Passing the USMLE Step 2 CS
Understanding the Enemy
The Clinical Skills portion of the USMLE Step 2 exists to ensure medical students have the requisite skills to conduct a basic history and physical at the level expected of a PGY-1 Resident. In the past students often disregarded the importance of this exam as it had an extraordinarily high pass rate. After all conducting history and physicals is a fairly routine part of the clinical years of medical school, which is when most students write this exam. Rumor has it that due to these pass rates being so high, the USMLE reformulated the exam in 2012 and made a number of changes. While the pass rate is still quite high, it is no longer an exam that should be trivialized.
The only practical portion of the USMLE process, Step 2 CS can only be taken in a few centers nationally and none internationally. This means international students must make the journey over to the continental US to complete this requirement. It is a one day 8 hour exam, which consists of 12 patient encounters. Each encounter lasts 15 minutes or less and you are given 10 minutes to complete a patient note. Any time you save on the patient encounter can be transferred over to time spent on the note, but you cannot re-enter the patient room after you leave. All notes must be typed, hand written notes are no longer an option. Not all 12 encounters are scored, but unfortunately you are not aware of which encounters will be and won’t be scored, much like on other USMLE Step exams you are never aware which questions will count and which are experimental.
There are two breaks, the first being 30 minutes where some food is provided (though you can bring your own) and the second being 15 minutes long. I believe the first break is after 5 cases, the second after 4 additional cases normally. You are only required to bring your own white coat and stethoscope leave all other equipment at home. You will be provided with gloves, blood pressure cuffs , otoscope etc. You will also get paper, pen and a clipboard before the encounters for you to write notes on. Patient encounters may be in person, via telephone (no physical exam required) or with a parent in the room (in the case of some pediatric patients). However, the majority will be with the one standardized patient.
You will be told to stand in front of the patient door prior to each case. As you hear the bell to inform you the examination has begun you may reveal the patient information provided on the door. They indicate patient name, patient gender, age, reason for visit, and vital signs. You can accept the information to be accurate and unless indicated (orthostatic hypertension etc.) you do not need to repeat the vital signs. You will hear another bell when there are 5 minutes remaining, and another bell when the encounter has completed. You will then go out and complete your patient note. There are cameras present in each room but they are there for safety reasons, the video is not used to review your patient interaction.
How is it Scored?
The USMLE Step 2 CS is scored in three components. The Integrated Clinical Encounter (ICE), Communication and Interpersonal Skills (CIS) and Spoken English Proficiency (SEP). The exam is pass/fail and you must pass all three components to pass the examination.
The following excerpts are taken from the USMLE CS Info Manual.
Emphasis is mine in the below quotes.
[blockquote cite=”USMLE CS Info Manual” type=”left, center, right”]
The ICE subcomponent includes assessments of both data gathering and data interpretation skills. Scoring for this subcomponent consists of checklists completed by the standardized patients for the physical examination portion of the encounter, and scoring of the patient note by trained physician raters. The patient note raters provide global ratings on the documented summary of the findings of the patient encounter (history and physical examination), diagnostic impressions, justification of the potential diagnoses, and initial patient diagnostic studies. Cases are developed by committees of clinicians and medical school clinical faculty and comprise the essential history and physical examination elements for specific clinical encounters. Copies of the patient note template, sample patient note styles, and software to practice typing the note are available on the USMLE website.
Examinations that MUST NOT be done: rectal, pelvic, genitourinary, inguinal hernia, female breast, or corneal reflex examinations. If you believe one or more of these examinations are indicated, you should include them in your proposed diagnostic work-up.
- Ensure you complete all required Physical Examinations and document them on the patient note
- In the past you did not have to justify your diagnoses, you now have to, so get in the habit of listing a few reasons why you believe in a diagnosis. Practice coming up with legitimate backing including findings from your history, vital signs and signs from your physical exam. Include any positive and negative findings.
- The history section of the note be as through as possible, but also be aware that you may run out of space. It is very rare to run out of space on the physical examination field, so be through, avoid non-standard abbreviations and include a system by system breakdown.
- History should have a HPI, ROS, Pmhx, Pshx, Meds, Allergies, Fhx, and sexual history if applicable.
- Physical examination findings should be focused and relevant. You luckily aren’t expected to preform every physical exam on every patient, and the time limit won’t permit it. Have an idea before you enter the room of which physical exams you want to complete, and let the history guide your decision. Document them as needed, also remember to document your vital signs again, and mention any pertinent findings.
- It is easier to do well on the physical part as many patients will not have the actual physical finding associated with their condition. Students often struggle getting all the points in the note section. You must substantiate your findings!
[blockquote cite=”USMLE CS Info Manual” type=”left, center, right”]
The CIS subcomponent includes assessment of the patient-centered communication skills of fostering the relationship, gathering information, providing information, helping the patient make decisions about next steps and supporting emotions. CIS performance is assessed by the standardized patients, who record these skills using a checklist based on observable behaviors. Examinees demonstrate the ability to foster the relationship by listening attentively, showing interest in the patient as a person, and steroids online for sale by demonstrating genuineness, caring, concern and respect. Skills in gathering information are demonstrated by use of open-ended techniques that encourage the patient to explain the situation in his/her own words and in a manner relevant to the situation at hand, and by developing an understanding of the expectations and priorities of the patient and/or how the health issue has affected the patient. An examinee demonstrates skills in providing information by giving an explanation of what is likely occurring in terms the patient can understand, and by providing reasons that the patient can accept. Statements need to be clear and understandable and words need to be those in common usage. The amount of information provided needs to be matched to the patient’s need, preference, and ability. The patient should be encouraged to develop and demonstrate a full and accurate understanding of key messages. Helping the patient make decisions is demonstrated by outlining what should happen next, linked to a rationale, and by assessing a patient’s level of agreement, willingness, and ability to carry out next steps. Examinees demonstrate ability to support emotions when a clinical situation warrants by seeking clarification or elaboration of the patient’s feelings and by using statements of understanding and support
- This section has changed dramatically in recent years and what was before a “general feel for the student” has been replaced with a regimented checklist. It doesn’t matter anymore if the patient loves you if you don’t do what’s on the checklist you’ll run into trouble.
- Work on your active listening, if you aren’t sure what to say next RECAP. Recap what they just said to you and add “just to ensure I’m understanding this correctly”. Use that time to think of what to do next.
- Ask “Is there anything else?” They may have told you a million things, but always always recap and then ask”Is there anything else?” or “Did I miss anything?” You’d be surprised how often you’ll get that million and oneth fact that may completely alter your diagnosis. The standardized patients are also often hold out unless pressed 2-3 times, holding out a vital fact until the second or third attempt.
- Showing interest in the patient as a person – This essentially means ask them something non-medical. O”h you work as a librarian that must be interesting, how do you like it?” or “Oh you have two kids what do they do? How old are they?” While open ended questions are great elsewhere, you can’t waste too much time here either just ask 1-2 simple things about their role outside that of a patient. Tie it into another question you would have to ask anyway (Occupation or job history etc.)
- Caring and concern – be genuine, this isn’t real but pretend it was. Tell them you understand it must be very difficult to have that problem (pain, weakness, diarrhea etc.)
- How their health has affected them – “That arthritis must make it difficult for you to work as a carpenter” or “Tell me more about that?” “How have you found your work affected by your fatigue?” “How has your MS affected your family life?” Tie something else you found out about them into their medical condition. Asking them how it affected their family or occupation is the easiest way to do so.
- ABCs! Always be Closing! Remember to close off any patient encounter, if you are running out of time remember closing is worth more than doing that extra physical exam. Always! The 5 minute warning is a good reminder, you should be on your last physical examination at this time. Remember to recap what your history and physical findings are to the patient. Tell them 1-3 things you suspect it may be if possible the 1-3 tests you intend to run. Tell them what you suspect and what will come next for them (So we’ll run those tests Mrs. Jones or we’ll schedule a follow up appointment in 2 weeks Mrs. Jones to see how this progresses etc.) Then follow up and ask “Do you understand the next steps?”
- Before you wrap up, ask them if they have any more questions or concerns. “That is the plan going forward Mr. Edwards but before I leave do you have any more questions or concerns you want to discuss?” Also this is a great time to build in partnership – “We will work on helping you deal with your fatigue together Mr. Jones” or “I know we can get to the root of this together and make you feel better Mrs. Jones”. Also a great time to offer any counselling for a second time or recap what you plan to do for that as well.
[blockquote cite=”USMLE CS Info Manual” type=”left, center, right”]
The SEP subcomponentincludes assessment of clarity of spoken English communication within the context of the doctor-patient encounter (for example, pronunciation, word choice, and minimizing the need to repeat questions or statements). SEP performance is assessed by the standardized patients using rating scales and is based upon the frequency of pronunciation or word choice errors that affect comprehension, and the amount of listener effort required to understand the examinee’s questions and responses [/blockquote]
- This is often only a problem for international students for whom english is not a primary language, the only real solution is practice.
Last Minute Tactics
- PRACTICE! You can find a practice note here! It’s no use practicing any other way than using the actual note format you’ll see day of. Here are a few Sample Notes as well – Sample Note #1 & Sample Note #2
- Ideally you want to take this examination during or after IM or Family Medicine. These rotations afford you plenty of practice doing H&Ps, and will allow you to be comfortable doing many of them in rapid succession.
- You may introduce yourself as a medical student or doctor – it doesn’t matter. Just don’t mention your institution/school.
- Practice at least 50% of the cases in First Aid with a friend acting as a standardized patient under time constraints. After each case, write the note using the practice note website above and allow your friend to evaluate it according to the FA guidelines.
- Consul everyone who needs it. Remember CAGE and discuss safe sex, smoking cessation, and illegal substance cessation. Remember to mention it during closing and within your note. Offer more materials if they are interested in learning, and a follow up appointment to discuss it further.
- Practice is the best way to know what tests should be ordered next, seriously the biggest reason anyone fails this exam is lack of practice.
- Wash your hands before every patient encounter.
- Normally the patient is gowned or a gown will be on your seat to start the exam. Offer it to them for the physical exam, or if already gowned while doing the exam gown any part of them not being examined. People often forget this, but it’s a vital part of the physical exam to protect a patient’s dignity. For example if examining the chest requires you to lift the gown, put additional gown/cloth to cover the patient’s abdomen.
- Talk during your physical exam! First ask permission to do the exam, then dictate everything you are doing. This will keep you organized but also ensure the standardized patient remembers everything you did so they check it off.
- Beware of the tricks! Often a patient may come in a bandage, you must remove it and see if there are any physical findings underneath and then reapply it. Patients may complain of headaches or photophobia, remember to offer to turn down the lights if it makes them more comfortable.
- Be courteous. Inform the patient you will warm up your stethoscope by rubbing it on your hand before placing it on them, as you know it may be cold.
- Be prepared to deal with an an aggravated patient – you were late, all doctors are the same etc. Defuse the situation and once you accept blame and apologize normally the standardized patients become quite cooperative.
- Speak at their eye level whenever possible. Shouldn’t need to be said, but don’t intimate or tower over the standardized patient.
- Take notes when needed, and spend the amount of time outside the door that you are comfortable with. If you need to think of 1-3 differentials before you enter do so, if you can do that while you wash your hands do that instead. Ideally the more time you save the better, but don’t become unorganized trying to save time.
- Did I mention to Practice! Practice!!
[mailchimpsf_form] Good Luck and don’t stress you’ll ace it!