First Aid for USMLE Step 2CS.pdf

I NTRODUCTION

Since 1998, all international medical graduates (IMGs) have been required to

pass a clinical skills exam known as the Clinical Skills Assessment, or CSA—a

test involving clinical encounters with “standardized patients”—as a prerequi-

site to entering residency training in the United States. With the introduction

of the USMLE Step 2 Clinical Skills (CS), however, U.S. and Canadian med-

ical students as well as IMGs are now required to demonstrate basic clinical

competencies in order to enter residency training and take the Step 3 exam.

Even if you are a seasoned pro at taking standardized exams such as the

USMLE Step 1 and Step 2 Clinical Knowledge (CK), you may ﬁnd it chal-

lenging to prepare for the USMLE Step 2 CS—which, like the CSA it has re-

placed, uses live patient actors to simulate clinical encounters. Common mis-

takes students and IMGs make in preparing for the Step 2 CS include the

following:

Panicking because of the unfamiliar format

Inadequate practice with mock patient scenarios prior to the actual exam

Not developing a logical plan of attack based on patient “doorway infor-

mation”

Not understanding the required objectives for each patient encounter

Poor time management during patient encounters

Becoming ﬂustered by challenging questions or situations

Taking unfocused histories and physical exams

Failing to understand how to interact with a patient appropriately

Not performing easy but required patient interactions

This book will help guide you through the process of efﬁciently preparing for

and taking the Step 2 CS with four organized sections:

Section I introduces you to the USMLE Step 2 CS.

Section II reviews critical, high-yield steps to take during the patient en-

counter.

Section III provides high-yield minicases for common doorway chief com-

plaints to help you rapidly develop focused differentials during the exam.

Section IV has full-length practice cases to help you simulate the real thing.

USMLE STEP 2 CS—THE BASICS

What Is the USMLE Step 2 CS?

The United States Medical Licensing Examination (USMLE) Step 2 CS is a

one-day exam whose objective is to ensure that all U.S. and Canadian med-

ical students seeking to obtain their medical licenses—as well as all IMGs

seeking to start their residencies in the United States—have the communica-

tion, interpersonal, and clinical skills necessary to achieve these goals. To pass

the test, all examinees must show that they can speak, understand, and com-

municate in English as well as take a history and perform a brief physical

exam. Examinees are also required to exhibit competence in written English

and to demonstrate critical clinical skills by writing a brief patient note (PN),

some follow-up orders, and a differential diagnosis.

The Step 2 CS simulates clinical encounters that are commonly found in clin-

ics, physicians’ ofﬁces, and emergency departments. The test makes use of stan-

dardized patients, or SPs, all of whom are laypeople who have been extensively

trained to simulate various clinical problems. SPs give the same responses to all

candidates participating in the assessment. When you take the Step 2 CS, you

will see 10 to 12 SPs, but cases will be mixed in terms of age, gender, ethnicity,

organ system, and discipline. For quality assurance purposes, a video camera

will record all clinical encounters, but the resulting videotapes will not be used

for scoring. The cases used in the Step 2 CS represent the types of patients who

would typically be encountered during core clerkships in the curricula of ac-

credited U.S. medical schools. These clerkships are as follows:

Internal medicine

Surgery

Obstetrics and gynecology

Pediatrics

Psychiatry

Family medicine

It should be noted that examinees do not interact with children during pedi-

atric encounters. Instead, SPs assuming the role of pediatric patients’ mothers

recount patients’ histories, and no physical exam is required under such cir-

cumstances.

There is no physical exam in

pediatric encounters.

How Is the Step 2 CS Structured?

Before entering a room to interact with an SP, you will be given an opportu-

nity to review some preliminary information. This information, which is

posted on the door of each room (and hence is often referred to as “doorway

information”), includes the following:

Patient characteristics (name, age, sex)

Chief complaint and vitals (temperature, respiratory rate, pulse, blood

pressure)

You will be given 15 minutes (with a warning bell sounded after 10 minutes)

to perform the clinical encounter, which will include reading the doorway in-

formation, entering the room, introducing yourself, obtaining an appropriate

history, conducting a focused physical exam, formulating a differential diag-

nosis, and planning a diagnostic workup. You will also be expected to answer

any questions the SP might ask, to discuss the diagnoses being considered,

and to advise the SP about follow-up plans. After leaving the room, you will

have 10 minutes to write a PN.

How Is the Step 2 CS Scored?

Of your 10 to 12 patient encounters, 10 will be scored. Two people will score

each encounter: the SP and a physician. The SP will evaluate you at the end

of each encounter by ﬁlling out three checklists: one for the history, a second

for the physical exam, and a third for communication skills. The physician

will evaluate the PN you write after each encounter. Your score, which will be

based on the clinical encounter as a whole and on your overall communica-

tion skills, will be determined in the following manner:

DG score. To determine your DG score, SPs will document your abil-

ity to gather data pertinent to the clinical encounter. Speciﬁcally, SPs

will note whether you asked the questions listed on their checklists, suc-

cessfully obtained relevant information, and correctly conducted the

physical exam (as indicated by the performance of the procedures on

their checklists). Your ﬁnal DG score will represent an average of your

performance with all 10 SPs. If you asked questions or performed proce-

dures that are not on an SP’s checklist, you will not receive credit but at

the same time will not lose credit for having done so.

ICE = DG + PN.

PN score. A physician will score your PN according to predeﬁned crite-

ria, including organization, quality of information, data interpretation,

legibility, and the absence of egregious or dangerous actions. Your ﬁnal

PN score will then represent the average of your individual PN scores

over all 10 clinical encounters. Your ICE score will represent the sum

of your DG and PN scores (ICE = DG + PN).

Communication (COM) score. In addition to assessing your data-gather-

ing skills, SPs will evaluate your interpersonal skills (IPS) and your proﬁ-

ciency in spoken English. Your IPS will be assessed on four criteria: rap-

port, interviewing skills, personal manner, and counseling. Your overall

COM score will be the sum of your averaged IPS scores and your spoken

English proﬁciency rating.

The grade you receive on the USMLE Step 2 CS will be either a “pass” or a

“fail.” In order to pass the Step 2 CS, candidates must attain a minimum score

in both ICE and COM. This minimum passing score, which is based on the

achievement of a prespeciﬁed performance standard, is periodically reviewed

and adjusted. In 2000, the passing rate for IMGs taking the old CSA was

80.4%. IMGs who were U.S. citizens fared better (87.1% passing rate) than

did non-U.S.-citizen IMGs (78.7% passing rate). Pass rates have increased in

2001 and 2002 (see Table 1-1).

Integrated Clinical Encounter (ICE) score. The skills you demonstrate

in the clinical encounter are reﬂected in your ICE score. This score con-

sists in turn of a data-gathering (DG) score and a patient note (PN)

score.

T able 1-1. CSA Pass Rates for IMGs

2001

2002

CSA tests given

7,240

8,964

Pass rate for ﬁrst-time takers

84%

82%

In recent pilot studies, U.S. students were found to have performed at the

same level as IMGs whose native language was English.

The mean performance of U.S. students was lower than that of IMGs in

the area of clinical skills.

The mean performance of U.S. students was higher than that of IMGs in

the area of communication skills.

Using the Educational Commission for Foreign Medical Graduates’

(ECFMG’s) pass-fail standards, the passing rate of U.S. students was slightly

higher than that of ﬁrst-time IMG test takers, whose passing rate was 83.3%.

U.S. students and IMGs had

similar passing rates in Step 2

CS pilot studies.

How Do I Register to Take the USMLE Step 2 CS?

To register for the Step 2 CS, you must have obtained a passing score on the

USMLE Step 1. You should also bear in mind that registration information and

procedures are constantly evolving. For the most current information on register-

ing for the USMLE Step 2 CS, go to www.usmle.org or check with your dean’s

ofﬁce. IMGs should also refer to the Web site of the ECFMG at www.ecfmg.org.

For U.S. and Canadian medical students, the registration fee for the

USMLE Step 2 CS is $975 (at least through June 2005). Students will register

using the National Board of Medical Examiners (NBME) Interactive Website

for Applicants and Examinees (click the appropriate link at www.nbme.org).

For IMGs, the registration fee is currently $1200. IMGs can either apply on-

line using the ECFMG’s Interactive Web Application (IWA) at

http://iwa.ecfmg.org or download the paper application from the ECFMG

Web site and mail it to the ECFMG along with the registration fee. Although

there is no speciﬁc application deadline, you need to apply early to ensure

that you get your preferred test date and center.

After your application has been processed, you will receive a scheduling per-

mit by e-mail as well as a CD containing an orientation manual and a video

of sample encounters. You will then be eligible to take the Step 2 CS for one

year, starting when you are entered into the scheduling system to take the

exam. Your scheduling permit will list your eligibility period, scheduling in-

structions, and identiﬁcation requirements for admission to the exam. You

can schedule the test either through the NBME or ECFMG Web sites or via

telephone. Access information will be included with your registration materi-

als. Note that test centers offer both morning and afternoon sessions. You may

be offered an afternoon session if you select a date and center for which

morning sessions are already ﬁlled. Try to select a date and center that will al-

low you to have a morning session (when you are fresher and more relaxed).

Apply early to get a ﬁrst

choice on test centers and

morning-session dates.

Although you cannot extend your eligibility period for the Step 2 CS, you can

reschedule your exam date. The fee is $50 if rescheduling is done more than

30 days before the original test date, $150 if it is done within 30 days, and

$400 if it is done after a missed test date but within the eligibility period.

Where Can I Take the Exam?

The Step 2 CS will be administered at ﬁve regional centers (see Figure 1-1).

Additional centers are currently under consideration.

For detailed information about cities, hotels, and transportation, please refer

to the USMLE Web site (www.usmle.org) or the ECFMG Web site

(www.ecfmg.org).

How Long Will I Wait to Get My Scores?

Step 2 CS results are reported by “snail mail” (not by phone, fax, or e-mail)

six to eight weeks after your exam date. If you do not receive your results

within that time, you must send a written request for a duplicate report to the

NBME or the ECFMG. As mentioned above, the score report you receive

will indicate only whether you passed or failed the exam. The numerical

score you achieved will not be disclosed to you or to any of the programs to

which you apply. Once you pass the Step 2 CS, your passing score will re-

main valid for the purpose of applying for residency training.

FIGURE 1-1. Step 2 CS Test Centers, 2004

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