In 2013, an article published in the New England Journal of Medicine raised concerns about the value of the exam. The authors calculated that the test fee alone cost students $36 million annually, and that the cost of detecting a single student who failed the exam on back-to-back attempts was $1.1 million. A letter to the editor from the leadership of the NBME and the FSMB in response to the article highlighted the need to view the value of the Step 2 CS in terms other than just cost; specifically, they state that, "Although (the authors') interest in cost is consistent with the current climate in health care, the 'value' referenced in their title is a function of quality as well as cost. They fail to fully consider the long-term effect of this assessment program on patient safety and satisfaction, societal expectations, and effective medical education." They also note that inclusion of Step 2 CS in the USMLE "brought the USMLE closer to meeting the expectations of the public that physicians exhibit competence in communicating with and examining patients."