Administered in two parts, passage of both portions of Step 2 of the United States Medical Licensure Examinations® (USMLE®) is a typical requirement in order to graduate and begin the first year of residency. Half of that equation will be impossible for some medical students in the upcoming residency application cycle.

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The USMLE program announced in late May that it had suspended Step 2 Clinical Skills (CS) exams for a period of 12-18 months. The Step 2 Clinical Knowledge exam, like the Step 1 and Step 3 exams, will be administered at testing centers and, to meet demand caused by delays, on some medical school campuses.

Factors behind the suspension

Unlike other variations of the Step exams, Step 2 CS is administered in five cities across the country. For some students, the facilities are a flight away. The discouragement of non-essential travel played a role in the decision to suspend its administration.

Another factor, according to representatives from the two organizations that oversee the exams—the National Board of Medical Examiners (NBME) and the Federation of State Medical Boards (FSMB)—was that the all-day exam uses an exam format with standardized patients.. That could introduce health and safety risks at a time when physical distancing measures remain in place in order to reduce the spread of the coronavirus.

“We recognized that there is a very high likelihood that this COVID-related disruption will be continuing, whether it’s some of the travel elements, some of the local restrictions and guidelines or even the potential for a second wave,” said David Johnson, the FSMB’s chief assessment officer. “With that in mind we felt that it would be very challenging to create any sort of revised exam on an accelerated timeline.”

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Fallout in the Match

Step 2 CS’ aim is to examine clinical skills in a performance-based setting, rather than a multiple-choice exam, and as is the case for any Step exam, its primary purpose is medical licensure.

Still, its secondary purposes do influence the residency selection process. With factors weighed including communication and interpersonal skills and spoken English proficiency, Step 2 CS is an important metric for international medical graduates looking to match into a U.S. residency program.

While the exam is suspended the FSMB and NBME will work with the medical education community as they seek other attestations of a candidate’s clinical skills.

“During the suspension of the exam, other attestations of clinical skills may be appropriate,” said Michael Barone, MD, MPH, a pediatrician who is vice president of licensure programs at NBME. “Many of these go outside the purview of the USMLE program and are more related to the educational process.”

As far as what the exam’s suspension means for the licensure process, the organizations behind the exam are working with stakeholders, in particular state medical boards, to determine if students who progress into residency during the time period at which the exam is not being offered will still be required to take it.

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Future of Step 2 CS

Representatives from the USMLE tout Step 2 CS as a standardized assessment of important clinical skills, and that the exam has the support of many medical school faculty. The exam has, however, come under fire in recent years.

Detractors say that the exam is costly and time consuming for trainees who are taking on debt and lacking in schedule flexibility. Step 2 CS’ suspension may present an opportunity. Among the considerations being examined is a remote version of the exam which is formatted to measure competencies important for clinical practice.

“The competencies that have been assessed in the prior incarnation of the exam, mainly communications, are critically important,” Dr. Barone said. “We envision being able to do some communications assessment in a format where we are not bringing patients and staff together. What we are talking about is a format that allows for competency assessment in this pandemic, and one that provides more value for examinees and state board stakeholders.”

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 manage the shifting timelines, cancellations and adjustments to testing, rotations and other events.  

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