International variation in performance by clinical discipline and task on the United States medical licensing examination step 2 clinical knowledge component

Acad Med. 2014 Nov;89(11):1558-62. doi: 10.1097/ACM.0000000000000488.


Purpose: To investigate country-to-country variation in performance across clinical science disciplines and tasks for examinees taking the Step 2 Clinical Knowledge (CK) component of the United States Medical Licensing Examination.

Method: In 2012 the authors analyzed demographic characteristics, total scores, and percent-correct clinical science discipline and task scores for more than 88,500 examinees taking Step 2 CK for the first time during the 2008-2010 academic years. For each examinee and score, differences between the score and the mean performance of examinees at U.S. MD-granting medical schools were calculated, and mean differences by country of medical school were tabulated for analysis of country-to-country variation in performance by clinical discipline and task.

Results: Controlling for overall performance relative to U.S. examinees, results showed that international medical graduates (IMGs) performed best in Surgery and worst in Psychiatry for clinical discipline scores; for clinical tasks, IMGs performed best in Understanding Mechanisms of Disease and worst in Promoting Preventive Medicine and Health Maintenance. The pattern of results was strongest for IMGs attending schools in the Middle East and Australasia, present to a lesser degree for IMGs attending schools in Europe, and absent for IMGs attending Caribbean medical schools.

Conclusions: Country-to-country differences in relative performance were present for both clinical discipline and task scores. Possible explanations include differences in learning outcomes, curriculum emphasis and clinical experience, standards of care, and culture, as well as the effects of English as a second language and relative emphasis on preparing students to take the Step 2 CK exam.

Publication types

  • Comparative Study

MeSH terms

  • Clinical Competence*
  • Education, Medical, Undergraduate / standards*
  • Education, Medical, Undergraduate / trends
  • Educational Measurement*
  • Female
  • Foreign Medical Graduates*
  • Humans
  • Licensure, Medical / standards*
  • Male
  • Reference Standards
  • Schools, Medical / statistics & numerical data
  • United States