By Karen Lewis
In the plenary talk, “Standardized Patients: The First- and Second-Half Centuries,” Ann King, Assessment Scientist for the United States National Board of Medical Examiners (NBME), informed the audience at the 10th Annual ASPE Conference in Nashville, TN that changes are ahead for the Clinical Skills Exam—very welcome changes, at least from this SP educator’s point of view.
As stated on their website, the purpose of the United States Medical Licensing Examination (USMLE) is to assess “a physician’s ability to apply knowledge, concepts, and principles, and to demonstrate fundamental patient-centered skills that are important in health and disease and that constitute the basis of safe and effective patient care.” It does this in three examinations called Step 1, Step 2, and Step 3. “Step 2 Clinical Skills (CS) uses standardized patients to test medical students and graduates on their ability to gather information from patients, perform physical examinations, and communicate their findings to patients and colleagues.”
According to Ann King, during 2004-2010 the NBME has conducted 2,000,000 clinical skills assessments. What they learned in the process will inform the exam in the coming years. Most of the changes stem from the growing evidence base for the importance of communication skills and the call for more patient centered care. These concerns coupled with the concern of whether the skills they are testing are really what interns need for competency have led to a rethinking of the 2CS format.
Certainly many of us have experienced what Ann described as the “just getting your ticket punched” behavior of learners. They ask questions and give responses almost by rote rather than react to SPs’ responses. Are these performances artifacts of the exam, and if so, what does that mean for the exam and what does it tell us about the examinee’s communication skills and his/her ability to perform patient centered care?
The same point can be made about SP performances. The cases are sometimes so overly standardized that the patients respond the same way no matter what the examinee says. Contingent responses are built in to help SPs react to different examinee behaviors, but the result is that encounters are stilted rather than interactive. As Ann explained, “in our efforts to be fair, we swung too far in order to convince the medical community of standardization.”
The answer, said Ann, is to think beyond the biomedical information as they create cases. To do this, the assessment experts have come up with a six function construct.
1. Fostering the relationship
2. Information gathering
3. Information provision
4. Making decisions
5. Supporting emotions
6. Enabling behaviors
All of these functions will have sub functions. While some of these items are similar to the current construct, they differ in that they consist of behaviors that are observed or not observed instead behaviors that are evaluated using a 9-point scale rating.
Perhaps the most surprising portion about this construct is that it will replace the history checklist, allowing SPs to more clearly focus on the new instrument. As for their scripts, the SPs will be trained on a personality profile that guides their behavior, freeing them from the constraint of remembering examinee questions and enabling them to respond more naturally in the encounter.
I think I can speak for those of us who construct and administer exams in our own institutions that emulate 2CS: Hooray! How many of us have felt torn between training our SPs to portray a case that felt “real” on the one hand and training them to have standardized responses that were “fair” on the other? How many of us have spent a great amount of time delineating things like, if the examinee does this, do x; if he does that, do y? In my experience, simulated activities where the SP can perform within the confines of a behavior profile almost always accomplish better learning for our students, clearer educator understanding of what they have learned, and more informed ideas about the next steps. I look forward to learning more about the new and improved Step 2CS.
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