Discontinuation of the USMLE Step 2 Clinical Skills Examination: Studying the Past to Define the Future

The United States Medical Licensing Examination (USMLE) Step 2 Clinical Skills (CS) was discontinued in January 2021, marking a significant milestone in assessment of clinical skills. In this commentary, the authors trace the history of the Step 2 CS exam-beginning with its early roots in the 1960s up to its discontinuation in 2021. In this new era, the medical education community is replete with opportunities for advancing methodology and content associated with clinical skills assessment. The authors propose 3 main lessons gleaned from this rich history and modern evolution, which are aimed at defining a future that includes creative collaboration toward development of comprehensive, equitable, student-focused, and patient-centered clinical performance assessment. First, as it has done throughout history, the medical education community should continue to innovate, collaborate, and improve upon methods of clinical skills assessment. Second, medical educators should continue to shift to more complex and student-driven approaches of assessment, that is, assessments that provide an unstructured environment, are realistic with respect to the natural conditions, and do not limit students to lists of options or force them to take a certain path of reasoning. Third, medical educators should continue to rethink the role of assessment and ensure that all assessments, regardless of stakes or type, provide sufficient feedback for the student to identify areas of strength and weakness.

A history of assessment in medical education

The way quality of assessment has been perceived and assured has changed considerably in the recent 5 decades. Originally, assessment was mainly seen as a measurement problem with the aim to tell people apart, the competent from the not competent. Logically, reproducibility or reliability and construct validity were seen as necessary and sufficient for assessment quality and the role of human judgement was minimised. Later, assessment moved back into the authentic workplace with various workplace-based assessment (WBA) methods. Although originally approached from the same measurement framework, WBA and other assessments gradually became assessment processes that included or embraced human judgement but based on good support and assessment expertise. Currently, assessment is treated as a whole system problem in which competence is evaluated from an integrated rather than a reductionist perspective. Current research therefore focuses on how to support and improve human judgement, how to triangulate assessment information meaningfully and how to construct fairness, credibility and defensibility from a systems perspective. But, given the rapid changes in society, education and healthcare, yet another evolution in our thinking about good assessment is likely to lurk around the corner.

Histology and Embryology Education in China: The Current Situation and Changes Over the Past 20 Years

In mainland China, histology and embryology (HE) are taught in one course as an essential component of medical curricula. The effectiveness of HE courses directly affects the quality of medical students. To determine the present situation and changes in HE teaching in Chinese medical schools, a nationwide survey was conducted among the HE departmental leaders. In total, 66 responses were included in the study, representing prominent Chinese mainland medical schools. The results revealed that most HE teachers have medical educational backgrounds; an increasing number of teaching staff with PhDs have joined the teaching staffs. A range of 71 to 90 HE curriculum contact hours is predominant. The ratio of theory to practice for HE contact hours is 1:1 at half of the surveyed medical schools. The numbers of students in each laboratory are less than 30 and from 31 to 60 at 23 and 36 medical schools, respectively. Virtual microscopy is employed in 40% of the surveyed medical schools. Didactic teaching is the most common strategy, although new teaching approaches are being employed gradually. During the past 20 years, both the total number of HE teachers and the number of HE teachers with medical educational backgrounds have been reduced in at least half of the surveyed schools. A total of 83.33% of the surveyed schools have reduced their HE contact hours. Almost half of the Chinese medical schools remained unchanged in both their ratio of theory to practice and the number of students in each laboratory. The data derived from this study help to understand the development of the HE discipline at Chinese medical schools.

A Crisis of Trust Between U.S. Medical Education and the National Board of Medical Examiners

This Invited Commentary is an independent opinion piece and companion to the Perspective by Carmody and Rajasekaran that appears in this issue of Academic Medicine. The National Board of Medical Examiners (NBME), a 501(c)(3) nonprofit, is a powerful gatekeeper to the medical profession in the United States. According to publicly available tax data, the NBME, which has increased its number of income-enhancing products, had revenues of $153.9 million (M) and net assets of $177.6M in 2017, earnings (revenue less expenses) of $39.7M in 2013-2017, and a highly compensated management team. Medical students are ultimately the source of nearly all the NBME's revenue, and the NBME has contributed to the growth of medical student debt. The NBME has operated as a monopoly since its agreement in the early 1990s with the Federation of State Medical Boards to cosponsor the United States Medical Licensing Examination (USMLE). Although the NBME has developed valuable products and is ostensibly governed by a capable board, the NBME has inherent financial conflicts of interest and may be benefiting from the current "Step 1 mania" undermining undergraduate medical education. Here, the author makes 4 recommendations to reestablish the trust of the U.S. medical education community in the NBME: (1) the NBME should recuse itself from current discussions and policy-making decisions related to changes in the score reporting of the USMLE Step 1 exam; (2) the NBME should disclose and be transparent about all aspects of its finances; (3) new NBME products, changes in pricing, and changes to pass thresholds should be approved by an oversight committee, independent of the NBME; and (4) the NBME (and USMLE) should not charge students or residents for retaking any of its licensing examinations.

Psychometrics and its discontents: an historical perspective on the discourse of the measurement tradition

Psychometrics has recently undergone extensive criticism within the medical education literature. The use of quantitative measurement using psychometric instruments such as response scales is thought to emphasize a narrow range of relevant learner skills and competencies. Recent reviews and commentaries suggest that a paradigm shift might be presently underway. We argue for caution, in that the psychometrics approach and the quantitative account of competencies that it reflects is based on a rich discussion regarding measurement and scaling that led to the establishment of this paradigm. Rather than reflecting a homogeneous discipline focused on core competencies devoid of consideration of context, the psychometric community has a history of discourse and debate within the field, with an acknowledgement that the techniques and instruments developed within psychometrics are heuristics that must be used pragmatically.

Teaching More by Grading Less (or Differently)

When we consider the practically universal use in all educational institutions of a system of marks, whether numbers or letters, to indicate scholastic attainment of the pupils or students in these institutions, and when we remember how very great stress is laid by teachers and pupils alike upon these marks as real measures or indicators of attainment, we can but be astonished att he blind faith that has been felt in the reliability of the marking systems.

[Examinandi, doctors and medical councils. Reform proposals concerning surgico-medical education and examinations at the University of Vienna around 1800]

This essay examines the workings of the so called Court Committee for the Revision of University Studies. The main duty of this institution was to evaluate the structure of the whole educational system of the Habsburg Empire. These records have not received much notice hitherto from historians of medicine. Nevertheless, they deserve attention, as they are quite full of information regarding the "how" of medical education and health care management around 1800. Johann Peter Frank, at that time professor at the Medical Faculty of Vienna was responsible for reform proposals. His deliberations shed fresh light not only on the structures of Viennese Medical Faculty itself but also on different educational policies in the medical sciences in Central Europe around 1800.

The status of interprofessional education in Canada

This article describes the history and development of interprofessional education (IPE) in Canada from its conceptual beginnings in the 1960s to today. The status of IPE in Canada is viewed in relation to the broader international movements for IPE and collaborative healthcare. The current goals and principles of the Canadian Interprofessional Health Collaborative are reviewed, and the future of IPE is considered in light of these goals.

American Interprofessional Health Collaborative: historical roots and organizational beginnings

This article describes the emergence of the American Interprofessional Health Collaborative to rebuild capacity for interprofessional education and care in the U.S. through an inclusive, evidence-based and open exchange of information and resources. Also described are the historical context and the national and international climate for its emergence.

Lessons from the past--historical trends in the RACGP examination

Assessment within any medical specialty college is often an area that elicits deep feelings within the medical community. The speciality of general practice is no exception, and there are a number of deeply held and widespread beliefs about The Royal Australian College of General Practitioners (RACGP) Fellowship examination. This article seeks to publish historical data from past RACGP Fellowship examinations. It is anticipated that readers with an interest in past, present and future trends will find this information useful, and it is intended that the information contained in the article will be used to inform the many debates which focus on the RACGP Fellowship examination.

Science and culture around the Montessori's first "Children's Houses" in Rome (1907-1915)

Between 1907 and 1908, Maria Montessori's (1870-1952) educational method was elaborated at the Children's Houses of the San Lorenzo district in Rome. This pioneering experience was the basis for the international fame that came to Montessori after the publication of her 1909 volume dedicated to her "Method." The "Montessori Method" was considered by some to be scientific, liberal, and revolutionary. The present article focuses upon the complex contexts of the method's elaboration. It shows how the Children's Houses developed in relation to a particular scientific and cultural eclecticism. It describes the factors that both favored and hindered the method's elaboration, by paying attention to the complex network of social, institutional, and scientific relationships revolving around the figure of Maria Montessori. A number of "contradictory" dimensions of Montessori's experience are also examined with a view to helping to revise her myth and offering the image of a scholar who was a real early-twentieth-century prototype of a "multiple" behavioral scientist.

2007 Norden-Pfizer Distinguished Teacher. Evolution of a teacher: helping students learn

I was honored to receive the 2007 National Carl J. Norden-Pfizer Distinguished Teacher Award. This award reflects the impact that my mentors and students have had on my teaching. I have been fortunate to have dedicated mentors and wonderful students. It is through the support and guidance of colleagues and students that I have been able to grow as a teacher. My students have taught me a lot about being an effective teacher. I will share some key principles that I try to follow in my teaching. These principles can be used in any teaching situation in any discipline.

[The pharmacist examination in Keijo (Seoul, Republic of Korea) during the 1920s and Korean Pharmacy School (Chosen-Yakugakuko)]

This is a report of the pharmacist examination and pharmacy school in Keijo (present-day Seoul, ROK) during the 1920s. There were two kinds of examinations: 1) Given by the Ministry of Education, the same as that in Japan, and 2) Given by the Governor-General, almost the same examination as that of the Ministry of Education. The Korean pharmacy school (Chosen-Yakugakuko) was founded in 1915. Before 1914, the school of pharmacy was located in Taikan-Iin Medical School and lectures were given by the Pharmaceutical Society of Korea (Chosen-Yakugakukai).

[Where it is shown that a quarrel about precedence can lead to the Holy Bible]

The custom to print a "synthesis", for the last part of the mastership examination, the "chef d'oeuvre" was established in most of French towns. Kind of printed programme, the "synthesis" was a sheet of paper, of poster size. It listed the practicals to perform and the members of the jury, etc. The listing of the apothecaries participating in the jury used to be accompanied by elogious formulations i.e. "celeberrimo coet-cui pharmacoporum". The physicians immeditely reacted. How was it possible? Such elogious terms should be used for medicine doctors only! Not for apothecaries! Various printed arguments were exchanged and a tumultuous process took place. A judgement occured on December 14 1656: Such terms of Honour should be avoided in the future. During this judiciary episode, Latin citations from "Ecclesistics, 38" were exchanged. This ridiculous quarell rised nevertheless some serious questions. Didn't the translation of the Bible in modern languages contain some indaquancies concerning the people in charge of preparing and dispensing the medicines? A study of original Greek texts showed that it was the case.

A matter of explanation: assessment, scholarship of teaching and their disconnect with theoretical development

This commentary explores the development of assessment and its implications on the scholarship of teaching. Assessment and the scholarship of teaching's aim has been fixed on the practical and relevant, rarely furthering what we collectively know about student learning and development. As medical educators investigate important educational issues, informing assessment efforts with existing literature and a theoretical framework offers several advantages. Aligning sound assessment plans with a theoretical framework not only addresses essential questions about the extent students are learning, but provides direction, focus and coordination for future investigations.

The worshipful Society of Apothecaries of London

The Society of Apothecaries is both a City livery company and an examining authority for the medical profession. Founded in 1617 by the royal apothecary Gideon de Laune leading a breakaway group from the Grocers' Company, the Society was instrumental in raising the status of apothecaries as general practitioners. Under the Apothecaries' Act (1815) the Society examined for the LSA and it now awards the LMSSA (Licence in Medicine and Surgery of the Society of Apothecaries) and postgraduate diplomas, while maintaining the civic, charitable, and ceremonial traditions of a livery company of the City of London.

Pride or prejudice--issues in the history of children's nurse education

The history of the education of nurses to care for sick children is notable on two counts. First, that the advent of training for nurses in the care of children pre-dates that of nurses caring for adults. Second, that it is a history fraught with prejudice, threats and misapprehensions. Certain key issues recur throughout the 130 years that education of children's nurses has existed: most are as familiar to professionals in this arena today as they were at the turn of the 19th century. Central to these issues is the status of children's nurses within the profession. Often deemed second rate citizens in nursing spheres, relegated to a supplementary register in 1919, their skills and knowledge under-valued, the specialist needs of children's nurses have often gone unrecognised. Efforts to convince general adult nurses of the equity of their value and, in the light of the differences between children and adults, the importance of specialist pre-registration education, has at times been difficult to achieve. These factors have impacted upon, and been reflected in, the progress of education for children's nurses. It is these issues that this paper seeks to illuminate and explore, through an examination of the history and development of children's nurse education.

'Lower than a scullery maid'. Is this view of the British Poor Law nurse justified? Examination of probationer registers from Kensington Infirmary, 1890-1916

The Sairey Gamp image has been grossly overused in describing the 'un-reformed' 19th-century British nurse/midwife. For Dickens she was a literary device--an exaggerated portrait of the reality, which has often come to represent the true state of British nursing at the time. But were things uniformly bad in nursing? Those who nursed the sick in voluntary hospitals were, undoubtedly, not of the highest class but many, no doubt, gave reasonably good service. In workhouses those entrusted with caring for the sick were often able-bodied paupers, which added an additional disadvantage to the working class status of nurses in general. In this paper I will explore the myth in relation to selected citations from the literature and to data gathered from the probationer registers of Kensington Infirmary (St Mary Abbot's Hospital) in west London.

Archival note: an inquiry into the relationshp between Alfred Binet and Cyril Burt

Two recent archival items offer material for analysis of Alfred Binet's (1857-1911) and Cyril Burt's (1883-1971) relationship in the early twentieth century. Burt's letter to Binet's biographer Theta Wolf was an answer to her request for information about his contact with Binet. An analysis of Burt's account prompts more questions than it answers. His statements in the letter are compared with previous ones and are put into the context of the activities of the two men, but these do not enlighten us about his actual relations with Binet. The problem arises because of Burt's desciptive vagueness and lack of supporting evidence. Despite attacks against Burt's integrity made from 1976 onward, we found no conclusive evidence of false claims. The negative outcome of this analysis probably results from Burt's faulty memory, and herein lies the caveat that personal memories make unreliable material for historical accounts.

The development of objective techniques to measure nursing knowledge, 1941-1952

An indirect by-product of A Curriculum Guide for Schools of Nursing, released by the National League of Nursing Education (NLNE) in 1937, was the attention it focused on evaluating the nursing student objectively (1). The first such guide had been issued 20 years earlier and revised in 1927, with only a slight modification. During the NLNE annual convention one year after publication of the final revision, a Joint Committee on Nursing Test was appointed to consider the possibility of developing objective techniques to measure nursing on a cooperative basis. Representatives from the League, the Association of Collegiate Schools of Nursing, and the Department of Nursing Education, Teachers College, Columbia University, were charged with taking steps to initiate such a project and seeking funds to support it (1). At the time, Isabel M. Stewart, who initiated the effort, was the director of the Teachers College Department of Nursing Education as well as an active participant in several educational NLNE endeavors.

Educational assessment of mathematics skills and abilities

Mathematics assessments play a valuable role in identifying students' strengths and weaknesses and in developing and monitoring instructional practice. Over the last century, mathematics assessment has been refined as math content has changed as a result of curriculum reform. Today, researchers and practitioners use various assessment techniques to (a) identify students who have mathematics learning disabilities (LD), (b) target individual strengths and weaknesses across mathematics areas, (c) document the effects of mathematics instruction in a remedial or special program, (d) identify strategies that students employ during math activities, (e) conduct research about the characteristics of students with math LD, and (f) examine the technical characteristics of mathematics tests. This article provides an historical overview of the development of mathematics assessment and a description of specific strategies for conducting math evaluations.

History of the Medical Library Association's credentialing program

Since the Medical Library Association (MLA) adopted the Code for the Training and Certification of Medical Librarians in 1949, MLA members have reviewed and revised the program regularly. This paper traces the history of MLA's professional recognition program to illustrate how the program has changed over time and to identify the issues that have surrounded it. These issues include the value of the program to individual members, cost to MLA, appropriate entry requirements, certification examinations, and recertification requirements. The development and operation of MLA's current credentialing program, the Academy of Health Information Professionals, is described in detail.

19th-century academic examinations for physicians in the United States Army Medical Department

During the latter half of the 19th century, the United States Army commissioned medical officers or hired civilian physicians to serve its troops. The civilian physician signed a contract for services, and the candidate for a commission was subjected to rigorous examinations before becoming an officer. The rigorous testing of prospective medical officers was necessary because of the lack of standardization in the education of physicians. Examples of the test, statistics, and individual records show how the Army dealt with unqualified candidates.

To define a specialty: a brief history of the American Board of Anesthesiology's first written examination

The initial written examination of the American Board of Anesthesiology, a division of the American Board of Surgery, was given on March 28, 1939. For all anesthesiologists, this date has double significance. First, what was meant by anesthesiology as a medical specialty was defined through the questions posed on the first examination. Second, the physicians being tested that day were among the first physician-anesthetists to exploit the newly created path to recognition as specialists in the science and art of anesthesia by the American medical hierarchy. Gaining the support of organized medicine was an involved and arduous struggle that consumed most of the 1930s. A triumvirate of visionaries, Paul Wood, John Lundy, and Ralph Waters, was necessary to crystalize the goal of specialty recognition of physician-anesthetists. The first written examination was the consummation of this dream of equal status for anesthesia. The examination would not become repetitious, and within the first decade of testing, the style would change from an essay format to multiple-choice questions similar to the current form.

Original Edinburgh Fellowship Examination

The College Fellowship Examination has recently been revised. The original Seal of Cause of the Incorporation of Surgeons, granted in 1505, contained specific instructions regarding required knowledge and examinations, and the records show that oral and practical (and ultimately written) examinations were required from the start before any entrant could be admitted as a master of the Incorporation. Although the original examinations were an 'undergraduate' qualification, and the range of surgical knowledge available limited, the original aims of the examinations do not seem to have greatly altered over the last five centuries. The early records of the College relating to examinations have been surveyed, and an account is given here of examination policy and regulations, together with the topics prescribed to some 50 candidates in the first half of the 18th century.

Documenting Lystra Gretter's student experiences in nursing: a 100-year comparison with today

Lystra Gretter, who graduated from nursing school in 1888, chaired the committee that authored the Florence Nightingale Pledge and was instrumental in advancing nursing as a profession. As a widow with a daughter to raise, she faced many of the problems that nursing students are facing today.

[200 years ago: special medical degrees in the 18th century exemplified by Halle]

The taking of a medical doctor's degree in the 18th century differed considerably from that one of our days. At the example of the Faculty of Medicine of Halle University the courses of the regular proceeding are described including the legally possible modalities of graduation. The taking of the degree of honorary doctor were included into the series of particular graduations which took place under highly different prerequisites.