by Kevin M. Sanders

As of December 2004, all osteopathic medical students, in order to practice in this country, must pass the Comprehensive Osteopathic Medical Licensure Examination (COMLEX) Level 2-Performance Evaluation (PE). The standardized patient-based clinical skills examination is part of the COMLEX-USA, which is administered by the National Board of Osteopathic Medical Examiners (NBOME).

Although this past year was the first year COMLEX Level 2-PE was given, the 98 members of OU-COM’s Class of 2005 who took the board exam achieved a perfect pass rate on the exam.

“Congratulations! I’m proud of the college and its students for this accomplishment,” says State Sen. Joy Padgett.

The 100 percent success of our students on the exam, says Dean Jack Brose, D.O., is “remarkable.”

“Our faculty deserves a lot of credit for preparing the students for this, and our students deserve a lot of credit for taking this examination so seriously and preparing for it in the way that they did. To not have a single failure in the entire class of students is extraordinarily unlikely. It’s a remarkable achievement,” says Brose.

“We’re extraordinarily proud of our students and their board performance.”

 “A lot of credit should go to our admissions office for the quality of the student that is recruited and accepted into the college. Our admissions office has done a remarkable job of recruiting quality students.”

“I wasn’t surprised,” says Judith Edinger, director of predoctoral education, “by our 100 percent score.” She notes that OU-COM was one of the several pilot sites that NBOME used to conduct its trial evaluations of the exam.

In the seven-hour exam period of COMLEX Level 2-PE, medical students go through 12 standardized patient encounters, during which “patients” present problems commonly observed in primary care, outpatient or emergency room settings. Students are evaluated for proficiency in the Humanistic Domain (doctor-patient communication, interpersonal skills, professional demeanor) and Biomedical/Biomechanical Domain (history taking; physical examination skills including osteopathic palpatory skills, OMM and osteopathic principles; composing a Subject Objective Assessment and Plan (SOAP) note; clinical problem-solving; integrated differential diagnosis; formulation of a therapeutic plan). Students have up to 14 minutes to evaluate and treat each patient, followed up with 9 minutes to complete the SOAP note laying out their clinical findings and suggested treatment plan. Students receive a pass or fail for each domain.

As of 2008, all osteopathic medical students will be required to take and pass the exam prior to graduation, says the American Osteopathic Association Commission on Osteopathic College Accreditation.

Clinical skills tests, such as COMLEX Level 2-PE, says Peter Dane, D.O., associate dean for predoctoral education, are important.

“They are a way of assessing skills — mechanical and interpersonal. COMLEX Level 2-PE is a way of judging not only what students know but also what they can actually do. Paper and pencil tests can only assess your cognitive domain but not the behavioral domain,” says Dane.  

“It’s a no-brainer that this type of testing should have been done a long time ago.”

Several factors are responsible for the Class of 2005’s unprecedented 100 percent pass rate. Among those are the college’s simulated patient lab, early clinical contact, consistent clinical skills training in the Patient Centered Continuum (PCC) and Clinical Presentation Continuum (CPC) curricula, the implementation of the Objective Structured Clinical Examination (OSCE) and Centers for Osteopathic Research and Education (CORE) site clinical training.

“OU-COM was certainly one of the first, if not the first,” says Brose, “to have simulated patient labs right from the beginning. When I came here in 1982, we were already doing what amounted to an OSCE. Students not only had simulated patients, they did all the things they now do for the boards. What the national boards have created is a further refinement of what we’ve been doing all along. We’ve been fortunate enough to be way ahead of the curve.”

“Our tradition,” says Steven Clay, D.O., associate professor of family medicine, “has been simulated patient labs in which students begin to acquire the skills necessary to be excellent practitioners.”

Sharla Groves, coordinator of the simulated patient lab, prepares excellent laboratory experiences for clinical science and learning clinical skills, says Edinger.

“When I was at Kirksville,” says Clay, a 1985 graduate of the osteopathic medical college, “I never saw any simulated patients as a regular part of my classroom medical education.”

The college’s early clinical contact programs start in the first year of medical school. These programs facilitate our students working with primary care physicians in Southeastern Ohio in their practice settings by observing and learning from them as they work directly with patients.

“Dr. Robert Woodward, Sarah McGrew and Rosemary Butcher are instrumental,” says Edinger, “in preparing the way for a variety of early clinical and community experiences with area physicians.”

Our students develop excellent clinical skills, says Edinger, in no small part because the faculty of both curricula has made an effort to make sure that our students develop excellent history taking, physical examination and interpersonal communication skills. According to Edinger, small group work also really enhances students’ clinical thinking and interpersonal communication skills.

“Our clinical faculty emphasizes the development of clinical skills,” says Dane. Steven Clay, D.O.; Nicole Wadsworth; Robert Gotfried, D.O.; Chris Simpson, D.O.; and Bill Duerfeldt, D.O. — they were in charge of significant parts of the clinical sections of our curricula. They, clearly, have structured their educational programs to address those needs.”

Clay was also course coordinator for CPC skills for quarters I–VII. Clay says the clinical skills excellence that OU-COM students acquire is no accident.

“When we developed the CPC curriculum, we spent a long time working on various instructional blocks, during which we reworked the clinical skills part of it — history and physical exams, history taking, etc. — in line with the new curriculum. In each block we developed a skills component, how to do a history and physical, for instance, as relevant to that block, whether it was blood and immunity, cardiovascular or pulmonary. That allowed our students to study and practice their skills. We combined that with a little OSCE at the end, which included interaction with simulated patients. Students were required to interview patients and work with data, EKGs and X-rays. From their first quarter to through their second year they were practicing OSCEs with each block. The idea was to get them accustomed to working this way; it’s a good way of learning.

“My hope was that when they got the OSCE section of board exams, it wouldn’t be difficult at all, because they had been training and thinking that way all along. They did do well, so I feel very good about that.”

OU-COM’s incorporation of the OSCE was not in response to the national medical boards, says Brose, but rather a progression of what OU-COM was already doing in the first two years of medical education and through clinical rotations. OSCEs were first put in place in the CORE.

The college has an OSCE that is required of its third-year students. It is a four-patient OSCE as opposed to the 12-patient OSCE component of the COMLEX Level 2-PE.

Nonetheless, some students believe that OU-COM’s OSCE is more rigorous and challenging than the COMLEX, say Dane and Edinger. “They’ve said that once they got through our OSCE, they were very well prepared. They knew what to expect.”

Joanne Bray, M.B.A., clinical competency assessment coordinator, who coordinates the OSCE, has been great in helping us make adjustments as they were needed along the way, says Dane.

OU-COM students spend two years in clinical rotations, usually at CORE hospitals, during which they are trained and mentored by CORE clinical faculty and preceptors throughout the state. These two years are instrumental in shaping and fine-tuning clinical and interpersonal skills.

CORE assistant deans, says Edinger, help students in areas that need more proficiency development as identified in the OSCE.

These factors, plus the dedication of the students themselves, are largely responsible for the success the college has in producing capable, confident and clinically skilled osteopathic physicians ready to serve our state and nation.

“When NBOME came up with the idea for the COMLEX-PE,” says Brose, “we were completely comfortable with it. I think our students could have taken this test and been very successful a long time ago. This is one of the strengths of this college.”

The challenge for people in charge of curricular development is to be able to see around the corner — to see what might need to be coming next in medical education, says Dane.

“We were teaching and training our students,” says Dane, “in the things necessary for success on the national boards before those things were actually in place on the boards.”