Is This the End of Step 2CS?

On May 26th, USMLE announced on their website that amidst the prolonged coronavirus crisis in the United States, Step 2CS test administrations will be suspended for the next 12-18 months. While previously there was speculation that USMLE Step 2CS may switch to a telehealth online format to administer Step 2CS to students, USMLE noted in a statement that, “Due to the complexity of technical and psychometric work required, we have determined we will not be able to meet timelines for the immediate release of a revised exam.” As a result, Step 2CS has been suspended for at least a year. 

This cancellation begs the question: Is this the end of Step 2CS? While USMLE elaborated that over the next few weeks they will be announcing more detailed information on what this decision will mean for examinees, e.g., refunds, progression through education/training and medical licensure, many medical students and medical education professionals suspect that Step 2CS in its traditional form may be gone for good. 

USMLE Step 2 Clinical Skills (CS) is the 2nd part of the USMLE Step 2 exam. The first part of USMLE Step 2 is called USMLE Step 2 Clinical Knowledge (CK) and is a one-day multiple choice exam administered over a 9-hour testing session consisting of around 300 questions. Step 2CS on the other hand is not a written exam and requires students to travel to one of only 5 testing centers in the United States to work through twelve standardized “patient” encounters using actors. Successfully passing both Step 2CK and Step 2CS is required for medical students to be allowed to continue in their medical education and eventually sit for the final of the USMLE examinations, USMLE Step 3. 

While important for testing physician interaction with patients in a clinical setting, USMLE Step 2CS has in the past not been a favorite of American medical students or IMGs. By large, the frustration with Step 2CS has not been due to the difficulty of the exam, but rather its accessibility. With Step 2CS testing centers only located only in Atlanta, Chicago, Houston, Los Angeles, and Philadelphia, most medical students have to travel (some further than others) in order to take the exam. And, if you are a medical student or know a medical student, then you are aware of how difficult it can be to find time to travel for any reason during medical school. For IMGs specifically, Step 2CS has been regarded as quite a pain as it requires international travel which is of course much lengthier and more expensive than domestic. As such, many medical students are happy about the decision to temporarily cancel Step 2CS, but are anxiously awaiting what its replacement is going to be. 

As telehealth and online testing has been on the rise in recent years, even before COVID-19 there has been debate about whether or not to change the way Step 2CS is administered. Between advances in educational virtual reality technology and the development of secure online testing systems, the use of actors and travel for Step 2CS has seemed increasingly unnecessary. However, the counter argument for taking Step 2CS online has been and continues to be that in practice, doctors see real live patients. Thus the debate develops: Is VR or online format clinical skills exam administration sufficient in testing how medical students will interact with real patients in the future? In the context of COVID-19 and Step 2CS testing center closures, the answer is, hopefully. 

While USMLE has not yet announced what the alternative to traditional Step 2CS testing will be for the next 12-18 months, it is highly unlikely that they will simply make everyone wait a year to take Step 2CS and progress in their medical education. Over the last week, this has been a significant source of anxiety in the IMG community. Often, IMGs have to work extra hard to study for the USMLE exams as many international medical schools have different curricula and medical school timelines than of US-MGs. In order to take any USMLE exam, IMGs also must become ECFMG certified in order to assess whether they are ready to enter residency or fellowship programs in the United States that are ACGME accredited. Only after IMGs are ECFMG certified are they allowed to take the USMLE exams during their specified “eligibility period.” As international medical students must then plan their travel to an international USMLE testing center and then to the United States for Step 2CS all during their eligibility period, it is not surprising that they are feeling significant stress of the up-in-the-air Step 2CS situation. 

As everyone awaits the official announcement from USMLE, the big question still hangs overhead: Even after the 12-18 month cancellation period for Step 2CS, will it ever resume its traditional form? As USMLE noted in their statement, it’s not that a telehealth format of Step 2CS was decided against, rather the project of moving it online was too complex to roll out in a short period of time. 

Time will tell if this is the end of Step 2CS as we know it. For now, save this article as we will revise it when more information becomes available. 

Update 1/27/2021:

The USMLE Step 2CS cancellation is now permanent. According to a statement made yesterday by USMLE:

“After reviewing current and anticipated progress with the exam and in consideration of the rapidly evolving medical education, practice and technology landscapes, we have decided to discontinue Step 2 CS. We have no plans to bring back Step 2 CS, but we intend to take this opportunity to focus on working with our colleagues in medical education and at the state medical boards to determine innovative ways to assess clinical skills.”

At this time we are not sure what this means for IMGs looking to gain ECFGM certification as it seems clinical and communication skills requirements do still stand. We will provide an update as one becomes available.

Update 3/25/2021:

ECFMG announced yesterday that Step 3 eligibility requirements for IMGs will revert to what it was before Step 2 CS. The requirements as part of the announcement are as follows:

Step 3 eligibility requirements will conform with criteria established before Step 2 CS became part of the USMLE. The requirements, which can be found here, are:

• Passing scores on Step 1 and Step 2 Clinical Knowledge (CK), and
• An MD degree or DO degree from an LCME- or COCA-accredited U.S. or Canadian medical school, or
• The equivalent of the MD degree from a medical school outside the U.S. and Canada that is listed in the World Directory of Medical Schools as meeting ECFMG eligibility requirements, and obtain ECFMG Certification.
• Meets all other eligibility criteria as listed in the USMLE Bulletin of Information.

According to the ECFMG Certification criteria, individuals who did not take Step 2CS before its date of discontinuation must now fulfill the clinical and communication skills requirement by way of applying via one of six “Pathways” and taking the OET English assessment. Pathways include the following:

• Pathway 1: Already Licensed to Practice Medicine in Another Country

  Pathway 1 is for applicants who currently hold or have recently held a license/registration to practice medicine without supervision. Applicants who meet the eligibility requirements for Pathway 1 must apply to Pathway 1 in order to meet the clinical and communication skills requirements for ECFMG Certification, unless they failed Step 2 CS; see Important Note.

  See the Pathway 1 page for more information.

• Pathway 2: Already Passed a Standardized Clinical Skills Exam for Medical Licensure

  This Pathway is for applicants who do not currently hold, or have not recently held, a license/registration to practice medicine without supervision (Pathway 1), but who successfully completed a secure, standardized clinical skills exam as a requirement for medical licensure or registration in a country other than the United States.

  See the Pathway 2 page for more information.

• Pathway 3: Medical School Accredited by Agency Recognized by World Federation for Medical Education (WFME)
• Pathway 4: Medical School Accredited by Agency that Has Received a Determination of Comparability by National Committee on Foreign Medical Education and Accreditation (NCFMEA)
• Pathway 5: Medical School Issues Degree Jointly with a U.S. Medical School Accredited by Liaison Committee on Medical Education (LCME)

  Pathways 3, 4, and 5 are for applicants who have not yet obtained a license/registration to practice medicine without supervision (Pathway 1) and who have not already passed an acceptable standardized clinical skills exam for medical licensure (Pathway 2). An applicant to Pathway 3, 4, or 5 must be a student or a recent graduate of a medical school that meets eligibility requirements established by ECFMG.

  See the page for Pathways 3, 4, and 5 for more information.

• Pathway 6: Evaluation of Clinical Patient Encounters by Licensed Physicians

  Pathway 6 is for applicants who do not meet the eligibility requirements for Pathway 1, 2, 3, 4, or 5 and/or have failed Step 2 CS one or more times. To meet the requirements for Pathway 6, the applicant’s clinical skills must be evaluated by licensed physicians using ECFMG’s Mini-Clinical Evaluation Exercise (Mini-CEX) for Pathway 6.