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Out of Step: Making the (Unpopular) Case for USMLE Step 2 CS

Way back in April, I wrote a post about the recent push by medical students across the US — and beyond — to end Step 2 CS. Since then, the momentum behind the movement has been truly astounding.

In June, the AMA passed a resolution calling for the NBME and the Federation of State Medical Boards, who co-sponsor the USMLE, to retire Step 2 CS in favor of individual school-administered clinical skills exams. Though no official timeline has been set and it may take years before the exam is actually retired, by all accounts the process to formally end Step 2 CS has begun.

Though I did my best to stay impartial when I last covered this topic, I can’t help but empathize with the hundreds of students I have spoken with during my time at Med School Tutors, and with their complaints regarding Step 2 CS – and I see this bias in my writing on it. So this time around, I’d like to play devil’s advocate. Today, I’ll make the case for why we need Step 2 CS.  

Let’s start with the raw data.

Of the 20,190 US/Canadian MD students who took Step 2 CS in the 2014-2015 academic year, 4% of first time test-takers and 14% of retakers failed; of the 11,782 students from international schools, 20% of first-timers and 29% of retakers failed. In total, the number of students who didn’t pass Step 2 CS last year alone comes out to over 4,000.

Forget that these pass/fail rates are nearly identical to those for Step 1, which no one would suggest we abolish. Forget how problematic it is to transition a single standardized exam – which evaluates all students on the same playing field – to individual schools, which can have wildly varying curricula, teaching approaches, facilities, grade inflation and competency standards.

At the risk of sounding overly dramatic I’ll say that, as a doctor, you will have people literally put their lives in your hands on a regular basis. Think about how the mistakes of just one substandard physician could have potentially fatal consequences for hundreds of people. Now multiply that by over 4,000.

What those who advocate for ending Step 2 CS forget is the reason why we have these exams in the first place.

They’re not just to ensure that our physicians have competent knowledge levels and can take tests well. They’re also to protect the public and to ensure that the average person’s faith in our doctors is founded.

I’d like to end things here with a question: what makes someone a good physician? Is it simply having a mental rolodex of bugs and drugs they can use to narrow down question stems? Or is it the ability to apply knowledge to a real person and communicate that knowledge to them in an effective, compassionate way?

I’d argue that the things we so often take for granted – listening carefully, showing genuine empathy, explaining things to patients clearly, being even-tempered – are all vital characteristics of the platonic “good doctor” you all want to be. And these are all things that only Step 2 CS evaluates.

Then again, I don’t have to pay $1,500 and fly to Atlanta to not get that feedback.