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

Marcia Frellick

August 12, 2022

Upheaval during the COVID pandemic has forced a rethinking of the steps to medical licensure, most recently clinical skills assessments. As a result, medical students across the nation will likely start seeing new tests for clinical skills and clinical reasoning in the next couple of years.

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

Additionally, the passing minimum for USMLE Step 2 Clinical Knowledge (CK) bumped up 5 points in July.

New changes on the table center on 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, among other reasons, it became clear that requiring students to travel to a few centralized testing sites to interact with standardized patients was no longer feasible during a pandemic.

Quickly, the National Board of Medical Examiners (NBME), which runs the USMLE medical school tests, and the National Board of Osteopathic Medical Examiners (NBOME), which runs the COMLEX tests, scrambled to develop a new assessment to help state boards of medicine determine which students should be licensed.

Addressing Costs

In addition to extensive travel, longtime student complaints were that lodging and costs of both exams were onerous — and the demands placed on students highlighted access and equity issues.

The NBOME announced its new plan in July with those concerns included in its consideration. It is permanently closing its two testing centers and will no longer give a centrally administered COMLEX Level 2-PE exam.

Instead, the changes, expected for the class of 2024 and beyond, will include funding for partner colleges of osteopathic medicine interested in collaborating for research development of a new clinical skills exam to be delivered at the individual schools.

NBOME says it expects to begin taking proposals after September 30. The prototype also allows candidates multiple tries to pass the test. Only the passing score would be recorded on a transcript, he said.

John R. Gimpel, DO, MEd, president and CEO of the NBOME, told Medscape Medical News, "The core competency capstone for osteopathic medical students would be standardized across schools and delivered at on-campus facilities."

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

"There are multiple studies that validate these skills as important for patient care and associations with performance with patients and patient safety. The pilot studies that will be completed over the next 2 years will be conducted to add to validity evidence for the assessment of these essential patient care skills."

NBME Also Closing Test Centers

The NBME is also working to end the rest of its leases — it has already ended some — for its testing sites that had been used for the Step 2 CS exam.

"There are no plans to bring back a stand-alone, in-person clinical skills exam in the same format we've done in the past," Alex Mechaber, MD, vice president of USMLE for NBME, told Medscape Medical News.

Dr Alex Mechaber

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

For example, test takers would get video prompts of patients in clinical contexts and then provide spoken responses to questions that are posed by patients in the videos.

Similarly, a clinical reasoning pilot uses a sample electronic health record to evaluate diagnostic and therapeutic reasoning. Students would explain the "why" in 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 approval of the USMLE management committee, 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 runs the USMLE Step 3 test, told Medscape Medical News, "The absence of clinical skills as a set piece of USMLE does not mean we've abandoned assessing communication and related clinical skills and clinical reasoning. We're 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 administered at Prometric testing centers worldwide and taken by both US students and graduates 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, told Medscape Medical News that eliminating expensive travel to a testing site is an improvement on the current system.

However, another objection Carmody cites was that "there was little evidence provided to students or to schools or even to licensing authorities that these exams were measuring something meaningful, that they had validity."

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

"If the exam turns out not to perform as they hope, it then ought not to continue. Just like a clinical trial," Carmody said.

Another big function of the clinical skills exam was in 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 seems to be functioning well," he said.

Pathways 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 gears and developed a pathway system with six alternative ways international medical graduates could meet the clinical and communication skills requirements for ECFMG certification. 

"When USMLE made the unilateral decision to permanently discontinue the clinical skills exam, that's when we had to pivot because we felt significant responsibility to the public and program directors that we'd fulfill our obligation for the certification process," William W. Pinsky, MD, president of ECFMG, told Medscape Medical News. "The pathways are working well."

Results from this year's Match support his assessment.

According to ECFMG, more than 7500 IMGs obtained first-year residency positions in accredited US GME programs in the 2022 Match, an increase of 2.2% from last year and 4% from 2020, the last Match cycle not significantly affected by the pandemic.

Pinsky said, "I feel that the program directors believe our certification continues to assure them about the readiness of individuals in a pool from which they can choose candidates for supervised care and training."

Although the credentials are important for medical students, they are equally important for the public, Pinsky said. "The licensing exams are intended to assure the public that individuals have the right credentials for care."

Which Tests Are Best?

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

The American Medical Association adopted a resolution at this year's annual meeting of the House of Delegates supporting the creation of a single licensing exam for both DO and MD students, with a separate, additional osteopathic-specific test for DO students.

The NBOME and partner organizations recently offered this response to the resolution: "We highly encourage healthy and constructive dialogue with key stakeholders regarding solutions that mitigate, if not obviate, the need for any DO or MD student to be examined by two pathways to remain competitive 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 presented an opportunity to innovate. 

The decision to discontinue the traditional clinical skills test "creates the room for creativity and experimentation on the part of medical schools themselves," according to Johnson, the FSMB chief assessment officer. "Now they are not necessarily constrained by the construct we used previously."  

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

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