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USMLE Step 2 CS

The Step 2 CS (Clinical Skills) is the examination that was formerly known as the CSA. To put it as simply as possible, it is just an OSCE with loads of frills. Nothing difficult, I assure you. However, you have to pass it in order to secure ECFMG certification (and hence any chance of matching). So, I would strongly advise that you do not take it too lightly, regardless of what anyone says. Imagine how embarrassing it would be to get a pre-match at the place of your dreams… and having to call them to tell them that you will not be able to join their program because you failed the Step 2 CS…

Earlier, the TOEFL examination was also a requirement for ECFMG certification. However, since the transition from CSA to Step 2 CS, the TOEFL examination is no longer required. The Step 2 CS itself will be used to check your ability to communicate.

The examination is available to be given throughout the entire year; however, it must be given before a certain deadline. It keeps changing. You’ll have to check the ECFMG website (www.ecfmg.org) for the latest information.

There are some recommended times that one should give this exam. The vast majority of applicants are going to visit the USA on a three month visit visa. In this period, it would be highly desirable to give the Step 2 CS, interview at a dozen programs, and perhaps even sit for the Step 3 examination, if you have time. The biggest constraint is the fact that the interview season lasts from November to January – itself being a three month period. So, in order to maximize your chances of getting everything done before your visa expires, schedule the Step 2 CS somewhere in early November. You’ll get it out of the way before you start interviewing. Also, since you’ll land in the USA in early November, you can continue to stay till early February, potentially enabling you to sit for the Step 3 examination.

Of course, the earlier you give the Step 2 CS, the better. It’ll speed up the process of ECFMG certification and enable you to get an earlier date for the Step 3. This, in turn, will allow an earlier processing of an H1B visa (if that’s what you’re going for). So, you see, everything is connected. Another fact is that program directors will be more keen on interviewing you and ranking you when you have passed more examinations. If you can secure a six month stay in the USA, sit for the Step 2 CS in, say, mid-October. Some people flew to the USA specifically for the purpose of giving the Step 2 CS early. However, to do this, you’d have to have a long term visa to start off with (e.g. five year multiple) and plenty of funding.

Being the fortunate ones you are, another opportunity has opened up for you lot – one which was not available to us. Earlier, passing the USMLE Step 1 examination was a prerequisite for application for Step 2 CS. That rule has been abolished. All you need now are two years of medical school. Consequently, my advice would be that one should sit for the Step 2 CS during one’s final year electives (if one is doing these in the USA). Any earlier would probably result in insufficient clinical and OSCE experience.

There are five centers in the USA where the Step 2 CS examination can be given:

•    Philadelphia, Pennsylvania

•    Atlanta, Georgia

•    Los Angeles, California

•    Chicago, Illinois

•    Houston, Texas

Where you sit for the exam should not really make a difference.

•    There is a book in the market called “First Aid for the USMLE Step 2 CS (Clinical Skills Exam),” written by Vikas Bhushan and others. I would recommend this book for everyone. If one reads this and nothing else, it is more than sufficient. After familiarizing yourself with this book, if you feel you need more practice, then, go ahead and attempt the dozens of cases available in the Kaplan photocopy. More practice is always good. The exam is all about being able to deal with the patient as a reflex. Therefore, grab a friend and practice, practice, practice.

•    The Step 2 CS has three components (on the basis of which you’re marked):

o    Integrated Clinical Encounter (ICE) Subcomponent (Data gathering, Documentation)

o    Communication and Interpersonal Skills (CIS) Subcomponent (Questioning Skills, Information-sharing skills, Professional manner and rapport)

o    Spoken English Proficiency (SEP) Subcomponent

“Preparation:

Before going for the exam, watch the video and the Candidate Orientation manual that they provide (the candidate orientation manual is now available online - www.ecfmg.org/csa/com/index.html). If you are feeling very apprehensive, then read up the 47 cases given in the Kaplan CD photocopy. That gives a fair idea of what is tested in the exam. You can even go through the basic history and physical examination from Bates. The cases that generally come are very common complaints like chest pain, headache, backache, etc. And when you take the history, you’ll find that there is a wide differential. The history usually does not point to one specific diagnosis because they want to check whether you know the ‘right’ questions for those common complaints.

During the physical exam, check the relevant systems e.g. in a patient with chest pain, you would want to check the pulse, JVP, listen for crepitations in the lungs, feel the cardiac impulse, percuss the heart borders (or pretend to), listen to heart sounds, check for sternocostal tenderness, palpate the abdomen for any epigastric tenderness, and check for pedal edema. Most patients do not have physical findings. But in some cases, the patient may have real signs - crepitations with a COPD lung, an inflamed joint, etc. The patient may even mimic signs - loss of sensation or paralysis. So bottom line - keep your eyes and ears open.

During the patient encounter, you might get a ‘mean’ and ‘un-co-operative’ patient. Don’t worry. They are being deliberately mean. The trick is to be firm. Remain polite and try not to lose your temper.

Format:

There are 10-11 patient encounters (the 11th is usually not graded but you will not know which one is the 11th patient). One gets 15 minutes with each patient and then 10 minutes to write the patient note.  So that makes 25 minutes for each patient encounter.

The actual encounter is marked on a checklist by the patient. The checklist is for communication skills, the questions in the history that you asked and the maneuvers you performed in the physical exam. The patient fills this out once you leave the room. So what matters is not how you percussed the patient but whether you did it at all or not. This makes it much easier than our regular OSCEs. There are also points for knocking before entering, washing hands, draping the patient etc., so one needs to remember those.

The Basic Format, one should follow so that you don’t forget anything:

(Editor’s Note: Before you even knock at the door, pay attention to the case introduction written on the door. Read it carefully and jot down points on the clipboard. It is imperative to have your thoughts organized at this stage in order to avoid awkward pauses during the actual encounter. Write the name, age and any abnormal vital signs. You may even list your differential diagnoses. Write whatever mnemonic you use for history taking. Take your time at this stage and you will save time further on.)

1. Knock

2. Enter and address the patient by Mr. / Mrs. Surname

3. Introduce yourself as Dr. Surname

4. Walk to the sink, wash your hands and while you are at it, explain that you will  be doing a brief history and physical exam and will be discussing your impression with the patient.

5. Walk back to the patient and drape the legs (they are usually uncovered)

6. Sit or stand; whatever you find comfortable. Spend 5 minutes taking the history. Avoid using medical jargon. Ask both open ended and close-ended questions.

7. While taking the personal history, if the person smokes or drinks, counsel there and then...or one tends to forget near the end.

8. Spend 5 minutes on doing a focused and relevant physical exam.

9. Spend 5 minutes summarizing/reconfirming the history that you got, explaining to the patient what you think, he or she has, what investigations you think he/she should get. Remember to ask if he/she has any questions. (Editor’s Note: - Also ask the patient if there is anything else that he/she would like you to know. This provides the patient to guide you if you have been misled. Remember, the simulated patient is not out to get you).

10. Tell the patient when you would like to see him or her next. Say that it was nice meeting them. Walk out.

11. If you are done before time…then walk out and start on the note.

12. The patient note has to be written in legible clear handwriting. Practice on the sample sheet that they provide in the information booklet. Since there is less space on the paper, put only relevant points and important negatives down.

Warning:

Avoid speaking to anyone inside or outside the exam center about the exam. You are not going to do any better by sharing your case histories or exams. But you might certainly end up paying for it if you do!!

Only people with serious problems in communication fail the exam (those who don’t know how to speak English) and if you are not in that category, you don’t need to worry.

Things to take with you to the exam center:

1) White Coat

2) Stethoscope

3) The CSA permit

4) Passport

5) They provide a pen

6) Dress professionally but comfortably (the way one dresses for a viva)

7) Panadol, lunch (if you think that the salad, fruit and chips that they provide will not whet your appetite. They have turkey sandwiches) and Chocolate if you want to. Coffee, soft drinks and water is provided.

Travel and Places to stay:

You can search yahoo for making a reservation at a hotel. Usually, the rates are lower if you book on the Internet .The website (www.usmle.org) provides a list of hotels near all the testing centers, some of which even offer special discounts for CS test takers! (you will have to show them a copy of your scheduling permit, of course).

Regarding the Philadephia center, the Marriott and the Divine Tracy are right opposite each other and 3-minute walk from the center. There are plenty of other places to stay. You can find them on the net.

Try and make it to the city at least a day prior. It is important to keep room for contingencies. Remember to put all the things that you are going to take to the exam center in a hand bag as one runs the risk of losing checked-in luggage.

Website:

For more detailed information, use the following link -  www.ecfmg.org/usmle/step2cs/index.html

Another thing which may prove useful… After giving the Step 2 CS, one tends to wait impatiently for the result, because one can only apply for the Step 3 after passing it (along with all the other exams, of course). At that point in time, even the wait between the dispatch (as told by OASIS) and the actual receipt of the result (by mail) seems long. A simple way of finding out if you have passed is by trying to apply for the Step 2 CS again (don’t worry, you will not be charged for trying!) After inputting your information, the website will tell you that you cannot apply for this examination because you have already cleared it. If this happens, you have passed! Apply away for your Step 3! If not, well, better luck next time!

Note: This article has been derived from "Roadmap to Residency" authored by AKU graduates, with permission from few of the authors. Name of the original author, has purposely not been mentioned on request of one of the authors, for privacy reasons. If you are the original author of this article and want your name to be mentioned or wish this article to be modified/ removed from this website, please contact us and we would be more than happy to entertain your request. We fully respect your privacy, acknowledge your efforts put in authoring this article and appreciate your hard work involved in it.

STEP 1 or CS?

Hello doctor,

the information your site provides is commendable. i have just started with the prep of my steps but i am having second thoughts if taking CS is better to start with than step 1. what do you suggest?

Regards

Form 186 - Rejected Twice

My Form 186 has been rejected twice now! Both the times ECFMG has sent me a letter which gives general guidelines on how to fill the form 186, my mistake has not been pin pointed. The first time I rang up ECFMG they said there was a problem with the seal. But they have rejected my form 186 this time too. My College's Student clerk is not at all helpful. I dont know wat to do. Thought of taking CS with my elective in chicago in Jun. I am running out of time and am not able to think wat to do in this regard. PLease help me

how to apply for CS

Hi
I am planning to appear for CS in the month of april or may. Kindly help me with the procedure.


Thanks!

Please visit the CS section

umar's picture

Please visit the CS section of the website...

I am very busy these days and won't be replying to anymore queries. Apologies for any inconvenience and thank you for your understanding. All the best.

usmle step 2

can anyone tell me that  can i work in u.s.a after giving step 2  only and give the step 1 afterwards .....

what do u mean by work? if u

umar's picture

what do u mean by work? if u have work permit, then u can work anytime, even before steps!

I am very busy these days and won't be replying to anymore queries. Apologies for any inconvenience and thank you for your understanding. All the best.

F1 for CS? Urgent PLEASE

hi Umar bhai

i have got a slot at Kansas fr an elective for which i will be issued an F1 visa..how ever as many people do, i too wnt to appear in my CS exams{ havent given any steps} during my stay in the USA ..do i need to get a seperate B1/b2 for The CS or can i appear in it even if i enter US on an F1?

Kansas F1 Visa and Step2 Cs

Hi abr how are you doing. I too will be going to kansas for 2 months electives and i ll give the cs afterwards. There are no visa hassles as we can stay in the US for upto 60 days after the expiration of our i 20. I confirmed with the consulate official. Which months will you be in Kansas?

ok thnx for the info MR/MISS

ok thnx for the info MR/MISS who ever u are!!m in for july august..wht abt u?

Feb March. Do you know anyone

Feb March. Do you know anyone whos going in that time? or anyone reading this post going to Kansas in Feb March 2011?

hey man! nope sorry dunno any

hey man! nope sorry dunno any one in for feb march.. so ur leaving in 2 weeks eh! kool..good luck..i would like to be in touch with you to know about the Do's and don'ts . and the whole scenario at KUMC .plz send me an email. Hope to hear from u.Good luck :))

mutantaid@yahoo.com

I am not sure; better confirm

umar's picture

I am not sure; better confirm it either from some visa expert preferably from ECFMG or US consultate! I think ECFMG can help you with it!

I am very busy these days and won't be replying to anymore queries. Apologies for any inconvenience and thank you for your understanding. All the best.

Step2 CS application

Hi

I am a student at KE,

I have a valid, signed Form 186, signed by the Registrar.

I am a medical school student (not a graduate yet) and I don't have
any transfer credentials and shall be given diploma by the same school.

Do I need to submit a Form 187, then?

If you have any idea do let me. The Form 187 stuff is very confusing.

Thanks

I dont think u need to submit

umar's picture

I dont think u need to submit form 187, u can confirm from Sattar(Patiala) though! Form 186 is enough!

I am very busy these days and won't be replying to anymore queries. Apologies for any inconvenience and thank you for your understanding. All the best.

US clinical experience

thank you so much for the valuable guidance you have given us. It answers most of my doubts about CS but I was still wondering if it is alright to give the CS exam without having done any electives, observerships etc.? I am a medical intern from India and plan to give my CS soon, but am nervous since I havent ever been to the USA and also am not too sure of how different the patient interaction is in comparison to India. Can you please guide me as to what would be apt?

Thanks for ur kind words.

umar's picture

Thanks for ur kind words. Clinical electives help you for CS preparation but its not like you cannot pass CS without electives. You need to practice each case multiple times for CS, preferably with someone who has recently appeared for it, or at least preparing for it... Practice is the most important preparation rather than doing electives.

I am very busy these days and won't be replying to anymore queries. Apologies for any inconvenience and thank you for your understanding. All the best.

Hello Doc! I want to apply

Hello Doc!

I want to apply for Cs, I want to ask about the EMSWP, I have applied using IWA, but in the end it says my medical college participates in EMSWP and It should verify me as a student using EMWSP. Who should I talk to about it? I am in KE, Lahore, Pakistan.How would I know about the officials who can Sign form-186. Please reply quickly.

Go to Sattar Sahab of Patiala

umar's picture

Go to Sattar Sahab of Patiala block. He would guide you! I think either Registrar or VC signs form 1-186!

EMWSP verification of KE is done by Rashid of computer lab!

I am very busy these days and won't be replying to anymore queries. Apologies for any inconvenience and thank you for your understanding. All the best.

timing my step 2 cs

hello,

i am currently in my fourth year m.b.b.s from india. i am planning to pursue an elective in u.s next year, sometime bet sept-dec '11. i was thinking of giving my step1 in sept2011. i want to know how to proceed from then on.. can i give my step 2 ck first since ill be in u.s for the electives, then probably come back and study for step2cs? or is it better to give them in order? is there any specified time period for giving step2cs? or for that mater step3? how long does it take to prepare for step2 ck, cs and step 3? will i be able to study during my last year [internship in india] ?please help.

There is no specified order

umar's picture

There is no specified order or time period for any of USMLE exams as long as you give them within 7 years... I guess... the time for prep and other issues of prep vary highly from person to person...

I am very busy these days and won't be replying to anymore queries. Apologies for any inconvenience and thank you for your understanding. All the best.

extra paperwork? visa issues?

hi, thank u for the prompt response. in case i happen to take step2 cs before the other exams, what extra paperwork would i have to do when i need my ecfmg certification? will getting visa be tougher if i do my step2 cs first?

No extra paperwork... just

umar's picture

No extra paperwork... just regular forms and documents which are required for step 1... I am not sure about visa issues... it should not be a problem but few years back our seniors used to say it is better if u apply after step 1 and ck but I am not sure about its validity!

I am very busy these days and won't be replying to anymore queries. Apologies for any inconvenience and thank you for your understanding. All the best.

ste2 CK


Thank you for writing such helpful information. It would also be good if someone could throw some light on how and where to prepare from for step2 CK?

you are most welcome anytime!

umar's picture

you are most welcome anytime! The pleasure is all mine!

I am very busy these days and won't be replying to anymore queries. Apologies for any inconvenience and thank you for your understanding. All the best.

 well some of the programs

umar's picture

 well some of the programs prefer candidates who have completed all their exams in their first attempt while the remaining don't seem to care more about it; they look at your electives, US LORs, research experience etc.......so it varies from program to program but it does not mean u wont get a residency...so plz dont think pessimistically... u wud definitely get somewhere... there is a famous urdu poem by Amjad Islam Amjad

"Jo mil gya use yaad rakh, jo na mila usey bhool ja"

(Always remember what you have got in life and look forward to what you can achieve further, not caring for what you have lost in life.) tc and best of luck!

I am very busy these days and won't be replying to anymore queries. Apologies for any inconvenience and thank you for your understanding. All the best.

Thank You!!

incredible sir!!! Thanx for those encouraging words!..I'll surely work with more enthusiasm to acheive what i still can!

if u plan to apply in a

umar's picture

if u plan to apply in a primary care specialty like int. med... then the chances are affected...somewhat decreased but still many places don't care if you fail...as long as you have it cleared now...anyhow in other non-clinical specialties like radio, patho...it does not matter much...tc and best of luck!

I am very busy these days and won't be replying to anymore queries. Apologies for any inconvenience and thank you for your understanding. All the best.

thanx!

Thanx a lot sir!...i totally get what you mean to say.. But ironically i want only Internal Medicine..I feel that's the only thing i'm meant to do in life!..Moreover other residencies are more competetive considering that i'm an img!..Can you please elaborate a little bit on how it affects my chances of getting int med in a univ program?? I'm extremely thankful to you!

failed in step 2 cs

Hello Doc!

I'm a fmg, recently graduated.. got 99(237) in step 1 but recently got my cs resukts and failed in ICE component:(.. I'm totally disappointed!!!!!!! I had great ambitions of getting into a university program.. How are my chances affected if i apply with cs passed in second attempt?? Please help!

P.S: I have three months of US clinical experience too with 3 LORS from Foreign docs.

with the owners

with the owners permission.... you are welcome to get this history format which i followed and many of my friends followed afterwards and got the pass result..

contact my email address for the format...

junaidbinnasir@hotmail.com

regards

dr junaid nasir

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