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USMLE exam Dumps Source : United States Medical Licensing Examination

Test Code : USMLE
Test Name : United States Medical Licensing Examination
Vendor Name : USMLE
Q&A : 400 Real Questions

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USMLE United States Medical Licensing

examining Demographics, Prior tutorial efficiency, and united states scientific Licensing Examination scores | Real Questions and Pass4sure dumps

To check whether demographic ameliorations exist in united states medical Licensing Examination (USMLE) examination rankings and the extent to which any changes are defined through students’ prior educational fulfillment.

Hierarchical linear modeling of facts for U.S. and Canadian allopathic and osteopathic clinical graduates testing on USMLE Step 1 all through or after 2010, and completing USMLE Step 3 by means of 2015. leading outcome measures have been computing device-based USMLE examinations: Step 1, Step 2 medical capabilities, and Step three. examine-taker qualities blanketed sex, self-identified race, U.S. citizenship fame, English as a 2d language, and age in the beginning Step 1 attempt. Covariates covered composite scientific school Admission look at various (MCAT) scores, undergraduate grade factor general (GPA), and previous USMLE rankings.

a complete of 45,154 examinees from 172 clinical schools met criteria. The sample turned into sixty seven% white and forty eight% feminine; three.7% non-U.S. citizens; and 7.four% with English as a 2d language. Hierarchical linear models examined demographic variables with and devoid of covariates including MCAT ratings and GPA. All Step examinations confirmed giant differences with the aid of gender after including covariates, various by way of Step. Racial modifications were followed for each and every Step, attenuated by means of the addition of covariates.

Demographic adjustments in USMLE performance had been tempered by way of previous examination performance and undergraduate efficiency. additional analysis is required to determine elements that contribute to demographic ameliorations, can support educators’ identification of scholars who would benefit from tips getting ready for USMLE, and might help residency program administrators in assessing efficiency measures whereas assembly diversity dreams.

J.D. Rubright is senior psychometrician, national Board of clinical Examiners, Philadelphia, Pennsylvania.

M. Jodoin is vice chairman of Psychometrics and records analysis, national Board of scientific Examiners, Philadelphia, Pennsylvania.

M.A. Barone is vp of Licensure, national Board of scientific Examiners, Philadelphia, Pennsylvania.

Acknowledgements: The authors thank Monica Cuddy and Kimberly Swygert for his or her useful feedback on early drafts of this manuscript.

Funding/assist: None suggested.

different disclosures: Drs. Rubright, Jodoin, and Barone are employed by means of the country wide Board of clinical Examiners.

ethical approval: Institutional evaluate board approval with “exempt” reputation granted by American Institutes for analysis, Washington, D.C.

Correspondence may still be addressed to Jonathan D. Rubright, country wide Board of clinical Examiners, 3750 Market highway, Philadelphia, PA 19104; mobile: (215) 590-9885; electronic mail

Becker professional training Expands past u.s. scientific Licensing Examination® (USMLE®) With New Collaborations and choices | Real Questions and Pass4sure dumps

DOWNERS GROVE, ill.--(enterprise WIRE)--Becker knowledgeable schooling, a global chief in expert education and a part of Adtalem international education, introduced two essential new initiatives to expand past the present USMLE guidance path. Becker is collaborating with 4MedPlus to be sure that its students have convenient access via a single tool to key certifications needed ahead of the start of their medical courses. moreover, Becker is additionally including a GuideRN Self examine to prep nursing students for the NCLEX-RN - the standardized examination required to develop into a board certified nurse.

New 4MedPlus Compliance iBookPlus+ providing

The 4MedPlus Compliance iBookPlus+ is an online path tool which allows for practitioners, employers, educators and organizations to deliver entry to required and informed compliance gaining knowledge of for body of workers, students and contributors with a single click on. compatible with pc, MAC/iPad and Android on all browsers, the iBookPlus+ points an online interactive academic hub where college students can promptly establish proficiency in regulatory, compliance and safety topics in healthcare abruptly.

The six certificates of proficiency accessed with the aid of Becker students in the compliance iBookPlus+ encompass:

  • knowing HIPAA for the staff professional
  • NYS Mandated an infection control and Barrier protection
  • Bloodborne Pathogens coverage
  • Needlesticks and Sharps protection
  • OSHA/PPE fundamentals for Healthcare people (OSHA/PPE)
  • complete Tuberculosis Prevention (TB)
  • Completion of each and every route in the bundle achieves a 4MedApproved certificate of proficiency with Nursing CEU's, health care provider CME and college credit score purchasable. The iBookPlus+ tool also offers access to tons of of particular person modules and a large number of further classes for custom-made compliance. All PDF certificates are dispatched upon iBookPlus+ completion to students as well as to the administrator or distribution checklist linked to the account and a complete admin panel is blanketed which permits for monitoring and administration of student growth.

    Becker Launches New GuideRN, Self-Paced getting to know program, to Prep Nursing college students for NCLEX-RN

    Becker skilled schooling is launching a brand new GuideRN Self study software to help nursing college students prepare for their NCLEX verify required to develop into a board certified nurse. featuring 21 core discipline themes, the GuideRN self look at comprises a full curriculum of nursing subjects to support students prepare for the NCLEX, including Nursing Sciences, simple skills, knowledgeable specifications, and Examination practise.

    furthermore, the GuideRN device offers greater than 30 hours of modular on-line content material grounded within the fundamentals of medication, in addition to full-colour illustrations, pictures and embedded animations to help carry medical themes to life and illustrate the tactics of the human physique. also, the conclusion of every chapter includes apply inquiries to boost the understanding of specific nursing topics and the person has the option to add more than 2,000 UWorld question financial institution questions providing certain explanations which are written to simulate the NCLEX examination.

    “through our partnership with 4MedsPlus and our new GuideRN Self analyze application, we are remodeling the normal getting to know technique inside key areas of clinical look at to supply interactive, superior exam prep options that are effortlessly purchasable across contraptions,” pointed out David Bartholomew, vice president, Healthcare at Becker professional training. “Becker’s focused increase plan will continue to provide our students with components tailor-made for complete realizing and entry to the key information mandatory to prevail in lots of areas of medical examination and certification prep.”

    Becker professional schooling has helped very nearly half a million individuals put together to succeed on professional exams including the USMLE and now in both clinical certifications and NCLEX. To be trained more about Becker skilled schooling, talk over with

    About Becker expert education

    Becker expert training is a member of Adtalem international education (NYSE: ATGE), a world training company headquartered within the united states. The firm's intention is to empower college students to achieve their desires, find success and make inspiring contributions to our global community. Becker is global chief in professional training serving the accounting, undertaking management and healthcare professions. very nearly half a million gurus have prepared to advance their careers through its CPA exam overview, ACCA® courses, CMA exam assessment, PMP® exam overview, USMLE® assessment and carrying on with knowledgeable schooling lessons. during its more than 60-12 months heritage, Becker has earned a powerful track checklist of pupil success through world-class educating, curriculum and getting to know equipment that enable its students to advance the expertise and performance talents vital to dwell forward in an ever-changing business world. For more assistance about Becker knowledgeable schooling, visit

    About Adtalem international schooling

    The aim of Adtalem international training is to empower students to obtain their desires, find success and make inspiring contributions to our world neighborhood. Adtalem international training Inc. (NYSE: ATGE; member S&P MidCap four hundred Index) is a number one international education issuer, and the mother or father firm of Adtalem Educacional do Brasil, American college of the Caribbean college of drugs, affiliation of certified Anti-cash Laundering experts, Becker professional training, Carrington college, Chamberlain university, DeVry college and its Keller Graduate school of administration, Ross college faculty of medicine and Ross institution college of Veterinary medication. For greater tips, please talk over with

    concerning the 4MedPlus agency

    4MedPlus agency is the main issuer of accredited carrying on with training CME/CEU on issues concerning fitness IT, compliance, security, regulatory requirements, government incentives, health and security, and extra. Healthcare gurus are in a position to meet their ongoing practicing wants wholly on-line on their own agenda, which inspires greater efficient delivery of scientific functions and beneficial time administration for superior affected person care. 4Med supplies their lessons via an extensive community of tutorial catalog partnerships and via their own on-line practicing catalog gadget.

    USMLE® is a joint software of the Federation of State medical Boards (FSMB) and the national Board of clinical Examiners (NBME). test names and other emblems are the property of the respective trademark holders. none of the trademark holders are recommended, sponsor or support Becker professional education in any method.

    NCLEX-RN® is a registered trademark of the countrywide Council of State Boards of Nursing and this trademark owner doesn't sponsor, advocate or help Becker knowledgeable training in any method.

    Kaplan USMLE Step three: next step for diabetic with nausea, vomiting | Real Questions and Pass4sure dumps

    if you’re getting ready for the us scientific Licensing Examination® (USMLE®) Step 3 exam, you might need to comprehend which questions are most frequently overlooked through test-prep takers. take a look at this example from Kaplan medical, and browse an expert clarification of the reply. also take a look at all posts in this collection.  

    This month’s stumper

    A seventy four-12 months-historical man with insulin-stylish diabetes mellitus and chronic renal failure involves the emergency department as a result of he has been nauseated and vomiting for 24 hours. He denies any chest ache or belly pain. He underwent his activities hemodialysis the day gone by without any complications.

    the person’s temperature is 38.eight ºC (one hundred and one.8 ºF), blood force is one hundred twenty/70 mm Hg, and pulse is 110 beats per minute. abdominal examination displays guarding in the correct higher quadrant without a tenderness or peritoneal signals. Laboratory studies exhibit a leukocyte count number of 24,000/mm3 and a serum bilirubin of two.2 mg/dL. Ultrasound examination of the appropriate higher quadrant fails to exhibit gallbladder stones.

    Which of the following is the finest next step in the administration of this patient?

    A. Order a CT scan of the abdomen.

    B. Order a colonoscopy.

    C. Order a hepatobiliary iminodiacetic acid (HIDA) scan.

    D. Order intravenous antibiotics and endured statement.

    E. Order an higher GI endoscopy.

    The proper answer is C.

    Kaplan medical explains why

    The HIDA scan is probably the most correct diagnostic check for illnesses of the hepatobiliary tree, and it will ascertain the diagnosis. Acalculous cholecystitis is associated with lots of situations, together with diabetes, trauma, mechanical ventilation, burns, childbirth and many others.

    These sufferers may additionally not latest with classical indications of cholecystitis; signs and indicators will depend on the underlying predisposing medical condition. Acalculous cholecystitis is characterized by way of the absence of gallstones and often even through biliary sludge.

    Ultrasound is the formula of choice to make the diagnosis, on account that it could visualize the gallbladder and also the liver, pancreas, and kidneys. Ultrasound will display a thickened gallbladder wall, pericholecystic fluid, gasoline inside the gallbladder wall and evidence of surrounding irritation. If the ultrasound fails to make the diagnosis, a HIDA scan may be positive.

    Why the different answers are incorrect

    choice A: Ordering a CT scan of the stomach will not add a good deal to the analysis. This patient’s scientific presentation is obviously linked to the biliary tract, and if the ultrasound fails to display the analysis, CT scan is not the imaging formulation of option to look at the biliary tract.

    option B: Colonoscopy isn't useful in the workup of biliary signs.

    alternative D: Intravenous antibiotics are indicated to treat cholecystitis, however within the presence of gangrene or unresponsive cholecystitis, surgery is indicated. persisted observation can result in worsening of the indicators and signs and the building of issues comparable to systemic sepsis; for this reason, remark and administering antibiotics on my own is not the most useful choice at the present. further comparison is required.

    choice E: An upper gastrointestinal endoscopy helps within the prognosis of pathology within the belly or duodenum, however usually are not positive in this affected person.  

    tips to bear in mind
  • Acalculous cholecystitis is linked to a lot of circumstances, including diabetes, trauma, mechanical air flow, burns, childbirth, and many others.
  • it's marked by using the absence of gallstones and sometimes even biliary sludge.
  • Ultrasound is the modality of option for analysis.
  • whether it is equivocal, then a HIDA scan is the next most desirable option.
  • For extra prep questions about USMLE Steps 1, 2 and three, view different posts in this series.

    The AMA chosen Kaplan as a favored company to aid you in accomplishing your intention of passing the USMLE® or COMLEX-us of a®. AMA contributors can shop 30 % on entry to additional analyze components, corresponding to Kaplan’s Qbank and high-yield lessons. be trained more.

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    United States Medical Licensing Examination

    Pass 4 sure USMLE dumps | USMLE real questions | [HOSTED-SITE]

    Becker Professional Education Expands Beyond United States Medical Licensing Examination® (USMLE®) With New Collaborations and Offerings | real questions and Pass4sure dumps

    DOWNERS GROVE, Ill.--(BUSINESS WIRE)--Becker Professional Education, a global leader in professional education and part of Adtalem Global Education, announced two major new initiatives to expand beyond the current USMLE preparation course. Becker is collaborating with 4MedPlus to ensure that its students have easy access via a single tool to key certifications needed prior to the start of their medical programs. In addition, Becker is also adding a GuideRN Self Study to prep nursing students for the NCLEX-RN - the standardized exam required to become a board certified nurse.

    New 4MedPlus Compliance iBookPlus+ Offering

    The 4MedPlus Compliance iBookPlus+ is an online course tool which allows practitioners, employers, educators and organizations to deliver access to required and recommended compliance learning for staff, students and members with a single click. Compatible with PC, MAC/iPad and Android on all browsers, the iBookPlus+ features an online interactive educational hub where students can quickly establish proficiency in regulatory, compliance and security topics in healthcare all at once.

    The six certificates of proficiency accessed by Becker students in the compliance iBookPlus+ include:

  • Understanding HIPAA for the Workforce Professional
  • NYS Mandated Infection Control and Barrier Protection
  • Bloodborne Pathogens Protection
  • Needlesticks and Sharps Safety
  • OSHA/PPE Basics for Healthcare Workers (OSHA/PPE)
  • Comprehensive Tuberculosis Prevention (TB)
  • Completion of each course in the bundle achieves a 4MedApproved Certificate of Proficiency with Nursing CEU's, Physician CME and College Credit available. The iBookPlus+ tool also provides access to hundreds of individual modules and numerous additional courses for customized compliance. All PDF certificates are dispatched upon iBookPlus+ completion to students as well as to the administrator or distribution list associated with the account and a comprehensive admin panel is included which allows for monitoring and management of student progress.

    Becker Launches New GuideRN, Self-Paced Learning Program, to Prep Nursing Students for NCLEX-RN

    Becker Professional Education is launching a new GuideRN Self Study program to help nursing students prepare for their NCLEX test required to become a board certified nurse. Featuring 21 core subject topics, the GuideRN self study includes a full curriculum of nursing subjects to help students prepare for the NCLEX, including Nursing Sciences, Fundamental Skills, Professional Standards, and Examination Preparation.

    In addition, the GuideRN tool offers more than 30 hours of modular online content grounded in the fundamentals of medicine, as well as full-color illustrations, photos and embedded animations to help bring medical topics to life and illustrate the processes of the human body. Also, the end of each chapter includes practice questions to enhance the understanding of specific nursing subjects and the user has the option to add more than 2,000 UWorld Question Bank questions providing detailed explanations that are written to simulate the NCLEX exam.

    “Through our partnership with 4MedsPlus and our new GuideRN Self Study program, we are transforming the traditional learning process within key areas of medical study to provide interactive, advanced exam prep solutions that are easily accessible across devices,” stated David Bartholomew, Vice President, Healthcare at Becker Professional Education. “Becker’s focused growth plan will continue to provide our students with resources tailored for comprehensive understanding and access to the key information needed to succeed in a variety of areas of medical exam and certification prep.”

    Becker Professional Education has helped nearly half a million people prepare to succeed on professional exams including the USMLE and now in both medical certifications and NCLEX. To learn more about Becker Professional Education, visit

    About Becker Professional Education

    Becker Professional Education is a member of Adtalem Global Education (NYSE: ATGE), a global education provider headquartered in the United States. The organization's purpose is to empower students to achieve their goals, find success and make inspiring contributions to our global community. Becker is global leader in professional education serving the accounting, project management and healthcare professions. Nearly half a million professionals have prepared to advance their careers through its CPA Exam Review, ACCA® Courses, CMA Exam Review, PMP® Exam Review, USMLE® Review and Continuing Professional Education courses. Throughout its more than 60-year history, Becker has earned a strong track record of student success through world-class teaching, curriculum and learning tools that enable its students to develop the knowledge and performance skills necessary to stay ahead in an ever-changing business world. For more information about Becker Professional Education, visit

    About Adtalem Global Education

    The purpose of Adtalem Global Education is to empower students to achieve their goals, find success and make inspiring contributions to our global community. Adtalem Global Education Inc. (NYSE: ATGE; member S&P MidCap 400 Index) is a leading global education provider, and the parent organization of Adtalem Educacional do Brasil, American University of the Caribbean School of Medicine, Association of Certified Anti-Money Laundering Specialists, Becker Professional Education, Carrington College, Chamberlain University, DeVry University and its Keller Graduate School of Management, Ross University School of Medicine and Ross University School of Veterinary Medicine. For more information, please visit

    About the 4MedPlus Corporation

    4MedPlus Corporation is the leading provider of accredited continuing education CME/CEU on topics relating to Health IT, compliance, security, regulatory requirements, government incentives, health and safety, and more. Healthcare professionals are able to meet their ongoing training needs entirely online on their own schedule, which encourages more efficient delivery of medical services and effective time management for better patient care. 4Med delivers their courses through an extensive network of educational catalog partnerships and via their own online training catalog system.

    USMLE® is a joint program of the Federation of State Medical Boards (FSMB) and the National Board of Medical Examiners (NBME). Test names and other trademarks are the property of the respective trademark holders. None of the trademark holders are endorsed, sponsor or support Becker Professional Education in any manner.

    NCLEX-RN® is a registered trademark of the National Council of State Boards of Nursing and this trademark owner does not sponsor, endorse or support Becker Professional Education in any manner.

    Impact of the United States Medical Licensing Examination Step 2 Clinical Skills Exam on Medical School Clinical Skills Assessment | real questions and Pass4sure dumps

    The United States Medical Licensing Exam (USMLE) Step 2 Clinical Skills (CS) exam constitutes a new requirement designed to standardize clinical skills assessment and ensure minimum competence for those seeking licensure as physicians. The exam has generated debate within medical schools about their role in preparing students for clinical practice and for the licensing exam.1 High registration fees, travel expenses, and limited feedback describing performance have dampened student enthusiasm for the new requirement.2

    Educators hoped that the Step 2 CS would motivate schools to enhance clinical skills curricula and testing in undergraduate medical education. The majority of schools now administer a comprehensive standardized patient assessment at the end of the core clerkships.3 However, the extent to which the national licensing requirement is promoting greater focus on content emphasized in the Step 2 CS is poorly understood. One study found that 55% of medical schools had modified their curriculum in response to the Step 2 CS exam, although the nature and extent of those modifications were not described.4

    We designed this study to explore the following questions with the directors of established clinical skills assessment programs: (1) what is the purpose of in-house clinical skills assessment after a major change in licensing requirements; and (2) how is the Step 2 CS affecting medical school clinical skills curricula and assessment?


    In a prior survey of curriculum deans,3 we identified schools that administered comprehensive clinical skills assessments and requested the names of individuals responsible for standard setting and remediation. A “comprehensive assessment” was defined as a multistation, cross-disciplinary exam outside of a single clerkship involving standardized patients. In Fall 2005, we randomly selected 44 of the 62 identified individuals and extended invitations to participate in an interview study. Potential subjects received up to two phone or e-mail invitations to participate. One subject declined the invitation. We interviewed 25 of the 44 invited subjects, stopping when thematic saturation was reached. The University of California, San Francisco, Institutional Review Board approved the study.

    We chose a qualitative methodology because closed-ended survey questions might not have captured the complexity of participant responses. Instead, we were able to elicit and consider respondents’ open and in-depth descriptions of the internal and external forces influencing their schools’ approaches to clinical skills training and assessment.

    One investigator (KMK) conducted semistructured telephone interviews lasting 30–60 minutes. Participants provided verbal informed consent. The five investigators developed the interview instrument based on group expertise and results of prior work.3 The interview included open-ended questions addressing participant perceptions of and experience with comprehensive assessments, as well as perceived impact of the Step 2 CS exam. After 14 interviews, the investigators refined the interview guide by adding probes, improving flow, and eliminating redundancy. The additional probes were designed to ensure that interviewees elaborated on the rationale for their current exam design, as well as the purposes of the exam in relation to other curricular and assessment activities. Interviews were recorded and transcribed verbatim. The interviewer reviewed all transcripts for accuracy prior to analysis.

    Interviews were coded to identify major themes. Three investigators (KH, AT, KMK) independently read three transcripts to generate codes, which were combined and reconciled. Four more transcripts were used to generate additional codes and refine previously identified codes. These three investigators used the refined code list to code 10 transcripts, and the remaining 15 transcripts were coded by two investigators. Discrepancies were discussed among the investigators until consensus was reached. All five investigators met to review the coded data and identify larger themes. ATLAS.ti V 5.0 software (Scientific Software Development GmbH, Berlin) was used to organize and retrieve coded data.


    The 25 participating schools represented all four U.S. geographic regions as defined by the American Association of Medical Colleges. Thirty-six percent of participating schools were private institutions and 64% were public—an exact match of the national distribution. Ten schools in the sample had been conducting exams for 10 or more years, whereas six schools had been conducting exams for three or fewer years.

    Respondents reported that their in-house exams serve multiple purposes: assessing competence, providing feedback to both curriculum and students, and preparing students for the Step 2 CS exam. One participant explained:

    We had a lot of debate about what’s the purpose of this exam, are we teaching to what was then a future clinical skills test, are we trying to ensure that our students are competent in their clinical skills before they leave us, are we trying to get information and feedback to the curriculum about student strengths and weaknesses, and knowledge base and skills. And we decided yes, all of those things.

    Prioritization and emphasis of these purposes varied, as did perceptions of how the exam needed to be structured to serve each defined goal.

    Competency assessment

    A major purpose of the in-house assessment was to ensure that students graduated with competency as defined by local faculty. Many schools revisited the need to conduct local assessments of basic competence in the setting of the new licensing requirement:

    We’ve had those conversations: do we want to continue this or not? We’ve said yes, we’re going to continue it. One for practice, and two as a school we wanted to make sure that our students were graduating with these skills.

    Most schools believed their in-house exams were more difficult than the Step 2 CS exam, a difference which they felt made their in-house programs superior both as measures of competence and as preparatory exercises for the national exam. Schools noted the importance of using their internal exams as a means of assessing competencies that were highly valued by their faculty but which were unlikely to be addressed in the national exam:

    We were interested in looking at oral presentation skills, so we built that in. We were also looking at test interpretation, so we build that in, and they don’t necessarily include that in the USMLE Step 2. We also tried to step up the level of our exam—my impression is that the USMLE Step 2 looks at common ambulatory problems. Very basic. So we try to make our patients a little bit more complex, a little bit richer for the students.

    Cases that challenged student skills with cultural competence, evidence-based medicine, and communication with complicated patients were referenced as local priorities not addressed in the national exam. Participants also cited numerous limitations of clerkship evaluations in assessing clinical skills competence, including grade inflation, reliance on knowledge assessments, and insufficient observation of students. For many, these deficiencies elevated the importance of conducting a comprehensive exam.

    Conflicts arose when the faculty had not defined or agreed on competencies. One participant explained:

    Does this in-house exam look like the curriculum? When we don’t have competencies driving the discussion, it’s a little sketchy, because we don’t have faculty saying every student should know how to do the following.

    Schools where students had failed the national exam at higher than expected rates were left to consider whether locally defined competencies aligned with the expectations of the national board. One of these schools described the challenge:

    To make sure my students pass the USMLE, I have to dummy them down a little bit. They exhibit such sophisticated skills that they do things that are not captureable. And they skip over some of the more dreary, routine things that these kinds of scoring require.

    Feedback to students

    Feedback to students was considered a critical purpose of the in-house exam. Schools diverged in their beliefs about the optimal balance of formative and summative feedback. Although all schools provided some feedback to all students, as a rule students with the lowest scores received the most information and follow-up. Many participants noted that the in-house exam created opportunities to engage students who had not previously received or responded to feedback about their performance:

    It gives me an opportunity to take a student who has an odd affect and now there’s data. Instead of me just saying, ‘Gee, this may be a problem; you don’t make good eye contact,’ I can say now, ‘This is a problem. You’re not making good eye contact. It’s been noted in your clerkships and, here on the OSCE, you did poorly.

    Many participants identified barriers to student feedback. Some schools that were heavily invested in administering a high-stakes exam offered no feedback to students during the exam and restricted student access to checklists or videotapes afterward. Others cited limited faculty time as a barrier to providing individual feedback. Another challenge was to ensure that students were focusing on concepts, as opposed to cases, when considering feedback on their performance.

    Students asked to see their checklist items, thinking that would help them—it was too vague to say that they had messed up on the history or physician patient interaction. But we didn’t give it to them purely because we felt it’s not just about this exam. So we didn’t want to train them too specifically to memorize certain skills.

    Participants described a tension between channeling resources for summative assessment versus clinical skills education:

    If you’re doing high-stakes exams, the students are not getting feedback because you can’t do that with a high-stakes exam. If schools are using it as an instructional tool then I think that’s great. It would be nice to be able to do that and then give feedback after each station by faculty members. It takes a lot of faculty members to sit and watch all the stations. We did that a couple of years and it was just a huge undertaking.

    Participants uniformly observed that the USMLE exam promoted student buy-in to standardized patient exams and enhanced students’ motivation to receive feedback on their clinical skills. Many schools devised strategies for providing such feedback, including class meetings, class letters highlighting common errors, and, at sites where policy did not prohibit providing detailed feedback on individual performances, individual score reports or videotape reviews. One school with a longstanding exam and a high degree of faculty commitment to it combined a format similar to the national exam with faculty observers who provided individualized teaching and feedback at each station. Another school with a small class assigned a dean to each student for score review and learning plan development.

    Feedback to curriculum

    Most respondents believed that exam data helped with curriculum evaluation, but few described specific, effective feedback mechanisms. Many described reporting exam results to educational leaders, though the efficacy of this practice varied:

    I go to the clerkship directors after each year’s results are available. I go to their meeting and they’re always so upset that the students don’t demonstrate the depth of questioning and feel that they need to teach that. They do teach that and they’ll teach it again, and next year it’s the same. So, it’s not clear we’re getting anywhere with that.

    At other schools, exam performance data describing pervasive deficiencies in students’ skills prompted new training efforts earlier in the clinical skills curriculum, such as special lectures or specific physical exam teaching in clerkships.

    Exam preparation

    All participants acknowledged the need to use in-house assessments as a tool for preparing students for the licensing exam. Overwhelmingly, schools followed the USMLE format when designing new in-house assessments, and those with longstanding exams implemented formatting changes that increased their exams’ similarity to the Step 2 CS. Common modifications included adjusting the number and length of stations and the interstation format.

    Although many schools viewed these changes positively, others were resigned to making changes for the purpose of national exam preparation. One school that had modified the in-house assessment format did so begrudgingly:

    We’ve altered what we ask the students to do at the close of the transaction. I had designed individual post visit assignments. And I changed all that and I went to writing SOAP notes, because that’s what you’ve got to do there. So it has crimped our style.

    Still, most schools did not feel that changing their exam format to mirror the USMLE significantly altered the primary purpose of their internal exam:

    We have always considered clinical skills to be very, very important here, and it’s always been a high priority. So I don’t think USMLE changed the priority. I think in terms of the in-house exam that it’s made the students more interested in using it as a preparation assessment for the thousand-dollar test.

    Two schools with longstanding clinical skills assessment programs felt that the licensing exam was redundant, though they agreed with the principle of national standards for clinical skills competency. Nonetheless, both had modified the format of their in-house assessments to increase similarity to the Step 2 CS.

    Local exams and the national exam

    Some schools with new in-house exams described struggles with basic administrative issues such as timing of administration, scoring methodology, and identifying mechanisms for reporting results to students and curricular leaders. These schools faced the dual challenge of securing faculty and student buy-in for their internal exams while also determining the extent to which their local efforts should be influenced by the new national requirement. In contrast, schools with established programs described firm values regarding student assessment and integration of standardized patient experiences throughout the curriculum:

    I’m just happy that we were able to set up our comprehensive exam before the CS exam came down the pike, because I feel that it was the right thing to do with our curriculum. We now have standardized patient exams starting in week 8 of our curriculum. It’s how we set up our model of education.

    The presence of the Step 2 CS exam as a measure of minimum competence led some schools to reassess the purpose of in-house exams. These schools did not plan to abandon standardized patient experiences, but rather to change the emphasis of their efforts:

    When the Board Exam became required for licensure, we began talking about: Do we need our exam as a high stakes exam? Can we take the funding and put that into a formative program within the context of the clerkships?

    All participants endorsed the national exam and in-house exams as validating the importance of clinical skills for medical students:

    It elevates clinical skills more to a par with the cognitive skills that up until now have been alone in what counts as a qualified student. The students of course complain a great deal about the inconvenience, the money, the travel, the time. As do we. But I am deeply grateful that the students now see, in terms that they cannot misunderstand, that the medical establishment requires demonstration of these interpersonal skills before they’re going to qualify them as a doctor.


    The Step 2 CS exam has motivated schools with established clinical skills assessments to view their exams not only as competency assessments but also as preparatory experiences for the licensing exam. Many schools have designed new exams or modified existing exams to reflect the Step 2 CS format, changes that many students and faculty perceive as important for familiarizing students with a testing situation in a realistic, lower-stakes setting.

    The Step 2 CS was created in part by a desire to focus attention on clinical skills training.5 Our results suggest that faculty and students have responded to the emphasis on testing clinical and interpersonal skills with enhanced motivation to ensure competency. Experience with other high-stakes testing indicates that learners perform better when they are given the opportunity to participate in setting learning goals and practice required skills,6 and the USMLE exam creates an institutional obligation to provide these experiences.

    Schools in our study varied in the perception that the national exam created a burdensome obligation to “teach to the test.” Whatever their enthusiasm for the USMLE exam, schools responded consistently to the licensing exam by mimicking its format, changes that were motivated by a desire to make their in-house exams more useful as preparation for licensure. However, to be truly useful for learning, a high-stakes in-house exam must be preceded by formative assessments that are based on the learning goals established by the teacher and the institution.7 Schools that articulated clear values about clinical skills training that predated the Step 2 CS exam were able to incorporate the external mandate into their training programs with relative ease. In contrast, many schools were still developing mechanisms to use assessment information to enhance the curriculum and provide individual student feedback. Whether the quantity, quality, and utility of this curricular and student feedback will increase over time is unclear.

    Our study is limited in that participants all had established clinical skills assessment programs; the minority of schools without such programs may perceive different challenges in clinical skills training. Further, our participants’ perceptions may differ from those of other faculty at their institutions. However, the study is strengthened by the fact that we interviewed individuals who were intimately involved in developing and implementing comprehensive clinical exams, individuals whose views are critical to understanding issues in clinical skills assessment. We had a large sample size for a qualitative study, which yielded a range and depth of information about a dynamic topic.

    This study illustrates the ways in which medical schools are incorporating a new licensing requirement into their vision of clinical skills training, and the tensions that influence defining competency, providing opportunities for formative and summative assessment, allocating resources, and preparing students for licensure.


    The authors thank the Josiah Macy Jr. Foundation and the participating schools.

    Kaplan USMLE Step 3: Next step for diabetic with nausea, vomiting | real questions and Pass4sure dumps

    If you’re preparing for the United States Medical Licensing Examination® (USMLE®) Step 3 exam, you might want to know which questions are most often missed by test-prep takers. Check out this example from Kaplan Medical, and read an expert explanation of the answer. Also check out all posts in this series.  

    This month’s stumper

    A 74-year-old man with insulin-dependent diabetes mellitus and chronic renal failure comes to the emergency department because he has been nauseated and vomiting for 24 hours. He denies any chest pain or abdominal pain. He underwent his routine hemodialysis yesterday without any complications.

    The man’s temperature is 38.8 ºC (101.8 ºF), blood pressure is 120/70 mm Hg, and pulse is 110 beats per minute. Abdominal examination reveals guarding in the right upper quadrant with no tenderness or peritoneal signs. Laboratory studies show a leukocyte count of 24,000/mm3 and a serum bilirubin of 2.2 mg/dL. Ultrasound examination of the right upper quadrant fails to reveal gallbladder stones.

    Which of the following is the best next step in the management of this patient?

    A. Order a CT scan of the abdomen.

    B. Order a colonoscopy.

    C. Order a hepatobiliary iminodiacetic acid (HIDA) scan.

    D. Order intravenous antibiotics and continued observation.

    E. Order an upper GI endoscopy.

    The correct answer is C.

    Kaplan Medical explains why

    The HIDA scan is the most accurate diagnostic test for diseases of the hepatobiliary tree, and it will confirm the diagnosis. Acalculous cholecystitis is associated with a variety of conditions, including diabetes, trauma, mechanical ventilation, burns, childbirth and many others.

    These patients may not present with classical signs of cholecystitis; signs and symptoms will depend on the underlying predisposing clinical condition. Acalculous cholecystitis is characterized by the absence of gallstones and sometimes even by biliary sludge.

    Ultrasound is the method of choice to make the diagnosis, since it can visualize the gallbladder and also the liver, pancreas, and kidneys. Ultrasound will reveal a thickened gallbladder wall, pericholecystic fluid, gas within the gallbladder wall and evidence of surrounding inflammation. If the ultrasound fails to make the diagnosis, a HIDA scan may be useful.

    Why the other answers are wrong

    Choice A: Ordering a CT scan of the abdomen will not add much to the diagnosis. This patient’s clinical presentation is clearly associated with the biliary tract, and if the ultrasound fails to reveal the diagnosis, CT scan is not the imaging method of choice to observe the biliary tract.

    Choice B: Colonoscopy is not helpful in the workup of biliary symptoms.

    Choice D: Intravenous antibiotics are indicated to treat cholecystitis, but in the presence of gangrene or unresponsive cholecystitis, surgery is indicated. Continued observation may result in worsening of the symptoms and signs and the development of complications such as systemic sepsis; therefore, observation and administering antibiotics alone is not the best option at this time. Further evaluation is required.

    Choice E: An upper gastrointestinal endoscopy helps in the diagnosis of pathology in the stomach or duodenum, but will not be helpful in this patient.  

    Tips to remember
  • Acalculous cholecystitis is associated with a variety of conditions, including diabetes, trauma, mechanical ventilation, burns, childbirth, and many others.
  • It is marked by the absence of gallstones and sometimes even biliary sludge.
  • Ultrasound is the modality of choice for diagnosis.
  • If it is equivocal, then a HIDA scan is the next best option.
  • For more prep questions on USMLE Steps 1, 2 and 3, view other posts in this series.

    The AMA selected Kaplan as a preferred provider to support you in reaching your goal of passing the USMLE® or COMLEX-USA®. AMA members can save 30 percent on access to additional study resources, such as Kaplan’s Qbank and High-yield courses. Learn more.

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