To the Editor: The demise of the Step 2 Clinical Skills (CS) exam of the United States Medical Licensing Examination (USMLE), together with the USMLE Step 1’s transition to a binary reporting format, means that applicants for medical licensure have a single objective opportunity (Step 2 Clinical Knowledge) in proving their candidacy. 1 Programs may be reluctant to hire international medical graduates (IMGs) whom they have not previously observed in a clinical setting. As a potential substitute for the Step 2 CS exam, we propose that direct clinical observation of several new patient interactions during clerkships, or online assessment of communication and interpersonal skills while interacting with standardized patients, be included in respective clerkship evaluations. Structuring away-rotation evaluations for an IMG to include this scored component could reassure program directors of an IMG candidate’s preparedness for residency. To understand why an alternative clinical scoring component is needed for IMGs applying for residency, we need to examine the rise and fall of the Step 2 CS exam. The rise of the Step 2 CS exam has an interesting history. In the 1980s, U.S. residency program directors were concerned that the clinical competence of some IMGs was grossly deficient compared with their medical knowledge. 2 Subsequent events 3 led to the inception of the Clinical Skills Assessment (CSA) in 1981. The CSA’s validation led to its incorporation as a mandatory component for Educational Commission for Foreign Medical Graduates certification of IMGs in 1998 and subsequently for U.S. medical students as well. 4 Concerns voiced about subjecting only IMGs to the CSA were among the reasons for this change 4; this paved the path for the introduction of the Step 2 CS exam in 2004. Step 2 CS was not well received by U.S. medical students, though. The limit of taking the exam at only 5 U.S. centers, necessitating travel, plus an additional $975 examination fee, was unpopular. Despite growing questions regarding the utility of the exam and the high pass rate of nearly 97%, passing this exam was made a prerequisite for taking the USMLE Step 3—the final exam needed for obtaining medical licensure. 4 In the end, the COVID-19 pandemic, which necessitated travel restrictions and social distancing precautions, pushed the Step 2 CS exam to extinction. The Step 2 CS exam may have been flawed, but IMGs applying to U.S. residency programs need a new way to demonstrate their clinical competency. Structuring away-rotation evaluations for IMGs to include direct clinical observation or an online assessment could fill this gap.