Saturday, November 14, 2015

USMLE Step 2 CS for Canadians

This week I spent a day in Houston writing the USMLE Step 2 CS. Whereas Step 2 CK ("Clinical Knowledge") is a written exam that can be taken at Prometric computer testing centres in Canada, Step 2 CS ("Clinical Skills") is an OSCE that can inconveniently only be done in five American cities. It's less of an assessment of clinical competence than it is an exercise in acting -- not to mention a cash grab (the testing centres run 8 am - 3:30 pm and 3:30 pm - 10:30 pm Step 2 CS sessions everyday with a constant stream of students handing over 1250 USD each). Anyhow, it's a hoop that cannot be avoided, so here's how a Canadian might go about preparing.

Why would a Canadian bother writing the USMLEs? What are the downsides of writing the USMLEs? Why am I writing them?
Answered in the Step 1 post :)

When is the best time to write Step 2 CS?
The USMLE Step 2 CS is roughly equivalent to the Canadian LMCC MCCQE Part II. Therefore the most efficient time to write it would be in residency, when you've just studied for your MCCQE Part II (this may be in May of PGY-1 or October of PGY-2, depending which MCCQE sitting you register for). If you'd like to coordinate your MCCQE Part II and USMLE Step 2 CS dates closely, be sure to register well in advance for Step 2 CS -- I was a little late and ended up having to write them about two weeks apart (not that I think it made any real difference).

How much does Step 2 CS cost?
1250 USD (which amounted to 1630 CAD).

Where can I write Step 2 CS?
The testing centres are in five cities: Los Angeles, Chicago, Philadelphia, Houston, and Atlanta. I found it helpful to read the information on each city's testing centre (including transportation and hotel suggestions) on the CSEC website when making my decision.

Why Houston?
At the time that I scheduled my exam, Houston had availability closest to the date of my LMCC MCCQE Part II exam. Furthermore, the flights worked out well so that I could travel there direct from Edmonton the day before the exam and fly back right after the exam (glad Air Canada had that 7:30 pm departure!).

Houston also had more convenient and affordable accommodation than some of the other cities, with Baymont Inn and Suites (65 USD if you ask for the medical student exam rate) just a block over from the testing centre, with free airport shuttle and free breakfast. The hotel is nothing special but was clean, comfortable, and stored my luggage while I was at the exam. I simply walked back over after the exam (with all the other med students who were staying there -- there were a lot!) and caught the 4 pm shuttle to the airport. It could not have been more convenient.
unfortunately this is my impression of Houston: the couple blocks of North Sam Houston Parkway outside of the hotel and testing centre
There are also a number of places to eat nearby -- from a restaurant in the Park Inn next door to McDonalds to Waffle House, where we went. We don't have Waffle House in Canada and it felt like an appropriate thing to do in the South. Also, comfort food...
pre-exam dinner: chili hashbrowns and waffles

What is the format of Step 2 CS?
From the USMLE website:
"Step 2 CS includes twelve patient encounters. You will have15 minutes for each. Immediately after each patient encounter, you will have 10 minutes to complete a patient note. If you leave the patient encounter early, you may use the additional time for the note.

You will be asked to type (on a computer) a patient note similar to the medical record you would compose after seeing a patient in a clinic, office, or emergency department. Finally, you will list the diagnostic studies you would order next for that particular patient. If you think a rectal, pelvic, inguinal hernia, genitourinary, female breast, or corneal reflex examination, or a throat swab, would have been indicated in the encounter, list it as part of the diagnostic studies. Treatment, consultations, or referrals should not be included. Patient notes are rated by licensed, board-certified physicians."

My day looked like this:
7:55 am -- I arrived at the testing centre and registered. Staff covered the name on my white coat with tape and clipped my number badge on it (there were 24 students writing; we were each identified by a number).

8 am -- I put my stuff in a locker (not to be accessed until the end of the day) and sat down at my assigned table in the break room. We were shown an orientation video and were allowed to familiarize ourselves with the equipment in a mockup of the exam room (all you need to bring is your stethoscope -- everything else is available in every room).

8:30 am -- Start of the exam. We were each given a clipboard with 12 sheets of paper and 2 pens. We each stood in front of a door and when instructed were allowed to slide a panel over to read the prompt -- it always said something like "68 yo F presents to doctor's office with chest pain" and listed vitals. As soon as we had finished reading the prompt we could enter the room. We had 15 minutes for each encounter to perform a history, physical, tell the patient the likely diagnosis and what investigations we would order, and answer the patient's question(s). When 5 minutes were left there was a warning announcement. At 15 minutes we had to exit the room and had the next 10 minutes to type a patient note (history, physical, 3 differential diagnoses with supporting history and physical positives/negatives, and list of workup). If we finished in the room in less than 15 minutes, we could exit the room early and use the extra time to work on the typed note. I noticed that most people did this.

The twelve encounters were broken up as follows:
3 encounters
10-minute break
3 encounters
30-minute break with provided lunch
3 encounters
10-minute break
3 encounters

Most people brought snacks which they left on their assigned tables for break time. Water was provided. The free lunch was pretty great (chicken, rice, cooked vegetables, sandwiches, pasta salad, salad, raw vegetables, hummus, fruit, cookies).

3:15 pm -- All done!

Being broken up by breaks and lunch, the stations just flew by. It was hard to say how I did...I certainly felt more rushed than I'd expected and I had to be careful in the rooms to divide my time between history/physical/closing. Most of the time I was also rushing to get through my typed note in 10 minutes. I didn't find any of the stations particularly hard -- the actors are well-trained and not trying to trick you (unlike the Canadian exam where I was suspicious enough to "SIGECAPS" half the patients...).

The staff at the testing centre were friendly and efficient. They run this same test all day every day, so it goes like a well-oiled machine. The med students that I chatted with during breaks were all very nice; most were American but some had come from as far as Pakistan to write the exam.

How high do I need to score on Step 2 CS?
Step 2 CS is pass/fail :) And 98% of US/Canadian medical students pass (I'm trying to remind myself of this as I don't feel fantastic about how I did and keep thinking of things I could have done differently...but that's how OSCEs go, right?).

The actual scoring system is a bit complicated; I didn't pay too much attention to it, but from what I gather the score is derived from three components, each of which you must pass:
  • communication and interpersonal skills (CIS)
  • spoken English proficiency (SEP)
  • integrated clinical encounter (ICE)
If you'd like you can read more about the scoring system on the USMLE website.

How I studied for Step 2 CS:
Because I'd studied for the Canadian equivalent (LMCC MCCQE Part II) two weeks prior, I didn't do any extra studying for Step 2 CS. Retrospectively, I should have read First Aid for the USMLE Step 2 CS...just because it's an excellent resource and when you've paid USD 1250 plus airfare and hotel you don't want to be messing around. What I did do was read the introductory information on the format of the exam (i.e. the first 100 or so pages of First Aid for the USMLE Step 2 CS, which I'll admit I torrented and skimmed in the hotel the evening before). Kaplan's USMLE Step 2 CS Complex Cases, which a friend lent to me, had a similar introduction which I read between naps on the plane. There wasn't a need to read both -- I'd suggest just downloading the First Aid book and reading that one. I didn't have time to read anything beyond the introduction of First Aid, but I think I'd have felt more prepared had I read the rest of the book (or at least the mini-cases section).
The lady beside me on the plane asked skeptically if I was ready for my exam...probably after seeing me open this book to page 1.
You may also want to read the official information bulletin on the USMLE website. And here are some reasonably clear (unofficial) instructions on how to go about the history, physical, and patient note.

How does Step 2 CS differ from the LMCC MCCQE Part II?
Step 2 CS is essentially an exercise in acting -- and one with slightly different rules from the Canadian licensing OSCE. Here are a few differences that I noticed:
  • On the MCCQE Part II you are graded by a physician invigilator sitting in the corner of the exam room. On Step 2 CS you are graded by the standardized patient (there is no physician in the room; but a physician will later mark your typed note).
  • You will never be asked about treatment on Step 2 CS -- just DDx and workup.
  • Because you can't be asked about treatment, there will be no "manage this cardiac arrest" (ATLS/ACLS) stations on Step 2 CS.
  • It is always clear what is expected of you within each station on Step 2 CS -- and it is always the same (history, physical, closing; typed note). By contrast, each station in the MCCQE Part II specifies what you are intended to do on the door of the room ("perform a history" or "perform a focused physical" or "counsel"). Because you have to do everything on every Step 2 CS patient, time is tighter and it is important to budget it.
  • Every typed patient note on Step 2 CS has the same format (history, physical, DDx, workup) (as versus the MCCQE Part II where each PEP was a set of questions to answer).
  • Step 2 CS has more emphasis on empathizing/building rapport with pts. This is reflected in the "communication and interpersonal skills" and "spoken English proficiency" components of the score.
  • Some things that you need to be more cognizant of on Step 2 CS as compared to the MCCQE Part II include: draping, asking every patient about sexual history/LMP/OB/GYN history, asking CAGE questions when appropriate, briefly counselling any patient who has a suboptimal lifestyle (smoker, drinker, etc.), summarizing at least once, and leaving time to "close" (more on this below).
  • On Step 2 CS only very brief focused physical exams are required. Any physical findings will be quite apparent right away. So you won't be spending ten minutes going through the entire proper cardiac exam that you were taught in med school. Be aware that pts may fake findings (e.g. make "whooshing" sound with their mouth when you are auscultating their heart).
  • I had a phone station on Step 2 CS, where I spoke with a caregiver over the phone about a sick child.

Key points to remember for Step 2 CS:
Here are some things (that I learned by reading the First Aid introduction) that you need to remember for this specific exam:
  • knock on door, address pt by Miss/Ms./Mr. _____ to ensure it is the correct pt, introduce self as Dr. or medical student (your choice), ask if pt comfortable
  • place drape on pt (you can do this at the very beginning or just before the physical)
  • building rapport and empathizing with pt ("that must be difficult") are apparently very important -- be sure to make such comments along the way
  • ask every pt about sexual history
  • ask every female pt about LMP and OB/GYN history
  • always counsel -- if pt drinks a concerning amount ask "CAGE" questions and counsel on decreasing consumption; if pt smokes, counsel on quitting (you can make stuff up like "we can have you chat with our smoking cessation counsellor" or "we'll book a follow-up appointment to talk about strategies -- Champix/patch/gum/etc.")
  • summarize (I did this after the history and before the physical)
  • every pt who is in a gown needs a focused physical exam; pts not in gowns need not be examined
  • prior to the physical exam, wash hands (soap/water or hand sanitizer) or put on gloves
  • remember to say that you'd do a breast/pelvic/GU/digital rectal exam if appropriate -- you must also include these things under "workup" in the typed pt note if appropriate
  • if at the 5-minutes-left warning you haven't started your physical exam, get on it!
  • leave 3-4 minutes at the end to "close" -- this must be done for every patient -- basically say "It looks like you have have x because y and z, but other possibilities are a or b. We'll have to do some tests (tell pt which tests) to sort this out and we will phone you when the results are available. Do you have any questions (pt will have at least one question -- e.g. how long will this take to get better)?"
  • you don't have to know drug names or doses -- if a pt tells you a med that you are not familiar with, just ask them what it is for
  • you can type your note in sentences or point form; I found that I kept hitting the line limit when using point form, so switched over to sentences after the first couple of notes; there is also a character limit so be succinct
  • when typing your note remember that you can include both positive and negative information to support your diagnoses

I think that's all I have to say about Step 2 CS. It was a bit of a whirlwind, but nice to check another USMLE off the list. Hopefully I won't be rewriting...but we'll have to wait until February for scores. If you've written Step 2 CS and have any thoughts or advice to add, please do comment below!


  1. hey there WSC, thanks for your post about the USMLE step 2 CS. I had the unfortunate experience of taking this exam as an attending only to fail the CIS component. My mistake was not realizing how different this was from our Canadian equivalent in that the history and physical and relatively cursory and that the CIS component is evaluated solely by the actors. Its has been a few years since I took the MCCQE II in Canada but my memory is that there was a MD in every room with a checklist in hand. Maybe this has changed in the last few years?
    I am curious to know how you did on the exam and also curious how you knew to leave so much time to "close" the scenario. I read the FA manual cover-to-cover but may have gotten too bogged down in the details to notice this important concept.

    1. Ugh that's so frustrating! I think I knew about closing from the intro to the Kaplan book. But I agree, definitely different from the MCCQE II. And yes, we did have an MD in each room grading the MCCQE II when I wrote it last year, so that's another major difference. It sounds like you knew your material, so now that you've got the format down, I think you've got this! Good luck!

  2. Would love to know more about what you used to study for the MCCQE II!

    1. Hi Taryn! If you email me (windingspiralcase at gmail dot com) I'll send along what I used to study.


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