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The High Cost of USMLE Step 2 Clinical Skills

“I want to be a doctor.”

From the first moment a student decides they want to commit their life to the service of healing, something changes. They understand the time commitment they are making to succeed in school, master the MCAT and participate in as many extracurricular activities as possible while simultaneously saving the world.

However, few people consider the biggest sacrifice of all until long after they apply: the financial cost. Going to medical school is not cheap. First, you need to get in. For most accredited medical schools in the United States this requires a degree from a four-year undergraduate institution and completion of a series of prerequisites, all of which accompany a big tuition check. All aspiring medical students must also take a standardized test, the MCAT, which currently costs $305. Finally, there is the $160 processing fee to apply through AMCAS in addition to a $37 fee for each application. After your initial application submission there are additional secondary application fees and then, if you are lucky, the cost of travel, room and board at multiple locations across the country as you interview throughout the year.

For everyone accepted to medical school, this is only the beginning. Private medical schools average about $50,000 in tuition and fees each year. For those lucky enough to attend his or her in-state public school, the cost can be lower, but in some states only by about $10-20,000. These numbers do not include the cost of living, books or study materials that students must also pay for over their four years of education. In fact, it has been estimated that students graduating from medical schools incur an average debt of almost $180,000. This is a number not always considered by students before medical school, but it is something that hangs over the head of every student once they fill out their first FASPE form and it lingers well after school, residency, fellowship and maybe even the first few years of practice.

One of the major expenses that future doctors face is the cost of the United States Medical Licensing Exam (USMLE). This test is given in three parts, spread out across a student’s training, in total costing over $3,000. The most expensive item by far is the Step 2 Clinical Skills test, whose registration fee comes in at a whopping $1,275. However, unlike many other standardized tests, the Step 2 CS is only offered in Atlanta, Chicago, Houston, Los Angeles and Philadelphia; which means students who do not already live in one of these cities must travel to the test center and pay for any accommodations they need for the duration of the test. As a first-year medical student still reeling from the cost of applying to school, I was shocked to hear about this. It makes sense for us to be assessed on our skills through licensing exams, but to have to pay so much for them seems odd.

The secret that no one told you, however, is that this exam might not be as effective in assessing clinical aspects of care as one would like to think. The test is graded on a pass/fail system, without giving any constructive feedback to those who fail, and 99 percent of students pass in their first two attempts. Furthermore, though there have been some studies looking at the correlations between Step 2 performance and internship success, these studies were inconclusive at best and relied on data unreleased to students and the general public. Many students across the country have expressed frustration with the excessive cost of a test that doesn’t appear to benefit them in the long run. However, this year, a group of students at Harvard Medical School decided to do something about it and have called for a removal of the exam from the USMLE certification requirements. Their petition points out that the test was only added to the licensing requirements in 2004 and was not received well by either the American Medical Association or medical schools across the country. In fact, a 2003 study conducted by the AMA pointed out that the physicians who need improvement with patient communication are not new residents. They note that, “when clinical incompetence is the root of [an] error, often the physician is impaired or has been [in] practice for more than 10 years.” They also comment that, “not 1 physician had been sanctioned by a medical board for communication skills within the first 5 years of clinical practice.” The End Step 2 CS group also noted that while it is important for students to be evaluated on these skills, many schools already have clinical skills assessments in place. They have called upon the medical community as a whole to stand behind its future doctors, especially those underrepresented in medical care, to sign their petition to eliminate Step 2 Clinical Skills. The response has been swift and enthusiastic. Within 3 days the petition had 1,000 signatures and to date they have collected signatures from over 130 medical schools all across the country.

There was a day, though I can’t recall the exact circumstance, when I first said, “I want to be a doctor”; and on that day I was not contemplating the financial burden that statement bore. However, now that I am only a few months away from the start of my second year, I am beginning to feel its power more and more. I budget my money carefully, and make sure to save non-essential items for special occasions. When the study materials I want are too expensive, I team up with classmates and we split the cost. Hearing that there is a very expensive test in my future that doesn’t seem to be that essential to my growth as a physician bothers me. I want to make an investment in myself to be the best doctor possible. However, the Step 2 CS test is not an investment that seems to be worth the high price tag. I am already practicing these clinical skills every day and receiving strong, constructive feedback regarding my progress from my teachers. I don’t need to spend an additional $1,000 to be told that I can hold a conversation with a patient, or have the ability to create an empathetic relationship. What I need is to gain the scientific knowledge to diagnose diseases, the skills to discuss these diagnoses with patients and somehow survive medical school while spending as little money as possible.

Delaney Osborn Delaney Osborn (4 Posts)


The Geisel School of Medicine at Dartmouth

I am a first year medical student at Dartmouth and currently loving the rural New England lifestyle that I signed up for. I graduated from the College of William and Mary in 2013 where I majored in neuroscience and minored in philosophy. I also have a Masters in philosophy of medicine from King's College London. My interests include bioethics, end of life care, and neuroscience. When I am not hitting the books I can be found running, sailing, re-reading Harry Potter, singing to Taylor Swift, or snapping pictures.