Step 2CS Test Experience

[Scottish Chap]

Several years ago, the NBME thought it would be a good idea to develop an examination that tests proficiency in English and in practical diagnostic skills. This is a very expensive examination, and U.S. medical students hate it. I will not tell you anything that can't be found in commercial review books so my conscience is clear. Consistent with my other posts, I am careful not to discuss any specific clinical encounters or to reconstruct the examination from memory. This is forbidden by the NBME, and it’s unfair to other test-taker.

The Step 2CS examination is expensive and it can only be taken in the U.S. It is also an inconvenient test because it is only held in five places in the U.S.: Philadelphia (Pennsylvania), Atlanta (Georgia), Houston (Texas), Chicago (Illinois), and Los Angeles (California). Information on the examination can be found here: USMLE® : Test Content & Practice Materials

The first-time pass rate for U.S. medical students is about 95%. Interestingly, the pass-rate for repeat U.S. examinees is also around 95%. This means that there is likely an arbitrary component to this examination, and so it's definitely worth giving it the respect it deserves. The first-time pass rate for international medical graduates is much lower - somewhere between 70% and 79%. This is telling. Although it's uncommon for U.S. medical students to fail this test, it's not unheard of. It takes around 2-3 months to get your score during busy season and, like me, if you take the examination very late in the year, you could lose your position in a U.S. residency program if you fail the test between March and June and you are scheduled to start residency on July 1. Thankfully, I passed. A temporary state medical license in the U.S. demands passage of Step 2CS.

The examination takes all day and there are 12 stadardised patients (trained actors). You are graded in three areas: Integrated Clinical Encounter (ICE), Communication and Interpersonal Skills (CIS), and Spoken English Proficiency (SEP). This is a pass/fail exam. You are only told which areas are weak and strong on test day if you fail. I know several foreign medical graduates who have failed this test. Most of them practiced medicine for years in their own country and, for most, English was their second language.

For U.S. medical students, reading the first 60 pages of the First Aid for Step 2CS is more than enough. This is assuming that you paid attention in medical school. The first 60 pages of First Aid for Step 2CS tells you how the exam is structured. If you did not attend a U.S. medical school and English is your first language, I think you should also be fine. A friend of mine with MRCS qualifications turned up for Step 2CS with minimum preparation and having not seen patients for over a year. He was rusty coming out of the gates, but he passed. A friend who was a cardiologist in China did not pass on his first attempt (after getting good scores on Step 1 and Step 2CK). I practiced with him for a day before he took CS again. What was scary is that I thought he was better than me in the sense that his differential diagnosis covered everything in the First Aid review book (I would typically get 80-90% of them....but he never missed a point). However, the order of things in his physical examination, his manner, and the way he explains things to patients is very different from the way that we are trained to do it in the U.S. I think this was the major problem. Two ways of doing things - both effective - but always remember the people grading you are used to seeing U.S. medical students every day and, if they see an outlier who does things differently, that might cost you your pass in the exam. In U.S. medical schools, one sees standardised patients every year for four years, so there's really no excuse for flunking Step 2CS if you pay attention.

There are 12 patients. You are given minimal information on a piece of paper hanging on the door (it may have symptoms, vital signs etc.), and you will be expected (in about 15 minutes) to elicit a FULL history from the patient and do a FOCUSED physical examination. Nothing challenging. You are then given about 10 minutes (I can't remember exactly how long) to write this up. You can either use a computer or you can write. I am old-school and so I decided to write. This was a mistake. Clinically, I tend to work fast but I was so pushed for time that I ended up with huge concerns regarding the legibility of my write-ups. Decide ahead of time if you will write or use the computer and stick with that decision. There is a section for your H and P, and you will be expected to come up with the five most likely diagnoses and suggest the five best tests to order. Remember, ordering tests is no big deal in the U.S. and do not be frightened to put in MRI or CT (sensitivity and specificity are way higher then physical exam findings for most ailments and you're less likely to be sued.....it's just the way things are here). Of the 12 patients, 2 are allegedly "experimental" (they do not count them in your final score).

All of the ‘patients’ I had were excellent actors, and the exam covered every organ system and most specialties. Occasionally, you will have a telephone encounter (I had one) where you obviously cannot do an examination, but you are graded on your ability to counsel. Every patient will ask you a hard, blunt, and pointed question, so don't be scared. They are told to do this. Stay calm, and answer honestly. You may have the 'angry' patient, the 'worried' patient, the 'irresponsible' patient, and you must counsel them accordingly. If they smoke, tell them to stop (politely). Preventive medicine gets a lot of attention - in part due to the state of U.S. health care. Lastly, always be confident and always be humble. Arrogance in trainees is despised in medical schools in the U.S. and they tend to be more hierarchical than in other parts of the world. Keep this in mind on test day.

All of the equipment you will need is in the room with the patient: otoscopes, ophthalmoscopes, reflex hammers, penlights, amsler grids, Snellen eye charts, tuning forks, tonofilaments etc. You will only need a stethoscope and a white lab coat. Make sure your medical school cannot be identified on your lab coat or you will be asked to remove it, or you will have to cover it with a patch. They do not allow ANYTHING into the test areas. They are strict. I was not even allowed to take in a tissue, and I had a nasty cold. There are tissues at every station. After you blow your nose, don't be shocked if you open your eyes to find the exam proctor with a garbage can underneath your face (this happened to me). They are that strict. If you are still in the room five seconds after they tell you to come out, they will come in and get you and you will be issued a warning. If it happens again, they can report you to the NBME. I saw a few warnings on test day.

Overall, I don't know what to make of this examination. Modestly, I have always performed way above average on the wards in medical school, but I left the examination not knowing if I passed. I was that worried about how bad my handwriting was. Some of the best students in my class who do not have their score in hand presently feel the same way. Again, I am not sure why so many foreign medical graduates have a tough time with this. There are commercial prep. courses (Kaplan etc.) but I think they are worthless. My friend from China took one after failing CS and, honestly, I couldn't find a whole lot wrong with what he was doing when he and I practiced together.....other than his techniques being 'different' (probably better!) than the way we are taught in the U.S. He said that there were three foreign medical graduates in his test group on test day in Philadelphia. They all stayed in touch. None of them passed. If you are from the U.K., you should be fine. Bottom line: competence, English language proficiency, examining the way that U.S. physicians examine, and bedside manner are most important. Good luck!

[Crocodile Dundee]

Wow...interesting and illuminating I say. The U.S. medical system is always demanding and challenging. Same for the U.S. system in general and for medicine in the UK.