Hundreds of medical students at the University of Maryland, Georgetown University, Johns Hopkins University and George Washington University are joining a nationwide campaign to eliminate a standardized licensing test they say is redundant and a financial burden.
Students say that the test — the Step 2 Clinical Skills exam, which measures bedside manner and real-world problem-solving while students interact with people acting as patients — should be replaced with an alternative exam that the nation’s medical schools could administer free.
The Step 2 exam is expensive: There is a $1,275 registration fee, and because the test is offered in just five cities, students often have to bear the cost of travel and lodging. Fourth-year medical students who take the exam are traveling the country interviewing for residency programs about the same time, and they say the bills can become unmanageable.
“A thousand dollars for a medical student, especially one dependent on financial aid, is a lot of money,” said Sbaa Syeda, a fourth-year student at Johns Hopkins University School of Medicine. “If the school is able to offer us an identical exam, still test those skills and certify that we are able to be competent physicians, then there is no need for a second standardized exam.”
The campaign, which has gained the support of more than 16,500 students, residents and physicians from more than 130 medical schools since it began in March, touches on a larger debate about the astronomical costs of medical training. Medical students who graduated in 2014 had a median debt of $180,000, according to the Association of American Medical Colleges, and some are questioning whether the expensive steps they must take to become physicians are creating barriers to those of lesser means.
“We care about public trust,” said Samia Osman, a fourth-year Harvard medical student and an organizer of the campaign. “And we want to make sure there is evidence-based data supporting the examination and that it is done a cost-effective way.”
Osman and other students say no evidence shows that the Step 2 exam improves patient outcomes. And although a handful of studies say exam results might predict future performance, other studies say the correlations are weak.
If nothing else, it certainly adds to the mountain of expenses medical students incur before earning a paycheck.
Licensing boards say that the existing exam system is quality-control measure in a profession that holds people’s lives in the balance.
Because not all medical schools provide the same level of training, officials say, students must undergo independent standardized testing to establish that they are ready to give patients the best possible care.
“Licensing boards have to have some bellwether to say this student has the competence to go into practice,” said Kim Edward LeBlanc, executive director of the Clinical Skills Evaluation Collaboration, which oversees the Step 2 exam. “The students bring up some legitimate concerns. But after 14 years on a licensing board, I can tell you that I would not feel comfortable giving a license to someone without this exam.”
It has been 12 years since the National Board of Medical Examiners and the Federation of State Medical Boards made the Step 2 mandatory for all aspiring physicians, not just international students wanting to practice in the United States.
The exam measures bedside manner by grading students on their interactions with a dozen people pretending to be patients. It re-creates routine doctor’s visits, with patients complaining of headaches, stomach pains or other common ailments. Students use the information from each 15-minute visit to determine the best course of treatment.
“We try to provide as much value to the students as we can, while also being in service to the state medical boards,” said Peter Katsufrakis, senior vice president for assessment services at the NBME.
Students opposed to the exam argue that the exercise offers no opportunity to assess their skills because the assessment report includes nothing more than a pass/fail score and no notes or comments on what they need to do to improve. Katsufrakis said he understands the concern but worries that providing more information could encourage cheating. He said the board could offer better feedback to schools.
Andrew Zureick, a fourth-year student at the University of Michigan Medical School, heard about the campaign and decided to submit a resolution to the Michigan State Medical Society seeking the elimination of the exam.
The professional alliance voted in early May to take the motion to an American Medical Association meeting in June, as did the Massachusetts Medical Society.
Organizers of the campaign were successful in getting the influential AMA to take up the fight. The association adopted a resolution in June promising to work with the Federation of State Medical Boards, the NBME and other stakeholders to replace the exam. The AMA has been critical of the exam and supported having medical schools strengthen their own clinical skills testing.
“There have to be better and more efficient ways to test students,” said James S. Gessner, president of the Massachusetts Medical Society. “There is absolutely no reason to bring students to five testing centers at a huge cost when the material can be administered on-site at schools.”
Some opponents of the national board’s testing policy contend that the organization is more concerned with the $36 million a year it earns from examinations than with student training. They question why the exam’s price is double the cost of the other licensing tests and why the board will not open more exam sites to reduce the cost of travel.
“Traveling to Philadelphia to take the exam, having taken a similar test a week before at school, was frustrating,” said Peter Kahn, a fourth-year student at the Albert Einstein College of Medicine in New York City. “This test is not only duplicative, but the astronomical expense of taking it is just insane.”
Katsufrakis said the other tests are computer-based exams that are not as resource-intensive as the clinical review. And new centers would increase the price of the exam because the board would need to offset the cost of extra staffing and leased space, he said.
If that is the case, the most efficient solution would be to let medical schools take over, Osman said. Medical schools are capable of managing the responsibility, and licensing boards could work with universities to devise national guidelines, she said.
“Creating guidelines would address quality control,” Osman said. “We should be more open to alternatives that can uphold public trust while reducing costs. People have to take out loans to take the test. It doesn’t make sense.”
It is ultimately up to state medical licensing boards to sign off on changes. A recent survey by the Federation of State Medical Boards suggests that most states are satisfied with the existing system. Ninety-five percent of the 43 boards that responded to the survey agreed that the skills exam should remain in place.
“The need for physicians who can really communicate with patients is important, and the clinical skills exam really addresses that issue,” said Kathleen Haley, executive director of the Oregon Medical Board. “There isn’t a standardization across the medical schools for that type of measurement. The more you have those skills reinforced at the exam level and at the schools, the better it is for patients.”
John E. Prescott, chief academic officer at the Association of American Medical Colleges, said the exam is more about licensing than medical education. Schools are working hard to ensure students are prepared, but their outcomes vary greatly, he said.
“Everyone wants to make sure that we are doing the right thing for patient safety,” he said. “There is an opportunity to stop and reflect on the purpose of the examination. Is it meeting its purpose? And if there are changes needed, what should they be? This is a healthy discussion.”