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The Step 2 Clinical Skills Exam: Just Another Hurdle


As you approach your fourth year of medical school, you begin to realize that medical school is all about conquering hurdles, whether they are basic science exams, shelf tests, or the different steps of the boards. Two years ago, the National Board of Medical Examiners (NBME) decided that medical students needed yet another hurdle to overcome, the Step 2 Clinical Skills (CS) Exam.

The Step 2 CS portion of the United States Medical Licensing Examination (USMLE) is designed to "assess the ability of examinees to apply medical knowledge, skills, and understanding of clinical science essential for the provision of patient care under supervision, and includes emphasis on health promotion and disease prevention." (1) The purpose of Step 2 CS is to determine how well a medical student or foreign medical graduate can collect information from a patient, perform physical exam skills, and communicate the information found in a medical record. These goals are accomplished through standardized patient-based examinations. The standardized patients are lay people trained to portray a clinical scenario. The cases demonstrated by the standardized patients are reviewed by practicing physicians and medical educators to ensure that they represent patients who would be seen in a current medical practice so as to reflect common symptoms and diagnoses. In order to ensure that all cases are distributed fairly and equitably across the country, the cases are based on an examination blueprint that is the same across the country on any given testing day. The examination is standardized so that the patients give the same information when they are asked the same or similar questions by different examinees.

The exam lasts approximately eight hours. Two breaks are given: the first is 30 minutes long for lunch and the second is 15 minutes long for a snack. The exam includes 11 or 12 patient encounters, a small number of which are not scored and are used for pilot-testing new cases. The testing area consists of a series of exam rooms equipped with standard exam tables, medical equipment, gloves, sinks, and paper towels. Outside each exam room is a cubicle with a computer where you will write your patient note after the encounter. Prior to entering the exam room, you will be able to review information posted on the exam room door giving the patient's name, age, gender, reason for visiting the doctor, and vital signs.

During your patient encounter, you will demonstrate a proficiency in focused history-taking and physical exam skills. From the information you gather, you will develop a preliminary list of differential diagnoses and studies that will help to clarify the diagnosis. These differentials and diagnostic tests should be explained to the standardized patient, and all of the patient's questions should be answered. You will have 15 minutes to complete the patient encounter. Remember that if you finish early and leave the exam room, you may not re-enter for any reason. If you do finish early, you may use the extra time to immediately begin writing your patient note.

Upon completion of each patient encounter, 10 minutes are allotted for you to complete a patient note. You may handwrite or type the note, whichever you are more comfortable doing. The note is a SOAP note similar to a clinic note that you would write in the medical record. You should record all pertinent history and physical exam findings, and you will be asked to list up to five differential diagnoses and up to five diagnostic tests that you would like to perform. Treatment, consultations, or referrals should not be included in the diagnostic work-up.

Step 2 CS is a pass/fail examination. The scoring is broken down into three subcategories:

  1. Integrated Clinical Encounter: includes assessment of data gathering and documentation skills.

  2. Communication and Interpersonal Skills: includes assessment of questioning skills, information-sharing skills, and professional manner and rapport.

  3. Spoken English Proficiency: includes assessment of clarity of spoken English communication within the context of the doctor-patient encounter. All three subcategories must be passed successfully in order to pass the overall examination.

There are five testing sites throughout the United States, in Atlanta, Chicago, Houston, Los Angeles, and Philadelphia. Once you have picked the testing site and are ready to register for your examination, be aware that there are often two testing times available for any given testing day. The morning exam usually begins around 8:00 a.m. and ends around 4:00 p.m. and the afternoon exam usually begins around 3:00 p.m. and ends around 11:00 p.m. Please be cognizant of which time slot you are registering for. Travel guides providing information about each testing location are available online. This site provides information about travel and transportation, driving directions, parking and lodging information, and visitors' bureau links for the individual testing cities.

A few helpful hints for test day:

  1. Get there a half an hour before your exam begins.

  2. Luggage may not be stored at the testing centers.

  3. Cubicles are provided for personal item storage during the test. However, these cubicles are not secured and cannot be accessed until the exam is over.

  4. You only need to bring your lab coat and a stethoscope. All other medical equipment will be provided in the exam rooms. You will not be allowed to have personal pens, paper, medical equipment, electronic devices, etc., in the testing area.

  5. There are no waiting facilities for spouses, family, or friends, so plan to meet them elsewhere after the exam is over.

  6. The proctors will cover with adhesive tape or badges anything on your lab coat that identifies your institution.

  7. Lunch and snacks will be provided for you.

  8. Stay at a hotel very nearby the exam site the night before. Travel early and don't try to beat the traffic, because if you are late, you will not be allowed to enter the exam.

For additional information about the USMLE Step 2 CS Exam, please view the USMLE website. I highly recommend reading the "Step 2 CS Content Description and General Information" packet and watching the orientation videos that are available on the website. The Step 2 CS is not something to stress over, but it never hurts to know what the next hurdle entails before you are faced head-on with it.

Megan McCauley
CSM Representative, Southeastern Region
Mercer University School of Medicine, 2006
E-mail: mccauleymd@yahoo.com


  1. USMLE Step 2 Clinical Skills (CS) Content Description and General Information; www.usmle.org; copyright 2004 by the Federation of State Medical Boards of the United States, Inc., and the National Board of Medical Examiners (NBME).

Back to December 2005 Issue of IMpact

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