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To the Editor: The education and deployment of physicians is necessarily a 2-part process. First, a student must gain the knowledge and skills required by the educating body. Second, regulatory authorities must be assured that the newly minted physician is capable of safe and independent practice. Recently, the US Medical Licensure Examination has added a new testing component, the Step 2 Clinical-Skills (CS) examination. The Step 2 CS requires examinees to show their knowledge of history taking, physical examination, diagnostic reasoning, and communications skills, using highly trained simulated patients at 1 of 5 official sites.¹ Given that the US Medical Licensure Examination offers legitimate and important content that can help validate a school’s educational programs, and that a school’s philosophy may be to help prepare students to pass state licensure examinations, most medical schools require passage of 1 or more of the US Medical Licensure Examination step examinations as a prerequisite for graduation.² We sought to assess the impact of adding the Step 2 CS on medical school curricula, graduation requirements, and costs.

Methods
Medical school deans in the United States and Puerto Rico were surveyed via an electronic questionnaire regarding actions their schools have taken due to the Step 2 CS implementation. The questionnaire consisted of 12 items with categorical responses of yes, no, or unsure, and 2 additional items regarding special help for students and faculty support for the Step 2 CS with other specific categorical responses. The initial e-mail request was sent March 17, 2004, and a reminder message was sent on April 5. Frequency distributions were computed for the 14 categorical response items.

Results
Responses were obtained from 98 (78%) of the 126 schools surveyed. The responses to the first 12 questions are shown in the Table. Fifty-five percent of schools report that they have modified their curriculum as a result of the Step 2 CS. Fifty percent of schools require passing scores in clinical coursework before taking the Step 2 CS and 63% require a passing score on this examination prior to graduation. Seventy-two percent of schools are taking steps to assist students with fees for taking the Step 2 CS and 54% of the schools are providing a practice examination to assist students with preparation. Faculty support for the Step 2 CS is mixed (46% positive/very positive, 29% indifferent, and 22% negative).

View this table: [in this window] [in a new window] Table. Impact of the US Medical Licensure Examination’s Step 2 Clinical Skills Examination on US Medical Schools*

Comment
The addition of the Step 2 CS as a new licensure requirement has led to curricular and other modifications, including access to additional student financial aid in a majority of US medical schools. The governance of medical schools reflects the interplay of societal issues, scientific advances, faculty concerns, and regulatory requirements (eg, physician licensure and institutional accreditation). Achieving an appropriate balance among these components is a challenging task for individual schools. Making a change in one requirement appears to result in a broad investment of resources by medical schools. However, it is not clear how the educational value of this new intervention can be measured. We believe that there should be an overarching review of this complex web of interacting bodies that affects the education of our nation’s physicians.

Steven A. Wartman, MD, PhD
wartman{at}uthscsa.edu
School of Medicine

John H. Littlefield, PhD
Academic Informatics Services
The University of Texas Health Science Center at San Antonio

1. Papadakis MA. The step 2 clinical-skills examination. N Engl J Med. 2004;350:1703-1705. FREE FULL TEXT 2. Barzansky B, Etzel SI. Education programs in US medical schools, 2002-2003. JAMA. 2003;290:1190-1196. FREE FULL TEXT

JAMA. 2005;293:424-425.

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