How to Study for USMLE Step 2CS

The USMLE Step 2 Clinical Skills exam aims to assess medical students’ ability to integrate clinical knowledge and practical skills, including physical exam maneuvers and interpersonal communication. This is an in-person exam, consisting of 12 fifteen-minute standardized patient encounters, followed by ten minutes to write a corresponding note. The test is about eight hours long, with a ten-minute break after the third encounter, a 30-minute lunch break after the sixth encounter, and a ten-minute break after the ninth encounter. Examinees are graded on three categories: Communication and Interpersonal Skills, Spoken English Proficiency, and Integrated Clinical Encounter.  The Communication and Interpersonal skills section refers to the ability of the examinee to foster relationships with the patients and demonstrate empathy. The Integrated Clinical Encounter section refers to the ability of the student to accurately assess, diagnose, and further investigate the chief complaint. While there are criteria for grading, it is important to keep in mind that the exam is Pass/Fail. Examinees will not receive a score for the exam.

Preparing for the USMLE exam can be quite challenging, especially since its structure differs so significantly from typical medical testing. We recommend studying for the two main components of the exam separately: standardized patient encounters and note writing. To study for the patient encounter, it is best to identify a study partner, likely another medical student, with whom you can practice. Use “First Aid USMLE Step 2CS” to read about the potential chief complaints you may encounter during the exam. Take turns with your study partner role playing as the patient and doctor and run through all chief complaints. Make sure you collect a full history, perform all necessary physical exam maneuvers, and generate a differential diagnosis with a plan for each case. You will be expected to spend the last few minutes of each encounter explaining your top diagnosis to the patient and directing them in the next few steps of your work up. Be sure to practice this skill as well. Use this technique for about three or four hours per day for the last two weeks prior to your exam. 

It may be helpful to create a list of generic questions that you will ask every standardized patient so that you develop a rhythm to history-taking. Some of these may include: name, preferred gender pronoun, smoking history, and drug and alcohol history. It may also be helpful to create a list of potential physical exam maneuvers to perform, so that you don’t accidentally forget to address a particular organ system. You don’t need to perform a comprehensive physical exam for each standardized patient; you must only enact the maneuvers pertinent to the patient’s chief complaint. If you are unsure which components of the physical exam are relevant to the case, you can always perform a heart and lung exam. Overall you should spend no more than 3-5 minutes of the encounter on the physical exam. Don’t forget to set a timer as you practice – 15 minutes passes quickly!

While the standardized patient encounter is a significant component of the exam, note writing is also an essential element. When you leave the standardized patient encounter, there are computers at the testing center on which you will be expected to write a corresponding note. The note consists of the following sections: history, physical examination, diagnostic reasoning, and diagnostic studies.  In the “diagnostic reasoning” section you must identify your top two or three diagnoses and give rationale for these selections, including relevant history and physical exam findings. In the “diagnostic studies” section, you must choose what future exam maneuvers, laboratory tests, or imaging studies you would order to work-up the patient more completely.

In order to study for this piece of the exam, you should write a note after each practice case. The tricky part of note writing is the timing. Ten minutes is extremely short. The USMLE offers a free online version of the Step 2CS Patient Note, seen here: https://www.usmle.org/practice-materials/step-2-cs/patient-note-practice2.html. Use this website to familiarize yourself with the structure of the note. The site also includes a timer, so you can mimic the testing setting and keep yourself within the 10-minute limit as you practice. If you are struggling to identify the proper diagnoses or create a logical plan, refer to “First Aid for the USMLE Step 2CS,” which includes over 100 cases that have been tested on the exam in the past, including descriptions of questions to ask on history-taking, proper physical exam maneuvers to perform, differential diagnoses by chief complaint, and follow-up tests to order. 

On test day, remember to stay calm! Many students experience performance anxiety, but remember that if you read the proper materials, and practice physical exams and note writing for each chief complaint, you will likely pass.  Some important last minute tips – always wash your hands immediately upon entering the patient exam room, introduce yourself as “student doctor” using your first and last name, take a minute to summarize your patient’s chief complaint before beginning the physical exam, and always give a possible diagnosis and future plan when wrapping up the encounter. Further, to prevent yourself from running out of time when writing the note, try and organize your thoughts during the patient encounter. Structure your handwritten notes in the exam room to reflect the way that your note will look on the computer after the encounter.

In this uncertain time of COVID19, many testing centers are closed and Step 2 CS involves physical interaction between many people – the examinees, the standardized patients, and the USMLE coordinators. While it is difficult to predict when the centers will reopen, it is important to stick to your organized study plan. Be prepared for your scheduled testing date. If your test is delayed due to the pandemic, you should arrange for a one week study refresher prior to your exam date.