On hold since May 2020, the Step 2 Clinical Skills (CS) exam—a portion of the United States Medical Licensure Examination® (USMLE)—was canceled permanently. The National Board of Medical Examiners (NBME) and the Federation of State Medical Boards (FSMB), the organizations that oversee the USMLE program, announced the exam's cancellation in late January.
The announcement comes roughly six months after the organizations announced they would review the exam's purpose and endeavor to create a modified version. The aim of Step 2 CS was to examine clinical skills in a performance-based setting, rather than a multiple-choice exam. As is the case with any Step exam, its primary purpose was medical licensure.
"NBME's commitment to performance-based assessment and clinical skills has accelerated. Our newest area of focus around competency-based assessment, and our exploration of novel assessments, will allow us to work with the medical education and regulatory communities to develop assessments of these essential skills and the optimal way to integrate these assessments into the education and licensure space," said Peter J. Katsufrakis, MD, president and CEO of NBME.
With its medical student members leading the charge, there have been multiple points at which the AMA has expressed a desire to reassess the value of the exam.
At the November 2020 AMA Special Meeting, the House of Delegates encouraged the NBME and FSMB to “eliminate centralized skills examinations used as part of state licensure,” including the Step 2 CS exam.
Questions about its usefulness have been persistent—given the annual pass rate well over 90%—as have concerns about its burden. The exam was offered in five cities, meaning most medical students had to incur travel expenses to take it.
“The students see this as a big victory,” said Kimberly Lomis, MD, the AMA's vice president for undergraduate medical education innovations. “It's admirable that this institution was able to recognize that they were doing something that didn't result in the intended value for all stakeholders involved and they stopped it. That's a huge decision on their part.”
Prior to the pandemic, international medical graduates were required to pass Step 2 CS to satisfy the clinical and communication skills requirements for Educational Commission for Foreign Medical Graduates (ECFMG) certification. Since June, the ECFMG has worked to create alternative pathways for IMGs to demonstrate the competency.
A move away from Step 2 CS doesn't mean that diagnostic and communication skills will be less emphasized in undergraduate medical education or residency selection. The exam's cancellation passes along the responsibility of assessing clinical skill readiness to medical schools.
“We still need to be very clear that it's important that we have high standards for clinical skills,” Dr. Lomis said. “Each school now becomes more responsible for a developmental process. If you are assessing these skills repeatedly over a student's time in an institution, it becomes more of a formative process; and when a student is struggling the school must help them get to where they need to be. That is both better for students and for the transition to residency: all can focus on true readiness for the next step in training as opposed to focusing on an exam. Our colleagues at the NBME are poised to facilitate this next phase, and our partners in the Accelerating Change in Medical Education consortium are eager to seize this opportunity to advance competency-based medical education.”
The Coalition for Physician Accountability, of which the AMA is a part, has launched workgroups to consider downstream implications of educational disruptions related to COVID-19. One of those workgroups will address how the residency selection process for the class of 2021 needs to adapt, recognizing challenges students face in compiling typical elements, including clinical experiences and Step exam scores.
The AMA has curated a selection of resources to help medical students and resident physicians manage the shifting timelines, cancellations and adjustments to testing, rotations and other events.