Licensing Exam Research Articles

Commercial Question Banks Present a Limited Scope of Sickle Cell Disease

INTRODUCTION Question banks are the most widely used educational resource for medical students and graduate medical trainees studying for professional licensing exams and are the preferred platform both for learning new material and for review. Trainees who use question banks to prepare for these critical exams achieve higher scores on their United States Medical Licensing (USMLE) Steps 1-3, which in turn predict success in residency clinical performance and ultimately, board certification. The content of question banks can therefore be regarded as a strong predictor of the clinical knowledge medical trainees are expected to master. This foundational knowledge base plays an important role in the formation and reinforcement of "illness scripts” that unconsciously drive real-life clinical decision-making. Sickle cell disease (SCD) is an underserved area of healthcare with large disparities between research-proven interventions and clinical practice. In particular, the growing population of adults with SCD suffer high morbidity and mortality due to insufficient access to SCD specialists and comprehensive SCD care. Most patients with SCD seek care from centers without important clinical expertise. Family physicians, internists, and ED physicians are primarily responsible for the treatment of many with SCD. When surveyed, these physicians report high levels of discomfort with SCD management due to lack of specialized knowledge and training. Our study is the first to examine SCD content in commercial question banks and determine how the disease is portrayed to medical trainees. We hypothesize that the pathophysiologic and clinical scope of SCD portrayed by question banks does not reflect the true epidemiology or scope of this complex disease. METHODS Nine of the most widely used commercial question banks for undergraduate and graduate medical trainees were accessed and searched for questions related to SCD. Inclusion criteria consisted of questions in which SCD was intended as the educational objective as featured in the question stem only. Questions were excluded if they featured SCD among the answer choices only, answer explanations only, or if sickle cell trait was intended as the primary educational objective. Questions that met all criteria were transcribed into RedCap software and three reviewers independently coded questions for content. Code book variables like sickle cell disease clinical complications were compiled using the 2014 NHLBI evidence-based guidelines for management of SCD. Questions coded with unique or discrepant entries were examined individually and final coding was determined by consensus. RESULTS A total of 22,152 questions were screened for inclusion from question banks listed in Table 1. Seventy unique questions featured SCD as the primary educational objective and were included in the analysis. Children aged 10 and younger formed the largest proportion of patients presented in questions (n=32, 45.7%). In contrast, data from the CDC Sickle Cell Data Collection Program shows healthcare utilization is lowest in children younger than 10 and increases with age [Green line in Figure 1]. The oldest patient in our dataset was 37 years old and there were two questions in which no patient age was mentioned. Clinical complications presented in questions were almost always acute (89%). The most common complications were acute pain, acute infection, and acute anemia presented in 42%, 41%, and 23% of questions, respectively. Only 4 patients (5.9%) presented in questions were taking hydroxyurea (HU). CONCLUSION Our novel study suggests that commercial question banks portray the patient with SCD as predominantly young and presenting with acute complaints. There is little focus on the multi-system organ dysfunction that ultimately drives the high morbidity and mortality associated with SCD. Disease-modifying treatments like hydroxyurea are rarely mentioned and evidence- based preventative care measures are not emphasized. Future research is needed to determine how this narrow portrayal of SCD risks reinforcing an overly simplistic "illness script” or narrative that may influence the clinical decision-making of practicing physicians. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Admission Criteria as Predictors of Licensure Performances among Graduates of a State University in the Philippine Cordillera Administrative Region

Proficiency in licensure examinations has emerged as a foundation of pride for graduates and an attraction for potential students to higher education institutions (HEIs). Therefore, the purpose of this study was to uncover the admission criteria that confidently predicted the licensure performance of graduates of a state institution in the Philippine Cordillera Administrative Region. This study used correlation research and 654 randomly selected graduates of Ifugao State University (IFSU) who took and eventually passed their licensure tests. The records of the university registrar and the Professional Regulations Commission (PRC) were the primary sources of data. To comply with research ethics and standards, written permission from university officials was obtained. The mean, standard deviation, and frequency were used to describe the descriptive variables. Multiple regression analysis was utilized to identify the significant set of predictors of license performance per licensure examination. A stepwise procedure was used to select the best model. The study concludes that the performance of graduates in the fields of agriculture, criminology, and teacher education in their respective licensure examinations can best be predicted by their high school grade point average and admission test scores, whereas the performance of graduates in the field of forestry in their licensing exam is best explained by their performance in their secondary education curriculum.
 
 Received: 25 August 2022 / Accepted: 20 October 2022 / Published: 5 November 2022

The impact of modifications in cadaver dissection time on student learning outcomes in a doctor of physical therapy program.

Human anatomy is a foundational component of medical and allied health professional education. Doctor of Physical Therapy (DPT) programs are required to teach anatomy, however the pedagogies used are at the discretion of faculty and institutions. Cadaver dissection may have been the predominant instruction methodology in DPT programs in the past; new technology provides alternative interactive teaching methods. This paper describes the modifications in an anatomy curriculum over 5 years in one DPT program, and the impact on student perception and learning outcomes. This was a retrospective, quantitative study that utilized a survey to collect data on student perceptions about the anatomy pedagogy; the learning outcomes analyzed were grades and licensure exam pass rates. We report on outcomes for five cohorts within one DPT program. IRB approval was obtained for the research. Despite the decrease in cadaver laboratory time after 2016, students' final exam grades in Gross Anatomy improved and the first time pass rate for the national licensure exam increased. Most students rated cadaver laboratory and the active learning assignments that replaced traditional cadaver laboratory time as valuable to their learning; however, there were differences in opinions between cohorts. Although the outcomes might not reflect a direct result of dissection time, the study confirmed that using alternative methods for teaching anatomy did not hinder student performance. Using innovative pedagogy allows educators to achieve student success in spite of decreased gross dissection time.

Licensing, Testing Disparities, and the Social Work Profession

Most readers will be familiar with the historical debates and contemporary outcomes of the consideration of whether social work is a profession. Following Abraham Flexner’s assertion in 1915 that social work is not a profession, the field has made sustained efforts to determine what separates it from other areas of practice and legitimize the practice of social work (see Daley & Pittman-Munke, 2021, for a description about this historical speech, its biases, and the field’s reaction to it). One component of this professionalization is licensure. Requiring social work licensure for practice is a mechanism of protecting the integrity and quality of social work services. The title of licensed social worker conveys a demonstration of competence for practice. In this century, professional licensure in the United States has primarily relied on an examination as one criterion, along with education, experience, and supervision (Dyeson, 2004). The use of a licensure examination is similar to those in allied professions such as teaching (Amanonce & Maramag, 2020), nursing (Oducado et al., 2019), and pharmacy (Park et al., 2021). As with any measure, though, a licensing exam may contain bias and other limitations (Aby, 2020).

Racial Disparity in Social Work Licensure Exam Pass Rates

Purpose: This article provides a brief overview of social work regulation and the context surrounding calls for greater transparency of demographic data related to social work licensing exam pass rates and the subsequent release of said data by the Association of Social Work Boards (ASWB). Methods: An exploratory review of the existing literature regarding social work regulation and bias in professional licensing examinations was conducted. Results: Conflicting perspectives on the necessity and impact of social work regulation have long existed. In recent years, the conversation has shifted to include concerns about potential bias within the regulatory system, specifically the licensing exams. These concerns led to widespread debates about the future of social work regulation and the need for greater transparency around exam outcomes. Conclusions: A comprehensive examination of existing regulatory frameworks emphasizing deficiencies of the social work licensure exam and the disparity of pass rates is paramount.

Transition from computer-based testing of national benchmark tests to adaptive testing: Robust application of fourth industrial revolution tools

In 2020, the COVID-19 pandemic strongly affected all sectors, including education. Across the globe, governments enacted policies restricting people's movement, affecting the educational assessment industry. During the lockdown, South Africa's National Benchmark Tests (NBTs) were cancelled. In contrast to paper-pencil and linear tests deployed for NBTs, computer-adaptive testing (CAT) is a modern alternative. CAT technology is widely used for licensing and certification exams in most developed nations. CAT is expected to be used by many educational assessment companies in sub-Saharan Africa for their high-stakes exams due to its reduced testing time and algorithms that produce stable and reliable results. This paper aims to provide an overview of the 4IR tools that will enable creation of a comprehensive CAT, such as feasibility studies, item bank development, test-and-calibrate item banks, and specifications for the final CAT. To successfully implement CAT, these steps are essential. The importance of thorough research and documentation in each stage of the CAT cannot be overemphasized. Based on Fourth Industrial Revolution (4IR) artificial intelligence tools, we conclude that CAT is an excellent modality to adopt for ensuring accurate evaluations of examinees' abilities within high-stakes exams. Keywords: CAT framework, Computerised adaptive testing, Fourth industrial revolution, Linear testing, National benchmark tests

Opinion article Challenges in acquiring United States Clinical Experience (USCE) by International Medical Graduates (IMGs)

International medical graduates (IMGs) from all other countries play a crucial role in the United States healthcare system. However, the path to becoming a licensed practicing physician in the United States is filled with unique challenges at each stage for the IMGs. Every year, there has been an increasing trend in the number of candidates applying for residency positions through the Electronic Residency Application Service (ERAS). Institutions have begun to adopt a holistic approach to selecting candidates from this large pool of applicants. In addition to the United States Medical Licensing Exam (USMLE) scores, several other aspects of the application have been given importance lately. One such aspect that has gained importance and has become quite challenging for IMGs is the United States Clinical Experience (USCE). This article reviews the various aspects of those challenges and discusses potential USCE opportunities for IMGs.

34699 Early life socioeconomic factors that influence specialty choice and USMLE test performance in United States medical residents: A single institution cross-sectional survey study

Studies show that minorities are underrepresented in high-paying subspecialties. Additional study is needed to further examine the extent to which early life socioeconomic background influences US physicians’ academic performance and medical specialty choice. We distributed a Qualtrics survey to all house-staff at Saint Louis University (approximately 600 physicians) and to other dermatology programs through a national Dermatology Program Directors Listserv. Survey respondents were asked about their demographics, family socioeconomic status, medical specialty, United States Medical Licensing Exam (USMLE) Step 1 scores, and amount of debt from loans. The medical specialties were grouped into 3 categories based on level of competitiveness according to 2020 NMRP applicant match data: least competitive with average Step 1 scores of 220-229, medium competitive with scores of 230-239, and highly competitive with scores of >240. Respondents were also stratified into low, medium, and high-risk groups based on having certain risk factors, including being female, nonwhite, non-Asian, foreign-born, and having a childhood household income <$50,000. Univariate analysis was performed. Average Step 1 scores were higher in respondents in the low-risk group (238) compared with respondents in high-risk groups (210), P = .016. More respondents in the low-risk group matched into competitive versus noncompetitive specialties (42% versus 35%), and more respondents in the medium risk group matched into noncompetitive versus competitive specialties (65% versus 55%). This study demonstrates that early life socioeconomic factors influence academic performance and specialty choice. The study is limited because it does not capture the personal preferences that factor into specialty choice.

Why Your Doctor Didn't Go to Class: Student Culture, High-Stakes Testing, and Novel Coupling Configurations in an Allopathic Medical School.

A clear pattern has emerged in allopathic medical schools across the United States: Most medical students have stopped going to class. While this trend among students is well known in medical education, few studies to date have examined the underlying sociological mechanisms driving this collective behavior or how these dynamics are related to institutional change in medical education. Drawing on 33 in-depth interviews with medical students in an allopathic medical school, we examine medical student culture and its role in shaping how medical students make sense of the institutionalized licensing requirement of the United States Medical Licensing Exam. We find that medical students learn to rely on digital recordings of their course content and third-party digital resources for Step 1 prep and stop attending their academic courses in person altogether. We argue that medical students create novel coupling configurations between local interaction and institutionalized licensure rules via their student cultures.

Start Where the Social Worker Is: Social Workers’ Perceptions of Clinical Licensure in Nebraska

Purpose: This study aims to evaluate the perceptions of clinical social workers compared to other mental health professionals (OMHPs). Methods: This exploratory survey research evaluates the perceptions of clinical licensure from social workers ( N = 519) and OMHPs ( N = 624) in a midwestern state. Results: The results indicate that most respondents believe that universities should be evaluated based on whether students pass licensing exams, and that faculty should be licensed. Many social workers feel ill-prepared to take a licensing exam. There are significant differences between social workers and OMHP in several areas. Additionally, differences are distinct between social workers who are people of color and White in their perception of universities’ ability to prepare them for licensing exams. Conclusions: This research serves as a prototype for a more extensive study exploring social workers’ perceptions of licensure's three main components: examination, supervision, and education.

The Unmatched Integrated Plastic Surgery Applicant: A Focus on Improving the Application.

The Unmatched Integrated Plastic Surgery Applicant: A Focus on Improving the Application.

Self-efficacy, uncertainty and anxiety among nursing graduates in response to licensing test postponement due to the COVID-19 pandemic: A mixed-methods study.

AimTo examine the relationships between self‐efficacy, uncertainty and anxiety among nursing graduates waiting for a mandatory nursing licensing test that was postponed due to the COVID‐19 pandemic.MethodsA total of 352 graduates of nursing education programs participated in this mixed‐methods study. The data were collected using an online questionnaire in June 2020.ResultsThe participants demonstrated high uncertainty and anxiety and low self‐efficacy towards the ability to succeed in the licensing exam. Graduates, who started working, reported lower uncertainty. Self‐efficacy, uncertainty, gender and family status contributed significantly to the explanation of 24% of the variance of the anxiety. The qualitative analysis revealed three themes: (a) emotional distress, cognitive challenge and social implications, (b) consequences for significant others and (c) strengthening of professional values and norms.ConclusionsA significant crisis like a pandemic is accompanied by acute cognitive burden and stressful emotional experiences and creates an unconventional situation that requires unusual solutions. Granting a temporary permit for employment as a nurse following the postponement of a licensing test contributed to the ability of nursing graduates to cope with the situation. Policies to deal with similar situations in the future emergencies should be developed and implemented.

Linking Social Work Licensure Examination Pass Rates to Accreditation: The Merits, Challenges, and Implications for Social Work Education

ABSTRACT Unlike other disciplines, social work has made accreditation decisions about undergraduate and graduate programs independent of licensure examination pass rates of graduates. While education, regulation, and practice are heralded as the three pillars of social work, there have been few meaningful linkages between them. Despite recognition that licensure impacts employment opportunities and salaries of social workers, the academy has been resistant to bridge the divide between educational assessment and licensure outcomes, resulting in hardship for some graduates. Students choose social work programs without knowing whether their education is adequate to pass “high stakes” licensure exams. In an era of greater accountability, and questions about the value of higher education, making licensure examination pass rates public and linking them to decisions when accrediting programs, seems prudent. However, this policy shift would likely change market demands and the stability of accreditation decisions enjoyed by social work programs to date.

Linking Social Work Licensing Exam Content to Educational Competencies: Poor Reliability Challenges the Path to Licensure

Purpose: There has been increasing interest in the academy to assist social work graduates to become licensed which is likely to grow as the Council of Social Work Education (CSWE) cites licensure pass rates as a post-graduation outcome required for accreditation by newly adopted standards. This study determines the ability of academics to reliably link Knowledge, Skills, and Abilities statements that are the bases of licensure tests with the CSWE competencies in the Educational Policy and Accreditation Standards (EPAS). Methods: Four full-time faculty members at two institutions conducted an interrater reliability analysis on practice tests to determine the extent to which licensure questions could be consistently linked to EPAS competencies. Results: Study findings indicate weak reliability between social work licensure examination questions and CSWE EPAS competencies. Conclusion: Lack of consistency threatens the path to licensure and may explain why graduates of accredited programs lack the requisite knowledge to become licensed.

Step 1 is Pass/Fail, Now What? Can Clinical Clerkship Grades be Used as a Reliable Metric to Screen General Surgery Residency Applicants?

IntroductionFor decades, the three-digit United States Medical Licensing Exam Step 1 score has been used to competitively evaluate and compare candidates during the residency application process. Starting in 2022, however, all Step 1 scores will be converted to pass/fail. A different quantitative measure will likely gain importance in its stead, one such being clerkship performance grades. This study aims to determine the consistency of class rank and distribution of clerkship grades reported by medical schools for applicants to a general surgery program. MethodsCandidates’ Medical Student Performance Evaluation letters from 141 unique US allopathic medical schools were reviewed for student overall class rank, the number of grading tiers in each clerkship, and the percent achieving honors criteria in each clerkship from the 2020 application cycle. Comparative analysis was performed by region and medical school prestige. ResultsMost medical schools rank students using a four-tier system (e.g., fail, pass, high pass, and honors). A third of schools do not provide an overall class rank of students (34.7% of schools); this was most prevalent in the Northeast and Western regions. Schools in the Central US more often rank their students in five tiers compared to the South (P < 0.01). The percent of students that achieve the highest grading tier varies across the core clerkships (mean 37.1%, range 6.5%-78%); an average of 34.5% of students meet the highest honors tier in their Surgery clerkship. Students at US News and World Report Top 20 medical schools are more likely to receive the highest honors tier, across all core clerkships and overall class rank, than students at schools outside the Top 20 (P < 0.05). ConclusionsIn the absence of the United States Medical Licensing Exam Step 1 score, the variability in clerkship grading tiers and overall class rank will likely pose a challenge to residency programs’ ability to stratify desirable applicants. Further transparency and standardization may be required to compare students objectively and fairly from medical schools across the country.

Race, But Not Gender, Is Associated With Admissions Into Orthopaedic Residency Programs.

Orthopaedic surgery is one of the most competitive but least diverse surgical specialties, with ever-increasing academic achievements (such as test scores) shown by applicants. Prior research shows that white applicants had higher United States Medical Licensing Exam (USMLE) Step 1 and Step 2 Clinical Knowledge scores as well as higher odds of Alpha Omega Alpha status compared with Black, Hispanic, and other applicant groups. Yet, it still remains unknown whether differences in application metrics by race/ethnicity sufficiently explain the underrepresentation of certain racial or ethnic minority groups in orthopaedic residency programs. In this study, we sought to determine (1) the relative weight of academic variables for admission into orthopaedic residency, and (2) whether race and gender are independently associated with admission into an orthopedic residency. The Electronic Residency Application System (ERAS) data from the Association of American Medical Colleges (AAMC) and the National Board of Medical Examiners (NBME) of first-time MD applicants (n = 8966) for orthopaedic surgery residency positions in the United States and of admitted orthopaedic residents (n = 6218) from 2005 to 2014 were reviewed. This dataset is the first and most comprehensive of its kind to date in orthopaedic surgery. Academic metrics, such as USMLE Step 1 and Step 2 Clinical Knowledge scores, number of publications, Alpha Omega Alpha status, volunteer experiences, work experience, as well as race and gender, were analyzed using hierarchical logistic regression models. The first model analyzed the association of academic metrics with admission into orthopaedic residency. In the second model, we added race and gender and controlled for metrics of academic performance. To determine how well the models simulated the actual admissions data, we computed the receiver operating characteristics (ROC) including the area under curve (AUC), which measures the model's ability to simulate which applicants were admitted or not admitted, with an AUC = 1.0 representing a perfect simulation. The odds ratio and confidence interval of each variable were computed. When only academic variables were analyzed in the first model, Alpha Omega Alpha status (odds ratio 2.12 [95% CI 1.80 to 2.50]; p < 0.001), the USMLE Step 1 score (OR 1.04 [95% CI 1.03 to 1.04]; p < 0.001), the USMLE Step 2 Clinical Knowledge score (OR 1.01 [95% CI 1.01 to 1.02]; p < 0.001), publication count (OR 1.04 [95% CI 1.03 to 1.05]; p < 0.001), and volunteer experience (OR 1.03 [95% CI 1.01 to 1.04]; p < 0.001) were associated with admissions into orthopaedics while work and research experience were not. This model yielded a good prediction of the results with an AUC of 0.755. The second model, in which the variables of race and gender were added to the academic variables, also had a good prediction of the results with an AUC of 0.759. This model indicates that applicant race, but not gender, is associated with admissions into orthopaedic residency. Applicants from Asian (OR 0.78 [95% CI 0.67 to 0.92]), Black (OR 0.63 [95% CI 0.51 to 0.77], Hispanic (OR 0.48 [95% CI 0.36 to 0.65]), or other race groups (OR 0.65 [95% CI 0.55 to 0.77]) had lower odds of admission into residency compared with white applicants. Minority applicants, but not women, have lower odds of admission into orthopaedic surgery residency, even when accounting for academic performance metrics. Changes in the residency selection processes are needed to eliminate the lower admission probability of qualified minority applicants in orthopaedic residency and to improve the diversity and inclusion of orthopaedic surgery. Changes including increasing the diversity of the selection committee, bias training, blinding applications before review, removal of metrics with history of racial disparities from an interviewer's candidate profile before an interview, and use of holistic application review (where an applicants' experiences, attributes, and academic metrics are all considered) can improve the diversity landscape in training. In addition, cultivating an environment of inclusion will be necessary to address these long-standing trends in orthopaedic surgery. Race, but not gender, is associated with the odds of acceptance into orthopaedic surgery residency despite equivalent academic metrics. Changes in residency selection processes are suggested to eliminate the lower admission probability of qualified minority applicants into orthopaedic residency and to improve the diversity and inclusion of orthopaedic surgery.

Professional Student Education and Training During the COVID-19 Pandemic.

The ongoing COVID-19 pandemic has presented numerous challenges to education at all levels, but has been particularly challenging for professional schools and other educational sectors that require intensive hands-on training. Those institutions have had to deploy and continuously adapt new learning strategies in response to an ever-changing pandemic landscape over the past two years, while at the same time meeting the rigorous proficiency standards for their students. This communication describes how two professional schools at Oregon State University, the College of Pharmacy and the Carlson College of Veterinary Medicine, pivoted in response to the COVID-19 pandemic to ensure continuity in student training. The adaptations included technological solutions, physical distancing, barriers, reduced group size and scheduling changes in the curriculum, and enhanced personal protective equipment. The available evidence suggest that the biosafety measures implemented to reduce the risk of COVID-19 in the hands-on educational setting appear to have been effective in preventing transmission during classroom and experiential learning activities. Professional licensing exam scores for the students of both colleges remain as high as pre-pandemic values, suggesting that the implemented changes in instruction did not have a detrimental impact on student learning. The scores will need to be monitored for several more years before firm conclusions can be drawn. Both colleges implemented creative solutions to the delivery of hands-on pedagogy that sought to balance risk of infection and the necessity to master critical skills that can only be acquired by active learning.

Connecting Biochemistry Knowledge to Patient Care in the Clinical Workplace: Senior Medical Students’ Perceptions about Facilitators and Barriers

Phenomenon : Medical students have difficulties applying knowledge about biomedical mechanisms learned before clerkships to patient care activities. Many studies frame this challenge as a problem of basic science knowledge transfer predominantly influenced by students’ individual cognitive processes. Social cognitive theory would support extending this framing to the interplay between the individual’s cognition, the environment, and their behaviors. This study investigates senior medical students’ experiences of biochemistry knowledge use during workplace learning and examines how their experiences were influenced by interactions with people and other elements of the clinical learning environment. Approach : The authors used a qualitative approach with a constructivist orientation. From September to November 2020 they conducted semi-structured interviews with 11 fourth-year medical students at one institution who had completed the pre-clerkship curriculum, core clinical clerkships, and the United States Medical Licensing Exam Step 1. The authors identified themes using thematic analysis. Findings : Participants reported that they infrequently used or connected to biochemistry knowledge in workplace patient care activities, yet all had examples of such connections that they found valuable to learning. Most participants felt the responsibility for making connections between biochemistry knowledge and activities in the clinical workplace should be shared between themselves and supervisors, but connections were often recognized and acted on only by the student. Connections that participants described prompted their effort to retrieve knowledge or fill a perceived learning gap. Participants identified multiple barriers and facilitators to connecting, including supervisors’ behaviors and perceived knowledge, and “patients seen” in clerkships. Participants also reported learning biochemistry during USMLE Step 1 study that did not connect to patient care activities, underscoring a perception of disconnect. Insights : This study identifies specific personal, social, and physical environmental elements that influence students’ perceived use of biochemistry during patient care activities. Though these findings may be most significant for biochemistry, they likely extend to other basic science disciplines. Students’ self-directed efforts to connect to their biochemistry knowledge could be augmented by increased social support from clinical supervisors, which in turn likely requires faculty development. Opportunities for connection could be enhanced by embedding into the environment instructional strategies or technologies that build on known authentic connections between biochemistry and “patients seen” in clerkships. These efforts could strengthen student learning, improve clinical supervisors’ self-efficacy, and better inform curriculum design.

Innovative Teaching Strategy to Incorporate Equitable Care With Unmanned Aircraft Systems in Obstetric Simulations in a Rural Setting

Nursing curricula include concepts aimed at producing well-rounded, safe graduates who will be able to pass the licensure exam. However, even in the best clinical rotations, it is rare that students would be exposed to the real-life scenario of supply and medication shortages secondary to the pandemic in a rural setting.

The Impact of Internal Medicine Clerkship Characteristics and NBME Subject Exams on USMLE Step 2 Clinical Knowledge Exam Performance.

Residency program directors will likely emphasize the United States Medical Licensing Exam (USMLE) Step 2 clinical knowledge (CK) exam more during residency application given the recent USMLE Step 1 transition to pass/fail scoring. We examined how internal medicine clerkship characteristics and NBME subject exam scores affect USMLE Step 2 CK performance. The authors used univariable and multivariable generalized estimating equations to determine associations between Step 2 CK performance and internal medicine clerkship characteristics and NBME subject exams. The sample had 21,280 examinees' first Step 2 CK scores for analysis. On multivariable analysis, Step 1 performance (standardized β = 0.45, p < .001) and NBME medicine subject exam performance (standardized β = 0.40, p < .001) accounted for approximately 60% of the variance in Step 2 CK performance. Students who completed the internal medicine clerkship last in the academic year scored lower on Step 2 CK (Mdiff = -3.17 p < .001). Students who had a criterion score for passing the NBME medicine subject exam scored higher on Step 2 CK (Mdiff = 1.10, p = .03). There was no association between Step 2 CK performance and other internal medicine clerkship characteristics (all p > 0.05) nor with the total NBME subject exams completed (β=0.05, p = .78). Despite similarities between NBME subject exams and Step 2 CK, the authors did not identify improved Step 2 CK performance for students who had more NBME subject exams. The lack of association of Step 2 CK performance with many internal medicine clerkship characteristics and more NBME subject exams has implications for future clerkship structure and summative assessment. The improved Step 2 CK performance in students that completed their internal medicine clerkship earlier warrants further study given the anticipated increase in emphasis on Step 2 CK.