P&S Students

Smaller than Life:
the Reality of
the New USMLE
Clinical Skills Exam

The P&S Class of 2005 was the first class required to take a new clinical skills exam as part of the U.S. Medical Licensing Exam. The exam followed more than 15 years of pilot testing to ensure it would be a reliable and objective way to test clinical skills. Students are expected to take the exam at the end of their third year of medical school. Because the exam was first offered in June 2004 at one of five test centers around the nation, most of the Class of 2005 took the exam during their fourth year. Megan Patrick, who has begun a medicine internship at Lenox Hill Hospital in New York City, writes here about her experience as "clinical test guinea pig."

OVER THE PAST YEAR, THE USMLE CLINICAL SKILLS EXAM HAS been at the center of a profession-wide controversy. Questions about its cost, feasibility, and fairness can be heard coming from every medical school classroom up through the halls of the AMA. As a member of the guinea pig class of 2005, I arrived at the Chicago testing site on a snowy morning in February, jet-lagged, $1,500 poorer, and uncertain of what to expect.
The testing site was in a modern office building a few miles from the airport. At 8 a.m., I was ushered into a waiting area with 23 other people in short white coats looking as confused as I felt. Some drank the coffee and tea offered by the testing site, but few spoke. The atmosphere was one of apprehension.
After a few minutes of waiting, we were signed in and oriented by a test center employee with a loud voice and an emphatic personality. "Treat each encounter the way you would any real patient visit," he said assuredly. There were, however, some major differences. We had only 15 minutes per standardized patient (SP), there were no invasive exams (rectal, pelvic, or breast), and if a patient acted out a physical finding, however unconvincingly, we were supposed to pretend it was real. In addition, we were being graded on everything from the comprehensiveness of our interview to the firmness of our handshake.
Before I knew it, I was standing outside the door of my first encounter. The information sheet listed the vital signs and a one-line description of the case, "17-year-old athlete with right-sided chest pain." I took a deep breath, put on my biggest smile, and knocked on the door.
The actor, in his mid-to-late 20s, was sitting on an exam table wearing only a hospital gown and his boxer shorts. He did not look up when I greeted him. Becoming increasingly more nervous, I launched into my interview. The SP answered my questions lifelessly, usually with a yes or a no. Halfway through my focused physical exam, he finally looked up to ask me his requisite "difficult" question. Would he have to give up wrestling? He seemed to take little interest in my response. The physical exam finished, I sat back down and explained what I thought was the problem and what tests would be needed to confirm my diagnosis. He looked at me blankly throughout. At last, I asked him if he had understood everything I had said. "Yes." Did he have any questions? "No." With another big smile and a handshake, I was back in the hall writing my note.
Each room contained an SP with another set of symptoms vague enough to have more than one potential diagnosis but straightforward enough to fit into the 15-minute time frame. There was a 35-year-old man with painless hematuria, a 42-year-old with amenorrhea, and a 64-year-old alcoholic with trouble walking. Nine of the 12 cases required a history and physical exam, two only a history, and one case was a mother on the telephone concerned about her sick infant. Although the cases themselves were interesting, ironically, in what was supposed to be a test of our communication skills, the SPs continued to be as dull and emotionless as talking mannequins. Compared to the dynamic and intense range of patient emotions I had witnessed over my four years at Columbia, these encounters seemed artificial and empty. Depression was on my differential diagnosis at least two-thirds of the time.
By 4 p.m., I finished with my last patient, wrote my last note, and was back on an airplane headed home. Six weeks later, I received my score report, a simple box with the word "Pass" in it. There was no breakdown of the test components, no feedback on my strengths and weaknesses, and no indication of how well I had done relative to my peers. Given the time, money, and controversy surrounding this exam, I had expected more.

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