USMLE Step 2 cs Exam Guide


USMLE Step 2 cs Exam Guide


Unfortunately, a few years ago the National Board of Medical Examiners (NBME) had this not-so-bright idea to examine candidates’ English proficiency within a clinical setting. This is not only an expensive exam, but it’s also one that’s certainly not popular among medical students. I will only share my personal experience in this article but I won’t attempt to reconstruct my exam because this is both unfair and legally forbidden.


The Step 2 CS exam’s difficulty lays not only in its content but it’s actually difficult to make your way to the exam itself. Its fees are considerable and it can only be taken in five U.S. cities, which are: Atlanta in Georgia, Chicago in Illinois, Houston in Texas, Los Angles in California and lastly, Philadelphia in Pennsylvania. This makes it a rather inconvenient exam, even for U.S. medical students.


The past rate for both first-timers and repeat takers of American medical students taking the USMLE Step 2 CS exam is at 95%. This indicates the likely presence of arbitrariness, so the exam should by no means be taken lightly. The pass rate for international medical graduates taking the exam for the first time is – not surprisingly – considerably lower at about 70-79%. U.S. medical students still have to be careful because although it’s much less common for them to fail this exam, it’s not impossible. It can also cause them to lose their positions in residency programs because a temporary medical license in the U.S. requires success in the Step 2 CS exam. This can be a considerable threat to their careers, if they take the exam very late in the year because the score takes up to 3 months to appear; right in time for the beginning of residency programs.


Now, for a brief description of the big day:


–          The exam takes all day, so be well-rested.

–          You’ll encounter 12 standardized patients, who are actually trained actors.

–          Your evaluation is in 3 main areas: ICE or Integrated Clinical Encounter, CIS or Communication and Interpersonal Skills and finally, SEP or Spoken English Proficiency.

–          This exam is not about scores; it’s a pass or fail exam.

–          Your areas of strength and weakness will only be reported to you in case of failure.

–          Unfortunately, IMGs (International Medical Graduates) are known to commonly fail this exam because it isn’t about their lack of medical experience, but rather about the fact that English isn’t their first language.


How to prepare for the exam:


Preparation will obviously differ from U.S. medical students to IMGs. For U.S. students, all they have to do is read the first 60 pages in the First Aid for Step 2 CS. This is of course based on the assumption that you weren’t a complete lost cause as a medical student. These pages are basically a guide to understanding the exam’s structure. As for IMGs for whom English is a second language, I think this would be sufficient reading material, as well provided that they are well prepared in other areas.



You have to understand that passing this exam does not solely depend on your knowledge as a medical student or graduate, but rather on a combination of that together with your skills handling the patient himself/herself. Things you need to work on involve:


–          The right order of points during a physical examination.

–          The manner of speaking and dealing with the patients.

–          Explaining the condition and course of management to the patient.


For IMG’s, this may be tricky because things in their countries are usually done in a slightly different manner than in the U.S. It doesn’t mean that the way they were taught is necessarily wrong; just different. As for U.S. medical students, there’s no reason to mess things up, since they’ve probably been practicing by dealing with countless patients for at least four years.


Managing the Exam Questions:


As I’ve mentioned before, you will be faced with 12 patients. On each patient’s door, a piece of paper will be hanging containing the miniscule amount of information (vital signs, symptoms, etc.) regarding this patient which you will be given and expected to base your answer on. In no more than 15 minutes, you should provide a full history of the patient and cover all major points in your physical examination. An additional 5-10 minutes will be provided for you to put this information down in writing. This writing may be down manually or by computer. Trust me and use the computer. It saves you time and is much less of a hassle, but make sure you’ve already decided on your method of writing before walking into the exam.


In your history and physical examination (H and P) section, you should write the five diagnoses you view as most likely in addition to the five best diagnostic tests you should order. Don’t be afraid to write something expensive like a CT scan or an MRI, because these tests are commonly used in the U.S. and great value is placed on the outcome of these tests because of higher specificity and sensitivity compared to the outcome of physical examinations.


Out of these 12 patients, 2 may or may not be experimental and if they are so, they do not affect your score.

The patients are usually really impressive actors and you’ll be faced with quite the variety: the angry patient, the anxious patient, the patient with a devil-may-care attitude who may even be smoking during the exam. Needless to say, you’ll have to politely ask him to quit smoking because all your actions are graded, especially when it comes to preventive medicine because of how health care is such a hotly-debated topic in the U.S. There may also be a few phone interviews where you’ll be graded on your ability to counsel the patient in absence of a physical examination.


Don’t let the patients’ questions intimidate you even if they may seem rude because they were most likely instructed to act that way. Be calm and collected and most of all, you must be humble! Nobody likes an arrogant medical trainee, especially in the U.S. where the hierarchy is almost sacred.


You won’t need to bring much with you on exam day. This is because you’ll find all the tools needed for examination beside each patient and because you won’t be allowed to take anything in there with you expect for your white coat and your stethoscope. You see, the word ‘strict’ does not do the exam proctors justice. You’re not even allowed to take tissues in there with you even if you’re suffering from a bad flu and are likely to sneeze over everything. Instead, you’re expected to use the tissues at each exam station and then dispose of them immediately. Lingering at patients’ bedsides after you’re instructed to leave can get you a warning or even cause you to be reported to the NBME. Exam day isn’t truly complete without a few warnings being handed out here and there.


You walk out of this exam feeling the same way you do walking out of every other exam making up the USMLE; feeling like you don’t know whether you’ve passed or not. The test is not impossible to pass but you walk out wondering if you’ve behaved the right way and if your handwriting was legible enough.


I don’t think that commercial courses marketed as being the key to help you pass this exam such as Kaplan, are all that helpful. It’s mostly a combination of being a well-studied medical student, who is fluent in English and knows the way patients are managed in the U.S. It’s undoubtedly a little easier for North American and British medical students, but that still doesn’t mean it’s impossible for other medical students around the world to pass it with flying colors.

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