Is Step 2 CS worth the cost?

NEJM has an article about the cost of the clinical skills portion of Step 2, response here. Basically the test, which is taken as a medical student and required to become licensed as a physician in the US, costs more than a thousand dollars, and even more if you’re not fortunate to attend school in one of the 5 measly cities in which it is administered and have to travel to a testing site. The test, which is pass/fail, consists of a bunch of stations with actors pretending to be patients with common problems: sore throat, back pain, anxiety, etc. You rotate through the stations, talk to and examine the patients, and then document your findings, and you’re evaluated on specific things that the powers that be have determined are important: if memory serves, they include asking the right questions, washing your hands, picking the right parts of the body to examine and doing it correctly, as well as certain patient-centered communication skills such as recapping what they’ve said so far. They also evaluate your English language skills (obviously a gimme for American students but this exam is also taken by people who went to med school in other countries and want to practice in this country).

It’s actually kind of fun, at least by the standards of taking a test. The issue is, it’s super easy to pass–98% of US students pass the first time, and 91% of the remaining 2% pass on retry. (Foreign grads do less well, but still almost 80% pass the first time.) And unlike the other medical licensing exams, it’s pass/fail, so there’s no way to differentiate who does well and who just squeaked by. So the argument is, why do we have a test that’s crazy expensive and doesn’t tell us that much? Having had to fork over my ridiculously large chunk of change, I totally get this argument. Eliminating it would be one less source of stress for students.

Except. There is the truism about what gets tested, gets learned. And even if most of my classmates didn’t necessarily study for CS in particular, we did more broadly, because preparing for it was incorporated throughout the curriculum. Medical schools want to stay accredited, and so they are motivated to change the curriculum to make sure their students pass. The patient simulation exercises that we do are actually helpful: unlike the majority of clinical time as a student, when you are either talking to patients unsupervised or watching as your resident or attending does the talking, you get to practice interacting with patients and get immediate feedback about how to improve from your instructor, classmates, and the “patients” themselves. That’s why unlike, say, professional meetings, simulation improves clinical performance and may even impact patient safety

Would schools do these simulations anyway? Maybe, since there’s good evidence that they’re an effective teaching tool. On the other hand, they’re expensive, and med schools aren’t always the most profitable of endeavors. So from that perspective, maybe keeping CS around for a while isn’t such a bad idea.


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