As field trials for the planned clinical skills enhancement of the United States Medical Licensing Examination (USMLE) are concluding, state medical boards across the country are discussing the pros and cons of requiring newly trained physicians to demonstrate basic clinical and communication skills as a requirement for initial licensure.
Many factors will influence this discussion. Some medical students oppose the examination for financial reasons. Some medical societies oppose the examination in response to medical students’ concerns. Perhaps even individual practicing physicians have weighed in on what they perceive to be a test that is redundant and too expensive for struggling young medical students. After all, can’t we just assume that U.S. medical schools have appropriately assessed the medical knowledge and skills of their graduates?
States have been administering medical licensing examinations since the early 1900’s. Twelve years ago, most state medical boards took an enormous step towards license portability by agreeing to require the USMLE as their examination for medical licensure. The USMLE is widely considered to be the premier medical licensing examination in the world. It provides a highly reliable assessment of the knowledge necessary to practice medicine safely. However, currently the examination only measures medical knowledge. It does not assess clinical and communications skills.
Data from the National Board of Medical Examiners, the Educational Commission for Foreign Medical Graduates and the Medical Council of Canada indicate convincingly that approximately 5 to 7 percent of newly educated physicians who successfully complete medical knowledge examinations are unable to pass a test of clinical and communications skills. Unfortunately for the American public, these data suggest that a significant number of young physicians who receive licenses to practice medicine in unsupervised settings such as emergency rooms do not have the clinical and communications skills necessary to provide an acceptable level of patient care.
When viewed within the context of 16,000 individuals graduating from US medical schools annually, these data equate to approximately 1,000 physicians each year who will be identified through the Clinical Skills Examination (CSE) as having inadequate clinical skills. Most of these individuals will ultimately pass the examination and obtain licensure after receiving additional training from their medical schools. But it is estimated that approximately 160 to 300 candidates will never pass the examination – even after multiple attempts. This is approximately the same number of candidates who fail to pass the cognitive components of the USMLE after multiple attempts.
We believe that public safety will be strengthened over the next decade if we are able to prevent some 1,600 to 3,000 physicians who are not able to demonstrate adequate clinical and communications skills from entering the practice of medicine. But more importantly, close to 10,000 physicians will be better practitioners because their deficits will be identified and remediated early in their education and training.
The proposed examination is not an insignificant expense. The CSE is expected to cost about $950. Students will be asked to travel to one of 5 to 7 regional testing centers so there will be added expenses associated with that travel. But are these costs really significant when looked at in the context of the cost of overall medical education?
Based on recent statistics released by the American Association of Medical Colleges, the average medical student graduates with about $100,000 of debt. Contributing to this debt is the travel and expense students incur to obtain residency-training slots. Today’s fourth-year medical students take as many as 8 to 12 trips annually to interview for residencies. They may take another 4 to 5 clinical rotations away from home to “audition” for potential positions – expenses that are absorbed by the students.
As a former medical school dean, I am sympathetic to the financial plight of our nation’s physicians in training. Yet the cost of the USMLE CSE represents less than 1 percent of their debt load at graduation.
Further, the expense is nominal when compared to the costs incurred by state medical boards to discipline physicians who do not have the requisite skills to practice medicine safely. Last year, state medical boards spent tens of millions of dollars to discipline slightly more than 4,000 physicians – less than 1 percent of the total practicing physician population. I believe these costs, like the costs for the CSE, reflect the realities of the profession’s willingness to self-regulate.
Finally, the NBME and the Federation have been diligent in containing the costs associated with delivering this examination. Neither organization will profit from administering the CSE. In fact, the NBME has invested close to $25 million to research and develop the CSE – dollars they do not intend to recover from the operational program.
The fundamental question to be answered in the debate about adding a test of clinical skills to the USMLE is whether doing so will best serve the American public. Each state medical board has as its core mission a responsibility to protect the residents of its state from physicians who are not able to provide minimally acceptable patient care. Enhancing the USMLE with an examination that will prevent a significant number of inadequately prepared physicians from entering the practice of medicine seems a logical step towards such an important public duty.
