To the Editor:
Recently, I took the United States Medical Licensing Examination (USMLE) Step 2 Clinical Skills (2CS) exam, and I was very impressed with the structure compared to that of objective structured clinical examinations (OSCEs) I have previously encountered.
I have the unique perspective of having taken OSCEs at both medical school and postgraduate levels in the United Kingdom and am significantly involved in medical education as an instructor and OSCE examiner at two UK medical schools.
OSCEs in the UK medical school system typically include stations requiring a single task to be performed, like examining the cardiovascular system, taking a sexual history, or consenting a patient for a colonoscopy. In my experience as both a student and an educator, this structure leads students to focus on the tasks individually. For example, they will spend time memorizing the steps of the cardiovascular examination and then practicing this on patients. Compartmentalizing these tasks does not represent true clinical practice and encourages students to consider each component separately.
Conversely, the USMLE Step 2CS exam truly captures the essence of the clinical practice students will face on day one as a doctor. This examination comprises 12 stations. At each station, the candidate is provided information on the reason for the patient’s attendance (for example, John Smith has come to your office with shortness of breath). The candidate is given basic demographics and clinical observations. He or she then has 15 minutes to take a focused history, perform the relevant examination depending on the history, and explain to the patient (a professional actor) his or her findings, differential diagnosis, and which investigations are required. In addition, the patients will have challenging questions for the candidates to manage, and some will offer other challenges, such as being angry or talkative. At the end of this 15 minutes, the candidate has 10 minutes to type a clinical note, including a section for justifying his or her top 3 differential diagnoses.
The USMLE Step 2CS requires the student to demonstrate multiple clinical skills, and it truly tests the application of his or her knowledge in a manner expected as a doctor. From the examiner’s perspective, it allows for efficient assessment of multiple aspects of clinical knowledge and skill simultaneously.
Taking the USMLE Step 2CS has opened my eyes to how effective OSCE examinations can be and has emphasized the deficiencies of the OSCEs I have experienced in the UK system.
Jason M. Ali, MA, MB BChir, PhD
Director of studies in clinical medicine, Churchill College, University of Cambridge, and specialist registrar in cardiothoracic surgery, Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge Biomedical Campus, Cambridge, United Kingdom; email@example.com.