Changes to the USMLE Step 2 CS Present New Challenges for IMGs
Beginning in June of 2012, the USMLE( U.S. Medical Licensing Examinations) has added new criteria for two of the scoring components of the Step 2 Clinical Skills exam. The changes include an expanded format for patient note writing which will now limit the differential diagnoses section to allow for up to three impressions, but will require the examinees to support each choice with history and physical exam findings collected during the patient encounter. Presumably, the component of data gathering will now be assessed by evaluating findings listed on the patient note rather than by SP checklists completed after each encounter.
The more significant changes, however, involve the CIS (Communication & Interpersonal Skills) component of the exam, which traditionally has posed the most difficulty for international and foreign medical graduates. In expanding on the former CIS subcomponents which assessed Professional Manner and Rapport, Questioning Skills and Information Sharing, USMLE has now restructured its evaluating criteria requiring examinees to demonstrate competence in the following areas: Fostering the Relationship, Gathering Information, Providing Information, Making Decisions, and Supporting Emotions. To implement these changes, USMLE has re-trained its standard patient evaluators, and has created new cases designed to further challenge test takers in these areas. Examinees will now be expected to take a more “patient centered” approach with their cases by encouraging patients to fully express specific concerns regarding their problem, and to share more responsibility with overall health decisions. An ability to genuinely communicate empathy to the patient when appropriate has become a higher priority as well. The goal is to create a more cooperative “partnership” with patients by establishing a trusting and comfortable environment, by evaluating and addressing the health needs and concerns of the patient, by providing education, and through gaining consensus with the patient for carrying out future plans.
While it is still too early to determine how these changes to the exam will impact passing rates for foreign graduates, it can be expected that CIS failures will increase. At the heart of the problem is the fact that many overseas institutions continue to focus almost exclusively on the “medical” component of patient care with little or no emphasis on the value of interpersonal communication. Cultural differences also make it difficult for many foreign trained doctors to feel comfortable with addressing the emotional impact of health problems on patients. Interestingly, in many foreign countries, expressions of caring and compassion by doctors are often interpreted as an over-compensation for an inadequate knowledge of medicine. In my experience with preparing foreign graduates for the CS, perhaps the biggest challenge has been in overcoming cultural indifference, and even resistance, to the concept of empathy. All too often, doctors follow the advice given in the “popular” preparation manual and simply recite “hollow”, scripted sounding statements which lack any sense of sincerity or genuineness. In all likelihood, these types of superficial, “cookie cutter” responses will no longer be adequate for communicating sensitivity and authentic concern. Language barriers also stand to significantly limit foreign test takers’ ability to spontaneously converse with patients about concerns and issues not directly related to the medical investigation aspect of the encounters.
Unfortunately, most of the preparation sources currently available cannot adequately address the specific obstacles that the changes to the CS exam present to foreign graduates. The most widely used cs prep book (you know the one) which, in my opinion, promotes unnatural, robotic behavior as a substitute for genuine caring and concern, has now become all but obsolete. Because new case challenges will now require examinees to not only listen more attentively but also to respond appropriately and empathically to a host of unforeseen issues, they can no longer rely on the usual group of standard “catch all” phrases (“I can understand your concern”) which may have been acceptable in the past. Sound communication skills begin with a sincere willingness to imagine what the patient is experiencing and demonstrating interest and compassion through non-verbal behaviors as well as with words. Any successful preparation for passing the USMLE Step 2 CS exam must start with a healthy understanding and appreciation for these concepts.