Palliative Care Competencies and Readiness for Independent Practice: A Report on the American Academy of Hospice and Palliative Medicine Review of the U.S. Medical Licensing Step Examinations

Context: It is unknown whether the palliative care (PC) content tested in the U.S. Medical Licensing Examination (USMLE) step examinations reflects the consensus-developed PC competencies. Objectives: To review the USMLE step examinations to determine whether they test the PC knowledge necessary for graduating medical students and residents applying for licensure. Methods: Eight PC physicians reviewed three complete examination forms and a focused 509-item bundle of multiple-choice questions (MCQs) identified by the USMLE content outline as potentially assessing PC content. Reviewers determined MCQs to be PC items if the patient was seriously ill and PC knowledge was required to answer correctly. PC items’ competency domains were determined using reference domains from PC subspecialty consensus competencies. Results: Reviewers analyzed 1090 MCQs and identified 242 (22%) as PC items. PC items were identified in each step examination. Patients in PC items were mostly males (62.8%), older than 65 years (62%), and diagnosed with cancer (43.6%). Only 6.6% and 6.2%, respectively, had end-stage heart disease or multimorbid illness. Fifty-one percent of PC items addressed ethics (31%) or communication (19.8%), focusing on patient autonomy, surrogate decision makers, or conflict between decision makers. Pain and symptom management was assessed in 28.5% of PC items, and one-third of those addressed addiction or substance use disorder. Conclusion: We identified PC content in each step examination. However, heart disease and multimorbidity were under-represented in PC items relative to their prevalence. In addition, there was heavy overlap with ethics, a focus on conflict in assessing communication skills, and emphasis on addiction when testing pain management. Our findings highlight opportunities to enhance testing of clinical PC skills essential for all licensed physicians practicing medicine.