Can OET Replace The USMLE Step 2CS?

Can OET Replace The USMLE Step 2CS?

By: Kiran S. Mahapure, MS MCh¹; Aashish Rajesh, MBBS²; Malke Asaad, MD³

The United States Medical Licensing Examination (USMLE) program announced a temporary suspension of Step 2 Clinical Skills (CS) exam for a period of about 12-18 months as a result of the restrictions imposed by the COVID-19 pandemic.¹ This has created a significant impact on graduate medical education in the United States, especially for International Medical Graduates (IMGs) who require this exam as a component for attaining certification by the Educational Commission for Foreign Medical Graduates (ECFMG), to pursue post-graduate training.² For the 2021 residency application cycle, the ECFMG has offered the Occupational English Test (OET) as an alternative for the CS exam, to be considered a satisfactory mark of the candidate’s language proficiency.³

The Step 2 CS exam was added to the USMLE series in 2004 by the National Board Medical examiners (NBME) and Federation of State Medical Boards (FSMB).⁴ Since then, it has been an integral component of evaluating medical students in three domains: Integrated Clinical Encounter (ICE), Communication and Interpersonal Skills (CIS), and Spoken English Proficiency (SEP). The ICE component tests fundamental history and physical exam skills together with medical reasoning and documentation, while the CIS component evaluates the examinee’s patient-centered interaction. Finally, the SEP component assesses the examinees’ clarity of spoken English.⁵

The Occupational English Test (OET) is designed specifically for physicians. It evaluates English language proficiency in four components: listening, reading, writing, and speaking. To meet the ECFMG’s requirement, applicants must attain a minimum score of 350 on each of these four components.³ However, even though OET replicates real-life communication scenarios⁶, it does not incorporate an assessment of the clinical skills and application of the clinical knowledge by the candidate.

A survey study in 2018 concluded that most residency program directors use Step 2 CS to screen residency applicants.⁵ The leaders of the NBME and the FSMB had highlighted that Step 2 CS brought the USMLE program closer to meeting the expectation that physicians would exhibit competence and confidence in communicating with and examining patients.⁷ Evidence of poor communication skills contributing to medical malpractice lawsuits have emphasized the need for standardized clinical skills testing of all medical students.⁴ Transitioning to the OET as an alternative pathway for attaining ECFMG certification compromises on this important competency assessment.

One of the major concerns raised with such a transition is the question as to how program directors would evaluate applicants certified through such pathways. Undoubtedly, applicants with the CS exam reports would be advantaged. In particular, IMGs would be at the receiving end of this decision as the clinical abilities and communication skills of US medical graduates are observed and documented in their medical student performance evaluations. Therefore, IMGs who were unable to pursue observership/clinical rotations with the current restrictions imposed by COVID-19 will be at a significant loss in terms of portraying their clinical skills to faculty evaluators. 

Considering the heterogeneity of the current applicant pool, a formal evaluation of clinical skills is the need of the hour. In light of current travel restrictions imposed by virtue of the COVID-19 pandemic, a virtual alternative should be considered. Telehealth is an evolving domain of health care and developing an understanding of how patients should be evaluated through virtual healthcare visits will benefit incoming residents in the wake of the pandemic and offer a more realistic glimpse of an applicant’s clinical abilities.^8,9 Evaluating patient approach, history-taking, communication, and English proficiency can all be accomplished through the implementation of this technology. Furthermore, this testing could be administered as a remote proctored examination that would allow applicants to test from home, a trend that is currently being implemented for shelf exams for senior medical students. 

In summary, the need for a uniform evaluation of the clinical skills of all applicants to MATCH 2021 cannot be overstated. An ideal replacement for Step 2 CS should assess the clinical knowledge and communication skills along with their English proficiency. Transitioning to a mini-virtual format of the same would serve as a viable solution.

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Authors’ Affiliation:

¹Department of Plastic Surgery, KAHER J. N. Medical College, Belgaum, Karnataka, India

²Department of Surgery, University of Texas Health Science Center, San Antonio, TX

³Department of Plastic Surgery, M.D. Anderson Cancer Center, Houston, TX

References:

1. USMLE Suspending Step 2 Clinical Skills Examination. https://covid.usmle.org/announcements/usmle-suspending-step-2-clinical-skills-examination/. Published 2020. Accessed July 16, 2020.

2. ECFMG|FAIMER Responds to Suspension of USMLE Step 2 CS Testing, Commits to Uninterrupted Pathway for IMGs to ECFMG Certification. https://www.ecfmg.org/news/2020/05/26/ecfmgfaimer-responds-to-suspension-of-usmle-step-2-cs-testing-commits-to-uninterrupted-pathway-for-imgs-to-ecfmg-certification/. Published 2020. Accessed July 16, 2020.

3. Requirements for ECFMG Certification for 2021 Match. https://www.ecfmg.org/certification-requirements-2021-match/oet.html#:~:text=ECFMG will accept the Occupational,the English language proficiency requirement.&text=To meet ECFMG’s requirement%2C applicants,Reading%2C Writing%2C and Speaking. Published 2020. Accessed July 17, 2020.

4. Johnson H. A critical review of standardized patient examinations as part of the USMLE. AMA J Ethics. 2003;5(12):426-429.

5. Paniagua M, Salt J, Swygert K, Barone MA. Perceived Utility of the USMLE Step 2 Clinical Skills Examination from a GME Perspective. J Med Regul. 2018;104(2):51-57. doi:10.30770/2572-1852-104.2.51

6. OET accepted in the US for both doctors and nurses. https://www.occupationalenglishtest.org/oet-accepted-in-the-us/. Published 2020. Accessed July 16, 2020.

7. Lehman EP, Guercio JR. The Step 2 Clinical Skills Exam — A Poor Value Proposition. N Engl J Med. 2013;368(10):889-891. doi:10.1056/NEJMp1213760

8. Thompson. Questioning a Virtual Alternative to Step 2 CS. https://opmed.doximity.com/articles/questioning-a-virtual-alternative-to-step-2-cs?_csrf_attempted=yes. Published 2020. Accessed July 16, 2020.

9. Virtual USMLE Step 2 CS Exam: How to Pass If It’s Online. https://www.medschoolcoach.com/virtual-step-2-cs-exam-how-to-pass-if-its-an-online-exam/. Published 2020. Accessed July 16, 2020.