Dec. 17, 2007

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Licensing Exam Off the Mark

Rachel Eastwood Jason Sanders

Early December brought anticlimactic results from the United States Medical Licensing Examination Step 2 Clinical Skills (CS) test: Pass. Nothing more, nothing less. Compared to the fairly common anxiety-surrounding three-digit Step 1 scores, you might believe this simple grading scheme would be welcome among medical students. After all, licensing exams are constructed psychometrically to determine mastery above a predefined threshold and not necessarily to predict future performance per an absolute score. But after studying the usual suspects for a week, spending a Sunday afternoon riding on a train to Philly, and shelling out $1,300 altogether (saved a bit by crashing at a friend’s apartment), I began to ask some critical questions about the process. Why is scheduling such a mess? Why does it cost so much, and who should pay for it? Why don’t I receive a numerical breakdown of my scores, since examinees receive no feedback during the test? Why isn’t my own medical school’s Objective Structured Clinical Examination (OSCE) sufficient?

Yet Another Exam

Prior to 2004, foreign medical graduates were required to take the Clinical Skills Assessment (CSA), but now everyone who wants to match at a residency program (and for many, to graduate from medical school) must pass Step 2 CS. For HMS students the deadline is Dec. 31 of the final year. Grading comprises three components, each of which needs be satisfactory: spoken English proficiency (SEP), communication and interpersonal skills (CIS), and the integrated clinical encounter (ICE). The last piece has several subcomponents, such as adequate history-taking, physical examination, note composition, and differential diagnosis.

How It Works

The adventure begins in the spring of a student’s penultimate year since spots must be booked far in advance. Given minimal penalties for switching the location or date (a practice actually encouraged), the calendar fills up early, with a flurry of cancellations and rebookings as the examinations approach. Only five sites administer the exam, with Philadelphia closest to Boston (otherwise, Atlanta, Houston, Chicago, or Los Angeles). While site centralization reduces costs and observer variability, travel requirements can be burdensome when students use air travel and book overnight accommodations. 

Step 2 CS makes for a busy day. You rotate through 12 patient stations divided by two breaks. Fifteen minutes is allocated for each clinical encounter, followed by 10 minutes to type or hand-write a note including history, physical exam, differential diagnosis, and diagnostic plan. A reminder knock two thirds of the way through each station helps those who neglected to bring an analogue watch, but the final knock means drop everything and leave—even if you’re just starting to provide closure. Most maneuvers are common sense and just plain courteous, but with such high stakes you tend to feel like a robot: drape the patient immediately upon entering the room, always ask for a full social and family history, wash hands for at least fifteen seconds, never listen through the gown, and so forth.

Room for Improvement

Standardized patients make sure that student doctors get the basics, that they don’t punt on a must-not-miss presentation. They are extremely helpful during the preclinical years as part of the patient–doctor curriculum. I owe a great deal to the men and women who helped me practice communication skills when first learning the art of history-taking and who helped me learn sensitive physical examination techniques (e.g., pelvic and rectal). But at the end of a medical school career, after caring for a multitude of genuinely ill patients on the wards, standardized patients are a bit of a letdown. Even their “challenging” comments and questions—e.g., “I’ve been waiting in the ER for over six hours!” and “Could this be a fatal disease, doctor?”—are literally catalogued in the review books. Plus, given the time constraints of the exam, standardized patients simply nod to most examinee replies, entirely unlike real patients in the context of raw emotions. The physical exam differs markedly, too. While the two-to-five-minute exams do strain one’s focus, they still feel artificial. I found myself thinking more about checking off the boxes than really listening to heart sounds or rating the tendon reflexes, as if regressing to preclinical times.

Consider another method of evaluation: at the bedside of a real, unknown patient in a clinical setting, under the supervision of an attending physician. This was exactly the model of the final exam on the neurology clerkship at Massachusetts General Hospital during my third year. And though perhaps impracticable on a large scale, it highlights the deficits of Step 2 CS. Though the latter might screen out a fraction of students who need remediation, it won’t predict the abilities of the remaining majority when they admit patients on their first intern call night, when there is no script to follow.

And this brings me back to the initial question: Why not allow medical schools to do their own CS assessments? If the Accreditation Council for Graduate Medical Education already accredits domestic institutions to train doctors, why doesn’t it entrust this task to them as well? A combination of bedside precepting during different clerkships with one or two comprehensive OSCEs seems far more valuable to gauge true proficiency and to provide formative feedback. A “Pass” seems fine, but doesn’t show me how to improve. Investing tuition in medical school makes sense, but I remain skeptical of the ROI on Step 2 CS.

—Jason Sanders is a fifth-year medical student at HMS.

The opinions expressed in this column are not necessarily those of Harvard Medical School, its affiliated institutions, or Harvard University.

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Copyright 2007 by the President and Fellows of Harvard College