Differential Weighting for Subcomponent Measures of Integrated Clinical Encounter Scores Based on the USMLE Step 2 CS Examination: Effects on Composite Score Reliability and Pass–Fail Decisions

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Medical schools administer locally developed graduation competency examinations (GCEs) following the structure of the United States Medical Licensing Examination Step 2 Clinical Skills that combine standardized patient (SP)-based physical examination and the patient note (PN) to create integrated clinical encounter (ICE) scores. This study examines how different subcomponent scoring weights in a locally developed GCE affect composite score reliability and pass–fail decisions for ICE scores, contributing to internal structure and consequential validity evidence.


Data from two M4 cohorts (2014: n = 177; 2015: n = 182) were used. The reliability of SP encounter (history taking and physical examination), PN, and communication and interpersonal skills scores were estimated with generalizability studies. Composite score reliability was estimated for varying weight combinations. Faculty were surveyed for preferred weights on the SP encounter and PN scores. Composite scores based on Kane’s method were compared with weighted mean scores.


Faculty suggested weighting PNs higher (60%–70%) than the SP encounter scores (30%–40%). Statistically, composite score reliability was maximized when PN scores were weighted at 40% to 50%. Composite score reliability of ICE scores increased by up to 0.20 points when SP–history taking (SP-Hx) scores were included; excluding SP-Hx only increased composite score reliability by 0.09 points. Classification accuracy for pass–fail decisions between composite and weighted mean scores was 0.77; misclassification was < 5%.


Medical schools and certification agencies should consider implications of assigning weights with respect to composite score reliability and consequences on pass–fail decisions.

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