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End of an Era: The Medical Community Responds to the Elimination of Step 2 CS

Op-Med is a collection of original articles contributed by Doximity members.

On the heels of their decision to transition the USMLE Step 1 to pass/fail, sponsors of the exam have delivered yet another momentous announcement: The Step 2 Clinical Skills (CS) component is no more. 

Step 2 CS, first introduced in 2004, was designed to test medical students’ clinical competence and communication skills to ensure the “safe and effective practice of medicine.” Yet many physicians who have taken the exam have questioned its utility — citing exceedingly high pass rates of nearly 97% — and lamented its high cost (upwards of $1,500), onerous scheduling, and limited testing site availability. As soon as the news broke, students, residents, and established physicians spoke out, most voicing their support for the move, but others expressing concern. 

Second-year medical student at Sidney Kimmel Medical College, Jonathan Xu, MS, reacted positively to the overall exam changes. “I think it comes as a relief to current MS4s who may have had to reschedule,” he told Doximity. “MS2s are mostly concerned with preparing for Step 1, which is transitioning to pass/fall next year, but we are generally happy with the change.” 

Susannah Boyed, MS, a third-year medical student at St. George’s University, shared the socioeconomic impact of the removal of Step 2. “It’s meaningful most urgently for lower-income students and those of us without generational financial backing of physician parents, grandparents, etc,” she said. “Medical training in the U.S. is increasingly prohibitively expensive at all points of training. I hope these changes clear the way for wider, more accessible paths that are designed for the realities of all students.” 

Physicians have also shared their resounding support. Emily Silverman, MD, tweeted, “Cheers to common sense, grassroots advocacy, and a more reasonable and humane medical education for all.” David Steensma, MD, tweeted that Step 2 CS was “highly problematic,” and that its elimination was, “the right decision, long overdue.” 

A recent graduate of Weill Cornell Medicine who took the exam six years ago told Doximity, “I wish this change had occurred during my time. At the time, I borrowed money from my family and worked odd jobs to raise the money to take the exam. My mother had to take off work to drive me to a testing center. I’m happy for those that will get to benefit from this moving forward, and am hopeful for the ways that the medical education process can become more accessible.” 

And societies like Students for Ethical Admissions are chiming in: “[We] applaud the decision to discontinue the USMLE Step 2 CS Exam (which has never shown appreciable value in learner assessment),” it said. "Now is the time for all of #MedEd to evaluate their systems and look for ways to reduce barriers.”

To be sure, several studies have demonstrated some tangible benefits of Step 2 CS. A 2016 study, for instance, found a positive association between students’ ability to interpret clinical data during the exam and their subsequent performance at taking patient H&Ps. An internal medicine physician who has practiced in South Carolina for over 30 years expressed concern that the termination of too many exams might leave medical students unprepared: “I think it comes down to what the assessment is testing for,” he said. “We don’t want a situation where prospective physicians are not being challenged and held to the same standards.”

Though the boards stated they have no plans to reinstate the exam, they did express a need to “determine innovative ways to assess clinical skills” moving forward. The implications point to potential changes to other areas of the exam down the line, or possibly greater onus on residency programs to broaden their approach to student evaluation. Interventional cardiologist Khurram Liaqat, MD, questioned the future of the exam in a thread: “Not sure if discontinuation [is] a good thing. This might be replaced by state-specific clinical skills assessment, hence chaos.” 

What’s more, the decision to eliminate Step 2 CS has put pressure on the National Board of Osteopathic Medical Examiners to follow suit and cancel the in-person clinical skills portion of its licensing exam for DOs. Several medical professionals in a Twitter thread rallied in support of that idea. “I can tell you, without question, that the COMLEX-PE is ... not needed, it's not special, and it needs to go away,” tweeted one DO instructor.

A long-term commitment to the exam could serve to alienate DOs from other clinicians, added Sara Peterson, fourth-year DO student at Kansas City University. “Future DOs already fight against *so much* stigma,” she tweeted. “Forcing us to ‘prove’ our skills with an exam that MDs will no longer take is only adding fuel to the idea that we are not/will never be equal.”

And for medical students pursuing their degrees abroad, there are still other questions. “Immigrants from certain countries used [the Step 2] CS exam for visa purposes,” Muhammad Zia Khan, MD, tweeted. “Now it will be very difficult.” 

The historic USMLE changes come with substantial support, albeit not free from implications and challenges. Though barriers are being removed to make medical education and skills assessment more accessible, the medical community recognizes that it is only the beginning of more necessary reevaluation. 

What are your hopes for the future of the USMLE and the next generation of physicians? Share your insights and ideas in the comments. 

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