In a recent article entitled “In Defense of Step 2 Clinical Skills,” Dr. Ken Simons, senior associate dean for graduate medical education and accreditation at the Medical College of Wisconsin, argues that the current student-led campaign to end the USMLE Step 2 CS examination is misguided and potentially dangerous.
“None of us looks forward to an expensive series of high-stakes exams, but those exams are there to protect the public,” Simons writes. “While I sympathize with the burden felt by students who already carry the much greater weight of their medical school costs, their petition fails to recognize a point of critical importance: Not only is the Step 2 Clinical Skills exam a necessary public safeguard, it has greatly strengthened the curriculum of medical schools nationwide.”
This claim, that Step 2 CS screens for potentially incompetent future physicians and therefore protects the public, has become the central justification for the test’s existence in the face of opposition. Another article reviewing the “End Step 2 CS” movement cites Dr. Peter Katsufrakis, senior vice president of the National Board of Medical Examiners (NBME), an organization which jointly oversees the USMLE along with the Federation of State Medical Boards (FSMB):
“It’s really just a part of what we do to become physicians and to demonstrate to the public that we have earned their trust — that they can put their faith in us and feel comfortable with it.”
Maybe this is lip service, maybe it’s not. Public safety is a virtuous goal that very few people try to wreck intentionally. Shortsightedness and distorted values, however, can do it without conscious effort, insidiously undermining any noble ideal that was there to begin with. For whatever reasons it was created, the exam does not protect the people. It harms them.
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The official position of the USMLE is that sufficient evidence exists to support the need for Step 2 CS, and they’ve compiled a lengthy list of publications they believe constitutes the rationale. Without going into tedious detail, let me assure you that the list is a selective representation of the literature — refusal even to include the New England Journal of Medicine article that established the view of the exam as a poor return on investment — and is chock-full of barely-related studies with findings trivial to the issue. Its most important studies looking directly at the Step 2 CS were conducted by measurement scientists working for the NBME, which is obviously a conflict of interest regardless of any honest attempts to be unbiased. Others were co-authored by Dr. Katsufrakis himself. The nature of these apparently momentous studies is to have the scientists measure a small positive correlation between exam performance and some desirable outcome, an exercise that notably says nothing about justification. Rather, it says something akin to “look, we designed a test which slightly reflects reality in terms of a student’s clinical skills.” This is far from justifying a mandatory $1275 exam.
A recent JAMA article written by the founders of the End Step 2 CS movement singles out other major flaws with one study’s conclusions in particular, and even the NBME’s researchers identify significant limitations, which the NBME predictably chooses to overlook when marshaling their rationale for Step 2 CS.
Dr. Simons argues that the implementation of Step 2 CS was an impetus for medical schools to develop superior clinical skills curricula and alludes to his home institution as a sterling example. He also claims that “every campus has one or two brilliant medical scientists with inadequate interpersonal skills” and without a standardized examination administered by the NBME, these maladroit students go on to cause the majority of disciplinary actions taken against physicians by state medical boards. He provides no evidence or sources in support of these positions. He further attests that variability from one program to the next means we cannot trust individual medical schools to reach a national standard necessary to ensure public safety. He must imply, then, that the clinics and hospitals hosting our clerkships and residencies also are insufficient to accomplish this goal. Perhaps all working doctors of the older generation who did not complete the Step 2 CS should be required to take it now, if that is the case.
In short, the argument that Step 2 CS protects patients is based on a tenuous assumption and is unsubstantiated, as the twelve years since the exam’s inception have produced no evidence to suggest it has a beneficial effect on patient interaction. A question should be raised at this point: why is it we feel the need to deliver so much reason, unbiased input and objective data in an attempt to overturn a policy when administrators were clearly under no such constraints to effect the policy in the first place? All the mentioned concerns as well as additional criticisms were brought up before Step 2 CS was introduced in 2004. When medical student voices were ignored, it was indicative of a loss of self-regulation and a dangerous imbalance. If you want a quick way to gauge the power status of each side in a conflict, look at the burden of proof one side feels versus the other. The disadvantaged group finds itself pressured to gather mountains of corroboration while that with the upper hand is allowed lax expectations. The exam’s continued survival is demonstrative of a laughable abuse of power.
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So, Step 2 CS doesn’t live up to its role as a public safeguard. That’s a problem, but perhaps more important is how the exam hurts medical students and how this might affect health care.
First, even if the test were to cost nothing, and travel and lodging were reimbursed, it would still be a hindrance to learning. This is something medical students have articulated frustration about for over a decade now. They find absolutely no educational value in preparing for it or taking it. Contrast this with the multiple choice question-based exams required by the USMLE, which have received far less objection from students in part because we see some degree of real learning value in the preparation process.
The exam is not free, though, and lodging and travel to a testing site are not reimbursed. This is where much of the indignation stems from as the examination fee — currently $1275 — is a cost very few can pay for, and therefore is added on to the already tremendous debt that comes with modern medical education in the United States. Since the test transforms into debt, the repercussions of debt must be weighed when considering the net utility for society.
Medical student debt is a topic warranting much more analysis and debate than I could ever cover here. To summarize the latest research in an almost criminally distilled way, students with higher debt report feeling more callous, are more stressed and more likely to regret the choice to become a physician. Debt is associated with cynicism, loss of altruism and feeling entitled to a higher income. More debt makes students less inclined to practice in underserved locations and may steer them away from primary care, the field that creates the greatest health value.
Julie Phillips, professor at Michigan State University College of Human Medicine and a leading researcher in the consequences of medical student debt, has an online video lecture recorded in 2013 that addresses many of the crucial issues surrounding this topic. It is worth watching the entire talk including the Q&A session. If one pays attention to how medical students describe this debt when asked about it — “overwhelming,” “exploited,” inciting resentment not just toward the education community but toward society as a whole, teaching them to look out for themselves and no one else, that people are behind every corner looking to take from them — the language is strong, but the beliefs aren’t exaggerated and the reaction is congruent.
Debt makes income a high priority, crowding out other values such as altruism and vocational fulfillment, values which often lead people into careers in medicine. Once this prolonged insult has sufficiently eroded medical student and physician well-being, it appears to seep into the patient’s world in the form of callousness, provider burnout and a deficient primary care workforce. Where is the public good in this?
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Step 2 CS purports to protect society from the U.S. health care system at a time when real problems exist, likely due to an overly complicated medical system, information loss during patient hand-offs, overworked physicians and residents, excessive time spent on documentation and a lack of a reliable error-monitoring system. We should be addressing these problems and not this non-issue of one or two students supposedly running amok with their poor clinical skills. Even if American health care was otherwise flawless, it is clear that Step 2 CS not only fails to do its job, it actually harms medical students and the general public alike.
The End Step 2 CS website allows you to sign the petition trying to achieve this goal.
As medical students, we need to understand something about ourselves: we are a bonanza waiting to happen. We are invested to the point of ultra-obedience and will jump through any hoops placed in front of us to advance in order to one day become working doctors. We will have good incomes and will never be unemployed. We are too absorbed in the details of medical knowledge acquisition and the fulfillment of educational and professional requirements to organize in any meaningful way. We have been following rules compulsively since high school because that is how one becomes a medical student. We are perfect borrowers. In financial language, we carry super-prime risk to lenders and creditors yet can be charged subprime interest rates. Why wouldn’t opportunists try to raise our tuition, add an expensive licensing exam, vie for our loan needs or in some way take advantage of us?
Let’s do a final tally for the involved parties: test administrators receive millions of dollars each year, lenders take even more profit from medical student debt, hotels in five major U.S. cities and the airlines receive a little extra business, medical students lose money and time and the general population gets more jaded and indebted physicians.
This is what Step 2 CS protects. Not the public.
Contributing Writer
University of North Dakota School of Medicine and Health Sciences
MS III at University of North Dakota School of Medicine and Health Sciences. From Ray, North Dakota.