USMLE Step 2 Clinical Skills

Highway Robbery

Might as well come out and say it. The Step 2 Clinical Skills test is a swindle foisted on medical students by bureaucrats with too much time on their hands and not enough to keep them occupied. It had its origin in the the clinical skills test administered to foreign medical graduates to ascertain their level of English proficiency and their comfort level with Western clinical skills under the theory that advocating consulting the entrails of a lizard in broken English would preclude you from practicing in the United States.

Since money could be made by making American medical graduates take the test, beauracrats hired other beauracrats to prove that we were not being taught how to interact with patients during our four years of medical school. Despite strong resistance from the medical community and medical students, money was spread around and the result was an expensive solution to a non-existent problem.

Step 2 CS is a day-long standardized patient exercise which tests your ability to take a history, do a physical exam, and write a note with an assessment and a plan. Nothing to it, right?

Right. The first time pass rate is in the mid 90 percent for American medical school graduates and very people study for it at all. So you see, and try to follow me here, if there really is a problem then people would be failing this thing left and right leading to the kind of studying we normally only see for the clinical knowledge portion of Step 2. Which does not happen. Medical schools do a good job of teaching you clinical skills. There is no problem.

Not to mention that Step 2 CS is pass/fail so it can’t even be used as a measure of anything other than your having at least the same skills as some guy from Bolivia who’s father paid the Minister of Health to get him into medical school.

But I digress. Step 2 CS is a done deal so you are going to have to take it. It was about a thousand bucks in 2005 not counting transportation and accommodation at one of the only twelve testing centers in the United States. (I took the test in Houston.)

As I mentioned, Step 2 CS is a day-long standardized patient exercise. For those of you who are not familiar with them, “standardized patients” are actors trained to pretend that they have various clinical conditions. Many medical schools use them to introduce students to the history and physical exam.

The Step 2 CS site is set up ostensibly like a real outpatient clinic. During the day you will see approximatley 12 standardized patients in a round-robin fashion moving from room to room rotating patients with your fellow examinees. Each clinical encounter consists of up to 15 minutes for a history and physical examination and then up to ten minutes to write your note. You can leave the patient’s room before your history and physical exam time is up and use this extra time for writing your note. Once you leave the room however you may not reenter.

Posted on the door of each room is a board with the chief complaint (as would be elicited by a nurse) the patient’s demographic information, and his vital signs. At a signal from the proctors, you knock on the door, enter, and begin the song and dance.

I will explain the history and physical exam in a later post (for those of you who are not in medical school yet, of course) but suffice to say that one enters the room, exchanges the usual pleasantries, elicits the Chief Complaint (CC), gets the History of Present Illness (HPI), and performs a physical exam.

To assist you the actor playing your patient may have moulage (makeup simulating an injury) as well as cards telling you the result of invasive exams like the digital rectal exam which you will not do on standardized patients.

(Some view the Step 2 CS as a digital rectal exam done on medical students.)

Now, here is the key to this portion of the test. Since this is a simulated real world clinic, you should do a focused HPI and physical exam. The patients will all have classic presentations of common clinical problems. I don’t think I will be violating the NBME’s non-disclosure agreement if I tell you that you might get a patient who’s chief complaint is chest pain and shortness of breath with exertion. In this case a complete neurological exam is not necessary, will gain you no extra points, and will eat into your time. There are no zebras on Step 2 CS.

Once you are done you exit the room and start writing your note which is essentially a SOAP note. You can write this on a form that is provided or enter it in a computer. The form has a space for the history, the results of the physical exam, your assessment and your plan. In the case of Step 2 CS your assessment is a differential diagnosis ( a list of the most likely causes for the patient’s symptoms) and your plan is the next step in the diagnostic work up.

Note that unlike on a real SOAP note your plan will not specify a treatment but only your next proposed steps in the diagnostic work-up.

In the case of chest pain with shortness of breath, your differential diagnosis might include Acute MI, Pulmonary embolus, GERD (heartburn), or PUD (peptic ulcer disease). Your plan for diagnostic work-up could be to draw cardiac enzymes, get an EKG, obtain a spiral CT scan, do a heart cath, or anything else you feel would be appropriate. You will not get any credit for suggesting treatment so save yourself the effort.

How long should your note be? Well, go look here:

Does that look like a long note? Of course not. It is not necessary to write the great American novel. I usually only needed ten minutes with the patient and five minutes for the note leaving me with ten minutes of thumb-twiddling time. Yet I saw most people leaving the room on the fifteen minute mark and scribbling furiously for the entire documentation time. They were obviously over-thinking it.

Focused history and physical. Concise note. That’s all there is too it.

The Step 2 CS exam is scored in three separate components each of which his pass/fail and all three of which must be passed. The first part is called the ICE or integrated Clinical Encounter which includes your history and physical exam skills as well as your documentation and assessment.

Communication and Interpersonal Skills (CIS) assesses your demeanor, your bearing, your use of empathy, your sensitivity, and even your appearance. Wear conservative clothes and a clean white coat.

The third tested area is English Proficiency.

All you will need for the test is your white coat and your Stethoscope. Every other piece of diagnostic equipment you need wll be in the room. PDAs and reference books are not allowed.

Do you need to study for the Clinical Skills test? I say no. I know there is a mini-industry of test prep material but your four years of medical school should be enough. Just act natural, do what you have been doing for your entire third and fourth year and don’t worry about it.