Medical Licensure in the United States Assessment of Clinical Skills
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Medical Licensure in the United States Assessment of Clinical Skills
Ann C. Jobe, MD, MSNExecutive Director
Clinical Skills Evaluation Collaboration(CSEC)
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Raising the Bar in Geriatrics Assessment
2010 Reynolds Grantee 9th Annual Meeting
October 25-27, 2010
St. Louis, Missouri
(sample of slides from presentation)
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Clinical Skills Evaluation Collaboration
CSEC• A Collaborative
Partnership, established in 2003, between the Educational Commission for Foreign Medical Graduates (ECFMG) and the National Board of Medical Examiners (NBME)
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A Look Back in Time
• USMLE - introduced in early 1990’s • Single examination pathway for initial medical
license (graduates of US and international medical schools)
• A national standardized series of exams to assure minimal competency
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United States Medical Licensing Examination (USMLE)
• Each of the three Steps of the USMLE complements the others
• • No Step can stand alone in the
assessment of readiness for medical licensure.
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United States Medical Licensing Examination (USMLE)
• Step 1• understanding and application of important
concepts of the sciences basic to the practice of medicine
• Multiple choice exam
• Step 2 • application of medical knowledge, skills, and
understanding of clinical science essential for the provision of patient care under supervision
• Clinical Knowledge (CK)• Multiple choice exam
• Clinical Skills (CS)
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United States Medical Licensing Examination (USMLE)
•Step 2CS •Standardized patients used to assess an examinee’s ability to• gather information from patients, • perform physical examinations, • communicate their findings to patients and
colleagues
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United States Medical Licensing Examination (USMLE)
• Step 3• application of medical knowledge and
understanding of biomedical and clinical science essential for the unsupervised practice of medicine
• Multiple choice exam and computerized case simulations (CCS)
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Life Cycle of a Physicianin the United States
Step 1
Year 1Year 2
Medical SchoolYear 3Year 4
Step 2 CK
Step 2 CS
NRMP Match
Postgraduate
Training3-7 yrs
Step 3
Fellowship
Board Certification
ExamsRecertification
q 7-10 yrs
Practice
Licensure
Maintenance of Certification
American Board of Medical Specialties (ABMS)Specialty Boards
State Licensing Authorities
United States Medical Licensing Examination
(USMLE)
Relicensureq 1-3 yrs
Maintenance of Licensure
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Miller’s Pyramid
Action
Performance
Competence
KnowledgeKNOWS
KNOWS HOW
SHOWS HOW
DOES
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Kirkpatrick Criteria
4. ResultsChange in organizational practiceBenefits to patients/clients
5. BehaviorTransfer learning to workplaceLearners apply new knowledge and skills
6. LearningChange attitudes/perceptionsChange knowledge/skills
7. ReactionCustomer satisfaction related to participation in
educational activities
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COMPETENCY
• “Core Competencies” Accreditation Council for Graduate Medical Education (ACGME)
American Board of Medical Specialties (ABMS)
• Patient Care• Knowledge• Communication and Interpersonal Skills• Professionalism• Systems-Based Practice• Practice-Based Learning and Improvement
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Correlations among Step scores
Step l Step 2 CK Step 2 CS
Step 2 CK ~.65 --------- -----
Step 2 CS Data-gathering Communication/IP skills Spoken English proficiency Patient note
.19.09.09.20
.26
.16
.13
.30
-----
Step 3 ~.50 ~.70 N/A
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USMLE Step 2 Clinical Skills
• Mastery of clinical and communication skills, as well as cognitive skills, by individuals seeking medical licensure is important to the protection of the public. (from USMLE Bulletin of Information)
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Step 2 CS Examinees
YEAR TOTAL USMGs IMGs
2009 34,837 18,983 15,854
2008 35,224 17,711 17,513
2007 33,832 17,711 16,121
2006 32,843 17,473 15,132
2005 31,939 17,671 14,268
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Step 2 CS Fees• USMG – increase of $100(10%)
over 6 year period– 2004-2006: $975– 2007: $1,005– 2008: $1,025 – 2009: $1,055– 2010: $1,075
• IMG– 2004-2009: $1,200– 2010: $1,295
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USMLE Step 2 Clinical Skills
• The cases cover common and important situations that a physician is likely to encounter in clinics, doctors’ offices, emergency departments, and hospital settings in the United States.
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Presentation categories
• Include, but are not limited to, cardiovascular, constitutional, gastrointestinal, genitourinary, musculoskeletal, neurological, psychiatric, respiratory, and women's health.
• Examinees will see cases from some, but not all, of these categories.
• The selection of cases is also guided by specifications relating to acuity, age, gender, and type of physical findings presented in each case.
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• Each Step 2 CS “session” includes 12 twenty-five minute patient encounters. • 15 minutes with patient• 10 minutes for patient note
• The examination lasts approximately 8 hours. Two breaks are provided:• 1st break is 30 minutes long (lunch)• 2nd break is 15 minutes long (snack).
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Step 2 CS Components
• Communication and Interpersonal Skills (CIS)
• Spoken English Proficiency (SEP)
• Integrated Clinical Encounter (ICE)• Data gathering (DG)
• History & PE• Patient note (PN)
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Step 2 CS Components
• USMLE Step 2 CS is a Pass/Fail examination
• Each of the three subcomponents (CIS, SEP, ICE) must be passed in a single administration in order to achieve a passing performance on Step 2 CS
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Assessment of Communication and Interpersonal Skills (CIS)
• CIS performance is assessed by the standardized patients• a global rating of these skills using a series of generic
rating scales• same CIS scale for all 12 encounters• 3 sub-components:
• Information gathering (questioning skills)• Information sharing• Professional manner and rapport
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Assessment of Communication and Interpersonal Skills (CIS)
Questioning skills - examples include: • use of open-ended questions, transitional statements,
facilitating remarks • avoidance of leading or multiple questions, repeat
questions - unless for clarification, medical terms/jargon unless immediately defined, interruptions when the patient is talking
• accurately summarizing information from the patient
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Assessment of Communication and Interpersonal Skills (CIS)
Information-sharing skills - examples include: • acknowledging patient issues/concerns and clearly
responding with information • avoidance of medical terms/jargon unless immediately
defined • clearly providing
• counseling when appropriate • closure, including statements about what happens
next
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Assessment of Communication and Interpersonal Skills (CIS)
Professional manner and rapport - examples include: • asking about
• expectations, feelings, and concerns of the patient
• support systems and impact of illness, with attempts to explore these areas
• showing • consideration for patient
comfort during the physical examination
• attention to cleanliness through hand washing or use of gloves
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Assessment of Communication and Interpersonal Skills (CIS)
Professional manner and rapport - examples include: • providing opportunity for the
patient to express feelings and/or concerns
• encouraging additional questions or discussion
• making • empathetic remarks
concerning patient issues/concerns
• patient feel comfortable and respected during the encounter
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Assessment of Spoken English Proficiency (SEP)
• SEP performance is assessed by the standardized patients• using rating scales; same scale for all 12 encounters• based upon
• frequency of pronunciation or word choice errors that affect comprehension
• amount of listener effort required to understand the examinee's questions and responses
• clarity of spoken English communication within the context of the doctor-patient encounter (e.g., pronunciation, word choice, and minimizing the need to repeat questions or statements)
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Scoring of the Step 2 Clinical Skills Subcomponents
The ICE subcomponent includes assessment of:• Data gathering (DG) - patient information
collected by history taking and physical examination
• Documentation (PN) - completion of a patient note summarizing the findings of the patient encounter, diagnostic impression, and initial patient work-up
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Scoring of the Step 2 Clinical Skills Subcomponents
• Data gathering (DG) performance is assessed by the standardized patients • using checklists developed by committees of
clinicians and medical school clinical faculty• checklists comprise the essential history and
physical examination elements for each specific clinical encounter
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Scoring of the Step 2 Clinical Skills Subcomponents
• The patient note is rated/scored by trained physician raters
• The patient note (PN) consists of three areas• Medical History and Physical Examination• Differential Diagnosis• Diagnostic Workup
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Scoring of the Step 2 Clinical Skills Subcomponents
• Scored holistically• Relevant and correct information• Congruency/consistency with specific case –
based scoring guidelines• Integration/synthesis of information• Organization, coherence, cohesiveness, flow,
legibility
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Performance on Step 2 CS
• Failure rate for USMGs • 2004-2005: 4%• 2005-2006: 2%• 2006-2007: 3%• 2007-2008: 3%• 2008-2009: 3%
• Failure rate for IMGs • 2004-2005: 17%
• US Citizens: 11%• Foreign Citizens: 18%
• 2005-2006: 15%• 2006-2007: 23%• 2007-2008: 28%• 2008-2009: 27%
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Performance on Step 2 CS
• Passing rate for USMGs (first takers)• 2005-2006: CIS >99%; SEP >99%; ICE 98%
• 2006-2007: CIS 99%; SEP 100%; ICE 97%
• 2007-2008: CIS 99%; SEP >99%; ICE 98%
• 2008-2009: CIS 99%; SEP >99%; ICE 98%
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Performance on Step 2 CS
• Passing rate for IMGs (first takers) • 2005-2006: CIS 93%; SEP 98%; ICE 89%
• 2006-2007: CIS 87%; SEP 99%; ICE 85%
• 2007-2008: CIS 81%; SEP 92%; ICE 86%
• 2008-2009: CIS 84%; SEP 94%; ICE 84%
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• For more information about USMLE policies and procedures, and about specific exams – please go to:
• www.usmle.org