Thanks to COVID, Clinical Skills Testing Will Never Be the Same

Turns during the COVID pandemic have prompted a rethink of medical licensing steps, the most recent assessments of clinical skills. As a result, medical students across the country are likely to see new tests for clinical skills and clinical reasoning in the coming years.

This year, both the Step 1 of the US Medical Licensing Exam (USMLE) for MDs and the COMLEX-USA Level 1 Performance Exam for DOs have shifted from scoring to pass/fail systems.

In addition, the passing minimum for USMLE Step 2 Clinical Knowledge (CK) increased by 5 points in July.

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New changes on the table include the Step 2 Clinical Skills (CS) exam for MDs and the COMLEX-USA Level 2 Performance Exam (PE) for DOs that were permanently suspended last year when it became clear, among other things, that requiring students to travel to a few centralized testing sites to communicate with standardized patients was no longer feasible during a pandemic.

Soon, the National Board of Medical Examiners (NBME), which conducts the USMLE medical school tests, and the National Board of Osteopathic Medical Examiners (NBOME), which conducts the COMLEX tests, sought to develop a new assessment to help state councils determine which students must have a license.

Addressing costs

In addition to a lot of travel, there have long been complaints from students that accommodation and the cost of both exams were heavy – and the demands placed on students highlighted issues of access and equality.

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The NBOME announced its new plan in July, with those concerns in its consideration. It will permanently close its two testing centers and will no longer provide a centrally administered COMLEX Level 2 PE exam.

Instead, the changes, expected for the class of 2024 and beyond, will include funding for partner osteopathic medicine colleges interested in working together to deliver a new clinical proficiency exam to the individual schools.

NBOME says it expects to adopt proposals after Sept. 30. The current prototype will assess patient-physician communication skills and a practical physical examination, along with other skills and clinical tests with standardized patients.

John R. Gimpel, DO, MEd, president and CEO of the NBOME, said: Medscape Medical News“The capstone of the core competency for osteopathic medical students would be standardized in all schools and delivered at on-campus facilities.”

The prototype also allows candidates to make multiple attempts to get the best score. Only the highest score would be recorded on a transcript, he said.

“There are multiple studies validating these skills as important for patient care and associations with patient performance and patient safety. The pilot studies that will be completed over the next 2 years will be conducted to add validity evidence for the assessment of these critical skills on the field of patient care.”

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NBME also closes test centers

The NBME is also working to terminate the rest of its leases – it has already terminated several – for its test sites that had been used for the Step 2 CS exam.

“There are no plans to bring back a standalone, personal clinical skills exam in the same format that we have done in the past,” Alex Mechaber, MD, USMLE vice president for NBME, told IPS. Medscape medical news.

dr. Alex Mechaber

USMLE has been working on the content with medical schools, he said, and two pilot programs are underway for communication skills and reasoning skills. The first involves a review of “small slices” that test the way doctors communicate with patients, rather than a large, separate review, Mechaber added.

For example, test takers would receive video prompts from patients in clinical contexts and then provide spoken answers to questions posed by patients in the videos.

Similarly, a clinical reasoning pilot uses a sample electronic patient record to evaluate diagnostic and therapeutic reasoning. Students would explain the “why”when making a diagnosis or choosing a particular therapy.

“That’s very different from the traditional multiple choice questions that all of our exams have had in the past,” Mechaber said.

He added that with the approval of the USMLE management committee, the NBME plans to introduce the new exams within another 2 years.

David A. Johnson, chief assessment officer for the Federation of State Medical Boards, which conducts the USMLE Step 3 test, told Medscape Medical News“The absence of clinical skills as an integral part of USMLE does not mean that we have given up assessing communication and related clinical skills and clinical reasoning. We are looking for ways to do this creatively within the existing construct.”

These new items would be built into the existing USMLE computer-based 3-step series currently operated at Prometric test centers around the world and administered by US undergraduate and graduate students as well as international medical students and graduates.

A good start, but validation needed

Dr Brian Carmody

Bryan Carmody, MD, a pediatric nephrologist in Norfolk, Virginia, who blogs about medical education, shared: Medscape Medical News that eliminating expensive trips to a test site is an improvement over the current system.

However, another objection that Carmody cites was that “little evidence was provided to students or to schools or even to licensing authorities that these exams measured anything meaningful, that they were valid.”

He says the best thing NBME and NBOME can do as they build these new exams is to set the bar for the validity of the exams and explain how that evidence will be collected.

“If the exam doesn’t turn out to be performing the way they hope it should, it shouldn’t go ahead. Just like a clinical trial,” Carmody said.

Another big function of the clinical proficiency exam was vetting international medical graduates (IMGs), Carmody noted.

“ECFMG (the Educational Commission for Foreign Medical Graduates) has moved on without step 2 CS and has a system that appears to be functioning well,” he said.

Paths for International Medical Graduates

Step 2 CS has been used by IMGs to demonstrate the clinical and communication skills required for ECFMG certification.

Last year, when Step 2 CS was indefinitely suspended, the ECFMG quickly switched and developed a pathway system with six alternative ways for international medical graduates to meet the clinical and communication skills requirements for ECFMG certification.

“When USMLE made the unilateral decision to permanently suspend the clinical proficiency exam, we had to make a U-turn because we felt a great responsibility to the public and program directors that we would meet our commitment to the certification process,” William W. Pinsky, MD , president of ECFMG, said: Medscape Medical News. “The trails work well.”

The results of this year’s competition support his assessment.

According to ECFMG, more than 7,500 IMG freshmen achieved residency positions in accredited U.S. GME programs in the 2022 Match, an increase of 2.2% from last year and 4% from 2020, the latest Match cycle that was not significant. was affected by the pandemic.

Pinsky said, “I feel the program directors believe that our certification continues to reassure them of individuals’ readiness in a pool from which to select candidates for assisted care and training.”

While the credentials are important to medical students, they are equally important to the public, Pinsky said. “The licensing exams are designed to assure the public that individuals have the appropriate credentials for care.”

Which tests are best?

The discussion continues to focus on whether DO students should take the COMLEX exam but also take USMLE to compete fairly for residency with MDs.

The American Medical Association passed a resolution at this year’s House of Representatives annual meeting supporting the creation of a single licensure exam for both DO and MD students, with a separate, supplemental osteopathic exam. specific test for DO students.

The NBOME and partner organizations recently offered this response to the resolution: “We strongly encourage healthy and constructive dialogue with key stakeholders about solutions that will reduce, if not, the need for a DO or MD student to remain competitive. to be explored in two ways during the residency selection process. This dialogue should also focus on other opportunities to address the broader concerns about bias.”

COVID forced a change in the way testing had always been done, but it also provided an opportunity to innovate.

The decision to discontinue traditional clinical proficiency testing “creates the space for creativity and experimentation on the part of the medical schools themselves,” said Johnson, the FSMB’s Chief Assessment Officer. “Now they aren’t necessarily limited by the construction we used before.”

Marcia Frellick is a freelance journalist based in Chicago. She has previously written for the Chicago Tribune, Science News, and, and was an editor for the Chicago Sun-Times, the Cincinnati Enquirer, and the St. Cloud (Minnesota) Times. Follow her on Twitter on @mfrellick

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