Mailbag: Ending Step 2 CS, Application Caps, and In Person Interviews

Well, the inaugural Sheriff of Sodium mailbag last week was a big success… and since there have been some important developments since then, I figured we ought to clear out the old mailbox again before the holiday.  Think of it as my Thanksgiving gift to you.  

As before, these are real questions from real readers, though just as before, I’ve edited them for brevity, clarity, and to maintain anonymity.  

Did you hear?  The American Medical Association House of Delegates just passed a resolution calling for an end to the USMLE Step 2 CS and COMLEX-USA Level 2-PE exams! Could this be the end of these exams for good?

Yes, I heard.

But no, it won’t matter.

Remember, the AMA vigorously opposed the original USMLE Step 2 CS exam back in 2004. At the time, the New England Journal of Medicine politely reminded everyone that the NBME and FSMB could do whatever the flip they wanted.

Snippet from the NEJM article introducing the USMLE Step 2 CS examination.

The condemnation from the profession only matters if your organization actually cares what the broader profession thinks.  The USMLE doesn’t.

Even though medical students pay for Step 2 CS, the state medical boards are actually the USMLE’s customers.  The medical boards like USMLE Step 2 CS (or, at least, they like the appearance of requiring a clinical skills exam).  To the medical boards, whether the value of the exam outweighs the cost imposed on students is a moot point.  It looks good for medical boards to require a demonstration of clinical skills, and it looks bad to stop requiring it.

Instead of the four-figure tests administered by the NBME and NBOME, the AMA resolution calls for a “replacement examination process to be administered within [U.S. MD and DO] medical schools that verifies each medical student’s competence in key clinical skills required to be a physician.”  It’s a logical solution, and if done well, it could satisfy the medical boards’ desire to verify clinical skills prior to licensure.

Sadly, there’s a problem: many medical schools don’t want to do this.

This is a point I hadn’t appreciated until I began writing about USMLE Step 2 CS last year.  After I posted Part 2, I got an e-mail from a former dean.  During the #EndStep2CS movement, he started to explore whether using the school’s Objective Structured Clinical Evaluation (OSCE) in lieu of Step 2 CS could be a viable option.  

Both his boss and the clinical skills education faculty hated the idea.  

Both of them had the same concern: they didn’t want the school to have to be the bad guy.  Students already pitched a fit about losing a point here or there on the OSCE, and would fight vehemently about how they should have received a higher grade.  They feared that failing students would at least create an ugly situation – and might even generate a lawsuit.  They strongly preferred to outsource this responsibility to a third party.

Now, I have no idea how widespread this sentiment might be.  (My instinct says that most schools would have more backbone.)  But the fact that it was ever expressed – at a very highly ranked U.S. medical school, no less – was very disappointing.  It makes me worry that, even though many students and faculty (myself included) favor the idea of having accredited medical schools vouch for their students’ clinical skills proficiency, efforts to implement such a system might be sabotaged from the inside.

It highlights another part of our broken system that I haven’t yet focused much on: the medical school.  Look for more on this in the future.

The USMLE just announced that they’re going to bring back Step 2 CS in a computer-based format.  What can we do to prevent this?


I’m going to be brutally honest: not much.

Look, since the USMLE’s announcement in May, I’ve been warning everyone that Step 2 CS would come back; that we won’t be able to prevent it; and the best we can do about it is advocate for a more beneficial and less harmful testing model.

Not long ago, I wrote that even after considering it from every possible angle, I could only envision three strategies that could end Step 2 CS: a lawsuit, successful political lobbying, or new market competition.  

None of those things seems likely, but if you want to force the USMLE to abandon Step 2 CS, you know what you need to do.   Lawyer up.  Lobby your state representative.  Build a competitor and leverage the state medical board to accept your test.  

(And to respond to one e-mail in particular: no, just convincing your state’s medical board to accept the results of the state university’s OSCE won’t work.  Why?  Because the state board will still require USMLE Step 3 for licensure – and the FSMB will not allow you to register for Step 3 until you’ve passed Step 2 CS.)

My point is, shouting into the void on social media will not work.  Neither will circulating petitions or sending angry letters to the NBME demanding that they just walk away from the test.  They’re not gonna do it.

Coming soon: the new, “revitalized” computer-based clinical skills licensure exam: USMLE Step 2 CS Total Landscaping.

That said, Step 2 CS is vulnerable now.  

Converting to a computer-based test weakens the test’s face validity, and likely diminishes its consequential validity as well.  That’s important, because in the absence of any good evidence that the exam has predictive validity, these have long been the arguments the NBME has used to justify why we need USMLE Step 2 CS.

Even some of those that supported Step 2 CS may have concerns about a computer-based test, and the NBME may be willing to make some concessions to gain broader acceptance of the test.  In other words, there may be the opportunity to change certain aspects of the exam by arguing for a test that has a lower cost; is less inconvenient; provides greater transparency; generates useful feedback to examinees or residency programs; and/or is studied carefully to demonstrate predictive validity.


How can you say you support applicants if you advocate for application caps?  If applications are capped, NO IMGs will MATCH IN USA RESIDENCY PROGRAMS AGAIN.  IMGs HAVE TO APPLY TO 100 PROGRAMS TO GET 1 INTERVIEW!!!  HOW DO YOU NOT UNDERSTAND THIS???

Well. You got me there.

Just last week, I was reviewing applications for our program.

I read one.

Kind of lackluster. I was getting ready to move it to the No Interview pile… but then I saw it.

Oh crap.

We were the 100th program he’d applied to.

“Well, I guess he’s got us,” I said, as I swiftly moved his application over to the Interview pile.

(I hope it’s obvious that I’m being sarcastic. But this line of logic kills me.)

I say that application caps will improve the system and benefit most applicants – IMGs included.  I’ve explained why in the past – including more detailed rebuttals of the point this reader raised.  

Why are some residency programs requiring in person interviews?  Isn’t that prohibited this year?  

With COVID-19 cases surging, requiring in-person interviews may be selfish, short-sighted, and fly in the face of public health guidance and good old fashioned common sense, it’s not technically against any rule.  

Yes, the Coalition for Physician Accountability – the super-organization composed of the ‘alphabet soup’ of organizations that rule medical education – recommended that all interviews be virtual this season.  But despite the enormous power of the organizations involved, the recommendation itself has no teeth.  Programs can do what they want.

My advice?

  1. Name names.  The programs who do this should be held up to scrutiny.  Name names.  Let the institution and program leadership articulate why they believe that the recommendations everyone else is following shouldn’t apply to them. (Some people have already done this on social media, and if you send me other links, I’ll link to them here as well.)
  2. Vote with your feet.  If a program has so little regard for their staff and their patients as to send applicants traveling from one COVID-infested facility to another, think about how they’re gonna treat you as a resident.  (Hint: it won’t be good.) 
  3. Channel your rage.  Sometimes, it feels good to rail about this kind of thing on social media.  But if you want to effect change – not just blow off steam – make sure you’re putting your words in the right ears.  Think about who actually has the power to make the change you want, and talk in their direction.   

This last point is an important one, and I may revisit it in an upcoming mailbag to address a different question I received just today.  But with Thanksgiving rapidly closing in, I think it’s time to sign off and go count my many blessings.  So to all of you who take the time to read my words – or who send me your words to read – I hope you take a moment to count your blessings, too.  


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