USMLE Step 2 CS overview

Time:

I feel about 4-6 dedicated weeks is enough time to prepare for the CS. I know of people who passed after reading for only one week and also know of those who failed after preparing for more than 6 weeks. I also know double 99ers who failed the CS at first attempt and those who passed even though they had low step 1 and CK scores. All in all this is a very unpredictable exam and should not be taken lightly.

Material:

First aid for the CS is the most widely used book for step 2 CS. I personally used it and found it very useful. For an IMG like me just First Aid is probably not sufficient and I strongly recommend using an additional resource. Most commonly used ones include Usmleworld, and Kalplan. Also there are a number of scattered blogs and discussions full of advice. Do not get lost reading too many things. Read few things but read them well.

I recommend making a diary with useful notes from all the available resources and then using that diary for practice. You should try and make a rough ‘pro forma’ that you can use for every case.

Importance of practicing with a partner can not be overemphasized. You should hard try to get a 'guinea pig' for yourself. If not you must at least practice with the mirror. Read a scenario from the text (for example Usmleworld or First Aid) and enact the case. After that go back to the text and see what you missed.

Patient notes are very crucial in scoring your exam performance. Many tend to underestimate this part of the CS exam. You must practice writing the patient notes many times before you actually take the exam.

In the end do remember to view the tutorial beforehand and familiarize yourself with the flow of things.

General things to remember:

Act as if this is a real life situation. That is what is expected of you. Patients are actors but they are experienced. They do what they do every single day! If you are not comfortable they will know. So practice well and be comfortable in saying things however artificial they may sound to you.

Listen to them carefully. If you don’t get what they say request them to repeat it. When talking talk clearly. IMGs have a tough time speaking slowly. We tend to rush through what we say. Try to avoid that. Keep your sentences short. Many people focus on speaking English the American way. I don't think one should attempt doing that. It may end up as a blunder if you try to mask your accent. Speaking slowly should suffice. Also the Simulated Patients are quite used to hearing all kinds of accents.

Do not ask more than once question at once. If the patient’s facial expression tells you that he didn’t understand – repeat/rephrase.

Keep talking to the patient when examining him. Keep him aware of what you are doing. Be gentle, polite and make them feel that you care! Show empathy. If you are an IMG you will soon realize that ‘sorry’ and ‘thank you’ are used much more frequently than you are used to.

Wrapping up and ending well is as important as making a good first impression. Be prepared to summarize and discuss the ‘plan’ with the patient.

What are they looking for*?

Have a look at this Step 2 CS failed report. You must see it in order to know where to focus.

Components of the scoring system:

The ICE subcomponent includes assessment of:

• Data gathering - patient information collected by history taking and physical examination
• Documentation - completion of a patient note summarizing the findings of the patient encounter, diagnostic impression, and initial patient work-up

The CIS subcomponent includes assessment of:

Questioning skills

DO

Use of open-ended questions,

Use transitional statements,

Facilitate remarks

Accurately summarize information from the patient

DON’T

Ask leading questions

Ask multiple questions

Repeat questions unless for clarification

Use medical terms/jargon unless immediately defined

Interrupt when the patient is talking

Information sharing skills

DO
Acknowledge patient’s issues/concerns
Respond clearly with information
Provide counseling where appropriate
Close the conversation appropriately and include statements about what happens next

DON’T
Use medical terms/jargon unless immediately defined

Professional manner and rapport

• ask about
• expectations, feelings, and concerns of the patient
• support systems and impact of illness, with attempts to explore these areas
• show
• consideration for patient comfort during the physical examination
• attention to cleanliness through hand washing or use of gloves
• provide opportunity for the patient to express feelings/concerns
• encourage additional questions or discussion
• make
• empathetic remarks concerning patient issues/concerns
• patient feel comfortable and respected during the encounter

The SEP subcomponent includes assessment of:

• Clarity of spoken English communication within the context of the doctor-patient encounter (e.g. pronunciation, word choice, and minimizing the need to repeat questions or statements)

(* partly from the USMLE website)

The most common subcomponent due to which students fail is ICE.

Types of cases that you will find in Step 2 CS:

Clinic cases

Preventive care (Health check up)

Sick visit (Common clinic problems like backache, headache etc)

Lab result follow up (e.g. lipid profile)

Chronic disease follow up (e.g. Asthma, diabetes)

Drug refill

Pre employment physical exam

Parent of a child (History only. No examination)

Emergency patient (Trauma, Respiratory distress, Pain)

Telephone encounters