Volume 348:1294-1295 March 27, 2003 Number 13
http://content.nejm.org/cgi/content/full/348/13/1294-a
A Clinical-Skills Examination for Medical Students?
To the Editor: It has been almost 40 years since a medical student was
tested on his or her bedside manner before being licensed to practice
medicine. In 1964, this portion of licensure testing was discontinued
because of questions of fairness and validity. Thirty-one years later,
in 1995, the Federation of State Medical Boards (FSMB) adopted a new
policy calling for the inclusion of such an examination, stating that
implementation should occur when the examination "was shown to be valid,
reliable, and practical."1 Believing that the first two criteria have
been met, the National Board of Medical Examiners (NBME) has gone
forward with the planning.
The proposed examination is the Clinical Skills Assessment Examination.
Examinees will see 10 to 12 standardized patients in one day, having 15
minutes with each patient for the history taking and physical
examination and 10 minutes to write a note. The expected cost of the
examination is $950 - more than the combined costs of Steps 1 and 2 of
the U.S. Medical Licensing Examination ($840). The clinical-skills
examination will be administered at five or six locations, leaving many
students with the burden of significant travel time and costs.
Currently, the average graduating medical student has a debt burden of
nearly $100,000.2 On the basis of the principal and interest accrued on
loans, estimates place the cost of the first two steps of the Medical
Licensing Examination and the Clinical Skills Assessment Examination at
over $5,000 per student. Our question is, does this meet the FSMB's
requirement that the examination be practical? A number of
organizations, all of which support training in clinical skills for
medical students, are opposed to the examination in its current form.
These include the American Medical Association (AMA), the AMA Medical
Student Section, the Association of American Medical Colleges, and the
American Medical Student Association.
The data largely show that current grading strategies used by medical
schools do not accurately measure a student's ability to communicate.3
The data also show that some U.S. medical students are capable of
passing their clinical rotations without adequately developing these
skills4 and that this inadequacy may contribute to the likelihood of
being sued for malpractice.5 The data do not show that requiring
students to take a clinical-skills examination for approximately $1,000
(a total of $3,000 with travel and interest) will prevent this kind of
inadequacy.
We ask that the FSMB and NBME take their time in making sure that this
is the right answer, that students should be shouldering this burden,
and that the benefits outweigh the burden. If they are not sure, the
Clinical Skills Assessment Examination should be put on hold until these
issues can be resolved.
David E. Winchester, B.S.
University of South Florida College of Medicine
Tampa, FL 33617
Kimberly Ruscher-Rogers, B.S.
Florida State University College of Medicine
Tallahassee, FL 32306
References
1. Position of the Federation of State Medical Boards: in support of
a standardized patients component to the USMLE. Dallas: FSMB, 2003.
(Accessed March 7, 2003, at
http://www.fsmb.org.)
2. OSR-AAMC resolution on clinical skills exam. Washington, D.C.:
Association of American Medical Colleges, 2003. (Accessed March 7, 2003,
at
http://www.aamc.org/members/osr/aamcresolution.htm.)
3. Gomez JM, Prieto L, Pujol R, et al. Clinical skills assessment
with standardized patients. Med Educ 1997;31:94-98.[ISI][Medline]
4. Stillman PL, Regan MB, Swanson DB, et al. An assessment of the
clinical skills of fourth-year students at four New England medical
schools. Acad Med 1990;65:320-326.[Abstract]
5. Beckman HB, Markakis KM, Suchman AL, Frankel RM. The
doctor-patient relationship and malpractice: lessons from plaintiff
depositions. Arch Intern Med 1994;154:1365-1370.[Abstract]
