Despite intense opposition from medical students, two national organizations in charge of the medical licensing exam are forging ahead with plans to institute a nationally standardized clinical skills exam for the graduating class of 2005.
Officials from the Federation of State Medical Boards, which determines the criterion necessary for medical licensing, and the National Board of Medical Examiners, which administers the test, cited the accountability of doctors to the public as a motivating factor to implement the Clinical Skills Assessment Exam.
"Our responsibility is first to protect the public and in so doing improve health care," said Dr. James Thompson, chief executive officer of the FSMB and the former dean of Wake Forest University School of Medicine.
Although few contest this goal, medical students such as James Floyd see glaring flaws with the clinical skills exam as it stands to be implemented.
"How can you nationally standardize something so subjective as human interaction?" Floyd asked.
The third-year medical student has personally waged a battle against the employment of the test because of his belief that there is little if any evidence to prove the exam will be reliable.
"There is no data to show the validity of the test, to show that what [they're] trying to do is right," Floyd said.
Although NBME Vice President Dr. Peter Scoles refuted this claim, he admitted that evidence for the validity of the exam was scant. "We don't have outcomes data for the United States," he said.
However, this exam has been researched and studied for 15 years - more than any other professional exam - and was part of the original design of the current United States Medical Licensing Exam. With studies from Canada examining the validity of their exam, NBME and FSMB officials are confident that the American version will yield similar results.
Floyd countered this optimism, noting that it is difficult to deduce what or who the test would differentiate.
"Ideally, the clinical skills test should weed out the people who don't have the clinical skills," he said. "The entire medical community knows there is no validity or reproducibility [in the results]."
Another issue concerning medical students is the financial burden such an exam would impose. The test itself is slated to cost $950, and medical students would face additional travel and lodging costs to get to national testing centers. The exam hinges upon the video-recording of medical students as they interact with standardized patients to later assure consistency in the marking of medical students by the simulated patients.
The FSMB is planning on five national centers, two of which have already been constructed in Atlanta and Philadelphia. Because the initial investment into testing centers has already been made, medical students charge that the organizations are prompted solely for fiduciary reasons.
"The motivation for the exam is not one of public safety, but a financial one.... There has been no evidence of external validity - that is, will this test weed out people who will become bad doctors or reduce disciplinary activity by state licensure boards," said Dev Kalyan, a second-year medical student.
Both Kalyan and Floyd, also president of the Duke chapter of the American Medical Association, feel that the evaluation of clinical skills should be performed by faculty at each medical school and enforced by the Liaison Committee on Medical Education, the institution that accredits medical schools.
Although Duke currently has a clinical skills exam in place as part of its curriculum, Emil Petrusa, associate dean of curriculum assessment, said many medical schools are failing to adequately teach or assess skills. For this reason, faculty like Associate Professor of Cardiology Dr. Robert Waugh, are excited about the prospect of the hands-on standardized exam.
"We don't have a good way to make sure every student has been exposed to everything we want them to," he said, adding that simply testing the students' cognitive skills is not enough.
Although Floyd and Kalyan agree with this assessment, they believe the time for the clinical skills exam is still premature and lament the fact that neither the AMA nor medical students have much of a say in the implementation of the exam.
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