To the Editor:
In a Letter to the Editor, Saheb Kashaf1 argues that Step 2 Clinical Skills (CS) of the United States Medical Licensing Exam should be expanded to reflect the increased importance of the physician–patient relationship; however, this position fails to consider the costs and benefits of Step 2 CS and the limited value of attempting to standardize clinical skills assessment.
The slight benefits of Step 2 CS do not justify its expense. A previous analysis demonstrated that the cost of discovering a repeat failure by a single examinee exceeds $1.1 million.2 Expanding the scope or depth of Step 2 CS would likely increase costs even further. Also, as Saheb Kashaf1 notes, the increasing burden of chronic disease makes long-term physician–patient relationships as important as ever, but Step 2 CS, which consists of simulated one-time patient encounters, does not evaluate a student’s ability to build therapeutic alliances. Indeed, scores on the Communication and Interpersonal Skills (CIS) subcomponent of Step 2 CS offer limited value in predicting communication ratings for internal medicine residents.3 Moreover, to my knowledge, no research has shown that adoption of the Step 2 CS requirement has been associated with improved patient satisfaction ratings or other outcomes.
Even if the benefits of Step 2 CS exceed its costs on an absolute basis, one must consider whether attempted standardization is necessary. The primary advantages of standardized tests are formalizing common competencies and facilitating reliable score comparison. These advantages are significant for Step 1 and Step 2 Clinical Knowledge (CK), which provide numerical scores and extremely detailed outlines of content. In contrast, Step 2 CS confers neither of these advantages. Though Saheb Kashaf1 asserts that Step 2 CS “forces medical schools to adhere to a minimal set of universal criteria in teaching communication,” the examination neither proposes nor mandates specific communication standards. The CIS scoring information consists only of a few brief paragraphs describing widely recognized communication practices in medicine, such as demonstrating empathy and asking open-ended questions. In addition, Step 2 CS, as a strictly pass/fail exam, is not intended to compare students quantitatively.2 Though clinical skills assessments can be structured, they remain inherently subjective and can never be standardized to a similar extent as Step 1 and Step 2 CK.
Most medical schools conduct institutional clinical skills assessments. Whereas Step 2 CS offers virtually no feedback to students, medical schools can more efficiently support students with detailed, actionable feedback and, if necessary, remedial instruction.
Kishore L. Jayakumar
MD/MBA candidate, Perelman School of Medicine/Wharton School, University of Pennsylvania, Philadelphia, Pennsylvania; ORCID: http://orcid.org/0000-0003-3042-5301; e-mail: firstname.lastname@example.org.
1. Saheb Kashaf M. Clinical skills in the age of Google: A call for reform and expansion of the USMLE Step 2 CS. Acad Med. 2017;92:734.
2. Lehman EP 4th, Guercio JR. The Step 2 Clinical Skills exam—A poor value proposition. N Engl J Med. 2013;368:889–891.
3. Winward ML, Lipner RS, Johnston MM, Cuddy MM, Clauser BE. The relationship between communication scores from the USMLE Step 2 Clinical Skills examination and communication ratings for first-year internal medicine residents. Acad Med. 2013;88:693–698.