What programs lost when Step 2 CS disappeared, and what hasn't replaced it

On January 26, 2021, the NBME and the Federation of State Medical Boards announced they were permanently discontinuing USMLE Step 2 Clinical Skills. The exam had been suspended since May 2020 because of COVID-19, and after a year of review, the co-sponsors decided that bringing it back wasn't worth the effort. They framed the decision as an opportunity to "work with colleagues in medical education and at the state medical boards to determine innovative ways to assess clinical skills" (USMLE.org, January 2021).

Programs have since built local approaches, but no national successor assesses spoken clinical communication.

What Step 2 CS actually did

Step 2 CS wasn't beloved. It was expensive ($1,300+ per attempt), required travel to one of five testing centers, and tested a narrow slice of clinical skills in a high-pressure, artificial setting. Medical students and program directors complained about it for years.

But it did something that nothing else in the system did: it provided a standardized, independent assessment of whether a medical student could communicate with a patient, take a focused history, and document a clinical encounter. Every student who matched into a residency program had passed the same communication bar, regardless of which medical school they attended or how their school ran its own OSCEs.

That common denominator is gone. And the downstream effects are showing up in residency programs that now have to assess communication competency without any shared reference point for what incoming residents can actually do.

The national assessment gap

When the USMLE announced the discontinuation, they said that clinical reasoning and communication skills would be assessed through other steps in the exam sequence. Step 3 still includes computer-based case simulations, and some communication content was added to Step 1. But these are written exams testing clinical reasoning, not live assessments of a trainee's ability to sit with a patient and have a conversation.

Medical schools have responded in scattered, uncoordinated ways. Some expanded their OSCE programs. Others lean more heavily on clinical rotation evaluations. A few have built capstone clinical skills assessments for fourth-year students. But there's no standardization across these approaches, which means a program director in Chicago has no way of comparing the communication training a resident received at one medical school versus another.

The question that Step 2 CS answered, however imperfectly ("can this person function safely in a patient communication setting?"), now has no consistent answer at the point of residency entry.

Milestones 2.0 raised the standard

In the same period that Step 2 CS disappeared, the ACGME rolled out Milestones 2.0, which created harmonized Interpersonal and Communication Skills (ICS) subcompetencies across all specialties for the first time. Before the harmonization work, ICS was described in 176 different ways across the 26 core specialties (Edgar, Roberts, and Holmboe, Journal of Graduate Medical Education, 2018). Programs used different frameworks, different language, and different assessment criteria for what was supposed to be the same competency.

Milestones 2.0 fixed the language problem. Three harmonized ICS subcompetencies now apply across every specialty: ICS-1 covers patient and family-centered communication, ICS-2 covers interprofessional and team communication, and ICS-3 covers communication within healthcare systems. That's real progress, and it gives Clinical Competency Committees a shared framework for the first time.

The shared framework gives programs common language, but each program still needs a way to collect evidence against it.

The assessment gap in practice

The ACGME's own survey data shows the disconnect. 96.1% of respondents said they understood ICS-1 as a concept. 87.4% agreed they should be using it. But only 80.9% said they knew how to effectively assess it (ACGME, Strengthening ICS via Harmonized Subcompetencies). For ICS-3, the numbers followed the same pattern: 91.7% understood it, 87.0% agreed it should be used, and only 81.1% knew how to assess it.

The survey shows that understanding a subcompetency does not always translate into confidence assessing it.

A 2025 study by Santen et al. in Academic Medicine analyzed ACGME harmonized milestone data from PGY-1 residents across the six largest specialties and found that program-level differences accounted for roughly 22.5% of the variance in ICS ratings and 23.6% of the variance in professionalism ratings. The authors found meaningful program-level variation, which is one reason committees need to understand how local assessment practices shape the evidence they review.

What programs are actually doing (and why it's not enough)

Most programs have defaulted to the tools they already had: faculty observation during clinical encounters, informal feedback from attendings, and the occasional standardized patient encounter if their simulation center can accommodate it. The problem is that workplace-based assessment depends heavily on the assessor's frame of reference. A 2023 study by Kogan, Conforti, and Holmboe in the Journal of Graduate Medical Education found that faculty often need explicit frame-of-reference training to discriminate reliably between learner performance levels, and that without it, direct observation produces inconsistent ratings.

Workplace observation remains essential, but the available evidence depends on which encounters faculty can see and document. Programs need enough observations to judge a learner's pattern rather than one conversation.

Research on communication assessment has shown that approximately 45 patient-completed assessments may be needed for a highly reliable estimate of one provider's communication skills (Holmboe et al., Assessing Interpersonal and Communication Skills, 2021). That finding comes from a specific assessment method and should not be treated as a universal threshold for every program.

Local methods have not become a national successor

The USMLE's January 2021 announcement specifically mentioned the intention to develop innovative assessment approaches. Five years later, there is no new standardized exam, no unified clinical skills assessment framework, and no widely adopted replacement for what Step 2 CS provided. The various efforts by medical schools and professional organizations have produced guidelines and recommendations, but nothing that functions as a shared, standardized benchmark.

This matters for residency programs because they're now absorbing the full burden of communication assessment that used to be partially distributed across the USMLE system. Programs didn't get additional resources, additional faculty time, or additional assessment tools to take on this work. They just got the responsibility.

The ACGME's Milestones 2.0 framework requires programs to review communication at each developmental stage. That makes the quality and consistency of local evidence important even without a national exam.

What filling this gap actually requires

The loss of Step 2 CS does not mean every program needs another national high-stakes exam. Step 2 CS was a pass or fail assessment on a single day. Programs also need longitudinal evidence of how trainees communicate across multiple encounters, mapped to the ICS milestones their CCCs review.

Structured practice can give learners more observed conversations and give faculty a consistent record to inspect. That record should sit alongside workplace observation, SP assessment, and the other evidence a CCC already uses.

AI patients can add repeatable practice between scheduled encounters. Case-specific frameworks and transcript evidence give faculty another view of performance without turning a practice score into an entrustment or progression decision.

Five years after Step 2 CS disappeared, the national gap remains. Programs can respond locally by deciding which communication behaviors matter, giving learners enough spoken practice, and collecting evidence that faculty can inspect.