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The USMLE Step 2 CS exam inspires a sense of dread amongst many medical students. I certainly remember feeling intimidated when I began to study for it. After all, it has a drastically different format from other USMLE exams. But despite the controversies surrounding the Step 2 CS exam, it seems it will remain a requirement for US medical residency programs for the foreseeable future. So, if you are starting the process of preparing for CS, you have come to the right place.

Getting Started with Step 2 CS Prep

First, reassure yourself that overwhelmingly most people pass Step 2 CS, and for good reason! At the time most students take Step 2 CS, during the fall of senior year, they have completed the majority of their core clinical rotations. As one of these students, you have spoken to countless patients, completed many histories and physicals, and come up with your own differentials and clinical plans. Also, you’ve probably had an opportunity to practice for the CS format in an OSCE (which tend to mirror the CS format fairly closely at many schools). Generally speaking, you’ve had a lot of experiences to prepare you for your exam! Although I’ll admit I was nervous when I started preparing, as I walked out of my exam building in Philadelphia I remember feeling like I’d just had more or less a ‘day at the office’ on my Family Medicine or Internal Medicine rotation.

For all the flack it may get, Step 2 CS actually did strengthen my clinical skills. And after all that studying, it’s a rewarding feeling to have those key clinical steps solidified -- seeing an undifferentiated patient, taking a focused history, completing a focused physical exam, and then coming up with a differential diagnosis and plan independently. You feel tangibly closer to being a ‘real’ doctor! So without further ado, let’s explore what exactly this next standardized Step entails.

What is the Structure of USMLE Step 2 CS?

The Step 2 CS exam consists of 12 clinical encounters (10 are graded) with standardized patient actors over the course of an 8-hour day. The exam is graded in 3 sections: communication and interpersonal skills (CIS), spoken English proficiency (SEP), and integrated clinical encounter (ICE). All three sections must be passed together in order to receive a passing grade. Step 2 CS is offered at times provided on the NBME scheduling website, and can be taken at five cities in the USA: Atlanta, Chicago, Houston, Los Angeles, and Philadelphia. Additional information about the exam, including video examples of patient encounters can be found on the USMLE website.

 

How Do I Prepare for the Step 2 CS Exam?

Akin to your previous USMLE exams, getting ready for Step 2 CS is all about preparation. Fortunately, you do not need to dedicate as much time gearing up for this exam as prior ones (more about that later), as most of the preparation is about getting a sense for the format and refreshing your approach to the ‘bread and butter’ presentations and diagnoses. However there are a few HIGH YIELD resources that I definitely recommend, in order of importance:

1. If you remember one thing from this blog post, it’s that the core of your review should be the First Aid for Step 2 CS book. While you don’t need the newest version, the book has definitely gotten better with each iteration. Find a study buddy and go through a few cases every day, and try to time yourself to 8-10 minutes per encounter (saving 5-7 minutes for the physical exam). Pacing yourself is key, as I found it hard to do many encounters in one sitting since they are each a bit time intensive.

2. After you start to get the hang of the cases, practice writing your encounter note in the USMLE practice form. This is critical, as you are given limited time to write the note, and your success will be based on your efficiency and familiarity with the computer system (which is very similar to the practice note). There can also be an element of strategy in writing your note quickly, as this test taker demonstrates. You’ll notice she streamlines the process by writing the differential first, writing her HPI as bullets instead of full sentences, and then copying and pasting HPI and PE information into her differential at the end. Only 10 minutes is allotted to writing the note, which you will notice is insufficient, so a strategy that prioritizes efficiency over completeness is recommended. The First Aid for Step 2 CS will show you which details to prioritize for each chief complaint.

3. The final tool in your toolbox is a couple solid mnemonics to organize your thinking -- especially for less ‘medicine-y’ topics that may not be commonly top-of-mind. I liked having one in my back pocket for the potential pediatrics phone-encounter (CUB FEVERS PAM IF BIG DEALS) and GYN (LMP RTV CS PAP) visit, which you can Google to see what each letter represents. I wrote these out a few times each night during my dedicated study period until they were easy to recall. You can add on whichever ones will help you on the exam -- I also have trouble remembering the components of a diabetes visit, so I also used DIABETIC - NPH to remember all the questions to ask.

 

When you have a good handle on the cases, note-writing, and your mnemonics go ahead and tie it all together! Complete one (or a few) timed encounter(s) with a buddy, utilizing a high yield mnemonic each time, afterwards writing the note efficiently. Like on Step 1 you will be given an erasable laminated paper, so you can use this to structure your HPI and PE on the exam. I would write the top 3 possible diagnoses on my paper before seeing my patient to guide my history, followed by a history mnemonic (like OPQRST), and then which organ systems I planned to examine on PE all before entering the room to jog my memory in the encounter. This took less than a minute to complete and made me look much smoother during the visit. By test day, you’ll have a great flow of completing the HPI + PE in 15 minutes and then writing the note in 10 minutes. Remember there are points for offering the patient a drape and washing your hands!

When Should I Take Step 2 CS?

We generally recommend students try to sit for the Step 2 CS exam by August of 3rd year. Passing Step 2 CS is a graduation requirement for most schools, and it can take several months to get your results back. Thus, you want to make sure you sit for it with enough time to be able to remediate before graduation, if need be. The most popular time to sit for the exam is August - November and slots can book up 6+ months in advance, given the limited seats & testing centers. Scheduling far in advance is highly recommended! I ended up taking on the early side, in June of 3rd year, and was glad to have gotten it out of the way.

While the exam has historically high pass rates, it’s true that the exam failure cutoff was increased in late 2017. In 2017, 96% of US/Canadian test-takers and 82% of international test-takers passed on the first-attempt. The examiners have stated that they aim to decrease the pass rate by 3% for US test-takers and 8% for international takers. So while hopefully it’s not a valid concern for you, it’s a good idea to take it early in case you need to re-schedule!

How Long Do I Need to Study for Step 2 CS?

I blocked off two weeks during a light elective to study, which allowed me to put in a solid 1-2 hours each night. I aimed to run at least 1-2 cases with a friend for each day (sometimes over the phone with family members). In the two days before the exam, I reviewed the mini-cases at the back of First Aid for Step 2 CS and wrote out the key lab tests for each chief complaint.

What if I Fail Step 2 CS?

The most common cause of failure is the ICE (integrated clinical encounter) section - which consists of a graded check-list completed by the standardized patient on the physical exam, and your encounter and note, graded globally by physicians. Generally, students who fail don’t dedicate enough time to counseling in each encounter (should be done whenever relevant) and/or don’t practice writing the note.

If you fail and need to retake the exam, first take a deep breath and be reassured you are a unique and talented person IN MEDICAL SCHOOL and will still go on to be an amazing doctor. Students have failed and gone on to match at top residency programs!

How is Step 2 CS Test Day?

On test day, I felt the staff was very professional and accommodating. I accidentally brought my stethoscope with my school name on it, and they offered me a substitute since logos and identifiers were not allowed in the exam. Make sure to remember your test permit, white coat, and stethoscope (without logo)! You are not allowed to bring in your own pens or watch (there is a clock in each exam room). I thought the first encounter felt rushed (the time ran out right as the patient asked me the challenge question, and I didn’t have time to answer), but afterwards I began to feel comfortable and get into a flow. Remember, your grade is an average of 10 different encounters.

In the end, the test does have its positives. In the short process of studying for it, I noticed it helped me hone my clinical thinking and forced me to see patients more efficiently. At times, I surprisingly found myself enjoying this simulated ‘day at the office,’ and the SIM patients were quite good, fairly convincing in their portrayal of medical issues. I had a friend in my med school class who said it felt like fun ‘interactive theater.’ I also enjoyed exploring my test-site city, Philadelphia, as a potential city for residency - I learned on the interview trail that Philadelphia trains about ⅕ of all doctors in the United States. And afterwards, I celebrated with a Philly cheesesteak and a beer!

IMG_0243

A celebratory Philly cheesesteak with classic Cheese Whiz. My friend Lukas describes it as a ‘socially acceptable form of cheese,’ which is how you can tell he’s from Philadelphia.

Overall, I hope I’ve de-mystified CS a bit for you. It really isn’t so bad, and can offer a fun little ‘work’ trip before interview season starts. It’s not nearly as demanding as Step 1, but make sure to invest some time in preparing for this exam. You’ll thank yourself when it’s over and be just a little closer to calling yourself a doctor!

 

Here's our guide to mastering mnemonic memorization. And more tips for preparing for Step 2 CS!

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Zach Davidson

Zach Davidson

Zach graduated Magna Cum Laude from The Ohio State University where he studied Biology and Public Health. He is currently an MS4 at the Icahn School of Medicine at Mount Sinai in New York City. While in medical school, he TA'd Anatomy and Physiology for junior medical students and scored 250+ on Step 1. He has tutored since 2012, and enjoys working with students one-on-one to help them unlock their true potential. When not in the hospital, he enjoys browsing the Netflix catalog, thinking about watering his cactus, and exploring the NY state parks.
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