The United States Medical Licensing Examination (USMLE) is a demanding, multi-step process that takes place over several years during medical school. And passing it is tough. It’s important to learn the most important details of Step 2 Clinical Skills (CS) to understand the best ways to prepare and when to take this portion of a critical hurdle on your path to becoming a physician.

_Follow this link for a general overview of the USMLE test series._

Overview

The USMLE is a three-step exam series, with the second step divided into two tests — Step 2 Clinical Knowledge (CK) and Step 2 Clinical Skills (CS). This latter component is the only portion of the USMLE not taken on a computer. Instead, it involves mock interactions with “standardized patients" — that is, individuals who receive training to act as actual patients. The goal of this part of the exam is to assess medical students’ ability to obtain histories from patients, perform physical examinations, and communicate findings with both patients and other medical professionals.

Eligibility

Medical students may take Step 2 CS if they are officially enrolled in or have graduated from:

• An allopathic medical school — that is, one whose graduates earn an MD — in the U.S. or Canada and that is accredited by the Liaison Committee on Medical Education (LCME)
• An osteopathic medical school whose graduates receive a DO degree in the U.S. or Canada and which is accredited by the American Osteopathic Association{: target="_blank" } (AOA)
• A medical school in a location other than the U.S. or Canada that is listed in the International Medical Education Directory (IMED) and meets criteria established by the Educational Commission for Foreign Medical Graduates (ECFMG)

  Registering

Given the logistical challenges of providing standardized patients for testers, the USMLE 2 CS is only offered at five locations around the country, sites known as Clinical Skills Evaluation Collaboration{: target="_blank" rel="nofollow" } (CSEC) test centers. These facilities are in:

• Atlanta, Georgia
• Chicago, Illinois
• Houston, Texas
• Los Angeles, California
• Philadelphia, Pennsylvania

Students and graduates of allopathic or osteopathic medical schools in the U.S. or Canada can register for Step 2 CS on the National Board of Medical Examiners (NBME) website. Medical school students or graduates from other countries, on the other hand, must register on the ECFMG website.

The 2015 cost of Step 2 CS is $1,250 for students who attend or have graduated from medical schools in the U.S. or Canada, a fee that will rise to $1,275 in 2016. For students or graduates of medical schools in other countries, this portion of the exam costs $1,505. Additional fees may apply for date and location changes.

Scheduling

Given that there are only five test centers, registering and scheduling early for Step 2 CS is critical. Once you sign up on either the NBME or the ECFMG website, you will be able to schedule the exam for any available opening in the upcoming 12 months. Note that the peak season for USMLE Step 2 CS is between September and December.

# Determining When to Take Step 2 CS

Since Step 2 CS assesses your ability to act like an intern with primary responsibility for a patient, most students take the exam late in the clinical years of their med school education. In the past, most U.S. medical schools taught basic science coursework for the first two years of their programs, after which students took part in hospital-based clinical rotations for the following two years.

Recently, however, many institutions have moved the clinical component earlier, and students begin this part of their education in conjunction with their science classes. For example, med students might begin a rotation in a cardiac unit while simultaneously studying cardiac biochemistry, physiology, and pathophysiology. This shift enables them to focus on the abstract, academic aspects of their preparation at the same time as they are learning the practical applications of the material.

Since many students want residency admissions committees to see they have passed this section of the USMLE, combining coursework and rotations gives medical students the experience they need to be successful on Step 2 CS. Typically, candidates will take this assessment before they submit their residency applications in September of their final year of medical school. It’s important to remember, though, that scores may take up to three months to come back.

Structure

The USMLE Step 2 CS is an eight-hour exam that includes 12 individual patient encounters with 50 minutes of total break time (a 10-minute respite following the third patient encounter, 30 minutes for lunch, and a second 10-minute break after the sixth patient encounter). The aim of the exam is to determine whether you are sufficiently prepared to act as an intern who has primary responsibility for a patient, even though you remain under the supervision of a licensed doctor. It’s important to treat each person being examined as if she is a real patient — the direct care you provide will form part of the basis of your exam results.

# Timing

For each encounter, you will be given 15 minutes to review patient data, obtain a history, and perform a physical exam. You will then have 10 minutes to type a note on a computer, which should include details about the patient’s history, observations from the physical examination, data interpretation, possible diagnoses in order of likelihood, and diagnostic studies you have requested. Announcements will inform you when to begin, when five minutes remain, and when the encounter is over.

# Information

Before you meet each patient, you will receive a clipboard, blank paper for taking notes, and a pen. You will then hear an announcement that the encounter time has begun, at which point, you may review the patient information on the exam room door and make notes. The details you read there will include the patient’s name, age, gender, and primary complaint, as well as her vital signs and, perhaps, lab test results. You do not need to take the patient’s vital signs again unless you believe her situation specifically requires it. Some cases may involve a follow-up visit, and the instructions will indicate whether a physical exam is required in these instances. Others may necessitate a phone call to a patient, which will also be stated in the instructions.

# Setting

The encounter room is set up like a typical exam room, with standard exam tables, blood pressure cuffs, otoscopes, ophthalmoscopes, non-latex gloves, sinks, and paper towels. The only medical instrument you are allowed to bring into the testing center is a standard stethoscope. There will be a computer outside of the exam room, which you will use to compose the note.

# Strategy

The cases are structured so that a complete history and physical exam are not required — so take a focused approach. Please note, too, that certain types of physical assessments are not permitted, including rectal, pelvic, genitourinary, inguinal hernia, female breast, and corneal examinations.

Content

The content of Step 2 CS covers a broad spectrum of common and important disease processes, and includes mock patients with a variety of backgrounds and personalities. The range of conditions and patients is intended to determine whether candidates are able to provide safe, effective medical care to different sorts of people under a variety of circumstances. The physical systems tested fall into the following categories:

• Cardiovascular
• Constitutional
• Gastrointestinal
• Genitourinary
• Musculoskeletal
• Neurological
• Psychiatric
• Respiratory
• Women's health

Keep in mind that the authors of the exam are not trying to stump you with esoteric symptoms or diagnoses; the cases will reflect disease processes you are likely to encounter in a clinic or emergency department.

Scoring

Step 2 CS is graded on a pass/fail basis. You are scored on three subcomponents, and you must pass each one to achieve an overall passing result:

# Communication and Interpersonal Skills (CIS)

In this area, you are evaluated on your ability to communicate and create an understandable narrative for patients, including fostering a relationship, gathering and delivering information, helping patients make decisions, and providing emotional support. The standardized patients themselves assess each candidate’s CIS skills and record them using a checklist based on observable behaviors.

# Spoken English Proficiency (SEP)

Your ability to communicate clearly in spoken English is assessed by the mock patients according to a global rating scale.

# Integrated Clinical Encounter (ICE)

This component will test your data-gathering and interpretation skills. The overall ICE score is a combination of the results of the checklist for the physical examination that was completed by your standardized patients and ratings provided by physician-evaluators on the detailed notes you composed about those individuals you examined.

Scores for Step 2 CS are released based on a published reporting schedule, and typically take anywhere from one to three months to receive depending on when you take the exam.

The USMLE is a demanding, lengthy series of assessments, but many examinees enjoy Step 2 CS because it’s the component that gives you the opportunity to act like a real doctor. While you still need to prepare thoughtfully, your ability to communicate effectively also comes into play. So, make sure you know the content thoroughly — but also remember to treat your patients with compassionate care.

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Additional Resource:

• USMLE Step 2 Clinical Skills Content Description and General Information