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The Flawed Argument Against Clinical Skills Testing

Young doctor advises patient In June, the American Medical Association passed a resolution calling for an end to the clinical portion of the licensing exam required for all physicians in the U.S. The impetus for this was a group of medical students understandably unhappy about the exam’s expense ($1,275) and the cost to travel to one of the five testing centers to take it. But I and many medical educators believe strongly that this exam is vitally important to maintaining the standards of physicians’ clinical skills in the U.S.

Before diving into the controversy, here’s a brief look at the exam and why it was instituted.

The U.S. national licensing system for physicians is overseen by the National Board of Medical Examiners (NBME). It administers three written knowledge exams and one clinical exam (called Step 2 CS, for “clinical skills”). Step 2 CS is an Observed Standardized Clinical Exam where students have clinical encounters with 12 “standardized” patients.

The purpose of the exam is to ensure that all physicians licensed to practice in the U.S. not only have adequate “book knowledge,” but can apply this knowledge and demonstrate effective communication and interpersonal skills. Each student is allotted 15 minutes to take a patient history, establish a rapport with the individual, perform a physical exam, render a medical opinion and answer questions. The student then has 10 minutes to write a note explaining the diagnosis.

Why the arguments calling for an end to the test are flawed
While I’m sympathetic to the financial burden the exam imposes on the students, the movement to end the test has several serious flaws. The students behind the movement, dubbed End Step 2 CS, argue that the exam is not worth the cost, as few students fail and most medical schools already administer a similar exam.

First, while Step 2 CS opponents claim a pass rate of 99 percent, the overall pass rate for the last few years for graduates of all U.S. medical schools is actually 96 percent. That means 800 out of the 20,000 students taking the test annually fail; this is the same rate as for the written board exams—and no one is suggesting that we get rid of those exams.

Furthermore, students who retake the test have an 86 percent pass rate, increasing the number of students who are not granted licenses on the basis of this exam. For graduates of osteopathic schools the pass rate is 90 percent; it’s 80 percent for international medical school graduates.

Second, there are many problems with the notion of every medical school assuming responsibility for administering a clinical-skills exam. If all 140 medical schools conducted their own exams, we could have widely varying competency standards by which licensed physicians would be judged on their clinical skills. That’s neither right nor fair.

Now to the core financial issue. There are many reasons for the cost of Step 2 CS. The NBME is able to fund the resources necessary for a high-quality, scrupulously standardized and secure exam. If medical schools assumed the costs of administering the exam—including staff, quality control and statistical analyses—with anywhere near the care taken by the national boards, it would be very expensive. Those costs would likely get passed back to the students in the form of tuition increases or additional “testing fees.”

Patients and the Step 2 CS exam
An important issue not mentioned by those calling for an end to Step 2 CS is the impact it has had on medical education and the negative message its elimination would send to both the medical community and the public. Since the advent of Step 2 CS in 2005, the teaching and assessment of clinical skills have increased and improved immensely, benefitting students and patients.

The NBME is also actively engaged in adding innovative assessment techniques that will likely then be adopted by medical schools. Among educators, there are concerns that many of the gains in the quality of clinical-skills education made in the last decade could be lost without clinical-skills testing as part of the national licensing exam for physicians.

It is also abundantly clear that patients want physicians who are competent and can communicate effectively. Without a rigorously administered clinical licensing exam associated with a test of those skills, I fear that public faith in the profession will decrease.

Transparency and help needed
It is true that the National Board of Medical Examiners brought some of the criticism on itself by administering the exam with an extreme lack of transparency to both students and medical educators. While a great deal of security surrounding the content of the exam is needed, more could be known about the process that the NBME uses to set standards, establish specific objectives and determine assessment criteria. Most important, the NBME should share more information with students about their grades. Currently, they are told only which of the three sections (interpersonal and communication skills, English language proficiency and integrated clinical encounter) they passed or failed, with no indication of how close they were to passing or of their specific deficiencies. That’s valuable information that would help students improve their performance not just on the exam, but in real life as well.

Lastly, the cost of the exam is an unfair burden for students who are already acquiring enormous debt. Perhaps our nation’s healthcare system needs to subsidize the expense of the exam as part of the cost of ensuring the quality of American physicians’ clinical skills, a more-than-worthy goal.

Felise Milan, M.D.

Felise Milan, M.D.

Dr. Milan is professor of Clinical Medicine (General Internal Medicine), Albert Einstein College of Medicine and faculty attending physician, Department of Medicine, Montefiore Medical Center. She is also the recipient of the 2015 Harry H. Gordon Award for Outstanding Clinical Teaching.

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Comments on this entry are closed.

  • Ryan Archer October 2, 2016, 6:48 AM

    As a medical student, I would like to offer my rebuttal to your argument.
    1. The 99% pass rate refers to US medical students who pass on their first or second attempt. Using the numbers you cited, 96% of 20,000 = 19,200 Of the 800 who failed on their first attempt, 86% (688) go on to pass. 19,200 + 688 = 19,888 This equates to a 99.4% overall pass rate, which is the more accurate number because we cannot make inferences on what caused those initial 800 students to be counted as failures in the dataset. Were they sick? Did they have to leave the exam early for some reason? Or maybe they had test-day jitters? It is irresponsible to assume those 800 would be incompetent physicians as we do not know the circumstances.
    2. Nearly every US medical school already administers their own skills exam and passes the cost onto their students. If standards are your concern, this is precisely why the LCME exists. Just as state medical licensing boards and the NBME trust medical schools to deliver a standardized education for each physician’s degree, so too should they trust schools to perform a rigorous, high-quality clinical assessment as a component of that degree.
    3. Regarding public perception, I have never met anyone outside of the medical bubble who even knows this exam exists (and I have complained to many), so to state that its elimination would erode public trust is highly doubtful. Furthermore, we are not advocating the elimination of skills exams, just the one administered by the NBME. See point #2 above.
    4. Finally, regarding patients, you wrote: “Since the advent of Step 2 CS in 2005, the teaching and assessment of clinical skills have increased and improved immensely, benefitting students and patients.” I would very much like to see your source for this claim because, to my knowledge, there is no evidence demonstrating that the implementation of Step 2 CS improved patient safety / outcomes.