Frequently Asked Questions

WHY WAS STEP 2 CS CREATED?

The Step 2 CS exam was implemented to address important concerns -- assuring that all licensed physicians have basic clinical competencies and can effectively communicate with patients. These are important goals that deserve attention and resources. However, an expensive standardized exam is not a cost-effective method.

WHO WAS BEHIND THE CREATION OF STEP 2 CS?

The USMLE is jointly controlled by two organizations -- The National Board of Medical Examiners (NBME) and the Federation of State Medical Boards (FSMB). These two organizations were responsible for the addition of a national clinical skills exam to the medical licensure process in 2004.

However, Step 2 CS has been fought by many medical school administrators and the American Medical Association (AMA) since its introduction, Many medical schools initially made a symbolic stand against the new test by not requiring it for graduation. However, this gesture was short-lived, as doing so prohibited students from receiving additional financial aid to pay for the exam.

HOW MUCH DOES STEP 2 CS COST?

The test fee alone, currently $1,275 per student, costs over $36 million annually.

Step 2 CS is expensive. The test fee alone, currently $1,275 per student, costs over $36 million annually.[1] Since over 99% US medical students pass on their first or second try, it costs over $1 million to “catch” a single student who fails the exam on back-to-back attempts.[1] These costs do not include travel and lodging expenses, which are substantial for many students due to the scarcity of testing facilities, often exceeding $500. Given that most students finance their medical education with loans, the final cost can easily exceed $2000 per student. 

WHY DO YOU THINK COST IS SO IMPORTANT?

The total student debt burden in the United States has never been greater. In a climate where qualified, compassionate Americans might be deterred from the resource- and time-intensive commitment of medical school, eliminating unnecessary costs to medical education is vital. As these costs often fall hardest on underrepresented minorities in medicine, it is imperative that we, as a community of medical professionals, take actions to reduce the financial burdens of our education.

BUT SHOULDN’T MEDICAL LICENSING HAVE SOME MECHANISM TO IDENTIFY MEDICAL STUDENTS DEFICIENT IN CLINICAL SKILLS?

Yes, it absolutely should. And this identification is already done, time and time again, through each medical school’s clinical curricula. 

Over the past several decades, evaluating students’ clinical skills has become increasingly important in medical education in the United States and around the world. Consequently, the vast majority of schools already employ their own clinical skills exams. A survey from 2005 revealed that 84% of medical schools already conducted at least one clinical skills examination in the third or fourth year even before Step 2 CS was implemented.[2] Over the past decade, the adoption of a school-based skills exam has almost certainly increased.

Just as state medical licensing boards and the NBME trust medical schools to deliver a standardized education for each physician’s degree, so too should they trust schools to perform a rigorous, high-quality clinical assessment as a component of that degree.

IF CLINICAL SKILLS TESTING IS FEDERATED TO INDIVIDUAL MEDICAL SCHOOLS, WON’T WE LOSE STANDARDIZATION?

Standardization is a major argument used to support a national skills exam rather than school-specific exams. However, with something as complicated as an examination of clinical skills, we do not believe that 100% standardization is possible even with the current exam. Despite the best efforts of the USMLE, there will always be subjective variability by examiner.

Furthermore, the ultimate goal of the Step 2 CS exam is not to provide a reproducible score but rather to identify students who fail to meet basic qualifications expected of a good physician. Medical school-specific exams can conform to a standardized set of required competencies, which can be enforced through the accreditation process.

In addition, school-based skills exams have several benefits over the national CS exam. For example, while Step 2 CS provides students only a pass/fail grade and a bar graph of clinical versus interpersonal performance, medical schools can provide students with a much more comprehensive assessment as well as targeted feedback that can allow them to improve their skills in communication, history taking, physical examination, and clinical reasoning.

WILL ELIMINATING STEP 2 CS COMPROMISE PATIENT SAFETY?

To date, there is no evidence that Step 2 CS improves patient safety. This is another common argument used to support Step 2 CS -- the idea that the test serves an important public health role by protecting patients from physicians who cannot demonstrate basic clinical or communication competencies. While this is a lofty goal, it is purely theoretical and is not supported by evidence. 

Two recent studies by the NBME found weak correlations between Step 2 CS scores and end-of-year evaluations of internal medicine interns, although clinical skills scores added no additional predictive value beyond the written USMLE exams.[3,4] These studies have several important limitations. They include graduates of US and international medical schools, do not provide a comparison to individuals who failed Step 2 CS, and utilize raw Step 2 CS scores that are not provided to students. Additionally, faculty evaluations of house staff performance are subjective and susceptible to bias. In summary, the data do not prove a causative link between Step 2 CS and improved patient safety.

NBME is feverishly publishing papers in hopes of uncovering stronger evidence to support the existence of Step 2 CS, but given the extremely low failure rate of US medical graduates, this might be difficult.

Additionally, medical students who demonstrate clinical deficiencies -- whether diagnostic, communications-based, or professional -- are unlikely to be first identified during Step 2 CS, just as those struggling in basic science are unlikely to have their first problem on Step 1. Educating and mentoring medical students in clinical skills is best handled by each US medical school’s faculty, who are in the best position to know, understand, and remediate their students.

WHAT ABOUT GRADUATES OF INTERNATIONAL MEDICAL SCHOOLS?

Our proposal does not extend to graduates of international medical schools. Even before CS was introduced in 2004, international graduates were required to take a clinical skills exam to assure they have the clinical, communication, and language skills to practice medicine in an American setting.

Some might argue that it is unfair to require a clinical skills exam for only a subset of medical students. However, while nearly all US medical students pass Step 2 CS, the pass rate for international students is only 74%.[5] Furthermore, US medical schools can replace Step 2 CS with their existing Objective Structured Clinical Exam (OSCE) as part of the LCME accreditation process. However, LCME has no authority to assure that foreign medical school curricula are adequately assessing the clinical and English communication skills of their students.

WHO ACTUALLY HAS THE POWER TO ELIMINATE STEP 2 CS? DOES THIS REQUIRE LEGAL CHANGES?

The NBME and FSMB  have power to eliminate Step 2 CS as a requirement for US medical graduates. However, pressure from individuals (via our petition) and other professional organizations (like the American Medical Association) may influence the NBME.

State laws for medical licensure stipulate that students must pass USMLE Step 2, but do not explicitly mention CS by name, and thus no laws would need amendment.

WON’T A PETITION TO ELIMINATE CS JUST ENCOURAGE THE NBME TO RAISE THE PASSING THRESHOLD?

We trust that any opposition by the NBME towards this proposal will not result in a punitive reaction in the current administration of Step 2 CS. Our argument is not that a national clinical exam is without merit because almost everyone passes -- our argument, rather, is that this exam’s existence is inherently poor value for America’s grossly indebted graduates. Reactively making the exam more difficult would only enhance that fundamental problem.

HOW WILL THIS IMPACT PATIENTS’ PERCEPTIONS OF DOCTORS? DO WE RISK LOOKING LIKE WE’RE “GETTING OUT OF” AN EXAM?

We believe that patient perception of their physician rests on the quality of care and compassion delivered by that physician. American patients do not screen their doctors based on USMLE scores. Additionally, medical students and residents take dozens of exams; eliminating one does not render this community “under-tested”. 

REFERENCES:

[1] Lehman EP, et al. The Step 2 Clinical Skills Exam -- A Poor Value Proposition. New Eng J Med 2013; 368:889-91.

[2] Hauer KE, et al. A National Study of Medical Student Clinical Skills Assessment. Acad Med 2005; 80(10):S25-9.

[3] Winward ML, et al. The relationship between communication scores from the USMLE Step 2 Clinical Skills examination and communication ratings for first-year internal medicine residents. Acad Med. 2013 May;88(5):693-8.

[4] Cuddy MM, et al. Evaluating Validity Evidence for USMLE Step 2 Clinical Skills Data Gathering and Data Interpretation Scores: Does Performance Predict History-Taking and Physical Examination Ratings for First-Year Internal Medicine Residents? Acad Med 2016 Jan; 91(1):133-9.

[5] USMLE Performance Data. http://www.usmle.org/performance-data/