Howdy y’all!
Here is the text from the reference committee report that includes the committees recommendation to the House of Delegates (the folks who vote on decisions) about the clinical skills exam.
I’m still looking on the web site to see how the full house voted.
Take care,
Jeff
RESOLUTION 308 - PROPOSED IMPLEMENTATION oF CLINICAL SKILLS ASSESSMENT EXAM
RESOLUTION 319 - CLINICAL SKILLS ASSESSMENT EXAM
RESOLUTION 323 - STATE SOCIETY AND STATE MEDICAL BOARD SUPPORT TO DELAY IMPLEMENTATION OF THE USMLE CLINICAL SKILLS ASSESSMENT EXAM
RECOMMENDATION A:
Mr. Speaker, your Reference Committee recommends that the following Substitute Resolution 308 be adopted in lieu of Resolutions 308, 319 and 323;
RESOLVED, That our American Medical Association urgently contact the National Board of Medical Examiners (NBME), all organizations represented on the NBME Governing Board, and the Federation of State Medical Boards to request suspension of the implementation of the proposed Clinical Skills Assessment Examination (CSAE) until such time as:
1. The examination has been demonstrated to be statistically valid, reliable, practical, and evidence-based.
2. Scientific studies have been published in peer review journals validating the examination for US medical students and graduates and demonstrating that the fiscal and societal benefits of the examination justify the costs.
3. Testing sites are available in more reasonable geographic locations than currently proposed by the NBME, and be it further
RESOLVED, That our AMA and state medical societies encourage state medical licensing boards to exclude the CSAE from state medical licensure requirements until the above conditions are met; and be it further
RESOLVED, That our AMA continue the dialogue with the NBME and the Federation of State Medical Boards concerning the implementation of the CSAE, and be it further
RESOLVED, That our AMA ask its representatives to the Liaison Committee on Medical Education to ensure that medical students’ clinical skills are assessed regularly during their clinical training.
HOD ACTION: Substitute Resolution 308 be adopted in lieu of Resolutions 308, 319 and 323.
Resolution 308, Proposed Implementation of Clinical Skills Assessment Exam, introduced by the New York Delegation, asks our AMA to strongly urge the National Board of Medical Examiners to delay implementation of a Clinical Skills Assessment Exam and to ask the NBME to provide an itemized rationalization for the proposed cost for the Examination.
Resolution 319, Clinical Skills Assessment Exam (CSAE), introduced by the Section on Medical Schools, asks our AMA to endorse the concept of a national clinical skills assessment in evaluating suitability for licensure and to continue the dialogue with the National Board of Medical Examiners (NBME) and the Federation of State Medical Boards concerning the planned implementation of the Exam in 2004. Resolution 319 also asks our AMA to accept the offer of the NBME to share their analyses of the benefits of the CSAE and to urge the NBME to continue to consider cost and convenience in the implementation of the CSAE. The resolution further asks that AMA representatives to the Liaison Committee on Medical Education continue to emphasize the importance of formal clinical skills assessment during medical school.
Resolution 323, State Society and State Medical Board Support to Delay Implementation of the USMLE Clinical Skills Assessment Exam, introduced by the Medical Student Section and the Resident and Fellow Section, asks our AMA: to encourage state medical licensing boards to delay implementation of the Clinical Skills Assessment Exam (CSAE) from state medical licensure requirements until further analysis is made; to contact the National Board of Medical Examiners and all other appropriate organizations to request suspension of implementation of the exam until certain conditions have been met; and commends the Liaison Committee on Medical Education (LCME) for making clinical skill competencies a priority.
Your Reference Committee heard extensive testimony related to these three resolutions. Many of those who testified expressed concern about the cost of the proposed examination and about the need to travel to a site far from their medical school due to the small number of test sites that are being proposed. Although a general description of the steps being taken to validate the CSAE were provided by a representative of the NBME, many were unconvinced about this issue. A delay in implementation until these concerns are addressed was considered to be essential. It also was stressed that medical schools should evaluate clinical skills on a regular basis.
http://www.ama-assn.org/ama1/upload/mm/annual02/RefcomC.Annot.doc
[Jeff Jarvis…AGAIN!]
Howdy y'all!
OK, they've finally posted the final action of the AMA HOD (house of delegates) on the clinical skills exam. Here are the resolved clauses (aka the meat) of the approved resolution:
RESOLVED, That our American Medical Association urgently contact the National Board of Medical Examiners (NBME), all organizations represented on the NBME Governing Board, and the Federation of State Medical Boards to request suspension of the implementation of the proposed Clinical Skills Assessment Examination (CSAE) until such time as
1. The examination has been demonstrated to be statistically valid, reliable, practical and evidence-based.
2. Scientific studies have been published in peer review journals validating the examination for US medical students and graduates and demonstrating that the fiscal and societal benefits of the examination justify the costs.
3. Testing sites are available in more reasonable geographic locations than currently proposed by the NBME, and be it further
RESOLVED, That our AMA and state medical societies encourage state medical licensing boards to exclude the CSAE from state medical licensure requirements until the above conditions are met; and be it further
RESOLVED, That our AMA continue the dialogue with the NBME and the Federation of State Medical Boards concerning the implementation of the CSAE, and be it further
RESOLVED, That our AMA ask its representatives to the Liaison Committee on Medical Education to ensure that medical students' clinical skills are assessed regularly during their clinical training.
**************************
So, that's it. The final result is that the AMA will 'urgently' act to delay implementation of the CSA until the NBME can publish a better rationale for the exam's validity and improve the accessibility. It also says the AMA will pressure each state licensing board to exclude the requirement of the CSA for state licensure. That part is key because if the states don't require it, we don't have to take it.
Take care,
Jeff
[Betsy Westfall]
EVMS was a field-testing site for the CSA, so I went thru most of the pieces proposed for it. It's not a big deal test. The issue I have with it is the astronomical amount of money NBME wants to charge for it (on top of the already ridiculous costs of the rest of the USMLEs) and the limited locations they proposed for it, forcing many CSA-takers to fly to another city and pay for a hotel room there, which made the costs even worse.
If NBME is willing to charge a reasonable amount for it and offer it widely so that test-takers don't have travel expenses, the CSA wouldn't be a big deal. In the meantime, it's a good thing the AMA is acting to protect us from price-gouging and excessive travel costs for the )*& ( thing.
That's my two cents worth, having been thru the equivalent as a med student.
Blessed be,
Betsy
Howdy Betsy!
That’s my take on it exactly! As a student in the first class to be gouged, er, required to take it, I’m really hoping we can at least make Trey’s (and the other incoming first years) class the first. 
The real question from my perspective is what is the best way to accomplish the objective, ie making sure graduates can communicate and do good H&Ps. The NBME obviously thinks they should be involved. After seeing their price tag, I’m more inclined to think it should become an accreditation requirement that medical schools must require it before graduation.
Take care,
Jeff
[Jeff Jarvis]
One thing to keep in mind about the USMLE, and I’m sure the COMLEX, is that these exams are developed by third party non-profit agencies that then ‘sell’ these products to students. State medical licensing boards then decide if they want to require passage of these exams prior to licensure. Schools may also decide to require passage of any of these exams for graduation.
As an example, I can take Step II prior to Step I if I wanted to (say I were dropped really hard on my head). My school does, however, require that we take the steps in the regular order.
I bring up this issue because of Step II 1/2 or IIb or whatever the #### they end up calling the CSA. I was at one of our school’s curriculum committee meetings at which the CSA was briefly discussed. Without changes to our curriculum, our students would not be required to take or pass this exam. If, say, the Texas State Board of Medical Examiners decides to heed the AMA’s recommendations and not require the CSA for licensure, none of us Texans would have to take it, regardless of what the USMLE folks say.
Anyway, I hope that makes sense. I’m typing this at the same time I’m chasing my kids and watching “This Week with Somebody or Other”.
Take care,
Jeff
[Nat Belle]
Hey Jeff,
Our school and Mayo, has their in-house CSA exams. For us, our in-house CSA is required before we can graduate. We generally take this exam toward the end of our third year. We cannot progress to third year without a passing score on USLME Step I so you end up taking Step I before you can take Step II. We are required to take and pass Step II in order to graduate. When I was on my residency interviews, I was surprised at how many medical schools do not have this requirement. Georgetown just started requiring a passing Step II grade in order to graduate. Many FMGs take Step II and Step III before Step I because Step I typically gets them. Almost every American medical school had some kind of CSA already built into the curriculum. Some CSA exams were more sophisticated than others. The whole CSA came about because many FMGs were entering residency in this country without the ability to communicate with the English-speaking population. I can’t see where CSA needs to be mandated for American graduates since most of us are native English speakers. (Now if we had to communicate in Spanish that would be a different story). Adding another exam puts more dollars into the coffers of the testing facilities. What is this one test going to insure? Nothing.
Natalie in Va
Taking a break from ATLS
KCOM has a similar exam that is called the OSCE [Organized Structured Clinical Exam]. We take it in two steps. The first step must be passed prior to entering your third year clerkships. At this time, you are expected to be able to demonstrate competence in individual components of a patient exam and to interpret, on a fundamental level, certain diagnostic tests. For example, as I recall, we had to take a set of vitals, do a funduscopic exam, a mock rectal, identify elements of normal & abnormal heart sounds & lung sounds via audio tape, be able to ID the basic rhythm and lethal arrhythmias on an EKG and so on.
The second step is completed at the end of the third year and must be passed before we graduate. In this one, we have 4 patient exam scenarios where we had to review pt info, actually meet & interview the patient and conduct a directed pt exam. With this data, we had to draft a brief H&P, of the depth you expect construct in a general practitioner’s office, deliver a reasonable differential, rank those elements in order of probability and make therapeutic recommendations. In addition, we had 8 stations that required a more in depth understanding of exam skills. This short sections involved a focused vignette, demonstrating the specified skill, interpreting the results in the context of the vignette and making prognostic &/ therapeutic recommendations.
Even as much more difficult as the second step appears vs. the first, if you’ve paid any attention to what was transpiring during your third clerkships, it should pose little difficulty. The first one is challenging in that: 1) exam skills are still largely a novelty & 2) you really had no idea what to expect going into the test having never functioned in a clinically focused environment. Whereas in the second, I was able to accurately anticipate about 75% of what I encountered. Plus, you have done those things so many times, it has become almost “old hat”.
As I understand it, and we have discussed this ad nauseum in student<–>Admin forums & w/i the Alumni Board of Directors, these sorts of clinical competency exams are blossoming throughout all medical schools, both DO & MD. Through interacting with students at quite a few other schools, it seems that a large percentage of them either already have something like this in place or it is evolving. For those of you who are just now entering, or about to do so, you should anticipate these sorts of examinations being included in your education & training.
Another phenomenon that is spreading like wildfire, and seems to be more prevalent in the MD schools - but only temporarily, are end of clerkship examinations. These are not to be confused with the OSCE or OSCE-like examinations. These are old fashioned paper & pencil (fill in the infernal dot) style exams. [KCOM provides an extensive objective list for each clerkship prior to heading for your third year & provides b/t 150 to 200 study questions. Now, to be perfectly honest, those objectives and study questions really were not a good representation of what we encountered in the actual exams – but, this a new system (I’m only the third class to have to take them). And, the Clinical Sciences Dean is in the process of rewriting the whole system to make certain that the objectives, study questions and exam content are all congruent.] The intent of these examinations is to measure and subsequently ensure that a minimally acceptable level of clinical competence is being gained by the students. These exams tend to mix ‘book knowledge’ with ‘clinical knowledge’ and allegedly mimic what you should expect to encounter on Step 2. The MSU MD students I work with take a SHELF exam for each discipline that is authored by the NBME, the folks who write the USMLE.