Another USMLE Shocker: Step 2 CS Going Remote, Virtual

Marcia Frellick

November 20, 2020

The United States Medical Licensing Examination (USMLE) Step 2 Clinical Skills (CS) assessment is switching to a remote virtual format, according to an announcement detailed in a podcast on Thursday.

The all-day exam, which traditionally requires test takers to have physical contact with standardized patients, has been suspended during the pandemic for safety reasons.

Thursday's announcement came as a surprise, as sponsors of the test had announced in May that they would continue to suspend Step 2 CS for the next 12 to 18 months, as reported by Medscape Medical News.

"As Soon as Possible"

Christopher Feddock, MD, MS, executive director of the Clinical Skills Evaluation Collaboration, said on the podcast that the timeline has not been set for implementing the changes.

"While we want to relaunch the modified examination as soon as possible," he said, "the exam has an impact on residency match timelines, school curricula calendars and temporary eligibility policy changes currently in effect for both Step 3 and ECFMG (Educational Commission for Foreign Medical Graduates) certification."

David Johnson, MA, chief assessment officer with the Federation of State Medical Boards, said updates are expected "early in 2021" on the USMLE website and on social media.

Feddock said that surveys have gone out to first-year residents and program directors to gauge the core activities of interns and the level of skill expected for residents beginning supervised practice.

Announcement Met With Criticism

Bryan Carmody, MD, a pediatric nephrologist at the Children's Hospital of The King's Daughters, in Norfolk, Virginia, who has written extensively about changes to the licensing exams, questioned the timing of the announcement, which came 2 days after a resolution adopted at the American Medical Association (AMA) House of Delegates (HOD) meeting.

He told Medscape Medical News that the resolution called "upon the AMA to take 'immediate expedited action' to encourage the NBME (National Board of Medical Examiners) and NBOME (National Board of Osteopathic Medical Examiners) to eliminate USMLE Step 2 CS and COMLEX-USA [Comprehensive Osteopathic Medical Licensing Examination of the United States] Level 2-PE (performance evaluation)."

"[The HOD] called for a 'replacement examination process' to be administered by accredited medical schools. Maybe the timing is just coincidental, but for me, it was two big pieces of USMLE Step 2 CS news dropping in almost as many days."

Speakers who had testified in support of the resolution said the exam "has an extremely high pass rate" and has not identified serious deficiencies in students' education and training "used to justify" the expense and resources needed to take the test.

The USMLE's decision to move the exam to virtual and remote generated some pointed responses on social media.

Mike Booth, MD, associate dean at University of North Dakota School of Medicine in Bismarck and author of the adopted AMA resolution, told Medscape Medical News that the proposed change in the Step 2 CS format is "ridiculous. …The whole point of the exam is to put the student in front of a patient in a live interview format."

"Waste of Money"

Johnson acknowledged that sponsors have heard many complaints about the test, including the limited number of test sites, the cost of the exam (between $1300 and $1600), the "artificial nature" of the standardized patient, and the limited feedback exam takers received along with their scoring.

Stanislav Lazarev, MD, is one of several who feel that the Step 2 CS should be scrapped entirely. He tweeted Thursday that it is "an absolutely pointless test," motivated by profit. "Every US medschool has clinical skills exams in year 3 for each major specialty and these tests are sufficient," he writes.

Like Lazarev, Booth, and others argue that the CS exam is not necessary and the cost and resources it uses "should be put to better use." Booth says that the CS exam is "waste of money and a waste of resources. ...Ninety-nine percent of the students do pass the exam," he said. "The test isn't effective in finding things. We're chasing a problem that doesn't exist."

He said that in his years of teaching only three students of 175 have ever failed it and that the test is redundant given the thorough evaluation of skills already being done in medical schools.

The test administrators "have not been able to duplicate that," he said. "It's a very artificial environment with a lot of flaws."

Booth agrees with the need for testing in general but says that the CS exam isn't effective and the proposed changes only make things worse.

"Why does NBME want to be in the middle of this when we have well-paid, highly motivated clinical faculty people who can be there in the room or in the next room through a mirror watching what's going on?" he asks.

Carmody said that many students have long been opposed to Step 2 CS, for multiple reasons. It's possible, he said, that the computer-based exam would address some of the persistent objections.

"Although they haven't announced the registration cost, a virtual exam might be less expensive," Carmody said, "and should eliminate the need to travel to one of the testing sites. But implementing a computer-based exam will fuel some of the other concerns about Step 2 CS, such as its lack of predictive validity. Even the face validity of the exam to medical boards and the general public may be diminished by testing in this format." 

He said he will be watching to see if the NBOME follows suit.

"Typically they emulate whatever the NBME/USMLE does, and their COMLEX-USA Level 2-PE has come under heavy fire because, until recently, they'd refused to commit to a long-term suspension of the exam, and had instead continued to insist that osteopathic students should travel to Chicago (a city with a quarantine for visitors) to take the COMLEX-USA clinical skills exam."

"I wonder if they'll try to get rid of the in-person format when their test resumes, too," Carmody said.

Carmody has disclosed no relevant financial relationships.

Marcia Frellick is a freelance journalist based in Chicago. She has previously written for the Chicago Tribune, Science News, 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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