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September 2016

Time to Eliminate the Step 2 Clinical Skills Examination for US Medical Graduates

Author Affiliations
  • 1Harvard Medical School, Boston, Massachusetts
  • 2Now at Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
  • 3Now at Department of Medicine, Duke University Hospital, Durham, North Carolina
  • 4Now at Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
JAMA Intern Med. 2016;176(9):1245-1246. doi:10.1001/jamainternmed.2016.3753

The public charges physicians with a fundamental trust: preventing and treating disease. This duty requires the highest standards of knowledge, behavior, and skill. For this reason, testing has an essential role in the medical licensure process. But just as physicians are trained to be deliberate, evidence-based, and cost-conscious, certification processes should be held accountable to the same high standards. In our view, the required Step 2 Clinical Skills (CS) examination, which purports to evaluate clinical and communication skills, fails to meet these standards. Herein, we argue that the Step 2 CS examination should be discontinued as a part of the US Medical Licensing Examination (USMLE) series for graduates of US medical schools. As of June 13, 2016, 16 000 medical students and physicians had signed an online petition that we organized to demonstrate the widespread support for this position.1 As a profession, we must ensure excellence in clinical skills and communication among physicians—and the Step 2 CS examination is the wrong way to achieve this goal.

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2 Comments for this article
Concern about factual misstatements on Step 2 CS proposal
David A. Johnson, MA | Federation of State Medical Boards
I am concerned about the factual misstatements and proposal presented here:

1) Step 2 CS is part of the medical licensing examination, not a “certification process.” Certification assures expertise in a specific content area. USMLE assures minimal competence to practice general, undifferentiated medicine.

2) The authors describe the CSA as an assessment of “English-language proficiency.” Incorrect; it was an assessment of clinical and communication skills.

3) The authors posit that attendance at an LCME-accredited school ensures baseline standards of clinical proficiency expected by residency programs. The USMLE, as a licensing examination, is designed to assure competence to practice medicine
independently, after residency. It is not intended to ensure proficiency for residency, where physicians enter supervised practice.

4) The authors cite the Alvin article as supporting the argument that Step 2 CS has not had an impact on medical education. That article does not make that claim or provide the data the authors note. Furthermore, there is published data on the impact the exam had on education in a relatively short period of time.

5) The authors say medical schools “should be entrusted with the job they are licensed to undertake.” Medical schools are not licensed; they are accredited. They exist under the charter issued to the college/university. Furthermore, they issue diplomas, not licenses. The only entities with statutory authority to issue a medical license and to assess competence for licensure are state medical boards. Medical schools certainly prepare students for practice. But there is inevitably variation across schools in terms of the readiness of their graduates to begin patient care. One measure of such variation is Step 2 CS itself, where average pass rates by school range from mid-80% to 100%.

In short, schools are not the arbiter of physicians’ fitness to practice. State medical boards are. In the interest of public protection, they require independent assessment of all physicians prior to issuing a license. The authors gloss over the implications of their proposal. Plainly put, in their view international graduates should demonstrate their clinical skills proficiency through a standardized, nationally-administered examination, while US students take a non-standardized examination administered by their medical school, not an independent assessor. This would not only dismantle the common standard physicians must currently meet for licensure, it smacks of a ‘separate but equal’ mentality that has no place in today’s America.

The medical licensing community supports assessment of physicians’ clinical skills, as evidenced by multiple actions taken by the FSMB’s House of Delegates and the following statements about Step 2 CS –

“I wouldn’t feel comfortable giving a license without this exam.” (Former Louisiana board president, after more than a decade on that board)

“The need for physicians who can really communicate with patients is important; the clinical skills exam really addresses that…there isn’t standardization across medical schools for that type of measurement. The more you have those skills reinforced at the exam level and at the schools, the better it is for patients.” (Oregon board executive)
Step 2 CS and the Testing-Assessment Bureaucracy
Marc S. Frager MD | East Coast Medical Associates
David Johnson is writing for the Federation of State Medical Boards which administers the Step 2 CS and collects revenue generated from this exam. Now is the time for the FSMB and David Johnson to clearly demonstrate the value of this exam to society, and not the FSMB. The actual data to demonstrate value certainly does not exist. We need more than just testimony and speculation, as offered by Mr. Johnson to continue this travesty. .

Perhaps it is time to reconsider the value of the entire testing-assessment business to society including ABMS and the hotly contested Maintenance of Certification
process. The continued absence of any demonstrated efficacy, combined with the high prices, makes these procedures worthy of discontinuation.