Every physician who wishes to practice medicine in this country must pass a test most Americans have never heard of: Step 2 Clinical Skills. Approximately 20,000 medical students from U.S. and Canadian schools take it each year, paying hefty fees for a decidedly ineffectual exam. For anyone who wants to end waste in medical education, getting rid of Step 2 CS is a good place to start.
In this eight-hour test, future doctors move through a battery of standardized encounters with patient actors. Medical students have 15 minutes to meet with each actor, take a medical history, perform a physical exam and discuss next steps for the patient’s care. Afterward, students have additional time to write a patient note, as well as list relevant diagnoses and tests.
Until about a decade ago, these examinations were required exclusively of students from medical schools outside of the U.S. and Canada. Many felt, however, that it was unfair to subject only foreign medical graduates to this hurdle. So in 2004, the National Board of Medical Examiners and the Federation of State Medical Boards introduced Step 2 CS as a universally required exam. Step 2 CS was conceived with sound intentions: All of our physicians should meet certain standards prior to caring for patients. But it suffers from serious flaws. To start, it’s tremendously expensive. The registration fee alone is $1,275. The test is offered only in five cities – Philadelphia, Atlanta, Chicago, Houston and Los Angeles. Most medical students must therefore travel to distant test centers, paying out of pocket or racking up credit card debt for flights, rental cars and hotel rooms. For each student, the bill often comes to $2,000 or more.
Altogether, the costs for students from U.S. and Canadian medical schools are estimated to exceed $36 million annually. This price tag might be justifiable if Step 2 CS served its intended quality-control purpose. But it doesn’t.
Every year, 96% to 98% of medical students from U.S. and Canadian schools pass on their first attempt. What’s more, score reports include little more than pass/fail designations. As a result, students, medical schools and residency programs learn essentially nothing from the exercise.
A few studies, based on Step 2 CS numerical ratings never released to students, have found that performance on the test might predict eventual performance during residency. But those numerical ratings are inherently subjective (it’s hard to measure interpersonal skills). And the correlations are tenuous at best.
After 12 years of testing, there is virtually no evidence that Step 2 CS has improved patient outcomes or care.
We should do away with this wasteful national test and let medical schools take over. Most medical schools already conduct clinical skills exams; they could design future exams to meet national guidelines, perhaps modeled after Step 2 CS. This transfer of responsibility would eliminate millions of dollars in unnecessary educational costs while ensuring the clinical competency of our physician workforce.
The American Medical Assn. opposed Step 2 CS in the early 2000s and endorsed a similar approach to the one we’ve suggested, stating that clinical skills exams are “best performed using a rigorous and consistent examination administered by medical schools.” The American Assn. of Medical Colleges has also expressed concern over the financial burden placed on students by this national exam.
Under our proposed system, graduates from foreign medical schools would still need to take a standardized skills exam in order to practice here. These students have historically passed Step 2 CS at far lower rates than students from U.S. and Canadian schools. And since our medical students would also need to pass clinical skills exams on par with national guidelines, there wouldn’t be a double standard. The cost of higher education is a national crisis, with graduate and professional students carrying an especially heavy burden. Over 80% of physicians now graduate from medical school with educational debt; their average debt surpasses $180,000. Getting rid of Step 2 CS won’t fix the larger problem, but it would save medical students thousands of dollars that they really shouldn’t have to spend.