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