This issue of the Examiner is devoted in large part to the plans to include a Clinical Skills Examination (CSE) in the United States Medical Licensing Examination™ (USMLE™). As it nears implementation, considerable discussion of the CSE is taking place at medical schools and national association meetings and in the public press. The NBME hopes that the information in this issue will be useful to students, faculty members, members of state medical associations, and state medical boards.

Assessment of clinical skills was part of the NBME certifying examinations until 1964, when it was dropped "with regret" largely because of issues regarding validity and reliability of the one-on-one bedside examination process that was employed. Since that time, NBME staff members have worked diligently to develop psychometrically sound methods of assessing clinical skills. The design of the examination and the plan for the delivery network are results of this research.

The founding documents of the USMLE called for inclusion of a test of clinical skills in the examination when the assessment could be shown to be valid, reliable, and practical. The governing bodies of the NBME and Federation of State Medical Boards (FSMB) believe that the first two of these criteria have now been met. Final field tests of logistics of the examination are now underway. Unless these field trials disclose unsuspected technical problems or unexpected costs, the CSE will become part of the USMLE in 2004.

The USMLE CSE will consist of 10 to 12 encounters between candidates and standardized patients, lay persons extensively trained to reliably portray common out-patient clinical situations. Each encounter consists of a 15-minute session between the candidate and the standardized patient. Candidates are expected to gather information related to the patient's "chief complaint," perform a focused physical examination, answer questions the patient has regarding his or her condition, and explain plans for further evaluation, if necessary. Following the encounter, a candidate has ten minutes to prepare a note that documents pertinent historical and physical findings, makes an assessment of the patient's problem, and lists plans for further evaluation. During this time, the standardized patients "grade" the candidate's performance using carefully developed standardized checklists and rating scales. Candidate notes are subsequently scored by specially trained physician-raters.

The examination is designed to rate a candidate's ability to gather information during the history and physical examination, as well as to judge the ability to communicate findings to the patients. A candidate must pass both the information-gathering and communication components of the examination to receive a passing score.

Although much attention has been devoted to the communications aspect of the examination, it is also a critical test of a candidate's ability to develop a coherent process of inquiry. Although well constructed multiple-choice question (MCQ) examinations provide a highly reliable assessment of a candidate's knowledge base, even the best MCQ examinations do not approach the fidelity of the clinical skills examination for this critical measure of a physician's competency.

Initially the NBME had hoped to deliver the CSE at a network of 12 to 20 part-time test centers located at medical schools throughout the United States. Careful evaluation has shown this approach is not feasible. The NBME has concluded that the examination can be delivered most effectively in a core network of five to seven permanent test centers located at key points throughout the United States. Studies prepared for the NBME by external consultants indicate that as many as 75% of US medical students live within three or four hours surface travel time of a network with centers located at hub cities in the Northeast, Southeast, Southwest, North Coast, and West Coast.

The NBME has not ruled out the possibility that some medical schools may have both the desire and the facilities to serve as temporary additional test sites. The NBME hopes to begin discussion with interested schools in the fall of 2002. Any potential medical school test sites must meet all the requirements of fixed test centers for training of standardized patients, quality control, security, and candidate access. Costs incurred to meet these requirements would be the responsibility of individual medical schools.

The NBME has been collaborating closely with the ECFMG in the final phases of development and testing of the CSE. When the CSE is implemented in the USMLE, it will replace the current ECFMG Clinical Skills Assessment as a requirement for ECFMG certification. The NBME and ECFMG have recently opened a state-of-the-art clinical skills assessment center in Atlanta to serve as a site for field trials of the USMLE CSE and to supplement the current ECFMG Clinical Skills Assessment facility in Philadelphia. The ECFMG Philadelphia test center and the Atlanta test center will become regional test sites for the USMLE CSE. The locations of the remaining test centers will be determined early in 2003.

The CSE is designed to certify that successful candidates have the information-gathering and communication skills necessary to enter postgraduate training. It is intended for candidates who have completed at least the traditional core clerkships of the third year of the curriculum of an LCME-accredited medical school. The USMLE Composite Committee, which governs the USMLE program, will set policies for eligibility for the CSE after review of final field test results early in 2003. It is likely that the Composite Committee will require satisfactory completion of the CSE as a condition for registration for
Step 3 of the USMLE.

More details about examination policy, implementation dates, costs, and test center locations will be forthcoming in 2003. Please visit the NBME and USMLE websites for additional information on the CSE.

Feedback is encouraged at the Examiner. Please send e-mail to examiner@nbme.org
© 2002 NBME®