Questioning a Virtual Alternative to Step 2 CS

The Step 2 Clinical Skills exam (Step 2 CS) has faced criticism since it became a USMLE requirement in 2004. Its administration has faced new challenges during the COVID-19 pandemic, and in late May, USMLE announced the exam would be suspended for 12–18 months. This is an opportunity for USMLE to critically assess the value of the exam in general. Step 2 CS should not resume in its current form as a licensing requirement, given the lukewarm evidence that supports it and its considerable cost to students. A virtual alternative focused on telehealth would only further limit the utility of the exam and fail to assess communication skills globally.

Step 2 CS uses standardized patient interactions to assess interpersonal skills, spoken English proficiency, and data gathering/interpretation. The USMLE website justifies Step 2 CS within licensing by stating, “The standards to practice medicine safely should include not only clinical competence but also the ability to communicate effectively with patients and colleagues.” It suggests that Step 2 CS assesses communication skills in order to increase the safety of medicine. 

Prior to the COVID-19 pandemic, Step 2 CS received considerable criticism from both popular and academic communities. One online petition to end the exam has received more than 20,000 signatures. A 2013 NEJM Perspectives article called Step 2 CS a poor value proposition, estimating it cost $1.1 million to identify a student who has failed the exam twice. A 2013 study demonstrated limited value in Step 2 CS numerical scores (which are not reported as part of the pass/fail exam) in predicting resident communication skills. The study concluded that the relationship between scores and intern communication ratings is “relatively weak.” This is one of three studies that USMLE cites under a section titled, “What studies support the need [of Step 2 CS]?” and is the only one which attempted to argue the exam’s validity.

Despite poor evidence for the value and effectiveness of Step 2 CS, students are charged $1,300 and must travel to one of only five cities where it takes place. If students fail, they must retake the exam and pay the fee again. 

In May, USMLE announced changes to Step 2 CS due to the COVID-19 pandemic. Initially, it stated that COVID-19 accelerated existing plans to change the current format of Step 2 CS by implementing a virtual alternative focused on telehealth. By the end of the month, USMLE suspended the exam due to the complexity of “technical and psychometric work” required. In a podcast released by USMLE, administrators stated that the development of a virtual alternative presented complexities that “could be solved … with additional time.” This implies that a virtual alternative focused on telehealth, which USMLE did indicate it had existing plans for, may still replace the current exam.

Moving toward a virtually administered Step 2 CS exam would narrow its scope and further weaken its validity and value. Previously, Step 2 CS used a diverse array of simulated patient scenarios. By focusing on telehealth, its content becomes too limited to be used to assess communication skills holistically, as should be required by a licensing exam. Telehealth is an important domain of health care, and one which grew in importance with the emergence of COVID-19. It should not, however, be used as the sole component for a licensing requirement. 

Furthermore, factors such as eye contact and body language will be much more difficult to assess virtually. Nuanced and subjective skills such as empathy, trust-building, and compassion — which are already difficult to assess in-person — will be substantially more difficult to evaluate. Additionally, the ability to perform a physical exam will be truncated and changed significantly, resulting in a less generalizable skill: the virtual physical exam.

Many questions remain before a virtual exam could be considered a worthwhile requirement. Is it possible to generalize proficiency in simulated telehealth encounters to assess a student’s communication skills? What constitutes passing and failing when there has been little established telehealth curricula? How do you fairly assess physical exam maneuvers over video?

If USMLE does not address long-standing concerns regarding Step 2 CS’ cost and validity, it should not be a requisite for all students. This would not leave medical school graduates without formal assessment of their clinical skills. Medical schools are required to have clinical skills curricula that are stringently evaluated and accredited based on LCME standards. Currently, programs are grappling with how to adapt these clinical skills programs to limitations imposed by COVID-19. Individual medical schools have a much greater opportunity to continue modified in-person standardized patient programs or to shift in-person components of the clinical skills curricula to clinical years using real patient encounters. This allows students to practice in-person skills as part of a robust and cogent medical school curriculum per LCME standards.

One administrator noted that the suspension of Step 2 CS “does not create a conflict with state laws for licensure.” If this is the case, how much is actually lost with the end of Step 2 CS for licensing? Are the students graduating without having taken it less clinically competent or practicing medicine less safely, as USMLE suggests the exam prevents? 

According to the podcast, USMLE aims to be transparent, and takes into account examinee experience. If this is the case, then USMLE should weigh heavily more than 15 years of academic and popular criticism for a costly exam with little evidence behind it. Step 2 CS should not resume in its current format as a licensing requirement, and it should not be replaced with a virtual alternative. It risks becoming meaningless for test-takers, educators, and residency programs alike, unless these concerns are adequately considered and answered.

Christopher Thompson is a fourth-year medical student at the University of Michigan. He is applying into Internal Medicine and is interested in medical education and end-of-life care. He has no conflict of interests to disclose.

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