USMLE CS
The USMLE CS (or USMLE Step 2 CS) is the practical portion of the USMLE. I just finished taking this test and wanted to share some USMLE Step 2 secrets with you.
USMLE CS Basics
The USMLE Step 2 CS is a practical test. You will be
seeing standardized patients (read actors) that have different diseases. You probably had some of these types of experiences during your medical school training. At UCLA, we had several OSCEs (objective structured clinical examinations) that helped prepare us for USMLE CS.
Photo courtesy of TheeErin. Your standardized patient will be this happy if you follow the steps outlined on this page!
The basic format is as follows:
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Patient information. You will come up to a door that has your patient’s vital signs and chief complaint. (Martha Anderson a 42 year old woman comes in with abdominal pain. T 38.0 BP 120/80 HR 75 RR 12.)
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Encounter instructions. Under this, it will give you the following instructions: Take a focused history, perform a focused physical exam (do not perform rectal, genitourinary, or female breast exam), Explain your clinical impression and workup plan to the patient, write the patient note after leaving the room.
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You have 15 minutes with each patient. This means that you won’t have time to do
everything on every patient. Your history and physical exam really do need to be focused on the patient’s complaint and history. -
You then have 10 minutes to write your note. The space you have to write your note is limited. You will be able to write up to 5 different differential diagnoses and 5 different diagnostic tests to narrow your differential.
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You will see 12 USMLE case simulations for USMLE CS. It’s a long day but it goes a lot faster than USMLE Step 1 (at least for me it did). You have the option of choosing an AM or PM test time. It’s going to be about 8 hours from start to finish. The AM testing starts at 8AM and ends at around 4pm (mine actually got out closer to 3pm). The PM session starts at 3pm and gets out between 10 and 11PM. You will have an orientation for about the first half hour, see 5 patients, have a 30 minute lunch, see 4 patients, have a 15 minute break, then see your final 3 patients. One of the usmle step 2 secrets is to bring some food to snack on, although they provided us a very nice lunch in Los Angeles.
Limited places to take the test across the country. There are only 5 locations in the entire United States to take USMLE Step 2 CS. These are Los Angeles, Atlanta, Chicago, Houston, and Philadelphia. Another of the USMLE Step 2 secrets is to sign up early so that you get
a spot that is close to you.
The test is expensive! It costs over $1,100 to register for this test!
It is Pass/Fail. You either pass USMLE Step 2 CS or fail it. No middle ground. The pass rate for US and Canadian seniors is 97%, for International Medical Graduates it’s 76%.
Grading Categories. There are several different categories for which you will be graded. You need to pass each one to pass USMLE Step 2 CS.
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Integrated Clinical Encounter Score. This is a combination of your data gathering and patient note score. Basically it is your ability to ask the questions and perform the physical exam portions that make sense and are on the patient’s checklist for each usmle case simulation. The patient note score has to do with your ability to organize your patient note and provide pertinent positives and negatives. These are all typed unless something happens to the computer. You don’t have a lot of space, so it forces you to be focused.
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Communication and Interpersonal Skills Score. This is your ability to build rapport, act in a friendly way and counsel patients. Basically it’s a way to assess bedside manner.
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Spoken English Proficiency score. From the USMLE site, “SEP performance is assessed by the standardized patients using rating scales and is based upon the frequency of pronunciation or word choice errors that affect comprehension, and the amount of listener effort required to understand the examinee’s questions and responses.” For more information on these categories, click here.
USMLE Case Simulation Breakdown and Tips
Since you only have 15 minutes with each patient on USMLE Step 2 CS, it is important to plan and manage your time wisely. Here is the basic approach I took, using a lot of the strategy from First Aid for the USMLE Step 2 CS.
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30 Seconds-1 Minute. Look at the patient information chart and prepare my notes sheet (it’s blank when you get it). I developed a quick differential diagnosis based on the patient complaint, using the following mneumonic, VITAMIN DEP:
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Vascular
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Infectious/Inflammatory
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Traumatic
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Autoimmune
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Idiopathic
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Neoplastic
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Drug-related
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Endocrine
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Psychiatric
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This covered most of my bases for most complaints. I realized that sometimes sleep needed to be part of it.
Next, I would identify the systems that I would be addressing for the patient. For abdominal pain, for example, the systems I would use for that usmle case simulation would be GI (nausea, vomiting, change in appetite, weight gain or loss, diarrhea, constipation) and Constitutional (fever, chills, weight loss). I might add more depending on the basic history.
Next, I would write out the following mnemonic, OLDCARRT F PAPPS 10.
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Onset
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Location
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Duration
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Character
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Alleviating Factors
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Relieving Factors
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Radiation
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Temporal Factors (more in the morning, night,
etc) -
Frequency
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Previous Episodes
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Associated Symptoms
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Progression (getting better or worse)
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Precipitating Events (like a smack to the head
for a headache) -
Severity (1-10, or for things like fatigue how is it affecting daily life)
Finally, I would write out MASH (meds, allergies, surgeries, hospitalizations), FH (family history) and HEADDS (home, employment, activity (exercise), Diet, Drugs (tobacco, alcohol, other), Sex.
This was a lot to write, but it helped me organize my questions once I got in the room. I would suggest taking this time even if it takes a couple of minutes. You don’t want to go in there with no idea what you’re asking. I found it important to write out the differential before going in so that I could remember what questions would be important to ask and not forget about my differential if one diagnosis seemed obvious. You do not want to have “premature closure.” This means that you go in, think you know exactly what the problem is and forget about asking about anything else in the differential. This will get you in trouble. The other mnemonics just helped me remember to ask everything I needed. I have a tendency to forget them once I start talking to the patient. Taking this time to plan your encounter is probably the biggest one of my USMLE Step 2 secrets.
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Knock, introduce yourself, make eye contact, call the person by name, put the drape on the patient. Doing all of this will help you with your Interpersonal skills score on usmle cs.
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6-7 minutes. Get the history. I use the OLDCARRT F PAPPS 10 to help me get a basic history. It mainly works for pain, but parts of it can be used for other complaints on usmle cs. I also found that for patients that come in for basic checkups on blood pressure or diabetes, it helped me to organize my questions like this:
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Onset of disease
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Treatment
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Side effects of treatment (hypoglycemia, drug side effects)
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Comorbidities (HTN, obesity, hypercholesterolemia)
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Complications (stroke, peripheral neuropathy, etc.)
Again, make sure that for the USMLE Step 2 CS you do not do premature closure. Make sure you ask all questions relevant for your differential diagnosis. Also make sure you ask their meds, allergies, past medical history, family history and social history for USMLE CS.
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Summarize the patient’s history. This will help you to remember what you’ve talked about and give you points for patient communication and interpersonal skills for usmle cs.
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Ask permission to do the physical exam and wash your hands. If you forgot to drape the patient earlier, do it now. This again will help your interpersonal skills score for usmle step 2 cs.
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5 minutes. Physical exam. Now you do your physical exam for what makes sense for your particular usmle case simulation. For chest pain, make sure you do heart and lungs. Try not to guess what’s on the patient’s checklist for the usmle step 2 cs. When in doubt, just do what you would do with a patient in your clinic. However, make sure you put your stethoscope directly on skin. You want to do your physical exam like they teach you in Bates. I found this worksheet very helpful in reviewing the right way to do each part of the physical exam. If you hear the 5 minute bell and haven’t started your physical exam, it’s time to start. You can ask more questions as you do the exam.
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2-3 minutes. Counsel with patient. Discuss your impressions (differential diagnoses) with the patient. Be honest. Then tell them a few tests you would like to order. Don’t use jargon. Explain things in a way that the person can understand. Make sure you have enough time to do this. This is weighted heavily for the scoring on usmle cs. You can also use this time to counsel the patient on stopping smoking, cutting back on drinking or using safer sex practices if appropriate. Doing this is important and will also improve your score on the usmle step 2 cs for communication and interpersonal skills. Ask if the patient has any questions. This will make sure that you got any question the patient had on their checklist to ask.
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Write it up. Now you have 10 minutes to write up your case. I recommend using headings like HPI, ROS, Meds, Allergies, PMH, FH, SH to organize your subjective section. You probably won’t have room to write a lot on each of these sections, so make sure you focus it to the most important information. Whether a person is married probably doesn’t matter much if you think the person has appendicitis. Put only pertinent positivies and negatives in your physical exam section, again with headings like: HEENT, CV, Pulm, Abd, Ext, Back, Neuro, MSK. Then put up to 5 differential diagnoses and 5 diagnostic tests. Then that’s it! Time to move on to your next usmle case simulation for usmle cs.
Photo courtesy of TheeErin. This is you when you finish your 12th patient!
To review some of my USMLE Step 2 Secrets or Tips:
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Take care of the patient. Introduce yourself, smile, drape the patient, wash your hands, answer their questions. The patients may have some difficult questions for you. First Aid USMLE has some great example questions and answers and I would highly recommend buying that book and studying those questions and answers.
International graduates that fail generally fail the communication and interpersonal skills section. Take good care of your patient and you will pass this part of usmle cs. -
Plan your approach. 15 minutes can go by quickly. Taking some time at first to organize your approach is what was the most important of the usmle step 2 secrets for me.
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Have a broad differential. Whether you use my method of Vitamin Dep or some other method, go in with several possibilities in mind. If you find yourself focusing on one diagnosis, slow down and ask about other possible diagnoses. If you do this, you’re sure to do well on USMLE CS. US students that fail generally fail the data gathering/patient note section. Make sure you get enough info!
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Review your physical exam. You may have picked up some bad habits during third and fourth year of medical school. Make sure your exams are according to Bates.
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You may have a phone interview. It is possible that one of your usmle case simulations will be over the phone. Obviously there will be no physical exam for this part of the usmle cs, but the same principles apply for preparing for the call as with your other patients.
USMLE Prep
For USMLE CS, the best USMLE prep is your third year of medical school. You are seeing patients all the time and hopefully doing the things that usmle step 2 cs is testing. That is, taking a history and doing a physical exam. You are also hopefully developing rapport with patients by introducing yourself, making good eye contact and answering patient questions.
Where you might need some practice is in sharing your differential and plans for future tests with your patients. Often as medical students we wait to do this until we talk with the resident or attending physician. For me, I also needed to remember to drape the patients and needed to review my physical exam to do it according to Bates.
Besides seeing your patients, I recommend First Aid for the USMLE Step 2 CS.
Here are the benefits that I saw:
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It gives you a good approach for time management for each usmle case simulation
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There is a long list of potential difficult questions patients might ask along with answers to those questions. This helped me on the usmle cs.
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There are 41 full case simulations that give you the chance to see what might be on those checklists the patients have. I was able to check myself and find out where I was weak in asking questions for usmle cs.
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There is a big list of “minicases” organized by chief complaint to help give you a broad differential for common chief complaints.
This was the only resource I used for the USMLE Step 2 CS and I felt well prepared for the test. I also started practicing the things that First Aid for the USMLE said when I was seeing patients during my family medicine rotation, which I think helped as well.
You can also practice the usmle case simulations with your classmates or others. I practiced them with my wife. It helps to actually do the cases in a timed manner so you get used to the time constraints. It also helped me to figure out where I was weak with my history and physical exam, as well as things that I often forgot (like summarizing the history for the patient and draping).
If English is your second language, spend some time practicing these cases with a native English speaker. The same rule applies here as with the personal statement and interviews. Practice with someone who will give you honest feedback, so probably not your mom/girlfriend/boyfriend.
So, that’s my advice for USMLE CS. Get First Aid for the USMLE CS and start approaching your patients like the patients you’ll get on the test and you’ll do great. Best of luck!