To test the hypothesis that the clinical skills of many foreign medical graduates entering residencies in the United States are deficient, the Educational Commission for Foreign Medical Graduates (ECFMG) administered a second, more extensive pilot examination called the Clinical Skills Assessment Examination. The test was constructed after identifying those clinical skills considered to be suitable for testing in a large-scale examination conducted at multiple locations. The test was given to 635 foreign medical graduates (including 53 U.S. citizens) who had been certified by the ECFMG and to a reference sample of 123 graduates of U.S. medical schools. All of the graduates took the test prior to their first postgraduate year of training. The results did not differ significantly from those of a previous test. The clinical skills of 28% of the graduates of foreign medical schools who took the examination were found to be inadequate when compared with those of graduates of U.S. schools. The conclusion reached was that a clinical skills examination is feasible for inclusion in the ECFMG certification process.