AAMC Reporter: April 2006

Donald E. Melnick, M.D., President, National Board of Medical Examiners®

Viewpoint: "An Examination of Clinical Skills in the United States Medical Licensing Examination"

It is widely recognized that clinical skills are important to the safe and effective care of patients. The AAMC has been in the forefront of organizations within the house of medicine that have emphasized effective teaching and assessment of clinical skills.

From the time that the United States Medical Licensing Examination™ (USMLE™) was first conceptualized, more than 15 years ago, it has been the intent of the National Board of Medical Examiners (NBME) and the Federation of State Medical Boards (the organizations that sponsor the USMLE) to include clinical skills among the competencies assessed as part of the examination program supporting the U.S. medical licensing system.

In the more remote history of assessment for licensure, the NBME has sought to reintroduce assessment of clinical skills in evaluation for licensure since bedside examinations were eliminated from its certification program in 1964. After many years of development, this goal became a reality in June 2004, when USMLE Step 2 Clinical Skills (CS) was administered for the first time. The inclusion of the formal assessment of these skills is a milestone in the effort to measure the knowledge and skills necessary for the practice of medicine. 

Step 2 CS examinees rotate through a series of 12 stations in which they interact with standardized patients (SPs) who are meticulously trained to portray real patients. The cases represent a broad spectrum of common and important symptoms and diagnoses. Examinees are assessed on three subcomponents: Integrated Clinical Encounter (ICE), which includes the ability to take a relevant history, perform a focused physical examination, and clearly summarize findings in a patient note; Communication and Interpersonal Skills (CIS), which includes skills at gathering information, sharing information, and establishing a rapport with the patient; and Spoken English Proficiency (SEP), which requires clear communication within the context of the doctor-patient encounter.

For the ICE subcomponent, history-taking and physical examination skills are assessed by the SP using case-specific checklists, and the patient note is assessed by physicians who are trained in the rating process and in the focus of the specific case. The SEP and the CIS subcomponents are assessed by the SPs, who provide a global rating of these skills using a series of generic rating scales. Scores on all subcomponents are accumulated across cases, and pass/fail determinations are made at the total test level using criterion-based standards established by the Step 2 Committee. Examinees must pass ICE, CIS, and SEP to obtain an overall pass on Step 2 CS. 

The Step 2 CS exam is administered at five regional test centers in Atlanta, Chicago, Houston, Los Angeles, and Philadelphia. The centers have the combined capacity to administer as many as 35,000 Step 2 CS exams per year. During the first year of testing, more than 16,000 Step 2 CS examinations were taken by U.S. and Canadian medical students and graduates, and nearly 14,000 by international medical students and graduates. For their first attempt at Step 2 CS, the pass rate was 96 percent for U.S./Canadian students and 83 percent for international students. Through December 2005, nearly 17,000 (8,000 U.S./Canadian and 9,000 international) examinees have tested in the 2005-2006 academic year. Failing students from U.S./Canadian schools have the most difficulty with the ICE subcomponent, while international students or graduates are more equally challenged by all components.

Many research projects are further documenting the validity of Step 2 CS. The April 2006 AERA/NCME meeting, the May Ottawa Conference, and the November AAMC RIME meeting will include reports on research into examinee performance (international graduate performance on the SEP component, overall performance of U.S. citizen international graduates), Step 2 CS characteristics (confirmatory factor analysis of the underlying structure, relationships of Step 2 CS subcomponents with Step 2 Clinical Knowledge, examinee use of encounter time), and quality assurance of the examination process (standardized patient portrayal variability, enhancing SP performance through cognitive restructuring, and use of mini-CEX to rate examinee performance). Other cooperative studies are underway with medical schools to assess the relationship between intramural assessment of clinical skills and the USMLE assessment.

Despite concerns about cost and convenience, most U.S. students express satisfaction with Step 2 CS itself. In exit surveys completed by examinees, 79 percent indicate that CS is average or above average as an assessment of clinical skills; 87 percent indicate that the cases represent appropriate challenges.

Anecdotal reports suggest that the implementation of the clinical skills examination in USMLE accelerated the trend among U.S. medical schools to emphasize formal training and assessment of clinical skills. Examinee exit surveys indicate that, compared with the 2002-2003 pilot examinations, students are observed performing histories and physical examinations more often by both faculty and residents. 

Step 2 CS appears to be reliably and validly achieving its goals: assuring minimum competency in clinical skills in those seeking licensure and emphasizing the importance of clinical skills among the competencies requisite for effective medical practice.

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