Changes in standard of candidates taking the MRCP(UK) Part 1 examination, 1985 to 2002: analysis of marker questions.

BACKGROUND: The maintenance of standards is a problem for postgraduate medical examinations, particularly if they use norm-referencing as the sole method of standard setting. In each of its diets, the MRCP(UK) Part 1 Examination includes a number of marker questions, which are unchanged from their use in a previous diet. This paper describes two complementary studies of marker questions for 52 diets of the MRCP(UK) Part 1 Examination over the years 1985 to 2001 to assess whether standards have changed. METHODS: Study 1, which used routinely collected information on the performance of 4405 marker items, used a statistical method to assess changes in performance across diets. Study 2 compared performances of individual candidates on 28 individual marker items that were shared by the 1996/2 and 2001/3 diets. RESULTS: Study 1 found evidence that candidate performance on the MRCP(UK) Part 1 Examination showed a gradual improvement over the period 1985 to 1997, which was followed by a sharp decline in performance until 2001. The 'dog-leg' in performance at 1997/3 was not an artefact of changed Examination Regulations, mix of UK and overseas candidates, or time from qualification until taking the Examination. Study 2 confirmed that performance in 2001/3 was significantly worse than in 1996/3, that the poorer performance was found in graduates of UK medical schools, and that candidates passing the Examination in 2001/3 performed less well than those passing in 1996/2. CONCLUSION: There has been a decline in the performance of graduates from UK medical schools taking the MRCP(UK) Part 1 examination. The reasons for this are not clear, but the finding has implications for medical education, and further studies are needed of performance in other postgraduate and undergraduate examinations. The use of norm-referencing as the sole method for setting the pass mark over this period meant that candidates passing the MRCP(UK) examination also had a lower standard. The MRCP(UK) Part 1 and Part 2 examinations now have their standard set by criterion-referencing.

Response of aplastic anaemia and scleroderma to cyclosporin.

Scleroderma and aplastic anaemia (AA) occurred simultaneously in a patient. Treatment with antilymphocyte globulin (ALG) resulted in some improvement of the scleroderma and a partial, temporary response of the AA. Both the scleroderma and AA then responded dramatically to cyclosporin (CSA) therapy. Subsequently, a positive Ham's test, together with a reduction in the phosphatidyl-inositolglycan (PIG) anchored membrane proteins decay accelerating factor (DAF, CD55) and membrane inhibitor of reactive lysis (MIRL, CD59), confirmed a diagnosis of paroxysmal nocturnal haemoglobinuria (PNH) affecting erythroid, myeloid and lymphoid cell lineages. We hypothesize that the pathogenesis of the bone marrow failure in this patient was a stem cell defect with a secondary immune response involving T-lymphocytes that may have simultaneously triggered the pancytopenia and scleroderma.

A combined immunohistological and histochemical analysis of lymphocyte and macrophage subpopulations in the rheumatoid nodule.

The histochemical demonstration of acid phosphatase (ACP) and adenosine triphosphatase (ATP) has been combined with standard immunofluorescence techniques, using a panel of monoclonal and conventional antibodies, to examine lymphocyte and macrophage subsets and their microanatomical relationships within the subcutaneous rheumatoid nodule (RN). This analysis reveals that the RN is composed largely of strongly HLA-DR+, ATP- macrophages which contain lysosomal enzymes (ACP) in large amounts. The lymphocytic infiltrate which is sparse and poorly organized is comprised almost entirely of thymus derived lymphocytes (T cells) with a normal proportion of helper/inducer (OKT4+) and suppressor/cytotoxic (OKT8+) cells. These observations are in contrast to the findings in the rheumatoid synovial membrane of a prevalence of interdigitating type, HLA-DR+ cells and the predominance of helper (OKT4+) type T cells.