There is no place for USMLE Step 2 CS during a pandemic


As American cities continue to shelter-in-place to mitigate the spread of COVID-19, thousands of medical students are in limbo as they wait to see when they will be able to take their licensing examinations. The growing backlog of test-takers is particularly problematic for the Step 2 Clinical Skills examination, a one-day clinical performance exam which is held on limited dates at one of five testing locations across the United States.

The most recent update from the National Board of Medical Examiners states that test centers are scheduled to reopen on June 1 to resume administering Step 2 CS. The NBME has not established a contingency plan for how to take Step 2 CS should standardized testing center shutdowns persist longer than expected. This is a cause of anxiety for students, given that Step 2 CS is a requirement for medical school graduation and entry to residency. Moreover, passing Step 2 CS is one of the eligibility criteria for registering for Step 3, the final examination for medical licensure.

Many institutions are temporarily waiving the Step 2 CS requirement. Students will end up taking the test to complete the formal licensing process at a later date. However, I believe that the most worthwhile solution is canceling the examination altogether.

Step 2 CS has been a source of contention for years. Medical students are forced to spend thousands of dollars on registration fees, flights, and accommodations to be evaluated on skills such as communication and history-taking, which are already repeatedly assessed at our respective institutions. The vast majority of test-takers pass anyway; for the minority that don’t, failing may derail their residency applications pending a successful retake of the test. This is galling given the dearth of evidence to suggest that Step 2 CS is a predictor of improved outcomes in medical training, as admitted by NBME representatives themselves.

But the pandemic has given rise to significant new concerns. There will likely be more interruptions to the testing schedule over the next 18-month period as intermittent shutdowns occur to mitigate COVID-19 spread while we wait for a vaccine. The backlog will continue to grow.

Most importantly, medical students from all over the United States, Canada, and beyond converge upon five American cities to take Step 2 CS. In contrast to Step 1 and Step 2 CK, the test itself involves a series of patient interactions. Continuing to administer Step 2 CS exams means requiring medical students to place themselves—and their loved ones—at increased risk of COVID-19 exposure. It is a public health risk for the local communities of Atlanta, Houston, Los Angeles, Philadelphia, and Chicago. And, in a time of increasing medical personnel shortages, we cannot afford to delay medical trainee advancement on account of a Step 2 CS failure.

Fundamentally, Step 2 CS is a high-risk test in the setting of COVID-19 with unproven benefits that do not justify the tradeoff. Medical schools and residencies need to waive Step 2 CS as a requirement. Moreover, they need to push for the NBME to remove Step 2 CS from Step 3 eligibility criteria. The NBME itself needs to demonstrate that student safety and well-being takes precedence over the organization’s bottom line.

There is no place for Step 2 CS in the evaluation and promotion of medical trainees, especially during a pandemic.

Anna Goshua is a medical student.

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