First Aid for USMLE Step 2CS, USMLE

First Aid for USMLE Step 2CS

Indeks Finanse, Finanse(1), Filozofos, Fesenjan, Fenix,

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First Aid for USMLE Step 2CS, USMLE

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I NTRODUCTION
Since 1998, all international medical graduates (IMGs) have been required to
pass a clinical skills exam known as the Clinical Skills Assessment, or CSA—a
test involving clinical encounters with “standardized patients”—as a prerequi-
site to entering residency training in the United States. With the introduction
of the USMLE Step 2 Clinical Skills (CS), however, U.S. and Canadian med-
ical students as well as IMGs are now required to demonstrate basic clinical
competencies in order to enter residency training and take the Step 3 exam.
Even if you are a seasoned pro at taking standardized exams such as the
USMLE Step 1 and Step 2 Clinical Knowledge (CK), you may ﬁnd it chal-
lenging to prepare for the USMLE Step 2 CS—which, like the CSA it has re-
placed, uses live patient actors to simulate clinical encounters. Common mis-
takes students and IMGs make in preparing for the Step 2 CS include the
following:
Panicking because of the unfamiliar format
Inadequate practice with mock patient scenarios prior to the actual exam
Not developing a logical plan of attack based on patient “doorway infor-
mation”
Not understanding the required objectives for each patient encounter
Poor time management during patient encounters
Becoming ﬂustered by challenging questions or situations
Taking unfocused histories and physical exams
Failing to understand how to interact with a patient appropriately
Not performing easy but required patient interactions
This book will help guide you through the process of efﬁciently preparing for
and taking the Step 2 CS with four organized sections:
Section I
introduces you to the USMLE Step 2 CS.
Section II
reviews critical, high-yield steps to take during the patient en-
counter.
Section III
provides high-yield minicases for common doorway chief com-
plaints to help you rapidly develop focused differentials during the exam.
Section IV
has full-length practice cases to help you simulate the real thing.
USMLE STEP 2 CS—THE BASICS
What Is the USMLE Step 2 CS?
The United States Medical Licensing Examination (USMLE) Step 2 CS is a
one-day exam whose objective is to ensure that all U.S. and Canadian med-
ical students seeking to obtain their medical licenses—as well as all IMGs
seeking to start their residencies in the United States—have the communica-
tion, interpersonal, and clinical skills necessary to achieve these goals. To pass
2
the test, all examinees must show that they can speak, understand, and com-
municate in English as well as take a history and perform a brief physical
exam. Examinees are also required to exhibit competence in written English
and to demonstrate critical clinical skills by writing a brief patient note (PN),
some follow-up orders, and a differential diagnosis.
The Step 2 CS simulates clinical encounters that are commonly found in clin-
ics, physicians’ ofﬁces, and emergency departments. The test makes use of stan-
dardized patients, or SPs, all of whom are laypeople who have been extensively
trained to simulate various clinical problems. SPs give the same responses to all
candidates participating in the assessment. When you take the Step 2 CS, you
will see 10 to 12 SPs, but cases will be mixed in terms of age, gender, ethnicity,
organ system, and discipline. For quality assurance purposes, a video camera
will record all clinical encounters, but the resulting videotapes will not be used
for scoring. The cases used in the Step 2 CS represent the types of patients who
would typically be encountered during core clerkships in the curricula of ac-
credited U.S. medical schools. These clerkships are as follows:
Internal medicine
Surgery
Obstetrics and gynecology
Pediatrics
Psychiatry
Family medicine
It should be noted that examinees do
not
interact with children during pedi-
atric encounters. Instead, SPs assuming the role of pediatric patients’ mothers
recount patients’ histories, and no physical exam is required under such cir-
cumstances.
There is no physical exam in
pediatric encounters.
How Is the Step 2 CS Structured?
Before entering a room to interact with an SP, you will be given an opportu-
nity to review some preliminary information. This information, which is
posted on the door of each room (and hence is often referred to as “doorway
information”), includes the following:
Patient characteristics (name, age, sex)
Chief complaint and vitals (temperature, respiratory rate, pulse, blood
pressure)
You will be given 15 minutes (with a warning bell sounded after 10 minutes)
to perform the clinical encounter, which will include reading the doorway in-
formation, entering the room, introducing yourself, obtaining an appropriate
history, conducting a focused physical exam, formulating a differential diag-
nosis, and planning a diagnostic workup. You will also be expected to answer
any questions the SP might ask, to discuss the diagnoses being considered,
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and to advise the SP about follow-up plans. After leaving the room, you will
have 10 minutes to write a PN.
How Is the Step 2 CS Scored?
Of your 10 to 12 patient encounters, 10 will be scored. Two people will score
each encounter: the SP and a physician. The SP will evaluate you at the end
of each encounter by ﬁlling out three checklists: one for the history, a second
for the physical exam, and a third for communication skills. The physician
will evaluate the PN you write after each encounter. Your score, which will be
based on the clinical encounter as a whole and on your overall communica-
tion skills, will be determined in the following manner:
DG score.
To determine your DG score, SPs will document your abil-
ity to gather data pertinent to the clinical encounter. Speciﬁcally, SPs
will note whether you asked the questions listed on their checklists, suc-
cessfully obtained relevant information, and correctly conducted the
physical exam (as indicated by the performance of the procedures on
their checklists). Your ﬁnal DG score will represent an average of your
performance with all 10 SPs.
If you asked questions or performed proce-
dures that are not on an SP’s checklist, you will not receive credit but at
the same time will not lose credit for having done so.
ICE = DG + PN.
PN score.
A physician will score your PN according to predeﬁned crite-
ria, including organization, quality of information, data interpretation,
legibility, and the absence of egregious or dangerous actions. Your ﬁnal
PN score will then represent the average of your individual PN scores
over all 10 clinical encounters. Your ICE score will represent the sum
of your DG and PN scores (ICE = DG + PN).
Communication (COM) score.
In addition to assessing your data-gather-
ing skills, SPs will evaluate your interpersonal skills (IPS) and your proﬁ-
ciency in spoken English. Your IPS will be assessed on four criteria: rap-
port, interviewing skills, personal manner, and counseling. Your overall
COM score will be the sum of your averaged IPS scores and your spoken
English proﬁciency rating.
The grade you receive on the USMLE Step 2 CS will be either a “pass” or a
“fail.” In order to pass the Step 2 CS, candidates must attain a minimum score
in
both
ICE and COM. This minimum passing score, which is based on the
achievement of a prespeciﬁed performance standard, is periodically reviewed
and adjusted. In 2000, the passing rate for IMGs taking the old CSA was
80.4%. IMGs who were U.S. citizens fared better (87.1% passing rate) than
did non-U.S.-citizen IMGs (78.7% passing rate). Pass rates have increased in
2001 and 2002 (see Table 1-1).
4
Integrated Clinical Encounter (ICE) score.
The skills you demonstrate
in the clinical encounter are reﬂected in your ICE score. This score con-
sists in turn of a
data-gathering (DG) score
and a
patient note (PN)
score.
T able 1-1.
CSA Pass Rates for IMGs
2001
2002
CSA tests given
7,240
8,964
Pass rate for ﬁrst-time takers
84%
82%
In recent pilot studies, U.S. students were found to have performed at the
same level as IMGs whose native language was English.
The mean performance of U.S. students was lower than that of IMGs in
the area of clinical skills.
The mean performance of U.S. students was higher than that of IMGs in
the area of communication skills.
Using the Educational Commission for Foreign Medical Graduates’
(ECFMG’s) pass-fail standards, the passing rate of U.S. students was slightly
higher than that of ﬁrst-time IMG test takers, whose passing rate was 83.3%.
U.S. students and IMGs had
similar passing rates in Step 2
CS pilot studies.
How Do I Register to Take the USMLE Step 2 CS?
To register for the Step 2 CS, you must have obtained a passing score on the
USMLE Step 1. You should also bear in mind that registration information and
procedures are constantly evolving. For the most current information on register-
ing for the USMLE Step 2 CS, go to www.usmle.org or check with your dean’s
ofﬁce. IMGs should also refer to the Web site of the ECFMG at www.ecfmg.org.
For U.S. and Canadian medical students,
the registration fee for the
USMLE Step 2 CS is $975 (at least through June 2005). Students will register
using the National Board of Medical Examiners (NBME) Interactive Website
for Applicants and Examinees (click the appropriate link at www.nbme.org).
For IMGs,
the registration fee is currently $1200. IMGs can either apply on-
line using the ECFMG’s Interactive Web Application (IWA) at
http://iwa.ecfmg.org or download the paper application from the ECFMG
Web site and mail it to the ECFMG along with the registration fee. Although
there is no speciﬁc application deadline, you need to apply early to ensure
that you get your preferred test date and center.
After your application has been processed, you will receive a scheduling per-
mit by e-mail as well as a CD containing an orientation manual and a video
of sample encounters. You will then be eligible to take the Step 2 CS for one
year, starting when you are entered into the scheduling system to take the
exam. Your scheduling permit will list your eligibility period, scheduling in-
structions, and identiﬁcation requirements for admission to the exam. You
can schedule the test either through the NBME or ECFMG Web sites or via
telephone. Access information will be included with your registration materi-
als. Note that test centers offer both morning and afternoon sessions. You may
5
be offered an afternoon session if you select a date and center for which
morning sessions are already ﬁlled. Try to select a date and center that will al-
low you to have a morning session (when you are fresher and more relaxed).
Apply early to get a ﬁrst
choice on test centers and
morning-session dates.
Although you cannot extend your eligibility period for the Step 2 CS, you can
reschedule your exam date. The fee is $50 if rescheduling is done more than
30 days before the original test date, $150 if it is done within 30 days, and
$400 if it is done after a missed test date but within the eligibility period.
Where Can I Take the Exam?
The Step 2 CS will be administered at ﬁve regional centers (see Figure 1-1).
Additional centers are currently under consideration.
For detailed information about cities, hotels, and transportation, please refer
to the USMLE Web site (www.usmle.org) or the ECFMG Web site
(www.ecfmg.org).
How Long Will I Wait to Get My Scores?
Step 2 CS results are reported by “snail mail” (not by phone, fax, or e-mail)
six to eight weeks after your exam date. If you do not receive your results
within that time, you must send a written request for a duplicate report to the
NBME or the ECFMG. As mentioned above, the score report you receive
will indicate only whether you passed or failed the exam. The numerical
score you achieved will not be disclosed to you or to any of the programs to
which you apply. Once you pass the Step 2 CS, your passing score will re-
main valid for the purpose of applying for residency training.
FIGURE 1-1.
Step 2 CS Test Centers, 2004
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