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In January 2021, the USMLE Step 2 Clinical Skills (CS) test for medical school students and graduates was permanently discontinued. USMLE Step 1, Step 2 Clinical Knowledge (CK), and Step 3 are still required steps for medical students and residents.
The United States Medical Licensing Examination (USMLE) co-sponsors, the Federation of State Medical Boards (FSMB) and the National Board of Medical Examiners (NBME), made the announcement to officially cancel Step 2 CS for a variety of reasons. Let’s go over what this means for you.
For graduates of Caribbean medical schools, this change alters the documentation you must submit for ECFMG certification.
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What Step 2 CS Was Designed to Assess
USMLE Step 2 CS was an Objective Structured Clinical Examination (OSCE) that presented students with standardized patient encounters to assess their interpersonal skills, differential diagnosis, communication ability, and more.
Step 2 CS was often required to graduate from med school, and was always required for IMGs to obtain ECFMG certification.
Before it was suspended, Step 2 CS was designed to assess the following competencies:
- How test takers gathered information from patients
- How future doctors performed physical examinations
- How students communicated their findings from clinical encounters to patients and colleagues
But with the pandemic changing how physicians communicated with patients, the test needed to be suspended.
Why the Exam Was Discontinued
Back in 2020, the COVID-19 pandemic initially forced a suspension of the test, as it required test takers to interact with patients in person, practicing physical exams, for example, which was not possible during lockdowns and social distancing.
In January 2021, the USMLE Step 2 CS cancellation became permanent.
There is no plan to bring back Step 2 CS. Instead, the test developers have focused on collaborating with their peers at medical education institutions and state medical boards to develop innovative ways to assess clinical skills.
“It became clear that the relaunch of a modified Step 2 CS exam would not meet our expectations to be appreciably better than the prior exam.”
The USMLE program still believes independent standardized tests for medical knowledge and clinical skills are important. However, it now feels that clinical reasoning and communication skills will be able to be assessed in other USMLE Steps and other required tests.
Did Anything Replace Step 2 CS?
Nothing has directly replaced USMLE Step 2 CS (Clinical Skills).
However, for international medical graduates (IMGs), the Occupational English Test (OET) has been introduced as a requirement for IMGs to test their English proficiency, which the Step 2 CS used to do.
Firstly, the Step 2 CS had a high pass rate. About 95% of test takers passed it. Students who wouldn’t have passed Step 2 CS probably won’t pass other standardized tests required to apply to residency and practice medicine, so Step 2 CS doesn’t really need a replacement.
Secondly, the communication-testing portions of other USMLE Steps have been slightly enhanced since the discontinuation of Step 2 CS, and other school-based assessments have picked up some of the slack left by the suspension of Step 2 CS. So Step 2 CS is now completely irrelevant.
“Computer-based case simulations in Step 3 and communication content recently bolstered in Step 1 are examples of these efforts that will continue. While not a replacement for Step 2 CS, these formats continue to contribute positively, e.g., measuring critical knowledge of medical communication.”
Thirdly, Step 2 CS was very expensive to register for the exam and to travel to far-away testing centers, so no one is really sad it went away. No one’s fighting for it to return.
What This Means for Medical Students and Residency
The cancellation of Step 2 CS impacts your medical education journey. Let’s cover the different ways that medical students, residency applicants, and international medical graduates may be affected.
Financial & Logistical Impact
The discontinuation of Step 2 CS reduces the cost of medical education and lightens the financial burden on students. There were not many testing centers, so — on top of the $1,000+ registration cost — travel costs could push your cost burden even higher.
“Step 2 CS is cancelled! Every medical student’s bank account can celebrate! Given the high pass rates of this exam and the high cost and requirement to travel to a regional testing center, it has come under a lot of scrutiny recently. The cost to travel and take the exam can easily exceed $2,000, which can be a significant drain to medical students who are already hundreds of thousands of dollars in debt.”
Shift in Exam Pressure
For med students applying to medical residency, the cancellation of Step 2 CS — along with the move to a pass/fail grading scale for Step 1 — increases the pressure to score well on USMLE Step 2 CK (Clinical Knowledge).
A 250 is a good Step 2 CK score. A 260 is a fantastic score, making you competitive at top-tier residency programs. You need a 218 to pass the Step 2 CK, but your ERAS application may suffer if test performance is low.
“With Step 1 becoming pass/fail in 2021 and Step 2 CS now cancelled, students’ Step 2 CK scores must solely demonstrate their knowledge, clinical acumen, and ability to learn, interpret, and apply a vast body of knowledge. This now makes Step 2 CK an incredibly high-pressure exam with no margin for error. The good news is that means all of your effort, time, and resources can be focused on performing well on one exam, rather than multiple exams.”
Considerations for IMGs & Caribbean Students
Although permanently discontinuing Step 2 CS is great for most students, it may present additional challenges for Caribbean university graduates and international medical graduates (IMGs).
IMGs, including Caribbean and Canadian med school graduates, must now submit the Occupational English Test (OET) to satisfy the Educational Commission for Foreign Medical Graduates (ECFMG) eligibility requirements.
“Some residency program directors utilized the Step 2 CS as a standardized way to ensure that residency applicants were clinically adept, regardless of where they trained or went to school. With Step 2 CS now cancelled, it seems like international medical graduates must rely solely on their Step 2 CK scores to demonstrate their adeptness.”
Read Next: Friendlies Residency Programs for IMGs
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Joel Ramirez MD
Dr. Ramirez is an integrated vascular surgery resident at UCSF who is passionate about teaching and tutoring for several board exams. He has served on the University of California, San Francisco School of Medicine admissions committee and is committed to being a leader in medical education.
