Take That! Texas Students Scoring Well on Hated Clinical Skills Exam

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Medical Education Feature - June 2005

 

By  Ken Ortolon
Senior Editor

They didn't want to take it, but Texas medical school graduates and their counterparts across the country and Canada did quite well on the controversial test that measures their clinical and patient communication skills. The National Board of Medical Examiners (NBME) says 96 percent of U.S. and Canadian graduates passed the test on their first attempt. International medical graduates scored an 83-percent passing rate.

NBME's decision last year to begin testing medical students' clinical and communication skills as part of its licensing exam generated vigorous opposition from medical students who said it was unnecessary and too expensive. The Texas and American medical associations sought to delay the test, but the board moved forward.

Students from Texas medical schools are passing the exam at about the same rate as students nationally, with some schools posting slightly higher passing rates, according to the early results.

Not all Texas medical schools would release their passing rates, but information available from several schools shows Texas students' success.

About 150 students at The University of Texas Medical Branch (UTMB) in Galveston have received their test scores, and 97 percent passed. "Our students have done fine," said Steven Lieberman, MD, associate dean for educational affairs at UTMB. "We are proud of the work they have done."

Kathleen Fallon, MD, associate dean for student affairs and admissions at The Texas A&M University System Health Science Center College of Medicine, says roughly half of the 66 students in this year's graduating class have received their results and all passed.

Texas Tech University Health Sciences Center officials say their students have an 89-percent passing rate, but only about 40 percent of the graduating class of more than 130 have received their results.

UT Health Science Center at San Antonio officials declined to release their passing rate, citing privacy concerns. A spokesperson for the UT Health Science Center at Houston says the school has not compiled pass/fail data. Baylor College of Medicine and UT Southwestern Medical Center in Dallas did not respond to requests for information on their rates.

Osteopathic medical students are required to take a similar test, known as the Performance Exam, as part of their national licensing process. Jerry Alexander, PhD, director of academic information services at the University of North Texas Health Science Center, says 111 students from the 2004 and 2005 graduating classes have taken the exam. All passed. 

Better Than Expected

The clinical skills exam was launched in June 2004. Students must examine 10 to 12 actors trained to present with certain symptoms. They must establish a rapport with each "patient," conduct a history and physical, answer questions, and provide counseling where appropriate. After each encounter, students must note their findings, develop diagnostic impressions, and present treatment plans or plans for further evaluation.

As of mid-March, 17,700 fourth-year medical students and graduates had taken the exam. About half of those were U.S. and Canadian students and about half were students or graduates of international medical schools.

The 96-percent passing rate is slightly higher than NBME expected. Early projections were that roughly 6 percent would fail on the first attempt, with the failure rate dropping to less than 2 percent after retakes. 

Tracking Student Concerns

Despite high passing rates, however, there still is opposition to the exam, and medical students, medical school faculty, and AMA have raised concerns about how the test is implemented.

David Winchester, a fourth-year student at the University of South Florida College of Medicine and chair of AMA's Medical Student Section, took the exam in October and did not get his results until February.

Nanette Clare, MD, senior associate dean and associate dean for academic affairs at UTHSC-San Antonio, says late release of test scores is a huge disadvantage to students who fail.

"The first time they released scores was when residency programs were completing their rank list for students they wanted as residents," she said. "In doing that, it was a significant disadvantage to students who failed because they had no time to recoup."

NBME says nearly all of the 15,000 students who took the exam between June and December 2004 have received their results. There were some delays in reporting results during the initial testing period while NBME sought to accumulate sufficient data to support scoring and standard-setting activities. A statement on its Web site (www.nbme.org) said it is working to get test scores back sooner and that most students will get their results within eight weeks.

Dr. Fallon says some A&M students believe the test is too rigid.

"They feel like there's a set scenario they need to go through -- which may not be the only way to do things -- and if they don't follow this scenario, if they have their own way of doing things, or if they vary in any way, they're going to be marked wrong where it might not be wrong," she said.

Jason Huffman, a fourth-year student at TTUHSC in El Paso, sees little value in the exam. "It is silly to place us in a supposed clinical environment if the intent is only to test communication skills," said Mr. Huffman, who took the exam in February and was awaiting his results in late April. "Why not have a few structured interviews instead? It would be much less expensive in terms of time and money."

Although she says it fairly measured her ability to conduct a history and physical, the test "was redundant and completely not necessary" and a waste of money, said Kristine Renee Kuhl, who receives her degree this month from UT Medical School at Houston.

"It's like asking a fourth-grader to demonstrate that he can color inside the lines and tie his own shoes. I imagine that if you can pass your clerkships, pass your boards, and speak English, then you can pass this test."

Mr. Winchester says AMA's opposition to the exams revolves around the high cost ($950) and concerns over statistical validity of results. The AMA Medical Student Section has established a page on the AMA Web site where students can report their experiences with the exam. The site is located at  http://www.ama-assn.org/.

Ken Ortolon can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email at  Ken Ortolon.  

RELATED STORY

You failed. Oh, wait. No, you didn't.

The National Board of Medical Examiners (NBME) reported in April that a computer glitch caused more than three dozen medical students to be told incorrectly that they had failed the clinical skills exam.

In an alert posted on its Web site April 19, NBME said a review of data from the U.S. Medical Licensing Examination Step 2 CS exam by a quality control team detected a software problem that resulted in an incorrect pass-fail classification for 38 medical students whose test results were issued between Jan. 12 and March 30.

"Thirty-eight examinees were notified of a change in classification from fail to pass by express mail scheduled for delivery on April 20," NBME said. "We have also contacted the deans of the U.S. medical schools in which any of these students is enrolled. In addition, we are sending a corrected score report to any organization that received the previous, incorrect results as part of the transcript services or other reporting mechanisms."

NBME says it is reviewing data on students who received a passing score to see if some of those results also were incorrect. "At this point, it appears that few, if any, passing scores will be affected," the board said.

Nanette Clare, MD, senior associate dean and associate dean for academic affairs at The University of Texas Health Science Center at San Antonio, says one student there was among those who received an inaccurate failing grade. She says the problem could have an adverse impact on those students' ability to get the residency programs they want.

"I would be surprised if any weren't affected," Dr. Clare said. "I know that a couple of our students who had failed were called by residency programs they had applied to and were told that because of that failing result they could not list them on their rank list."

Most residency programs were not expected to use the Step 2 CS results in selecting residents this year, and only about half of U.S. medical schools have made passing the exam a condition of graduation. In Texas, only The University of Texas Medical Branch in Galveston requires passage; most other Texas medical schools only require students to take the test before graduation.

Anyone concerned about his or her score can contact NBME at (866) 504-8564, if calling from within the United States or Canada, or (215) 590-9260 from outside the United States or Canada; or by sending an email to step2cs@nbme.org

RELATED STORY

UTHSC-SA Opens Clinical Skills Laboratory

Medical students at The University of Texas Health Science Center at San Antonio will get plenty of practice honing their clinical and patient communication skills at a new clinical skills laboratory that opened there in March.

Nanette Clare, MD, senior associate dean and associate dean for academic affairs, says the new lab will give students an experience similar to taking the actual clinical skills test.

The new facility will allow faculty to observe encounters between students and actors pretending to be patients without being in the exam room. The laboratory includes 20 examination rooms, all of which are equipped with two-way mirrors through which faculty can monitor encounters. Ten of those exam rooms also have digital audio/video equipment to allow encounters to be recorded for later playback. Audio/video equipment will be installed in the remaining 10 rooms next year.

"The actor can watch it to learn how to be a better actor," Dr. Clare said. "The students can watch it to see what they did right or wrong. And faculty can watch it with them and give them feedback."

The exam rooms all have standard examination tables and clinical equipment, plus laptop computers on which standardized patients can evaluate student performance after each encounter. In addition to the exam room, the clinical skills lab has four mechanical simulation rooms equipped with human mechanical simulators that can be programmed to simulate cardiac arrest, respiratory arrest, and other conditions; two student classrooms; and one standardized patient classroom/lounge.

Dr. Clare says UTHSC-San Antonio graduates historically "have been very strong in their clinical skills." The new center, she says, will make them even better, especially at patient communication.

A grand opening for the facility is planned for later this year. 

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