Against Standardized Exams II

The clinical skills portion of the USMLE licensing exam attempts to gauge one's interpersonal skills. The exam is only administered at five cities in the U.S., and the cost to applicants is very high, perhaps as much as $1500 to take the test (registration, flight, hotel). 97% of applicants from U.S. medical schools passed in 2007-2008; applicants who don't pass can retake the exam.

Here's my problem with Step 2 Clinical Skills. With a 97% pass rate, the number needed to test is 33.3, and at $1500 per person, it costs about $50,000 to identify one applicant who fails. But the pass rate for repeaters is 92% (2007-2008). Therefore, the number needed to retest is12.5. Since the cost of finding a retester is $50,000, then the cost to identify an applicant who fails twice is $625,000.

That's a lot of money. The cost is borne collectively by applicants so its effect is diffuse. But I don't think it is cost-effective to spend over half a million dollars to identify a medical student who fails twice at the clinical skills portion of the licensing exam. Thus, I don't think it is reasonable to mandate USMLE Step 2 CS testing for all U.S. medical students.

I do think assessing interpersonal and patient communication skills is important. But I think it should be the responsibility of the medical school to make sure all the students they graduate can take a history and physical and treat a patient nicely. And they should already have mechanisms in place to do that. Indeed, all eight California medical schools have already instituted a clinical performance examination (CPX) designed by a consortium of clinical and medical educators. Our examination involving standardized patient interactions is taped and graded; we are evaluated on our interpersonal skills. It acts as a preparation for the Step 2 CS testing. I think it should replace the required Step 2 CS test. Furthermore, it's more useful than the USMLE because we watch our videos to generate feedback on our performance. This should be sufficient to ensure that our interpersonal communication skills are adequate.

Even more than that, I think the best assessment of patient-doctor skills is to ask patients. We never ask patients how students do. I think it would be appropriate and useful to survey patients or their families after a medical student interaction, both looking for alarm signs and general impressions. "Did the student introduce him or herself? Did he or she wash hands before examining you? Did you feel respected?" While certainly you will occasionally run into a disgruntled patient who doesn't give honest or useful feedback, I think overall it may work. Furthermore, we always tell patients that they are helping train a new generation of doctors; soliciting feedback really involves them in this process.

USMLE Step 2 CS is a financial burden on medical students. It is not a cost-effective test. It gauges a skill set that should fall under the responsibility of the medical school, and it can be assessed as well if not better by medical schools rather than a regulatory agency.