The End of USMLE Step 2 CS – Winners and Losers Edition

By now, you’ve heard the big news: the National Board of Medical Examiners and Federation of State Medical Boards announced today that they were permanently discontinuing their plan to relaunch the Step 2 CS exam.

Obviously, this truly shocking news demanded an emergency edition of Winners & Losers.

So let’s get to it: who wins – and who loses – when USMLE Step 2 CS goes away for good?

LOSER: Faith in the Sheriff of Sodium’s predictions.

Across an expansive, four-part series analyzing the exam and what to do about it, the one thing that I repeatedly said would never happen just happened. Yet here we are.

(One thing you can say about the predictions you get on my site: they’re worth at least as much as you pay for them.)

WINNER: The National Board of Medical Examiners.

Had the NBME had pushed forward with their plan to introduce the new “revitalized” virtual Step 2 CS exam, they would have been subjected to ridicule and scorn. And it would have been deserved.

From a business standpoint, it makes little sense to invest in a project that effectively affixes a giant “KICK ME” sign to your organizational buttocks – especially when your market monopoly really depends only upon your maintaining a modicum of goodwill within the medical profession and medical regulation communities. At this point, walking away was the right move.

(For the record, I can’t imagine the NBME abandoning clinical skills evaluation entirely. The fine print in their announcement – that their “commitment to performance-based assessment and clinical skills has accelerated” is almost certainly an omen that there is more to come.)

The NBOME has stubbornly refused to divest from their clinical skills exam.

LOSER: The National Board of Osteopathic Medical Examiners.

In contrast to the NBME – who rapidly divested from the Step 2 CS exam early in the pandemic – the NBOME has continued to invest in their clinical skills exam, the COMLEX-USA Level 2-PE.

The fact that the NBME rapidly moved on enabled them to walk away from the CS exam now without taking an additional financial hit: they’ll lose the revenue from CS, but also the expenses. Meanwhile, the NBOME took a seven-figure payroll protection plan loan to keep their operations going, invested in consultants from Johns Hopkins to figure out how to offer the exam amidst a pandemic, and even moved forward with plans to add a new test center. They’re gonna need to generate some revenue to justify those investments.

So naturally, the NBOME’s CEO – who rose to his lofty professional perch by bringing the Level 2-PE into existence – has already reached out to osteopathic medical schools to emphasize their commitment to plans to resume the COMLEX-USA Level 2-PE in spring 2021.

Dear NBOME Colleagues,

As an FYI, the USMLE program, announced today that they now plan to discontinue their relaunch of a modified Step 2 CS clinical skills exam.

After previously announcing the plan for a temporary “virtual CS exam,” the owners of the USMLE Step 2 CX now state that it was not feasible to deliver this by the announced timetable. In addition, they were meeting increasing resistance from some of their stakeholders. The American Medical Association and many of USMLE’s stakeholder groups, particularly MD students and their advocates, have been lobbying for the elimination of the Step 2 CS exam, many since even before it began in 2004, and there has been a marked escalation of these efforts since the pandemic. . .

Our plans to provide access to Level 2-PE again in April 2021 are progressing along well, of course, contingent on local and national conditions with the pandemic and our ability to provide safe access. . .

John R. Gimpel, DO

President and CEO, National Board of Osteopathic Medical Examiners

Osteopathic medical students were already angry about the handling of Level 2-PE. Look for that amorphous anger to coalesce into more organized efforts soon.


The NBOME’s heavy-handedness – and the animosity it has generated among many osteopathic students – will likely result in more DOs choosing to take the USMLE to meet state licensure requirements.

Remember, only a handful of states explicitly require COMLEX-USA for DO licensure – and since many graduating DOs have already taken USMLE Steps 1 and 2 CK, all they’d have to do is pass Step 3 to bypass the need for Level 2-PE (so long as their school doesn’t play henchman for the NBOME with a Level 2-PE graduation requirement).

(For those interested, back in the fall, I included a list of state-by-state osteopathic licensure requirements in this post – though the American Osteopathic Association password-protected after I linked to it. Still, you can find their list archived on the Wayback Machine.)

It took five years and a pandemic, but #EndStep2CS was ultimately successful.

WINNER: The #EndStep2CS movement.

Back in 2016, a group of medical students organized the most significant sustained challenge to the USMLE Step 2 CS exam. I’m sure this isn’t how they envisioned that their efforts would succeed… but all is well that ends well.

LOSER: Previous USMLE Step 2 CS test-takers.

To quote Alanis Morisette, it’s black fly in your Chardonnay. Or maybe it’s a death row pardon two minutes too late. Whatever it is, that $1300 you paid for your Step 2 CS exam ain’t coming back.

This end of Step 2 CS is even more bittersweet for all of those who initially failed the exam in the past – and suffered because of it.

LOSER: Standardized patients.

For standardized patients, participating in USMLE Step 2 CS had to be like playing in the big leagues, right? Now, the opportunity to perform like Cosmo Kramer will have to be achieved on a smaller stage.

(In all seriousness, I hope that that medical schools hire the well-trained SPs so that they can contribute to students’ education in a way that’s more formative than performative.)

WINNER: Residency program directors.

Now, PDs don’t have to worry about their interns and residents who haven’t taken Step 2 CS being recalled from patient care responsibilities to take care of a virtual patient at a Prometric center.

Of course, this only applies to MD residents, since as discussed above, the NBOME continues to foolishly cling to their ultimatum that all DOs must take Level 2-PE to complete the COMLEX-USA series – even if they’re already in residency when they take it. (Because clearly, we need these physicians to demonstrate that they’re ready to take care of real patients – when they’re actually taking care of real patients.)


For international medical graduates, the suspension of Step 2 CS resulted in a new requirement for ECFMG certification: the Occupational English Test.

The test ain’t cheap (~$450 U.S. dollars) – so when combined with the tenfold increase in the ECFMG’s credential verification, IMGs ended up paying just as much under the new system as they did for USMLE Step 2 CS.

Now, with Step 2 CS gone, the OET is likely here to stay.

The ECFMG has promised to expand their ‘pathways’ for IMGs to become eligible for the 2022 Match.

LOSER: IMGs excluded from the ECFMG pathways.

Without Step 2 CS, the ECFMG came out with five “pathways” designed to curate a group of IMGs who – based on their professional pedigree or performance on other standardized clinical skills exams – would reasonably be expected to have passed the Step 2 CS exam. Of course, these pathways didn’t include all IMGs, and undoubtedly excluded many who would have passed Step 2 CS – had there been a Step 2 CS for them to take.

What happens to these applicants now? It’s not clear.

The ECFMG has already indicated that they’ll continue the five pathways available for this year’s Match, and will add a sixth – but what that will require and who will be eligible remain to be seen. For now, these applicants are still on the outside looking in.

WINNER: Incompetent residency applicants.

The USMLE Step 2 CS exam was widely regarded as expensive and unnecessary by students at U.S. medical schools and the residency programs that train them. This belief was supported by data: when 95% of test-takers passed the exam on their first attempt, and 87% of those who initially failed subsequently passed (often without any additional preparation), what is the test really accomplishing?

For international medical graduates, though, only 75% of first-time test takers pass Step 2 CS. And within the group of test-takers who fail the exam, there are undoubtedly some who do not possess the basic English proficiency, information gathering skills, or clinical reasoning to succeed in a residency training program. The demise of USMLE Step 2 CS is good news for these folks – but not for their program director or patients.

As I’ve discussed before, it was the ECFMG that developed the clinical skills exam that would become USMLE Step 2 CS – and I wouldn’t be surprised at all if they choose to resurrect the Step 2 CS prototype for their own clinical skills exam again.

WINNER: Innovation in medical education.

The one positive legacy of the USMLE Step 2 CS era was a renewed interest in clinical skills education at many medical schools. Of course, even this benefit came at the cost of emphasizing a ‘checklist’ style approach to the history and physical exam to succeed on Step 2 CS, instead of the hypothesis-driven approach to diagnosis that master clinicians use to help actual patients.

Now, though, schools can again reconsider the goals of their clinical skills education. Schools that seize the opportunity to evaluate and certify the competencies that residency program directors care about will provide an advantage for their graduates in the highly-competitive residency selection market that’s increasingly devoid of discriminatory data. Better yet, they have the potential to move education and assessment in a direction that will ultimately improve patient care.

WINNER: Advocacy.

Once again, folks: advocacy works.

It’s true that this would have never happened without the COVID-19 pandemic. But it’s equally true that it would have never happened without the persistent and often angry voices of medical students and faculty demanding a better system.

Keep your voices up.


Step 2 CS, Part One: How Did We Get Here?

Step 2 CS, Part Two: The Resistance

Step 2 CS, Part Four: The Future of USMLE Step 2 CS