The case against the Step 2 Clinical Skills Exam

By | June 11, 2019

In the era of the recognition of vast burnout in medicine, particularly amongst medical students, there needs to be a call to address structural problems in medical education. One particularly low-hanging fruit is the Step 2 Clinical Skills Exam (Step 2 CS). The exam has a relatively short history. The National Board of Medical Examiners (NBME) developed the exam for American medical students in 2004; it had previously been developed for international medical graduates in 1998. The American Medical Association (AMA) deplored before the initiation of this exam and stated that assessments of clinical skills are “best performed using a rigorous and consistent examination administered by the medical school” and “should not be used in evaluation for licensure of graduates of LCME [Liaison Committee on Medical Education]- and AOA [American Osteopathic Association]-accredited medical schools.” The AMA worried that the test would neither improve patient safety nor improve clinical skills beyond the current level.

The AMA was correct as the test has been shown to do neither.

The test, however; has been shown to be a burden on students. Since 2016 over 18,500 medical students have signed an online petition to end Step 2 CS. In an unpublished poll, students oft-quoted finances as a particular source of burden. Registering for the test alone costs $ 1,290. This does not take into account the associated costs of travel, lodging, and food at one of the five tests centers in the approximately 3-million-square-mile continental U.S. (there are no testing centers in Hawaii despite the presence of medical students there) costs can easily exceed $ 2,000 for students. Each year, the exam rakes in $ 36 million for the NBME. Based on the failure rates of the exam, it costs $ 1 million dollars of student’s money to find the one student who fails two sequential exams. This can hardly be considered a cost-effective endeavor, and unfortunately, the costs are entirely borne by students already struggling with debt.” This unnecessary expense in the context of the average medical student debt at graduation of $ 166,750 is unconscionable. In 2002, when the NBME was discussing the rollout of the exam, the American Association for Medical Colleges (AAMC) encouraged the NBME to delay until alternative funding sources could lessen this new financial stress. The NBME did not wait.

The $ 1,290 exam comes at a time during fourth year when students are already spending thousands of dollars on applications, travel, and lodging for residency interviews. The beginning of fourth year is quite crucial to medical students as it provides an opportunity to further delve into a subspecialty or a critical time to discern which specialty to choose. This ought to be a time to concentrate on and excel at clinical care. Instead, given that it is an eight-hour exam, this exam often takes students out of clinical rotations for three days. This test must be scheduled months in advance — a time difficult to predict for many fourth-year medical students. Specifically, this time is often used to schedule sub-internships and “away rotations” in which students gain valuable clinical skills at other institutions. Scheduling Step 2CS, therefore, requires students to guess successfully which months they may be accepted to these away rotations; otherwise, they will suffer from interruptions in their learning time to take an exam with a 95% pass rate.

Medical student deans also find issue with the test. In a 2106 survey of 269 medical school deans at 125 different medical schools 88% were concerned about the cost of the exam, 83% were concerned about the inconvenience of the exam, and 68% were concerned about the lack of feedback provided to test takers.

Of course, learning clinical skills is of paramount importance in medical school, which is why students pay over $ 60,000 a year to attend a LCME accredited medical school. That is why 94% of LCME accredited medical schools require an Observed Structured Clinical Examinations (OSCEs) to assess students’ clinical skills and effectiveness of the curriculum during the fourth year. LCME accredited schools have the responsibility to “demonstrate that their graduates exhibit general professional competencies that are appropriate for entry to the next stage of their training” via teaching, assessment, and feedback. Step 2 CS offers no opportunity for feedback, leaving test-takers confounded as to what skills they performed well or need improvement on. There are three components to the exam: Communication and Interpersonal Skills (CIS), Spoken English Proficiency (SEP), and Integrated Clinical Encounter (ICE). The exam is testing skills that students have already demonstrated mastery of daily by virtue of passing clinical rotations and sub-internships.

The USMLE website has a section detailing the “efficacy” of Step 2 CS exam whose listed purpose is “protecting the public.” Instead, one of the listed publications only demonstrates that the exam is not inherently biased in structure (the gender of the standardized patient does not impact scoring of examinees); which is something that hardly constitutes congratulations at a $ 1,290 price-tag. Another listed study shows, a “modest relationship” between Step 2 CS communication score and communication ratings for first-year internal medicine residents. A study showing that people maintain their communication skills over time does not constitute a strong case for the utility of Step 2 CS. Another listed study discusses the variability in physical examination skills among U.S. medical students. This would be a reasonable argument for the exam if the exam did not take away from clinical time, or if there was any formative feedback available for students to improve. After 15 years of medical school students taking this exam, there is simply no evidence available that it has improved patient outcomes. There is; however, no shortage of evidence that this has become an unnecessary financial, time, and educational burden on students. Clinical excellence, clear communication, and compassion are the goals of medicine and most medical students; Step 2 CS does not help us achieve that.

Madeline Wozniak is a medical student.

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