USMLE Step 2 CS—Its Suspension: What you need to know

**UPDATE 01/26/2021 The Federation of State Medical Boards (FSMB) and NBME, co-sponsors of the United States Medical Licensing Examination® (USMLE®), are today announcing the discontinuation of work to relaunch a modified Step 2 Clinical Skills examination (Step 2 CS). https://www.usmle.org/announcements/

The United States Medical Licensing Examination (USMLE) is the one examination system accepted in every state, ensuring that all licensed MDs have passed the same assessment standards—no matter in which school or country they had trained. This central role in the licensing of physicians required an immediate reaction to the COVID-19 pandemic for the safety of examinees and test center staff. The Step 2 CS (clinical skills) part of the USMLE exam had to be suspended while a safer alternative could be developed. This article covers what has been happening since the suspension and what to expect in the Step 2 CS re-introduction.

What is the USMLE® Step 2 CS?

The USMLE Step 2 CS (Clinical Skills), along with Step 2 CK (Clinical Knowledge), typically comprise Step 2 of the three Steps of the U.S. Medical Licensing Examination (USMLE). The USMLE assesses a physician’s ability to apply knowledge, concepts, and principles and to demonstrate fundamental patient-centered skills that are important in health and disease and that constitute the basis of safe and effective patient care.

Both Step 2 CS and CK completion have typically been required to obtain the Educational Commission for Foreign Medical Graduates (ECFMG®) Certificate (https://www.ecfmg.org) needed by IMGs to start residency training.

What does the USMLE Step 2 CS measure?

According to the USMLE website (https://usmle.org): “Step 2 of the USMLE assesses the ability of examinees to apply medical knowledge, skills, and understanding of clinical science essential for the provision of patient care under supervision, and includes an emphasis on health promotion and disease prevention. Step 2 ensures that due attention is devoted to the principles of clinical sciences and necessary patient-centered skills that provide the foundation for the safe and effective practice of medicine.

Step 2 CS uses standardized patients to test medical students and graduates on their ability to gather information from patients, perform physical examinations, and communicate their findings to patients and colleagues.”

How did COVID-19 affect the USMLE Step 2 CS?

On March 13, 2020, the USMLE program suspended the administration of the Step 2 CS Examination due to the COVID-19 outbreak and the need to protect the health of examinees and test center staff. 

Since then, the USMLE has been working to re-introduce the Step 2 CS as soon as possible. During the suspension, the ECFMG established the five pathways for obtaining an EFCMG Certificate for those planning to participate in the 2021 Match. Applicants pursuing one of the pathways must also perform satisfactorily on the Occupational English Test (OET) Medicine (https://www.occupationalenglishtest.org). 

The pathways and the OET requirement are for the 2021 Match only. Longer-term plans are under development for administering the ECFMG Certification that may result in future changes to these requirements. For this reason, you must have taken the OET by the last available date in 2020. 

A noteworthy aspect of the OET is an online version for remote administration, called OET@Home (https://www.occupationalenglishtest.org/test-information/delivery-modes/oet-at-home/). The OET@Home is currently offered by invitation only, prioritizing individuals who have great difficulty in attending a test venue.

When is the last date to take the OET Exam?

The latest date to take the OET Medicine Exam in time for your test score to be received by the ECFMG early enough to both verify your pathway application status and get that information to the NRMP (National Resident Matching Program) before their ROL (Rank Order List) deadline is December 31, 2020. Available test dates for your region are listed on the OET site.

UPDATE – ECFMG must receive your OET Medicine results by January 31, 2021.

Did you know that ECFMG Certificates can expire when based on a pathway? 

The ECFMG developed the pathways for those seeking to start U.S. graduate medical education (GME) in the 2021-2022 academic year. If you do not enter such a program in that timeframe, your certificate will expire. You must also satisfactorily complete the first year of training to ensure your ECFMG Certificate does not expire. If you do not obtain a position in the 2021 Match, you must satisfy the then-current clinical skills requirements of a future Match to revalidate your certificate.

What is the future for the USMLE Step 2 CS?

The stated goal of the USMLE is “to deliver an initial performance-based assessment and to plan for continuous improvements over the next five years to help ensure the assessment continues to meet the needs of the community.” 

The effort to revitalize Step 2 CS is partitioned into three phases:

Phase 1 (completed): Discovery: Licensing needs assessment; prioritization; stakeholder input

Phase 2 (in progress): Design: Content delivery; feedback and scoring

Phase 3 (to come): Implementation: Training; Pretest; Pilot

The effort has been discussed in detail on the USMLE Connection podcast on the Clinical Skills Assessment Update, hosted by Suzanne McEllhenney, Director of Program Management for USMLE. Also participating were David Johnson, Chief Assessment Officer at the Federation of State Medical Boards, and Dr. Chris Feddock, the Executive Director for the Clinical Skills Evaluation Collaboration or CSEC, which administers the USMLE Step 2 CS.

The podcast covered the status of planning the future of clinical skills testing. There is an ongoing commitment to maintaining the highly valued performance measures of the past while adapting to future needs. Through focus groups and surveys, a collaborative research effort including the USMLE, the ECFMG, the FSMB (Federation of State Medical Boards), and the NBME (National Board of Medical Examiners) gathered input from a wide range of entities including state board members, faculty at medical schools, medical students and residents, international medical graduates, and residency program directors as a guide toward future development.

The collected data is part of USMLE’s vision and strategy for performance-based clinical skills assessment. There are two parts to this work. The priority is the re-launch of an updated Step 2 CS exam as soon as possible. They have also initiated a multi-year focus on clinical skills assessment improvement.

Feedback determined that the prior Step 2 CS succeeded in several ways: the exams, reliable scoring, the standardization of standardized patient performances across sites, assessment of skillsets and how relevant they are to clinical practice, and the professional and smooth operations of test administration.

Another determination was that certain aspects of the prior Step 2 CS would benefit from change: the limited number of U.S. testing sites, which is especially difficult for IMGs (International Medical Graduates), the cost of the exam, some perceptions of the nature of standardized patient interaction, and the limited feedback examinees receive on scoring.

What will change, and what will continue in the re-launch?

Moving forward, the exam will continue to focus on evaluating U.S. and foreign-trained physicians who are entering supervised practice. It will continue to gauge specific sub-competencies within the USMLE physician tasks of patient care communication.

A significant change is that the new assessment will be administered through a remote online delivery platform having examinees and standardized patients interact by video. This change will eliminate the prior Step 2 CS’s personal interaction and address both the prior difficulty of attending the test sites and provide a safer platform for examinees and standardized patients during the COVID-19 pandemic.

There is still no date set for re-launch. There are many interconnected details to account for, including residency match timelines, school curricula calendars, and the temporary eligibility policy changes currently in effect for both Step 3 and ECFMG certification.

The research also concluded that the stakeholder consensus supported the Step 2 CS exam’s ongoing need, finding that its assessment continues to be relevant and essential.

There was also a determination that the exam should continue to focus on several key things. These include the examinee’s effectiveness in conducting a clinical interview; their ability to communicate the resulting information to patients or the healthcare team; and evaluation of their reasoning skills, which will inform they are taking the proper steps in patient care.

While further research collecting input from the medical community is ongoing, there is a commitment to making timely updates on progress to examinees and stakeholders.

**UPDATE 01/26/2021 The Federation of State Medical Boards (FSMB) and NBME, co-sponsors of the United States Medical Licensing Examination® (USMLE®), are today announcing the discontinuation of work to relaunch a modified Step 2 Clinical Skills examination (Step 2 CS). 

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