USMLE Step 2 CS Facts

Do USMLE scores reflect an individual's clinical skills?

Standardized patients are frequently used to assess a medical student's clinical skills, including history taking, performing the physical examination, and interpersonal skills. There has been concern that medical school faculty may not be well suited to document these skills during routine evaluations because they infrequently observe students actually performing a history and physical secondary to time restraints and because the criteria by which students are judged may vary between different physicians. In part, this was the stimulus for the creation of the Clinical Skills portion of the USMLE Step 2. This raises the question of whether the USMLE adequately assesses one's clinical skills.

A 2005 study examined the relationship of performance on the Step 1 and Step 2 CK tests with performance in standardized patient situations in PGY1 year internal medicine residents. The results of both USMLE tests were found to correlate with each other, i.e. students who performed well on Step 1 tended to perform well on Step 2. However, both tests had very low correlation with performance on a standardized patient evaluation. Despite being the more clinically oriented exam, Step 2 was no better correlated with standardized patient performance then Step 1.

However, the findings of a 2003 study comparing program director ratings of residents to their performance in medical school yielded somewhat contradictory results. This study found a correlation between class rank and Step 1 and Step 2 scores with program director rankings of skills during residency. Potentially, this discrepancy is attributable to the fact that what standardized patient exams assess may differ from what residency program directors value in a resident. Taken together, these studies imply that students with higher GPAs or test scores likely have the intelligence and motivation to acquire more of the clinical skills needed to become excellent physicians, although higher test scores do not by themselves mean that a student will have better clinical skills.

References

Paolo A, Bonamino G. Measuring Outcomes of Undergraduate Medical Education: Residency Directors' Ratings of First-year Residents. Academic Medicine Issue: 78(1), January 2003, p 90–95

Rifkin WD, Rifkin A. Correlation between Housestaff Performance on the United States Medical Licensing Examination and Standardized Patient Encounters. The Mount Sinai Journal of Medicine 72(5); January 2005, pp. 47-49.

Can test anxiety contribute to failing the USMLE and what strategies are available for lessening anxiety?

Medical school can create a lot of stress. Medical students average in the 85th percentile of the general population for overall stress level. The stress in some students may be related to exams primarily, particularly important exams such as the USMLE. Testing may produce enough anxiety to qualify as an actual psychologic condition known as debilitating test anxiety. Potentially, this may contribute to USMLE failure in a certain subgroup of students. One aspect of this anxiety may result in underpreparation for the exam due to avoidance and/or procrastination. Students may also be overwhelmed with such a high level of anxiety during the test that attention and memory are affected. Many students may have experienced similar feelings associated with testing during high school or college, but were able to get by as the material at that time was less difficult.

There are techniques available to help students with debilitating test anxiety improve both their test preparation and level of anxiety during the test itself. Progressive muscle relaxation consists of sequentially tightening and relaxing major muscle groups in an attempt to facilitate relaxation. Systematic desensitization consists of forcing the student to attempt to remain calm while picturing the days leading up to and including the examination. It may even be helpful to practice a behavioral rehearsal, which may consist of simply imaging the test day itself or physically visiting and sitting within the actual test room. Psychoeducational techniques such as testing oneself before and after studying certain material may help to reinforce that progress is being made during the studying process. A 2004 study demonstrated that students who participated in techniques such as these had a higher pass rate on retaking the exam than the general retake population. While students may attempt to utilize these techniques on their own, working directly with a psychologist may be beneficial for some.

Reference

Powell DH. Behavioral Treatment of Debilitating Test Anxiety Among Medical Students. Journal of Clinical Psychology 60(8), 2004, 853-865.