About the USMLE Step 2 CS

Introduction

Every medical professional seeking to obtain a residency position in the United States must demonstrate their ability to provide safe and effective patient care under supervision (similar to the work of an intern during the first year of residency). These skills are assessed in the USMLE Step 2 CS exam – an 8-hour, pass/fail examination that is designed to test the examinee's ability to:

  • Perform focused histories and physical examinations
  • Communicate findings and diagnostic steps to patients in a clear and empathic manner
  • Recognize and counsel patients on relevant issues regarding health promotion and disease prevention
  • Document patient encounters efficiently
  • Apply knowledge of clinical science to suggest preliminary differential diagnoses and related diagnostic workup plans

Structure of the exam

  • During the exam, every examinee sees 12 standardized patients who simulate common medical conditions seen in various healthcare settings (e.g., outpatient clinics, emergency departments, etc.).
  • The test day is approximately 8 hours long, including 50 minutes of break time (two 10-minute breaks and one 30-minute lunch break; see also “Breaks” below).

Outline of the encounters

  1. Direct patient encounter (15 minutes)
    • History
    • Physical examination
    • Counseling
  2. Writing the patient note (10 minutes)
    • Documentation of the history and physical examination findings gathered during the direct patient encounter
    • Proposal of one or more preliminary differential diagnoses with supporting arguments
    • Creation of a diagnostic workup plan

Special case formats

  • Telephone patient encounters
    • The examinee must conduct a relevant patient history, counsel the patient or caregiver, and/or help with decision-making via a phone located in the examination room.
    • No physical examination is possible. The physical examination section of the patient note can be left blank.
  • Caregiver scenarios
    • The examinee interacts with a patient caregiver (e.g., of a child or elderly patient) and has to conduct a relevant patient history, counsel the caregiver, and/or help with decision-making.
    • No physical examination is possible. The physical examination section of the patient note can be left blank.
  • Skill demonstrations
    • Tasks include performing (sensitive) physical examinations on models or mannequins (e.g., rectal examination).
  • Tablet encounters
    • The examinee is presented with a digital image on a tablet (e.g., imaging or photo) and is asked to interpret it and explain it to the patient.
  • Communication scenarios
    • Tasks may, e.g., include counseling a patient on various health issues or discussing a difficult situation with a patient (e.g., breaking bad news).

Scoring of the exam

Score components

Of the 12 standardized patient encounters, only 10 predetermined stations count toward the final grade.

The exam is graded based on three core components.

  • Integrated clinical encounter (ICE)
    • Assesses the examinee's ability to gather and correctly interpret patient data
    • Determined by:
      • The standardized patient scoring the physical examination section of the encounter
      • Trained physicians rating the patient note
  • Communication and interpersonal skills (CIS)
    • Assesses the examinee's ability to establish and maintain a professional and trusting relationship with the patient as well as to communicate findings, counsel effectively, and demonstrate empathy
    • Solely evaluated by the standardized patient
  • Spoken English proficiency (SEP)
    • Assesses the examinee's spoken English (e.g., pronunciation, word choice)
    • Solely evaluated by the standardized patient

Examinees require a passing score in all three components (ICE, CIS, and SEP) in order to pass the entire exam. A failing score in any of the components will result in Step 2 CS failure!

Score report

  • Scores are released during a 4–5-week reporting period following each testing period. Depending on the date of the exam; , scores can therefore be reported up to 13 weeks after the test date. Exact reporting schedules can be found on the USMLE website (see “Tips & links” below).
  • The score report will feature a graphic representation of the performance range for all three exam components. There is no numerical score. Only the information about passing or failing the exam will be shared with residency programs.

The Step 2 CS exam is a pass/fail exam. No numerical score or graphic representation of your performance will be shared with residency programs.

Pass rates

Pass rates for 2015–2016 are as follows:

First-time examinees Repeaters
US/Canadian MD school 97% 85%
US/Canadian DO school 91% N/A
Non-US/Canadian MD school 82% 71%

While USMLE Step 2 CS traditionally has very high pass rates for US medical students, the exam recently underwent a change in performance standards that affects examinees taking the exam after September 10, 2017. Under the new standards, it is expected that the overall pass rate will drop by approx. 3% for examinees from US medical schools and by approx. 8% for those from international medical schools.

Planning the exam

US medical students Foreign medical students/graduates (FMGs)
Residency program requirements
  • Many residency programs require a passing score before programs submit their rank lists (mid-February).
  • Almost all residency programs require a passing score by the time candidates start applying for residency (September 15th of each year).
Recommended exam/score reporting date
  • Take the exam before December 31st of the year you intend to apply for residency.
  • Take the exam before July 15th of the year you intend to apply for residency.
  • For those who would like to be ECFMG certified by September 15th: Schedule a date so that you will have your results ready by July!
Other information
  • Follow up with your coordinator/dean of student affairs for the optimal testing period so that you will have your results ready for graduation.

Plan ahead! Test dates fill up very quickly, especially in the summer months, and score reporting can take up to 3 months. The USMLE website provides regular updates about the availability of test dates. After August 1, there are often only a few test dates available before the rest of the year!

Registration process

  1. Apply for an exam scheduling permit
    • The permit is valid for 12 months → Plan ahead and apply early!
    • Register with the right organization (see table below).
  2. Choose a test center
    • Atlanta, GA
    • Chicago, IL
    • Houston, TX
    • Los Angeles, CA
    • Philadelphia, PA
  3. Book an appointment
    • Appointments can be booked as soon as your scheduling permit is available.
    • Dates are often booked out up to 6 months in advance.
    • Look for an appointment about half a year before your desired test date and reserve it.
    • Appointments can be rescheduled free of charge up to 15 days before the exam.
  4. Plan travel and accommodation
    • Some hotels close to test centers offer a “USMLE Step 2 CS discount.”
    • For FMGs: It is important that you enter the US with the appropriate visa.
Students or graduates from LCM- or AOA-accredited medical schools within in the US/Canada

Students or graduates from medical schools outside the US/Canada

Organization NBME ECFMG
Service NLES IWA
Application fee $1,285 $1,565

Unless you have a good reason to delay your application, apply early for your scheduling permit and book an exam date. Rescheduling without any charge is possible up to 15 days before the exam.

Preparing for the exam

  • Watch the on-site orientation video (see “Tips & links” below)
  • Find a study partner
    • Ideally, a “real life” partner who you feel comfortable practicing with
      • Does not have to be a medical professional
    • Practicing via video calls is a good alternative if you cannot find a study partner close to home.
  • Go through practice cases
    • Practice each of the AMBOSS practice cases at least once.
    • If you are studying with another exam candidate, take turns playing the standardized patient.
    • Write the patient note after every encounter. A practice form very similar to the one on the real exam can be found in all AMBOSS cases.
    • Print out the list of approved abbreviations and have it ready while you type the patient notes so that you learn how to use them efficiently during the exam (see “Tips & links” below for the download link).
  • Time yourself
    • Set alarms to match the times of the announcements in the exam:
      • 0 minutes: “Examinees, you may begin your first patient encounter.”
      • 10 minutes: “There are 5 minutes remaining in this patient encounter.”
      • 15 minutes: “This patient encounter is now over. You must now leave the room.”
      • 23 minutes: “You have 2 minutes to complete your patient note.”
      • 25 minutes: “Examinees, the patient note portion of this encounter is now over. Please stop writing and place pens on your desk. Give your written patient note and blue scrap paper to the proctor.”
  • Review the cases
    • Compare your patient notes to the sample patient notes from our physicians.
    • Review the check marks in the history, physical examination, and communication and interpersonal skills sections.
    • Review physical examination techniques and counseling points that you missed.
    • Get feedback from your study partner about how she/he felt as your patient.
    • Mark cases; that you want to review again as favorites by clicking the star symbol in the upper right corner.

The key to success on the USMLE Step 2 CS is practice, practice, and more practice. For more advice on how to prepare, see tips and tricks for the USMLE Step 2 CS.

Taking the exam

It is absolutely normal to feel a little nervous and uncomfortable on your test day. Stick to your usual routine to minimize distractions.

Preparation for test day

What to wear

  • Professional but comfortable clothes that you can easily move around in
  • Men: slacks or dress pants, a dress shirt, a tie, comfortable dress shoes
  • Women: dress pants and a blouse, a nice skirt, a dress, dress shoes

What to bring

  • Documents
    • Government-issued photo ID
    • Exam permit
    • Confirmation notice
  • White coat
  • Unenhanced stethoscope
  • (Snacks)

What NOT to bring

  • Luggage (You will not be able to store any luggage at the test center.)
  • Jewelry (except for engagement and wedding rings)
  • Large hair accessories (e.g., clips, headbands)

Arrival at the test center and check-in

  • Arrive early
    • Plan your route and transportation ahead (consider morning traffic).
  • Check-in
    • Have your ID, exam permit, and scheduling notice ready for check-in.
    • Examinees are assigned a number to attach to each shoulder of their white coats.
    • Any information on the white coat that could identify the examinee or her/his institution is covered with white stickers.
    • Once everyone is checked in, all examinees are escorted to the orientation room.
  • Orientation room
    • Examinees are assigned a seat to sit at during orientation and breaks.
    • This is where snacks, food, breath mints, or medications that need to be accessed during breaks can be stored.
    • All other personal items are locked up during the exam. Personal items include but are not limited to:
      • Watches (of any kind)
      • Mobile phones
      • Other electronic devices
      • Wallets
    • Water, coffee, and tea is provided by the test center and available during the orientation and all breaks.

Shortly before the exam

  • The proctors present general information about the exam and show the on-site orientation video (see “Tips & Links” below).
  • Examinees are given the opportunity (and enough time) to test the equipment that will be provided in the exam rooms.
    • If you plan to use gloves, try them out!
    • If you plan to use hand sanitizer, try out how long it takes to dry!
    • Try out all the equipment, including the examination chair, otoscope, ophthalmoscope, and tablet.
  • When everybody is ready, the proctors line up the examinees according to their assigned number and escort them to the exam rooms.
  • All examinees are positioned in a long hallway with 12 (sometimes 24) examination rooms and 12 cubicles containing computers (for writing the patient note; see the on-site orientation video in “Tips & links” below).
  • Every examinee receives a clipboard, two pens, and 12 pieces of blue paper (1 piece per patient encounter).

Breaks

After every third patient encounter, you will get a break and the opportunity to use the restroom. During the lunch break, the test center will provide you with food, drinks, and snacks!

Timing Length
1st break After 3rd encounter 10 min
2nd break (lunch break) After 6th encounter 30 min
3rd break After 9th encounter 10 min
  • Lunch food provided
    • Sandwiches (cheese, turkey, chicken)
    • Muffins, cookies, brownies
    • Fruit (bananas, apples)
    • Coffee, tea, water, assorted soft drinks
  • The leftover food is available during the last break to snack on.

Do not talk to your fellow examinees about any of the exam content during breaks! Do not speak any language other than English!

Passing or failing the exam

Passing the exam

  • See “Scoring of the exam” above.

Failing the exam

  • You can retake the USMLE Step 2 CS up to three times within a 12-month period.
  • You are required to submit a new application and pay the application fee each time you take the exam.
  • There is an option to appeal and file for a re-scoring of the exam.
  • For US medical students: Contact your dean/office of student affairs immediately for advice on when to retake the exam.