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J Gen Intern Med. 2007 Aug;22(8):1155-60. Epub 2007 Jun 9.

Impact of student ethnicity and primary childhood language on communication skill assessment in a clinical performance examination.

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  • 1UCSF Department of Medicine, School of Medicine, University of California, P.O. Box 1364, San Francisco, CA 94143-1364, USA.



Clinical performance examinations (CPX) with standardized patients (SPs) have become a preferred method to assess communication skills in US medical schools. Little is known about how trainees' backgrounds impact CPX performance.


The objective of this paper is to examine the impact of student ethnicity, primary childhood language, and experience of diversity on the communication scores of a high-stakes CPX using SPs.


This research was designed as an observational study.


The participants of this study were third-year medical students at one US medical school.


The measurements used in this study were CPX scores from mandatory exam, student demographics and experience with diversity measured by self-report on a survey, and Medical College Admission Test (MCAT) and United States Medical Licensing Examination (USMLE) scores. A total of 135 students participated. Asian and black students scored lower than white students on the communication portion of the CPX by approximately half a standard deviation (Asian, 67.4%; black, 64.4%; white, 69.4%, p < .05). There were no differences by ethnicity on history/physical exam scores. Multivariate analysis controlling for MCAT verbal scores reduced ethnic differences in communication scores (Asian-white mean differences = 1.95, p = 0.02), but Asian-white differences were eliminated only after sequential models included primary childhood language (difference = 0.57, p = 0.6).


Even after controlling for English language knowledge as measured in MCAT verbal scores, speaking a primary childhood language other than English is associated with lower CPX communication scores for Asian students. While poorer communication skills cannot be ruled out, SP exams may contain measurement bias associated with differences in childhood language or culture. Caution is indicated when interpreting CPX communication scores among diverse examinees.

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