After 5 years of planning and preparation, the National Board of Examiners in Optometry (NBEO) will be implementing its new Patient Encounters and Performance Skills (PEPS) examination beginning in August 2024.
After gathering input from stakeholders industrywide, NBEO determined that a new exam format was necessary to parallel the advancements within the optometric profession.
The result was PEPS, a multidimensional clinical examination that emphasizes patient-centered care and assesses evidence-based knowledge and cognitive ability as it directly applies to practice.1
Overview of PEPS
PEPS, which is designed to include clinical decision-making, will replace the traditional Part III Clinical Skills Examination (CSE). This evolution is in response to the demands of modern optometry, which far exceed clinical skills alone.
To be truly qualified for independent optometric practice, today’s ODs must be proficient in information gathering, critical thinking, problem solving, and effective communication with a diverse patient population. PEPS aims to provide a more accurate vehicle to assess competence for initial licensure.1
Background on the NBEO boards
Across medicine, national board exams—a professional licensure process requirement—serve as a metric to gauge whether healthcare professionals are fully competent to act in an unsupervised role when directly caring for the American public.
Licensing boards conduct exams to fulfill this mandate. The NBEO’s organizational mission is to “serve the public and the profession of optometry by developing, administering, scoring, and reporting results of valid examinations that assess competence.”1
NBEO exam breakdown
Part I Applied Basic Science (ABS)
Part I ABS of the NBEO boards covers the discipline’s foundational sciences to demonstrate that the candidate has a working knowledge and can employ critical analysis of systemic and ophthalmic disease along with optical principles that may impact clinical practice.
Further, Part I boards primarily focus on the didactic coursework taught during optometry school.
Part II Patient Assessment and Management (PAM)
Part II PAM is dedicated to confirming whether a candidate has a sturdy grasp of clinical decision-making. This tests a candidate’s knowledge proficiency through case-based clinical presentations pertaining to ocular disease and visual system disorders.
It also assesses a candidate’s ability to optimize treatment and management plans which has been woven into the examination and receives a separate score referred to as TMOD (Treatment and Management of Ocular Disease).
Part III Clinical Science Examination
Part III CSE integrates this foundational and clinical knowledge with live, in-person patient encounters to assess communication, essential technical skills, and critical analysis in diagnostics and management in light of the ever-evolving contemporary standards of optometric practice.
Successful completion and passage of all three portions of the exam based on NBEO guidelines is required to proceed with the independent, unsupervised practice of optometry.1
What to expect from the Part III PEPS exam
In the new PEPS format, candidates will interact with standardized patients in a simulated clinical environment that also provides a software platform containing complementary patient information.
The encounters will take place at the National Center of Clinical Testing in Optometry (NCCTO), located in Charlotte, North Carolina, in state-of-the-art exam rooms that enable a standardized experience for each candidate while mimicking a real-life optometric setting.
During each encounter with the standardized patient, candidates will be expected to demonstrate their ability to appropriately assess, diagnose, treat, and manage ocular conditions.
What is a standardized patient?
A standardized patient encounter utilizes trained actors to assess both communication and clinical skills during a timed encounter. Patients are well-versed in the appropriate medical jargon and in accurately presenting and portraying a particular ocular condition.2
Throughout the encounter, the standardized patient will assess the candidate's skills, including basic communication, professionalism, and other relevant criteria based on a standardized scale provided prior by the testing committee.
The new PEPS exam format
The new examination will consist of 12 stations, including 10 patient encounter stations and two performance skill stations. Each station incorporates both clinical encounters, with competency domains that are measured by the “patient” during the interaction, and the SOAP (Subjective, Objective, Assessment, and Plan)-themed software interface for designated sections.
Candidates will be assigned an OE TRACKER number and also given an arm badge with an identifying number, which they are to wear throughout the exam.
Patient encounter stations
In each encounter station, candidates will be given a minimum of 15 minutes to:
- Complete a subjective patient history.
- Review the provided exam data as well as objective findings.
- Order any ancillary tests deemed medically necessary.
- Document their diagnosis(es).
- Record their assessment and plan outlining the treatment and management of a given diagnosis(es).
Of note, 3 minutes prior to the encounter, candidates will receive preliminary information, including patient demographic data, chief complaint, review of systems (ROS), and current medications. When the official timer begins, which is visible at the top of the screen of their assigned laptop, candidates will gather the patient history and refer to the additional clinical data provided through the software interface.
Information that might be included would be slit lamp findings, refractive results, and any pertinent information from the dilated fundus evaluation. Next, candidates are offered the opportunity to order additional tests deemed medically necessary for an accurate diagnosis.
To conclude, the candidate offers the patient a diagnosis consistent with the language of the International Classification of Diseases, Tenth Revision (ICD-10) coding system, appropriate education on the condition, a therapeutic treatment plan, and options for ongoing management. Throughout the encounter, candidates can set their own pace; however, all components must be completed within the time allotted.
The PEPS exam blueprint breakdown
The PEPS exam includes five competency domains with the most emphasis placed on Clinical Interpretation and Assessment (29%) followed by Management and Documentation (25%). The remaining weighted sections include Skills (22%) which evaluates the five core skills of a standardized patient (see next section for more details), Patient Education (13%), and Communication and Professionalism (11%).
The NBEO carefully constructed these stations and competencies to represent the major groups of diagnoses that an optometrist should be proficient in treating during direct patient care in a clinical setting.
Clinical skills stations
In the two clinical skills stations—one assessing the anterior segment and the other assessing the posterior segment—candidates will demonstrate the five skills (gonioscopy, tonometry, biomicroscopy, dilated biomicroscopy, and binocular indirect ophthalmoscopy [BIO]) determined to be most essential in diagnosing and managing common vision- and life-threatening conditions.
Each station will be no less than 15 minutes in length. The format of these two stations is very similar to the skill stations of the former NBEO PART III CSE.
10 tips for PEPS exam success
Prior to the exam
1. Utilize the NBEO resources.
In addition to a full orientation video and logistics—such as a candidate guide, site information, and an equipment list—the Part III PEPS webpage provides a Part III PEPS Software Interactive Tutorial, which can guide you through the exam platform and provide an opportunity to review sample patients, choose ancillary testing, go over findings, and enter treatment plans.
It also provides examples of the available equipment and set-up that will be used for the anterior segment and posterior segment skills portions as well as the criteria you will be graded on during patient encounters.
2. Practice prior.
Practice is the best preparation. Using the information gleaned from this article and the NBEO videos, setting up encounters with fellow students, family, or friends to become comfortable with clinical communication and completing the interview/skills portions within the allotted time can be the optimal recipe for PEPS success.
An extra tip is to utilize the provided assessment guidelines as a practice to have them rate you on your interpersonal skills and provide constructive feedback.
3. Plan to arrive early.
As it is incredibly common for travel plans to go awry, take every precaution to ensure you will arrive at the exam site with time to spare. If you do not live locally, build in extra travel time to arrive in Charlotte the night before the exam.
NBEO has obtained special contracted rates with several local hotels. Know the distance from your accommodations to the testing site and allow for incidentals, such as traffic and accidents.
If you are not driving, familiarize yourself with public transportation options, their schedules, and nearest stops. The same applies if you plan to walk from your hotel to the site—map the shortest route and give yourself plenty of time to stroll to your destination.
4. Get a good night’s sleep.
Being anxious prior to the test is normal and to be expected, but prioritize a good night’s sleep. If you have difficulty sleeping, consider using white noise or one of the many sleep apps designed to calm the mind and induce slumber.3
Plan for an early dinner, consider airplane mode on all electronics, and try to avoid any pre-bed stimulation (e.g., social media, bright lights, screens, unnecessary phone calls, or text messaging).
During the exam
A major component of the patient encounters will depend on basic communication skills, so remember the following:
5. Be aware of nonverbal communication.
Up to 93% of communication (38% voice tonality and 55% body language) is attributed to nonverbal. Don’t underestimate the power of a calm vocal tone, eye contact, a smile, and an open, forward-leaning posture.4
On the flip side, avoid speaking high or too quickly, looking around the room, frowning, sighing, fidgeting, crossing your arms, or other signals that indicate to the patient you are either hostile or disengaged. Remember to breathe along with speaking in a clear and composed manner.
As for the patient, remember these are actors trained to give you clues not only through their words but also their demeanor. Being aware and observant of their nonverbal clues of agitation, discomfort, or fear could help lead you to a diagnosis.
6. Engage in active listening.
Though the tendency may be to gather the facts as quickly as possible to move on to the assessment—especially when there is clock timing down—still give the patient ample time to speak without interrupting.
Again, they have been given the specific details needed for diagnosis and will supply them if given the opportunity. Repeat pertinent facts, clarify any confusing statements, and ask follow-up questions.
7. Respect and recognize diversity.
These encounters should mirror how you would behave in the real world with real patients. Therefore, above all else seek to provide a positive patient experience that is respectful. Beyond basic professionalism, go the extra step by taking into account cultural considerations, gender identity, and other aspects of diversity.
If not provided, ask for preferred pronouns. Take into account cultural differences regarding personal space and physical contact. Above all, employ empathy. Many ocular conditions elicit confusion, concern, anxiety, and apprehension from patients, which might require the candidate to address these emotions.
Subsequently, an empathetic provider oftentimes elicits greater transparency and compliance. Studies have even shown a correlation between empathy and increased therapeutic adherence with certain diseases.5
8. Exercise time management.
Be acutely aware of time. When you practice the encounters, as suggested earlier, set a timer and make certain you can perform the history taking, input of information, analysis, and counseling within the prescribed time frame. On the day of, make a point to check the provided clock at intervals throughout so you can adjust accordingly.
9. Regroup after each encounter.
As you rotate through the stations, take time to stop, breathe, and clear your mind. Take a moment to reflect on strengths and weaknesses from the prior station, so you can make your best effort to course-correct mistakes and continue to build on your experience, gain momentum, and improve throughout the exam.
10. Do not forget to wash your hands.
During the clinical skill portion of the exam, keep hygiene a priority and wash your hands. The most important procedure in preventing nosocomial infections—infections acquired by an individual during the act of receiving healthcare—is hand washing.6
In closing
The new, restructured Part III PEPS exam is designed to ensure only qualified candidates demonstrating key competencies, critical analysis, and superior communication can advance to independently practicing optometry.
This diligence and progressive approach is destined to elevate the standard of care within the optometric community.
Therefore, though the exam process is stressful by nature, take pride in knowing you are a pivotal part of the advancement toward more accurate diagnoses, focused management, and patient-centered eyecare.
