USMLE Step 2 Clinical Skills 시험 : 낮은 가치 제안(poor value proposition)

(site : http://chicagomedicaltrainingcenter.org/usmle/usmle-step-2-cs/)

시험에 드는 비용과 그 투자 수익률(ROI)을 고려하면 USMLE step 2 CS는 그 존재 가치가 낮고, 

따라서 없애는 것이 나을 수도 있다.

98%의 미국과 캐나다 응시자가 USMLE step 2 clinical skills (CS) 시험을 첫 번째 응시에 통과한다. 

또한 한 번 떨어진 사람들 중에서도 91%는 두 번째 응시에 합격한다. 

따라서 두 번 이상 떨어지는 사람은 1000명중 1.8명에 불과하다.

한 해에 17852명의 응시자가 있다고 할 때, 

두 번째 시험에서도 떨어지는 응시자는 그 중 단 32명 뿐이다. 

응시자 중 아무도 응시료를 내기 위한 대출을 받지 않는다고 하더라도, 

한 명의 '재수 실패자(double failure)'를 골라내기 위해서 드는 비용은 635,977달러에 달한다.

비슷한 논리로, "그러면 모든 USMLE 시험이 다 필요없는 것 아니냐" 하는 사람도 있지만, 

USMLE Step 2 CS만이 Pass/Fail로 결정된다. 나머지 시험은 정량적 결과를 제공한다.

또한 "모든 사람이 응시료를 내기 위해 대출을 받는 것은 아니지 않느냐" 라고 할 수도 있지만, 

여전히 이 시험을 보기 위해 돈을 내는 것에 대한 '기회비용'이 존재한다. 

돈이 자기 주머니에서 나가든, 대출을 해서 내든 근본적 차이는 없다.

미국이나 캐나다 의과대학을 졸업한 학생은 98%가 첫 번째 응시에서 이 시험을 통과하나, 

그 외의 외국 의과대학을 졸업한 학생은 79%만이 통과한다. 

따라서 이 시험이 미국이나 캐나다 외의 외국 대학 졸업 학생을 대상으로 해서는 의미가 있을 수 있다.

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Efforts to minimize the regulatory and administrative burden in U.S. health care have never been greater.

One regulatory domain that deserves greater scrutiny in this context is medical licensure

For example, the National Board of Medical Examiners (NBME) and the Federation of State Medical Boards (FSMB) mandate the purchase of four licensing products by medical students and resident physicians over the course of their training.

This three-step series of examinations is known as the United States Medical Licensing Examination (USMLE) and is jointly administered by the NBME and FSMB.

Given the pass rates among examinees and the exam’s cost, we believe that Step 2 CS provides a poor return on investment and little appreciable value to the U.S. health care system — and should therefore be eliminated.

Under the assumption that the average physician takes 15 years to pay off medical student debt, compounded interest would increase the aggregate annual cost of the Step 2 CS to $56.4 million.

If that were the case, given a standard inflation discount rate of 3%, the 15-year cost of the exam would be $36.2 million annually in 2012 dollars.

 

Ninety-eight percent of U.S. and Canadian examinees pass Step 2 CS on their first attempt.1 Examinees who must repeat the exam have a 91% pass rate, so the fraction of test takers who fail more than once is 1.8 in 1000.

Of 17,852 examinees taking the exam in a given year, we predict that only 32 per year would not pass the exam on a repeat attempt. Even if no examinee had to use a loan to pay for the exam, the cost of identifying a single “double failure” would be $635,977;

Some might interpret this analysis as suggesting that all written licensing exams should be eliminated, since all USMLE exams have relatively high initial pass rates (94% or higher for all M.D. candidates from U.S. or Canadian medical schools).1 However, in contrast with Step 2 CS — which is ultimately graded on a pass or fail basis — the remaining USMLE examinations externally report quantitative data on examinees’ performance relative to their peers.

Others may question the assumptions behind our calculations, noting that not every examinee borrows money to pay for

the test. Although this is a fair critique, the fact remains that money spent on the exam is no longer available to the examinee and so represents an opportunity cost of taking the Step 2 CS exam. This opportunity cost exists whether the exam is paid for out of pocket or with loans and serves as the rationale for compounding of interest.

One purpose of licensing exams is to identify insufficiently trained examinees in order to prevent them from practicing medicine, at least until appropriate remediation is undertaken. Step 2 CS has the potential to achieve this objective by identifying examinees who have difficulty communicating with patients, because English-language proficiency is one of the three skills tested.3 Indeed, the pass rates of examinees from North American medical schools are markedly different from those of examinees from international medical schools: 98% of U.S. and Canadian examinees have passed on their first attempt, whereas only 79% of those who attended medical schools outside the United States or Canada have done

so.1 

To paraphrase a quip often attributed to Everett Dirksen: a million here, a million there — pretty soon, you’re talking real money.

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N Engl J Med. 2013 Mar 7;368(10):889-91. doi: 10.1056/NEJMp1213760.

The Step 2 Clinical Skills exam--a poor value proposition.

Lehman EP 4th, Guercio JR.

Source

Department of Internal Medicine, Duke University School of Medicine, Durham, NC, USA.

Comment in

• Quality, cost, and value of clinical skills assessment. [N Engl J Med. 2013]
• The Step 2 Clinical Skills exam. [N Engl J Med. 2013]
• The Step 2 Clinical Skills exam. [N Engl J Med. 2013]
• The Step 2 Clinical Skills exam. [N Engl J Med. 2013]