Step 2 CS, Part Three: Winners and Losers Edition

Last winter, I started a series on USMLE Step 2 CS.

In Part One, I reviewed the history of the exam, from its humble origins in the first NBME exam to its more recent rebirth from the Clinical Skills Assessment for international medical graduates. In Part Two, I covered medical student resistance to the test – and why those efforts failed. And I promised that in Part Three, I would finally reveal my plan for what should be done about USMLE Step 2 CS.

But then, this happened:

All it took was a pandemic – the likes of which the world hadn’t seen for over a century – to stop USMLE Step 2 CS.

This, of course, is huge news that has implications for stakeholders throughout medicine. So just like I did on Twitter, it’s time to break this thing down, Winners & Losers style.

WINNER: The Class of 2021.

Yeah, that’s right. The class who has been getting its teeth knocked in by COVID-19 finally wins a round.

(Now take that $1300 refund and do something nice for yourselves, won’t you?)

LOSER: Residency program directors.

And no, it’s not because USMLE Step 2 CS provided valuable information to most PDs. It’s because 12-18 months from now, PDs will have a scheduling nightmare on their hands as all of their interns need time off to travel to one of five cities and finally take their CS exams. (And God forbid some of these residents fail the CS exam – because then PDs will become responsible for the Step 2 CS remediation that previously occurred in medical school.)

[n.b. – Fortunately, neither of these things will be an issue in light of the USMLE’s recent clarifications – see ADDENDUM below.]

LOSER: The Step 2 CS scheduling black market.

Before COVID-19, the USMLE ran their testing centers like a hotel manager that strives for a high occupancy rate or an airline executive who realizes that you can’t make any money flying around empty seats. They tried to keep the centers filled to capacity – so scheduling an exam could be tough.

In response, many examinees turned to the black market to get their desired testing date. For a fee (anywhere from a couple of hundred to a couple of thousand dollars for examinees seeking specific dates at the supposedly more IMG-friendly Houston center), the black marketers would run a script on the USMLE scheduling website and snap up any new opening the second it appeared. With CS suspended, this business opportunity is gone… for now.

Of course, if Step 2 CS does return in 12-18 months as promised, the CS scheduling black market will look like a crowded city bazaar once again.

WINNER: Researchers.

The absence of Step 2 CS will set in motion a natural experiment: Can anyone tell the difference between residents or physicians who took Step 2 CS and those who didn’t?

(My guess is no.)

LOSER: State medical boards.

Historically, the Federation of State Medical Boards has required passing Step 2 CS as a pre-requisite for Step 3 registration. This made passing Step 2 CS a licensure requirement – even if the test is not explicitly required by an individual state’s medical practice act – and sets up a dilemma for the FSMB and state boards.

In the wake of the CS suspension, the FSMB has announced that it will allow certain examinees* to take Step 3 without passing Step 2 CS.

Of course, after state medical boards allow physicians to become licensed without CS, it’s gonna be really hard to articulate a reason why future physicians should be required to pass the exam.

WINNER: The NBME.

Sure, they’ll have to make do without the over $40 million in revenue that the CS exam generates. (Trust me, they’ll be okay.)

But honestly, the NBME is better off suspending the test than proceeding with their previously-announced plan to require a virtual “telehealth” CS exam. Following through with that half-baked scheme could have created an even larger threat to the long-term viability of the CS exam. They protect their long-term interests with this move.

LOSER: The NBOME.

So far, at least, despite the COVID-19 pandemic, the NBME’s suspension of Step 2 CS, and plain old-fashioned common sense, the National Board of Osteopathic Medical Examiners continues to assert that they will resume testing for their Step 2 CS doppelganger, the COMLEX Part 2 PE.

(Gentlemen, prepare to take heavy fire.)

WINNERS: The founders of the #EndStep2CS movement.

Sure, Step 2 CS is just suspended – not cancelled.

But still – after organizing a petition campaign that resulted in over 20,000 signatures and getting stiff-armed by the NBME, this news has gotta feel good.

LOSERS: Any U.S. medical student who took CS before COVID-19.

C’mon, admit it.

Until now, you were a little smug knowing that you got Step 2 CS out of the way before the pandemic sent all of your classmates scurrying around in a panic.

But now? You’re just wishing you could get that $1300 back.

DOUBLE LOSERS: Anyone who *failed* Step 2 CS before COVID-19.

It’s one thing to graduate, rank, or license a physician who never took Step 2 CS – but what about someone who failed it?

Remember, ever since the #EndStep2CS campaign, around 5% of U.S. medical students have failed the CS exam. While 90% of these examinees repeat the exam and pass, it’s still a devastating and often career-altering event. And that was before COVID-19.

Now, anyone who was waiting for a Step 2 CS re-take has a black mark on their record that they can’t easily erase. And with CS suspended for 12-18 months, the light at the end of the tunnel for these examinees seems increasingly distant.*

LOSERS: International medical graduates (IMGs).

To apply for ACGME-accredited residency positions in the United States, IMGs must be certified by the Educational Commission for Foreign Medical Graduates (ECFMG). That certification requires passing USMLE Step 1, Step 2 CK, and Step 2 CS.

Will the ECFMG be willing to certify IMGs without some type of clinical skills assessment? I doubt it. (Remember, it was program directors’ and medical boards’ desire for a clinical skills exam for IMGs that led to Step 2 CS in the first place.)

Yet how IMGs will get certified without Step 2 CS is unclear. The ECFMG’s initial response reads like a statement from an organization that was caught completely off-guard by yesterday’s news.

How likely is it that the ECFMG will successfully identify “alternatives to Step 2 CS that can be available now” – when the NBME clearly failed to do so after scrambling for two months?

WINNER: The Unmatched.

Last year, IMGs filled 7,376 positions in the Match, making up 22.8% of all matched applicants. But if new IMGs are unable to get certified, residency programs will need to look more closely at previously unmatched applicants this year.

If IMGs cannot get ECFMG certification, residency program directors in pathology, internal medicine, neurology, and family medicine may need to look closer at previously-unmatched applicants – or risk having their programs go unfilled.

LOSER: Employees at the USMLE’s CSEC centers.

I’m told that over 700 managers and employees at the USMLE’s CSEC test sites will be released June 12.

Regardless of how you feel about the value of the Step 2 CS exam, its suspension means that more Americans are losing their jobs. It’s hard to celebrate that.

WINNER: The Virtual Step 2 CS.

The CS suspension temporarily puts an end to the USMLE’s previously-announced proposal to turn the CS into a virtual exam with a “telehealth” format. But I have a sneaking suspicion we haven’t seen the last of Virtual Step 2 CS. Read the USMLE’s statement closely and you’ll see what I mean.

A virtual exam could address two of the biggest complaints about CS – its cost and inconvenience.

Of course, a virtual exam will also raise new questions about validity and necessity. (Just imagine what it’s going to be like in 2022, when a post-call intern leaves the ICU or the OR to go take the new Virtual Step 2 CS, where they will interact by computer with a grimacing avatar or have a FaceTime call with an actor in order to prove their readiness to care for real patients.)

Still, with CSEC employees being dismissed, the USMLE won’t be able to scale back up to normal operations rapidly – even when COVID-19 clears. This is just my read of the tea leaves, and I may be wrong – but I think the USMLE is going to bet on a virtual future.

LOSER: Medical school clinical skills education.

For all its flaws, the USMLE Step 2 CS exam did result in more focus on teaching clinical skills in medical school. With Step 2 CS gone – and with medical schools facing the same problems with examinee/standardized patient safety and social distancing that necessitated its suspension – I’ve got to think that clinical skills education is going to suffer.

UNDECIDED: The fate of USMLE Step 2 CS.

Will the Step 2 CS suspension become permanent – or at least lead to significant improvements in the test’s nature, cost, and format? Or will the old Step 2 CS just hibernate for 12-18 months, then re-emerge?

(Ultimately, this one is up to us.)

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ADDENDUM (5/28/2020)

The USMLE has now clarified several of the initial uncertainties that their decision created, which changes some of the winners and losers above. These clarifications are listed on their website, but the highlights are:

1. U.S. MDs, U.S. DOs, and IMGs who have received ECFMG certification will be able to register for USMLE Step 3 without passing Step 2 CS.

The one group this leaves out are IMGs who have not received ECFMG certification. (The USMLE’s update also remains silent on how the ECFMG will provide certification without the CS exam, noting only that “other alternatives are being explored” and “an update… will be available in the coming weeks.”

2. Because of #1, suspension of Step 2 CS will not impact licensure.

“[The] FSMB has reviewed state statutes for medical licensing and confirmed that no legislative changes will be required because of the CS suspension. FSMB will work with the handful of state medical boards whose administrative rules list passage of Step 2 CS.”

In other words, an examinee who passes Step 1, Step 2 CK, and Step 3 can be licensed – which should obviate any need for interns to go back and take Step 2 CS in residency.

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