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authentic clinical management behaviors (Melnick, 1990a; Melnick, 1990b; Melnick & Clyman, 1988) The observed and recorded behavior is scored This new testing format has been a component of Step 3 since 1999 It makes up day of the 2 day test Its score is combined with the MCQ score in making pass fail decisions The Primum CCS simulated environment has several key characteristics Clinical realism is achieved by providing all the resources thousands of tests and treatments, appropriate locations for care encounters, realistic cues from patients and other members of the healthcare team that would be available in a real-life context The simulation creates a sense of time realism As the test taker moves the clock forward, patient condition changes based on the combined effects of the disease course over time and the effects of the actions of the examinee The test taker writes orders for tests and treatments using an uncued, free-text order entry system The simulated patient case begins with a statement of the patient s reason for the encounter The test taker is then free to gather several kinds of information The patient may be queried for more information about the problem and other medically relevant history The test taker may undertake various physical examination maneuvers Simulated time moves forward as the test taker uses time to gather this information The test taker may also, at any time, write orders for diagnostic studies, such as blood tests, x-rays, scans, etc Results of these orders do not appear until a prescribed time has passed At any point, the test taker can initiate treatments or undertake procedures such as surgical interventions However, in order to monitor the results of these interventions, the test taker must initiate additional history-taking, physical examination, or tests Depending on the patient s condition, the test taker may receive spontaneous cues from the patient, the patient s family, or other members of the health care team, reporting major changes in the patient s condition At any point in time, the patient can be moved between home, of ce, hospital, and intensive care Of course, the availability of tests and treatments varies across these sites of care The system ultimately ends the simulation, and presents the next case The history of developing the Primum simulation system contains some lessons for those anticipating the creation of new, authentic performance assessments The impetus for the NBME s effort to apply computer technology to its testing programs was clearly linked to the decision made by the NBME in the early 1960s to eliminate the bedside clinical component from the certifying examination It was with great reluctance that the NBME bowed to the mounting evidence that these exams were unfair In 1968, the NBME s Research Advisory Committee Alexander Barry, Robert Ebel, Hale Ham, Bill Mayer, Jack Myers, Kenneth Rogers, Dael Wol e, and Louis Welt recommended that NBME develop a computer-based simulation system to test physician skills previously tested in bedside examinations A prototype simulation of initial patient diagnostic evaluation was demonstrated for the American College of Physicians meeting in 1970 From 1970 to 1975, work on the simulation system continued as a joint effort with the American Board of Internal Medicine (ABIM) During this phase, ve.



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At a high level, Figure 61 demonstrates the concept of PBNM PBNM is a general concept that has been discussed in a variety of industry fora and publications It has been used for

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areas such as QoS management, con guration management, and fault and performance management In this chapter we will discuss the concept in general and then we will focus primarily on how the PBNM concept can be applied speci cally for security management for wireless ad hoc networks We start by providing a more detailed overview of the architecture used in PBNM We will then discuss in detail, speci c policy languages that have been proposed Policy languages merit particular attention because expressing policy languages is one of the most critical components of the architecture We will discuss how the PBNM architecture can be used in a distributed fashion At the end of this section we will also brie y discuss several standardization activities in this area 622 Architecture

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