GET RID OF Step 2 CS!

[LovelyBRass]

This article came out today in the NEJM
http://www.nejm.org/doi/full/10.1056/NEJMp1213760?query=TOC&

Their "Financial Analysis:"

Highlight:
"Given the fraction of examinees who fail Step 2 CS relative to its exorbitant costs, the exam offers a poor return on investment. Although an annual cost of $36 million may seem negligible in the context of the multitrillion-dollar health care industry, that is not a justification for it to continue unquestioned."

And the response:
http://www.nejm.org/doi/full/10.1056/NEJMc1301008

Highlighted paragraph:
"Lehman and Guercio suggest that perhaps international medical graduates, who account for approximately 22% of actively licensed physicians in the United States,5 should be assessed with Step 2 CS but that U.S. students should not. This approach would be antithetical to our nation's culture of promoting equity and to the history of legislative efforts to ensure nondiscrimination for all persons seeking a license to practice medicine in the United States. Allowing a person to bypass a licensing requirement solely on the basis of the location of his or her medical school shows a lack of concern about patient safety and the quality of health care."


What do you guys think?

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[CDI]

Nothing new really. It's been well known for a while now that it's just a money maker. They've invested millions into developing these exams and needed a way to recoup it. This is it.

Aside from the financial aspect, really odd things seem to happen with CS in terms of the actual outcomes. The way they pass/fail people seems quite arbitrary at times. I think the cost of discovering an examinee failure is even more glaring, since they don't even do that very well at times.

Scoring is secretive.
It, for whatever reason, takes months to get your result back.
The videos are supposedly not checked.
You can pass in the patient note, but subsequently bomb in data gathering.
AMGs failing in spoken english profiency... .
IMGs failing only to be informed when they re-apply that they had in fact passed the first time. (Subsequently filing lawsuits for discrimination and settling out of court - causing a further loss of funds.)
I've read about a resident who was informed that he had in fact passed CS the first time, but by that time he had already taken it the second time, went into the match with that fail attempt on his transcript, and matched...which may have hurt his final match outcome.

Terrible track record...

Better off just going with the TOEFL or something, and implementing a system where the actual residencies have more say with the candidates, perhaps some sort of short rotation-auditions, at least for IMGs.

 

[LovelyBRass]

I'm somewhat offended that it's considered discriminatory to ask IMGs to take CS but there's no outrage against asking foreign students to take the TOEFL.

Like any screening test, we look to test populations at highest risk, as this is most cost-effective. Why should this be different for medical licensing exams? The quality of medical education in the US is standardized by the LCME and therefore residencies know what they're getting. That's simply not the case for foreign-educated physicians.

 

[CDI]

I'm somewhat offended that it's considered discriminatory to ask IMGs to take CS but there's no outrage against asking foreign students to take the TOEFL.

Like any screening test, we look to test populations at highest risk, as this is most cost-effective. Why should this be different for medical licensing exams?

So, you're offended that IMGs aren't discriminated against?

 

[LovelyBRass]

So, you're offended that IMGs aren't discriminated against?

You mentioned TOEFL, which is somehow ok and non-discriminatory. I disagree that one method of screening English language proficiency ought to be morally acceptable and one should not.

When you offer a screening test, there is some level of discrimination in determining who receives that test. This is not meant to be offensive but practical and cost-effective.

 

[CDI]

You mentioned TOEFL, which is somehow ok and non-discriminatory. I disagree that one method of screening English language proficiency ought to be morally acceptable and one should not.

When you offer a screening test, there is some level of discrimination in determining who receives that test. This is not meant to be offensive but practical and cost-effective.

Do you know the what the FL in TOEFL stands for?

 

[LovelyBRass]

Do you know the what the FL in TOEFL stands for?

What is going on here? All I did was agree with you and try to jump off of that. My beef is with the author of the second article, not you.

 

[CDI]

What is going on here? All I did was agree with you and try to jump off of that. My beef is with the author of the second article, not you.

I was pointing out (which you failed to realize) that TOEFL is also discriminatory by its very name alone. Its for all those to whom English is considered a foreign language.

 

[Ronin786]

On a related note, how come IMGs pay 1440 for the CS while AMGs pay 1200.

I understand the "center fee" that you have to pay for Step 1 and 2 since they're not in the US. But CS is the same 5 test centers for everyone.

 

[CDI]

On a related note, how come IMGs pay 1440 for the CS while AMGs pay 1200.

I understand the "center fee" that you have to pay for Step 1 and 2 since they're not in the US. But CS is the same 5 test centers for everyone.

People working at ECFMG have to be paid some how.

 

[Textbookversion]

This article came out today in the NEJM
http://www.nejm.org/doi/full/10.1056/NEJMp1213760?query=TOC&

Their "Financial Analysis:"

Highlight:
"Given the fraction of examinees who fail Step 2 CS relative to its exorbitant costs, the exam offers a poor return on investment. Although an annual cost of $36 million may seem negligible in the context of the multitrillion-dollar health care industry, that is not a justification for it to continue unquestioned."

And the response:
http://www.nejm.org/doi/full/10.1056/NEJMc1301008

Highlighted paragraph:
"Lehman and Guercio suggest that perhaps international medical graduates, who account for approximately 22% of actively licensed physicians in the United States,5 should be assessed with Step 2 CS but that U.S. students should not. This approach would be antithetical to our nation's culture of promoting equity and to the history of legislative efforts to ensure nondiscrimination for all persons seeking a license to practice medicine in the United States. Allowing a person to bypass a licensing requirement solely on the basis of the location of his or her medical school shows a lack of concern about patient safety and the quality of health care."


What do you guys think?

So um why shouldn't we discriminate against those trained in unaccredited diploma mills off the coasts....

LCME = certain standards you have to meet to get in and stay in, and accreditation insures that. There's no reason we should have to take CS. True also for AOA I imagine. I think all graduates from a U.S. med school (md/do) should be exempted. I don't see how that's unfair.

 

[Ronin786]

Im a USIMG and I have no problem saying that theres nothing wrong with exempting US grads from the exam.

I would however like to know how many US grads actually fail this test? Because if the pass rate is 99% like I've heard elsewhere, its a load of baloney to say something like

"This approach would be antithetical to our nation's culture of promoting equity and to the history of legislative efforts to ensure nondiscrimination for all persons seeking a license to practice medicine in the United States. Allowing a person to bypass a licensing requirement solely on the basis of the location of his or her medical school shows a lack of concern about patient safety and the quality of health care."

 

[CDI]

Im a USIMG and I have no problem saying that theres nothing wrong with exempting US grads from the exam.

I would however like to know how many US grads actually fail this test? Because if the pass rate is 99% like I've heard elsewhere, its a load of baloney to say something like

Obviously they should exempt US grads, but they won't cause its money in the bank. It's just a one-time price to pay to move on. The people in charge can cook up stats as to how important it is, but ultimately its a money maker. How else do they justify the yearly fee increasing $100 every year?

To try to "legitimize" the exam, they have increased minimum passing scores and make minor pointless changes here and there as well. The catch: No one knows what the minimum passing scoring even is or how they truly grade this exam, meaning...its most likely just a quota system in place.

Previously 4% of AMGs, ~20% of IMGs failed, now its going to be something like 8% AMGs and ~35% IMGs failing.

What I don't get is how the scoring is still so secretive? I guess its how they can justify failing a certain number of people? I guess no one complains or speaks up since they are the "authority". Once you're through, you're through, and thats the end of it.

 

[CDI]

So um why shouldn't we discriminate against those trained in unaccredited diploma mills off the coasts....

LCME = certain standards you have to meet to get in and stay in, and accreditation insures that. There's no reason we should have to take CS. True also for AOA I imagine. I think all graduates from a U.S. med school (md/do) should be exempted. I don't see how that's unfair.

Its possible that if CS had a numerical scoring system these issues wouldn't be there. Instead, people would study and attempt to get a high score rather than seeing it as a money-driven minimum competency filter, that it currently is being Pass/Fail. After all, the actual CS pass %s are comparable to Step I pass rates for both AMGs and IMGs.

 

[OPTIMISITIC]

Nothing new really. It's been well known for a while now that it's just a money maker. They've invested millions into developing these exams and needed a way to recoup it. This is it.

Aside from the financial aspect, really odd things seem to happen with CS in terms of the actual outcomes. The way they pass/fail people seems quite arbitrary at times. I think the cost of discovering an examinee failure is even more glaring, since they don't even do that very well at times.

Scoring is secretive.
It, for whatever reason, takes months to get your result back.
The videos are supposedly not checked.
You can pass in the patient note, but subsequently bomb in data gathering.
AMGs failing in spoken english profiency... .
IMGs failing only to be informed when they re-apply that they had in fact passed the first time. (Subsequently filing lawsuits for discrimination and settling out of court - causing a further loss of funds.)
I've read about a resident who was informed that he had in fact passed CS the first time, but by that time he had already taken it the second time, went into the match with that fail attempt on his transcript, and matched...which may have hurt his final match outcome.

Terrible track record...

Better off just going with the TOEFL or something, and implementing a system where the actual residencies have more say with the candidates, perhaps some sort of short rotation-auditions, at least for IMGs.

Great analysis

 

[cheruka]

The clinical tests PE/CS are terrible tests. The patient encounters are nothing like real-life. I felt horrible after completing it, had to rush to the airport, take a 3.5 hr flight back, drive for 2 hrs and get home at midnight. The whole time, I felt doomed. I am usually fine with tests, do not get anxious etc. But this test is truly terrible and expensive. And then, you go to interviews wondering whether you passed or the actors failed because they thought you are ugly/arrogant etc. This must be the only test where highly trained med students get graded by actors hired based on whether the student was able to smile while going throught the misery of a long day.

 

[RenegadeSynapse]

I'm pretty sure my past playing Dungeons and Dragons prepared me better for the role-play farce that is CS than medical school did.

My school had us do a similar test, which was similarly frustrating, but I didn't have to shell out over $1,000 to be judged competent.

It's over, I passed with a reasonable margin, but I was quite anxiety-ridden for several months. Luckily, most of the folks I spoke with told me that they were very nervous as well after the test, and felt they missed a lot of stuff too. When people tell you, "it's fine, you speak english and didn't punch anyone in the face." it can be a little off-putting when you're so anxious. It's much easier to be smug about how easy of a test it is after you have your pass.

None of this matters, of course. I'd be very surprised if the test goes anywhere. As it's already been said: It makes a lot of money, it's a "feel good" thing; it allows the NBME/whoever else to give lip service to focusing on the humanistic aspects of medicine (which is a great goal, I think just this test is worthless in that regard), and the will to complain goes away after you pass it. I'll complain on a forum, to friends, but I (and i'm willing to bet most others reading this) arn't going to go all noble on the NBME and really fight to change it. I'd love to be wrong; this publication is perhaps evidence that I am.

 

[niikank]

Just got my step 2 cs result which i failed on account of failing the spoken English proficiency. Had 242 and 252 on step 1 and 2 ck respectively.
Still can't believe it. I am an IMG from a country where English is our formal language. I have studied in English throughout my education, from Nursery. During my examination there was no circumstance where i had to repeat a question because the patient could not hear what i said, i actually finished a minute or two before time in 9 /12 of my patient.
I am so shocked, asked for a score recheck and wrote a letter defending my proficiency in English. Read some of the complaints on this forum i though i should share my story.
Damage is i might not be able to apply for residency this year and even doubt wether the second attempt will be successful.

 

[Esprit00]

To be honest, I wish they were more open about the scoring. I can see the importance of the test for both USMG's and IMG's but the very subjective nature of it is what scares most people in my opinion and what scared me too. The whole score recheck thing where they only add up the marks again instead of viewing the tapes etc etc is totally pointless. There's no way to tell otherwise what went wrong and the feedback forms aren't detailed enough to let the student know what exactly they did wrong in the three components. I am so grateful that I passed and have to admit, this was the exam that made me the most nervous. At least we have NBME's to predict our scores prior to taking the other Steps. There's nothing here to predict how we do. .

 

[Ernny]

Just got my step 2 cs result which i failed on account of failing the spoken English proficiency. Had 242 and 252 on step 1 and 2 ck respectively.
Still can't believe it. I am an IMG from a country where English is our formal language. I have studied in English throughout my education, from Nursery. During my examination there was no circumstance where i had to repeat a question because the patient could not hear what i said, i actually finished a minute or two before time in 9 /12 of my patient.
I am so shocked, asked for a score recheck and wrote a letter defending my proficiency in English. Read some of the complaints on this forum i though i should share my story.
Damage is i might not be able to apply for residency this year and even doubt wether the second attempt will be successful.

Oh wow, I am sorry but that really sucked......
I am an AMG who came to the US when I was young (13 y/o) and I know I have an accent, but everybody has said I speak just fine and nobody (including the SPs on the CS) has trouble understanding me..... though I did have to clarify what I meant on 2 questions out of the whole 12 encounters........so hopefully my SEP is ok If they fail me on my SEP, I would be so pissed..... I honored most of my core rotations and have good evaluations commenting my communication skills...

Do you mind if I ask do you have an accent? Could that be the reason?
And please keep us posted on NBME's response regarding your defending letter!!

 

[njmedstudent973]

Or maybe if you are from an English speaking country you should exempt? I dont see why USIMGs need to write CS and from the fact that the majority of us rotate in US hospitals sl we have patient care experience. And the comment about the offshore schools producing mass amount of diplomas with no substance behind it is a bit absurd. Granted most of these schools are for profit and yeah they take your money but needless to say you have to work your butt off if not 100x more than an US grad so don't try to disregard people on that basis. When a us grad can just pass and get a competitive residency when a IMG who outscores them gets disregarded makes you question the logic behind standardized exams then. And is it a surprise that few US grads fail? Do you think perhaps the exam is scored differently based on the fact where you went to school? Come on the NBME isn't fooling anyone they can just get away with anything they propose with no questions asked. Hence the secrecy and total untransparent nature in which they operate. Bottom line cough up that $ and hope you are on the other side of that bar when the results come out!

 

[Nasrudin]

This test really was nerve racking. I think the larger picture is that we all think this is a wasteful exploitation of all of us.

I'm posting on this thread to say that if anyone is organizing to uproot this thing from our education count me in.

I passed. But I could easily see how it could of gone the other way by a few subjective criteria. Derailing my whole application and career in the process. It's just not right that that happens to people who work so hard.

 

[niikank]

Yes i have an accent but since i am not the first person from my country to write this exam i can't say whether or not that was the reason.Trying hard to be true to myself , just can't understand. I know the signs of a person who is struggling to hear what you are saying.
In regards to the letter, they replied stating you don't get any other explanation except for the one stated in the score report ie. ICE, CIS and SEP.According to them it's the average of the patient rating.
Yet to get the decision on the score recheck.

 

[niikank]

Oh wow, I am sorry but that really sucked......
I am an AMG who came to the US when I was young (13 y/o) and I know I have an accent, but everybody has said I speak just fine and nobody (including the SPs on the CS) has trouble understanding me..... though I did have to clarify what I meant on 2 questions out of the whole 12 encounters........so hopefully my SEP is ok If they fail me on my SEP, I would be so pissed..... I honored most of my core rotations and have good evaluations commenting my communication skills...

Do you mind if I ask do you have an accent? Could that be the reason?
And please keep us posted on NBME's response regarding your defending letter!!

Yes i have an accent but since i am not the first person from my country to write this exam i can't say whether or not that was the reason.Trying hard to be true to myself , just can't understand. I know the signs of a person who is struggling to hear what you are saying.
In regards to the letter, they replied stating you don't get any other explanation except for the one stated in the score report ie. ICE, CIS and SEP.According to them it's the average of the patient rating.
Yet to get the decision on the score recheck.
Hope you pass, i do not wish this feeling on anyone.

 

[mdpre001]

It seems like it is long past time for some transparency in grading of not only the CS exam, but the CK exam as well. We pay a lot of money for these tests, and can't get any more of an answer than what you were given? Give me a break! Why do we put up with this?

 

[Kal EI]

This article came out today in the NEJM
http://www.nejm.org/doi/full/10.1056/NEJMp1213760?query=TOC&

Their "Financial Analysis:"

Highlight:
"Given the fraction of examinees who fail Step 2 CS relative to its exorbitant costs, the exam offers a poor return on investment. Although an annual cost of $36 million may seem negligible in the context of the multitrillion-dollar health care industry, that is not a justification for it to continue unquestioned."

And the response:
http://www.nejm.org/doi/full/10.1056/NEJMc1301008

Highlighted paragraph:
"Lehman and Guercio suggest that perhaps international medical graduates, who account for approximately 22% of actively licensed physicians in the United States,5 should be assessed with Step 2 CS but that U.S. students should not. This approach would be antithetical to our nation's culture of promoting equity and to the history of legislative efforts to ensure nondiscrimination for all persons seeking a license to practice medicine in the United States. Allowing a person to bypass a licensing requirement solely on the basis of the location of his or her medical school shows a lack of concern about patient safety and the quality of health care."


What do you guys think?

When has our healthcare system ever concerned itself with finding cost effective ways of doing things?

I agree CS is a waste.

A solution could be to send a few employees to school sites over the span of a few months - that would save a ton. I know students at our school fly across the country to do it - while paying the insane fees. The journal article doesn't even take into account the travel and hotel expenses.

 

[je355804]

So um why shouldn't we discriminate against those trained in unaccredited diploma mills off the coasts....

LCME = certain standards you have to meet to get in and stay in, and accreditation insures that. There's no reason we should have to take CS. True also for AOA I imagine. I think all graduates from a U.S. med school (md/do) should be exempted. I don't see how that's unfair.

It's douches like you that cause AMGs to have to take the test.

The entire point is to screen out dbags.