On May 26, USMLE announced its decision to suspend the administration of the Step 2 CS (Clinical Skills) examination for 12–18 months in response to disruptions caused by the COVID-19 pandemic. The decision came after several months, during which tests were postponed in the hopes that a solution to the conundrum of administering an in-person exam during a pandemic would be found. With no solution in sight, the organization responsible for licensing new medical graduates in the U.S. took the unprecedented step of canceling one of the exams (with no firm date for rescheduling).
Step 2 CS has always been the odd one out among the several licensing examinations medical students have to take. Step 1 and Step 2 CK, the other two exams med students must pass prior to graduating, are completely computer-based multiple-choice exams. Both are designed solely to test the examinee’s medical knowledge and their ability to apply it. By contrast, Step 2 CS is a simulation exam in which examinees must interact with standardized patients — actors who simulate symptoms and history. Step 2 CS requires students to perform physical exams, provide a differential diagnosis and plan, and write a note based on what they found in their encounter.
USMLE has always avowed that Step 2 CS is necessary in order to ensure that new doctors are able to apply their knowledge in real-life situations. Although it was originally designed to test graduates of foreign medical schools — to ensure not only clinical competence but also English proficiency — it has been required for U.S. graduates since 2004.
Over the years, there have been persistent concerns about whether the exam provides benefits that outweigh its costs. The financial cost alone is huge. With a $1,300 registration fee, it is far more expensive than the other licensing exams. In the 2017–2018 academic year, over 20,000 U.S. MD students took the exam for the first time; at $1,300 each, students paid over $26 million for the privilege of taking this test. Most students finance their education — in part, if not entirely — through debt, meaning that the next generation of doctors will be paying for this test for years to come.
The price tag is even more striking when you take into account the exam’s high pass rate. On the first attempt, 95% of examinees pass … which means we are spending over $25,000 to identify a single student as potentially not proficient. And, if a student fails, they can retake the exam fairly quickly. The passage rate for retakes is 87% … which means it costs nearly $200,000 for USMLE to flag one U.S. MD student as needing improvement (i.e., a retake) before they can practice medicine.
And the cost does not end with registration fees. Many students, conscious of the deleterious effect that a failing grade could have on their career, pay through the nose for test prep books and courses. And then there is the travel. Prior to the disruptions caused by COVID-19, Step 2 CS was offered at only five testing sites around the country: Atlanta, Chicago, Houston, Los Angeles, and Philadelphia. As a result, most examinees travel long distances to a test center, and usually need a hotel room. Many students, including myself, pay for plane fare, as well.
What is the medical profession getting from this hefty expenditure of money, time, and effort? That new doctors need to be proficient in applying their knowledge in a clinical setting, in communicating with patients, and in writing notes is self-evident. The argument that Step 2 CS is the best way to ensure this proficiency is much more suspect.
Prior to the introduction of Step 2 CS in 2004, these skills were evaluated by medical schools. As students spend thousands of hours practicing these skills alongside their professors, deficiencies were arguably much more likely to be detected by professors than in the artificial, one-day environment of a CS testing center. The makers of Step 2 CS argue that their mandate is to certify that every graduating doctor is competent to practice medicine, and that they cannot delegate the responsibility to medical schools.
The argument can be made that both USMLE and individual medical schools have a role to play in ensuring that new doctors have the skills they need to practice safely and effectively. USMLE can proctor standardized tests that establish a baseline of medical understanding to ensure that, wherever they got their training, students across the country have sufficient knowledge. And the nation’s medical schools can provide the longitudinal, day-in and day-out evaluation that, though not as uniform as standardized testing, is vastly more in-depth and a closer approximation of real-world practice.
Ultimately, whatever the arguments, actions speak louder than words. The complete suspension of Step 2 CS — for more than a year, with no firm date for reinstatement — suggests that the USMLE can no longer argue this test is essential. Many organizations are having trouble providing their full range of services, but the bottom line is that, when something is actually essential, we find a way to make it happen. It is time for the USMLE to recognize what the pandemic has revealed: Step 2 CS is unnecessary.
Austin Reifel is a fourth-year medical student. He can be contacted on Twitter. Austin is a 2019–2020 Doximity Fellow.
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