USMLE Step 2 CS Suspended for at Least 1 More Year

Marcia Frellick

May 28, 2020

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Sponsors of the US Medical Licensing Exam (USMLE) announced on Tuesday that they will continue to suspend administering Step 2 Clinical Skills (CS) for the next 12 to 18 months in light of the COVID-19 pandemic.

"Due to the complexity of technical and psychometric work required, we have determined we will not be able to meet timelines for the immediate release of a revised exam," USMLE announced on its website.

The all-day test, which requires test takers to have physical contact with standardized patients, is designed to "test medical students and graduates on their ability to gather information from patients, perform physical examinations, and communicate their findings to patients and colleagues," according to USMLE.

Leaders say in the announcement that over the past 3 months, USMLE had considered several options for resuming the test, including using a telehealth model. The test is taken on a pass/fail basis.

"The USMLE's primary purpose remains medical licensure and meeting the assessment needs of state medical boards," David Johnson, chief assessment officer of the Federation of State Medical Boards, told Medscape Medical News in a statement. "We continue to review options available for a performance-based assessment that meets state boards' needs while remaining mindful of the secondary uses and impact of USMLE in medical education and training."

Many details are still to be worked out, but USMLE says it will refund testing fees.

"Over the next few weeks, we will be announcing more detailed information on what this decision will mean for examinees, eg, refunds, progression through education/training and medical licensure," they write.

Implications for IMGs, Program Directors

The decision has major implications for international medical graduates (IMGs) as well as program directors, who must decide how to rank residency applicants.

William W. Pinsky, MD, president and CEO of the Educational Commission for Foreign Medical Graduates (ECFMG), said the suspension decision puts the organization in an awkward position because ECFMG is responsible for vetting graduates from schools outside the United States and Canada, and the Step 2 CS has been an important tool in making sure the people they certify are proficient.

"It takes away a piece of our certification process," Pinsky told Medscape Medical News. "We very much feel responsibility to the public to assure that the people coming over for training have the proper skill sets."

Residency program directors also use the program for choosing and ranking students.

"Program directors have wanted this for the international medical graduates, if not everybody," Pinsky said. "We have a hole here. If we don't have an alternative way to help program directors understand who these people are, then it is possible that international medical graduates' opportunity to be successful in the match could decrease."

He said the test has been a requirement for many US students graduating from medical school, but since the pandemic started, those requirements have been waived. ECFMG has also required IMGs to pass the test for ECFMG certification, which is required for IMGs to enter US residency.

Now ECFMG is looking at alternatives for the test and will present them soon to its board.

"We can't abdicate our responsibility because others have made a decision," Pinsky said.

ECFMG says it also wants to make sure that changes in policy "don't disenfranchise international medical graduates. They're very important to our training programs and our health systems. We want them to be properly certified and valued," he continued.

Some Not Sorry Test Is Suspended

Kunal Sindhu, MD, a third-year radiation oncology resident in New York, who took the test 4 years ago, had been a critic of the Step 2 CS even before the pandemic.

Communication proficiency is covered in medical school, he said, and the time required and the expense of the exam are not worth the information it yields.

He notes that the test itself, which is given in only five cities, costs $1300 ($1600 for IMGs), but additional travel and lodging expenses are often incurred.

"I think it's viewed by most American medical students as superfluous," he said.

But he said there is value in retooling the test to make it more relevant for ensuring that physicians can communicate with patients and other physicians.

"That needs to be done quickly," he said. "We obviously depend on IMGs for the workforce."

Although online testing seems like it a viable option, he said, that would not measure what the test was designed to measure, and he says protests may grow as to its relevance if it were moved to an online exam.

"There have been calls to eliminate this test for a long time," he said.

Sindhu said the announcement leaves several questions unaswered, including whether students will eventually have to take the test when it is offered again or whether this group of trainees will be given an exemption.

Roy C. Ziegelstein, MD, vice dean for education at Johns Hopkins University School of Medicine in Baltimore, Maryland, told Medscape Medical News that the suspension of the test "is not unwelcome to many. "

"Step 2 CS took the responsibility away from medical schools for certifying students' ability to interview and examine patients and communicate their findings. While that standardized the test experience to a large degree, at the same time it placed extraordinary burden on medical students," he said.

He noted that students already saddled with debt are asked to take an expensive exam "that nearly all first-time test takers from US and Canadian schools will pass.

"There can be no doubt that many of the changes in how we teach and assess medical students that have resulted from COVID-19 are here to stay, and that is not necessarily a bad thing," he said. "One can only wonder whether this is one of those changes."

Tumultuous Year for Medical Testing

The Step 2 CS decision is the latest change made in a tumultuous year for the testing program.

On February 14, as reported by Medscape Medical News, USMLE dropped the bombshell that it would change Step 1 scoring from a three-digit number to pass/fail starting January 1, 2022. The announcement drew shocked responses from students and physicians.

That change was made after Step 1 had been widely criticized as playing too big a role in the process of becoming a physician and for causing students to study for the test instead of engaging fully in their education.

Pinsky, Sindhu, and Ziegelstein report no relevant financial relationships. Johnson is employed by the Federation of State Medical Boards.

Marcia Frellick is a freelance journalist based in Chicago. She has previously written for the Chicago Tribune and and was an editor at the Chicago Sun-Times, the Cincinnati Enquirer, and the St. Cloud (Minnesota) Times. Follow her on Twitter at @mfrellick .

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