are pretested before being used in live scoring, and those with acceptable statistics are reviewed and approved by interdisciplinary review committees before scored use. In addition, the governance committee for each examination approves the entire examination before release. Furthermore, every 3 years each question is reviewed to ensure currency. Examples of foundational science questions can be found on the USMLE website.2 Over the last 10 years, the Step 1 development committees have designed questions to assess the application of foundational science knowledge in the context of clinical or experimental vignettes. Assessing the application of knowledge rather than simply assessing recall and using vignettes enhances assessment of clinically relevant foundational science knowledge. Barbieri notes that the analysis by Dr McGaghie and colleagues3 shows that Step 1 and Step 2 clinical knowledge performance correlates poorly with clinical skills acquisition. This result is not surprising. The constructs assessed, medical knowledge, and clinical skills involve different domains and use different evaluation methods. Multitrait and multimethod validity would support a diminution of correlations when measuring the same domains by different methods (ie, a multiple-choice test and an essay examination) or different domains by the same method (ie, multiple-choice questions assessing knowledge of patient care and professionalism). The lowest correlation is expected when measuring different domains by different methods,4 such as correlating knowledge of patient care assessed by multiple-choice questions with an observational checklist of behaviors assessing communication and interpersonal skills. As medicine and medical education advance, the USMLE program will continue to use the highest standards of testing to enhance assessments. The USMLE program is committed to developing quality examinations relevant to the practice of medicine to protect the health of the public through the art of assessment. Steven A. Haist, MD, MS Peter J. Katsufrakis, MD, MBA Gerard F. Dillon, PhD Author Affiliations: National Board of Medical Examiners, Philadelphia, Pennsylvania. Corresponding Author: Steven A. Haist, MD, MS, National Board of Medical Examiners, 3750 Market St, Philadelphia, PA 19104 ([email protected]).

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Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. Disclaimer: All of the authors are actively involved in the USMLE program and are employees of the National Board of Medical Examiners, which is co-owner of USMLE with the Federation of State Medical Boards. 1. A Joint Program of the Federation of State Medical Boards of the United States, Inc, and the National Board of Medical Examiners. 2014 USMLE bulletin of information. http://www.usmle.org/pdfs/bulletin/2014bulletin.pdf. Accessed February 18, 2014 2. US Medical Licensing Examination. Sample items. http://www.usmle.org /foundational-science/step-1/sample-items/. Accessed February 20, 2014. 3. McGaghie WC, Cohen ER, Wayne DB. Are United States Medical Licensing Exam Step 1 and 2 scores valid measures for postgraduate medical residency selection decisions? Acad Med. 2011;86(1):48-52. 4. Allen MJ, Yen WM. Validity. In: Introduction to Measurement Theory. Monterey, CA: Brooks/Cole Publishing Co; 1979:95-117.

CORRECTION Incorrect Wording in Figure: In the Original Investigation entitled “Effect of Communication Skills Training for Residents and Nurse Practitioners on Quality of Communication With Patients With Serious Illness: A Randomized Trial,” published in the December 4, 2013, issue of JAMA (2013;310[21]:2271-2281. doi:10.1001/jama .2013.282081), language in Figure 1 was incorrect. On both the left and right halves of the figure, in the second, third, and fourth boxes beneath the “Randomized” oval, the language “evaluations received” should have read “evaluations sought.” This article has been corrected online.

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Basic science content in the USMLE Step 1--reply.

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