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A Standardized Patient Enrolled in Medical School Considers the National Clinical Skills Examination

Wettach, George R. MS

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During the three years before I entered medical school, I suffered a herniated disc, recurrent bouts of lower lobar pneumonia, and a grade 3 ankle sprain. Gastroenterologists asked me about my celiac sprue, then cardiologists nodded thoughtfully at my bilateral carotid bruits. I've been counseled for posttraumatic stress disorder in New York City and discussed my genital herpes in Phoenix. I became addicted to muscle relaxants and lost my expectant wife to a drunk driver, both in the same week. Actually, these were my experiences as a standardized patient (SP) before I donned the short white coat of a student physician.

In the extensive literature on SPs there are several features common to an operational definition.1–3 An SP, or simulator, is a healthy individual specially trained to portray the details common to a particular case or disease state. Emotional affect, medical and social history, and even physical findings may be presented in a clinical setting with sufficient realism to prevent detection by experienced interviewers.

The National Board of Medical Examiners (NBME) has recently decided to include an SP-based clinical skills examination as part of the United States Medical Licensing Examination (USMLE) Step 2, known as Step 2 Clinical Skills (CS). The current Step 2 of the USMLE has been used to gauge a student's ability to apply medical knowledge to supervised patient care, while Step 2 CS is intended to assess a set of interpersonal skills not measurable through multiple-choice questions. Step 2 CS will be administered separately as a day-long session of ten individual SP encounters, each lasting 15 minutes. In that time, an examinee must establish rapport, obtain a relevant history, perform a focused physical examination, and appropriately counsel the SP. Between encounters, the examinee must document findings, list diagnostic possibilities, and outline a treatment plan. From June 1, 2004 through June 30, 2005, the fee for the Step 2 CS for U.S. and Canadian examinees has been set at US $975.00.4

The proposed Step 2 CS has generated widespread discussion among student advocacy groups. The American Medical Student Association has urged its members to lobby the state medical boards, in addition to the NBME, against imposing this potentially costly requirement.5 The American Medical Association's House of Delegates, the association's policy-making body, adopted substitute Resolution 308 during its June 2002 meeting, expressing its concern about the proposed examination. The American Medical Association then contacted both the NBME and the Federation of State Medical Boards to request that implementation of the Step 2 CS be suspended until the examination had been determined to be statistically valid, socially beneficial, and geographically accessible. By my second week of medical school, representatives from medical organizations encouraged my classmates and me to join them. For the local chapters of the American Medical Association and the Medical Society of Virginia–Medical Student Section, opposition to the Step 2 CS was the first and most urgent part of their pitch to new medical students.

Eastern Virginia Medical School (EVMS), where I am a second-year medical student, has used SPs from the Theresa A. Thomas Professional Skills and Assessment Center for more than nine years. During that time, the number of SPs has grown as the demand for their talent has increased in medical education and corporate personnel training. Within days of matriculation, medical students here begin regular structured SP encounters as part of a course entitled “Introduction to the Patient.” Besides learning to elicit the patient's story, we are expected to acquire physical examination skills from SPs, who offer detailed feedback on aspects of observation, auscultation, and palpation. All of these skills can then be reliably scored by the individual SP after each session.

Most concerned students at EVMS know, therefore, that their extensive experience with our SPs far exceeds the proposed requirements that will be imposed by the Step 2 CS. For us, the cost of registering for the examination and traveling to one of the few test sites on borrowed money is not justified to verify skills that may be assessed locally.

When I was an SP, with each new case I received a protocol detailing my chief complaint, demographic characteristics (which reasonably matched my own), positive physical findings, and a medical history to cover any scars in the area to be examined. During each encounter, I would respond like an actual patient to the individual style of each interviewer. Poor technique, such as failing to establish rapport or questioning in an overly direct or aggressive manner, would yield less information or ambiguous answers.

A well-trained SP can simultaneously record while playing. If asked, I could step out of role to provide three types of feedback:

  • Objective—whether specific content relevant to the case had been addressed;
  • Process-related—how information was obtained through overall organization, types of questions, vocal tone, and empathetic responses; and
  • Subjective—degree of satisfaction with how I was treated and my willingness to return for follow-up visits or to comply with the advice I'd been given.

This reactive performance helps interviewers refine their ability to gather information efficiently and counsel effectively by observing a patient's response to the individual interviewer's manner. Accompanied by immediate feedback, an SP may facilitate an interviewer's self-reflection as well as help the interviewer to see the specific relevance of course material. Although this process may seem to introduce an intolerable degree of variability among encounters, it acknowledges the significant disparity between interviewers who maintain a sincere, respectful dialogue and those who do not.

The greatest difference among the expanding number of SP programs at U.S. medical schools is the range and depth of feedback they are capable of providing and are expected to provide. In this regard, EVMS is exceptional, both in the size and diversity of its SP population. Although other institutions are experimenting with several different approaches, the very presence of Step 2 CS would encourage most other medical schools either to create new SP programs or to adapt existing clinical skills instruction to a format favored by the NBME. The proposed Step 2 CS would rely on tightly scripted cases that may prevent a more natural conversational equilibrium. The SPs involved with the Step 2 CS must listen for a limited number of key words or phrases then respond with a specific memorized line, regardless of an interviewer's tone or nonverbal cueing. Over time, this would become the model for nascent SP programs at other medical schools.

The homogenizing influence of Step 2 CS is easily predicted by the abundance of preparation materials already commercially available to international medical graduates facing the clinical skills assessment. An anonymous online reviewer of one such text bragged that four cases he or she eventually saw were “very similar to the ones in the book, and the others were close enough to know exactly how to approach them.”6 According to this reviewer, there are even scripts provided, so your study partner can play the SP without knowing “anything about medicine.” Is there any doubt that the same competitive pressure among U.S. medical students will create an industry of review books and prep courses for the Step 2 CS?

In addition, interviewers would be notified whether they passed or failed, possibly as a percentage score, long after the specific details of the meeting had faded from memory. Without specific feedback on the method, how can a student remediate a failed examination? As with other components of the USMLE, it falls to the individual examinee and his or her school to determine the problem, then try to correct it. Seeing these skills in the broader context of a unique, intimate relationship should discourage us from assigning false meaning to a binary or numerical score.

Since I've taken the other seat and interviewed SPs from a less accustomed perspective on the other side of the desk, I have continued to learn about the dialogue between physician and patient. My earlier experiences as an SP hunting for distracting mannerisms, lapses into jargon, and ambiguous questioning has significantly affected my subsequent clinical interactions. For example, I have become more aware of my own tendency to offer detailed explanations of a diagnosis before ensuring the patient is both capable and willing to listen. In this way, an efficient, conversational style of gathering data during an interview can be learned and is a worthy prerequisite for effective medical practice. However, any assessment of clinical skills that relies on interactions with SPs must allow for a fuller range of responses and multifaceted feedback (content, process, and patient satisfaction) than would be allowed in the proposed Step 2 CS. The NBME's reliance on a series of script-centered encounters to obtain a narrowly defined assessment without immediate, detailed feedback does not fully ensure essential clinical competencies. The NBME should instead encourage all medical schools to integrate clinical skills instruction more fully throughout the didactic years without pressuring schools to provide students a very limited model of physician–patient contact. Otherwise, the Step 2 CS may sour an entire generation of health care professionals on an otherwise valuable learning tool.


1.Barrows H. Simulated (Standardized) Patients and Other Human Simulations. Chapel Hill, N.C.: Health Sciences Consortium, 1987.
2.Norman G, Barrows H, Gliva G, Woodward C. Simulated patients. In: Neufeld V, Norman G (eds). Assessing Clinical Competence. New York, N.Y.: Springer Publishing Company, 1985:219–28.
3.Stillman P, Burpeau-Di Gregorio M, Nicholson G, Sabers D, Stillman A. Six years of experience using patient instructors to teach interviewing skills. J Med Educ. 1983;58:941–5.
4.Federation of State Medical Boards of the United States, National Board of Medical Examiners. United States Medical Licensing Examination. Clinical Skills Examination: frequently asked questions 〈〉. Accessed 26 August 2003.
5.American Medical Student Association. AMSA's opposition to the National Board of Medical Examiners Clinical Skills Exam. 〈〉. Accessed 17 January 2003.
6.Anonymous review of Reteguiz J, Cornel-Avendano B. Mastering the Objective Structured Clinical Examination and the Clinical Skills Assessment 〈–8716159–6491230〉. Accessed 31 August 2003.
© 2003 Association of American Medical Colleges