“After all your expenses, for most students Step 2 CS is a $2,000 ‘free lunch’ packed into a forgettable eight hour day,” was my most common response to those who asked what I thought about USMLE Step 2 Clinical Skills.

I have never guarded my disdain for the Step 2 CS exam. To me, it seemed like a racket forcing US medical students to travel across the country to one of very few locations to take an exam on skills every stateside school is more than prepared to certify their students for in the first place.

The criteria students were scored on for Step 2 CS were exceedingly subjective and there never was any explanation of what examinee results meant.

Studies show that it costs over a million dollars to find one student who would fail the exam two times consecutively. Finally, after years of pressure by medical student and physician organizations, the Clinical Skills exam was put out to pasture during the COVID pandemic in 2020.

If you have read this far, it is probably with joy and curiosity about what comes next. The way the USMLE tested these skills was inefficient but the skills themselves are highly necessary for life as a physician, and we expect that medical education and medical school regulation and governing bodies will evolve in the next few years.

As Kimberly Lomis, MD, the AMA’s Vice President for Undergraduate Medical Education Innovations notes, “Each school now becomes more responsible for a developmental process. If you are assessing these skills repeatedly over a student’s time in an institution, it becomes more of a formative process; and when a student is struggling the school must help them get to where they need to be.”

This means that individual schools are going to end up becoming the gatekeepers to certification. And while most have infrastructure in place to prepare students for CS, many will now move to a curriculum that has both formative and summative assessments.

What does the discontinuation of Step 2 CS mean for US medical students?

Med students can expect that not a lot will change. It’s likely you’ll see something CS-ish coming to a campus near you, likely as part of your fourth year graduation curriculum. (Maybe they will continue the free lunch tradition of CS.)

The general idea will remain the same: the ability to review a rather straightforward medical case and take a comprehensive patient history and physical, and be able to communicate those findings in a (probably) computer note system.

What does the discontinuation of Step 2 CS mean for IMGs?

The dissolution of Step 2 CS is a little more difficult for IMGs and requires a quick alphabet soup lesson/review:

• The NBME (National Board of Medical Examiners) is a national body.
• The Federation of State Medical Boards is the body that represents all 71 state MD and DO boards.
• Together they create the USMLE exam that every state requires in its licensure (a reminder that medical licenses are a state venture).
• This always got pretty messy when it came to international medical schools because there is also a requirement to ensure English language competency (one of the three core skills graded by CS). The precursor exam to Step 2 CS was actually an exam only required of international medical graduates.
• Here is where the Educational Commission for Foreign Medical Graduates (ECFMG) came in (confused yet?): The ECFMG administered the exam that existed before CS and will likely take the lead again in this new era.
• During COVID, ECFMG created five pathways to help IMG students certify for the skills previously tested by CS and to qualify for the match depending on their individual situations.
• In addition, an Occupational English Test will certify English language competency. These pathways are expected to be expanded to six and possibly continue through 2022 and beyond. I expect that eventually they will fall into an equilibrium that will help make the process easy for students.

For all medical students and residents, the remaining USMLE exams are expected to incorporate limited elements of the CS exam. For example, the CCS Case portion of Step 3 tests similar skills to CS around clinical management, and Step 1 has committed to adding additional questions based on communication skills.

Ultimately, the hope is that these assessments become more efficient at accomplishing their goals of helping to certify medical students’ knowledge and skills and less wasteful with their funds and time. Step 2 CS’s elimination has me hopeful on both counts.