Letters to the Editor

Dear Editor,

Congratulations to the ISTM on a fabulous conference (CISTM8 in New York), and also on the inaugural Certificate Exam into which so many of you put so much work.

I hope you don't mind me passing on a few suggestions based on my experience with the recent ISTM exam. Please note that these are made with the intent of being `constructive criticism' with only the best intentions for ISTM members. As an academic (part time), I am only too aware of the difficulties in setting something like this up, and only hope that this will help future examinees and the ISTM. I admit to speaking as a general physician, as distinct from infectious disease physicians.

Overall, I thought the exam was fair and at an appropriate standard, covering the relevant areas. However, I am greatly disturbed that there was a marked overabundance of infectious disease content. I realize that there is a diplomatic/political agenda here in that to date, the bulk of travel medicine has been mistakenly equated with infectious disease, with a limited spattering of other topics. I felt that out of 200 questions, just 2 questions on biostatistics/public health, 1 or 2 questions each on jet lag, motion sickness and altitude sickness was inappropriate. There were no questions on assessing fitness to travel - the first and most important prerequisite. I can't recall any questions on injection technique (ID, IM, SC, etc.) or managing complications or patients' concerns, and very few questions on the impact of general medical conditions on travel related issues.

Whilst I am aware that returned travelers are likely to be treated at infectious disease tertiary hospital units, it should be remembered that the vast majority of travelers are well and healthy and, in fact, unlikely to see a primary care physician prior to travel. About 25% will see a primary care physician prior to travel, and less than 3% attend a travel clinic. I note that approximately 20% of attendees at the recent conference interactive sessions list themselves as `Family Physicians'. These figures should be reflected in the course and exam content. If on the other hand, the ISTM body intends that travel medicine is mainly infectious disease, then this should be clearly stated.

A second problem which stood out was that in trying to determine the best answer for many of the questions, it was clear that there was little evidence on which to base the supposedly correct answer. I believe this issue was emphasized by Professor Steffen. This was compounded by the wording of many of the questions. " What would be `your' management" may be a different question to " What are the `WHO guidelines'" . This was even further compounded by questions based on USA-centric information, as distinct from European, Australia, or UK-based experiences.

Thirdly, I believe this first exam should serve as a pilot in order to determine the relevant pass level. This means standardizing the paper to the appropriate level.

In summary:
1. Too much infectious disease content and too little emphasis on other travel related issues - infections only one of many issues
2. Inadequate evidence base for answers - as distinct from general management
3. USA centric - a problem for many
4. Inappropriate wording - recommend review of the use of "you"
5. Need for standardization

Once again, congratulations on the Certificate. I appreciate all the work and effort that went into it and hope my comments may be of some value for members.

Sincerely,

Dr Jonathan Cohen,
Melbourne, Australia

Here is a response to Jonathan's letter from Phyllis Kozarsky, MD, on behalf of the Exam Committee

Dear Dr. Cohen,

Thanks so much for your thoughtful comments about the exam. We certainly appreciate the constructive way in which you expressed your concerns and I would like to personally address them.

The content concerns are well stated. We did send the Body of Knowledge (BOK) to 100 travel health physicians (internationally) to rank the BOK sections in terms of what areas they felt were most important for pre-travel health clinicians to know and what percentage of questions should address each topic. We (including a professional testing service) received answers that we used to develop a distribution in order to decide how many questions should be written covering each topic in travel medicine. We are certainly able to modify this and will base any modifications on our feedback and results of this exam.

You have addressed a concern that we all have when speaking about questions in certain difficult-to-test areas - e.g. assessing fitness to travel is difficult and often subjective. As you mentioned, we had to be very cautious not to include questions for which there are little or no data to support the answers. As well, there are always concerns about the appropriateness of a number of biostatistics questions when our major concern is the knowledge necessary for administering pre-travel health advice and the constituency includes nurses.

We further appreciate your concern about the international nature of the exam. Looking at the exam committee and who wrote the questions (see ISTM website), please note that the group came from all regions and contained individuals representing many different types of practices. There was a major effort to not " nationalize" the exam in any way. This issue will be addressed again as all questions will be reviewed.

And finally, please note that a professional educational testing service has been working with us all along and has been referred to in many of our communications with the members throughout this process. As stated above, each question will be assessed and appropriate psychometrics will be performed.

I hope these comments are helpful. We have tried very hard to prepare a fair and representative exam, but realize that this initiative is indeed a " work in progress." Your comments will be taken very seriously as we move forward.

Very Sincerely,
Phyllis Kozarsky