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USMLE Step 2 Clinical Skills FAQ

In June 2004, a clinical skills examination was added to the USMLE Step 2 that tests medical students on their ability to gather information from patients, perform a physical examination and communicate their findings to patients and colleagues. The name of the examination is Step 2 Clinical Skills, or Step 2 CS; the current multiple-choice component of Step 2 is being referred to as Step 2 Clinical Knowledge, or Step 2 CK.

What does the clinical skills examination entail?

It is be a one-day test that mirrors a physician's typical workday in a clinic. For 15 minutes each, examinees will examine 12 "standardized patients," people trained to act like real patients. Examinees are expected to establish rapport with the standardized patients, elicit pertinent historical information from them, perform focused physical examinations, communicate effectively, and document findings and diagnostic impressions. After each encounter, examinees have 10 minutes to record a patient note, including pertinent history and physical examination findings, diagnostic impressions, and plans for further evaluation if necessary.

The cases cover common and important situations that a physician is likely to encounter in a general ambulatory clinic. Standardized patients are selected to represent a broad range of age, racial and ethnic backgrounds. Other possible stations include third party interviews (e.g., caregivers for children or frail elderly patients), telephone encounters, and physical examination stations. Pelvic, rectal, and female breast exams will not be part of the initial administration, but may be added later using mechanical simulators.

Who will be required to take the clinical skills component of USMLE Step 2?

In addition to meeting the current examination requirements to be eligible to register for Step 3 (i.e., passing Step 1 and passing the clinical knowledge component, which is the current version, of Step 2), students and graduates of LCME- or AOA-accredited medical schools must take and pass the clinical skills component of Step 2 if they: a) have graduation dates in 2005 or later, or b) have graduation dates prior to 2005 and have not passed the clinical knowledge component of Step 2 taken on or before June 30, 2005.

For students and graduates of international medical schools, Step 2 CS will replace the ECFMG Clinical Skills Assessment (CSA®) for purposes of ECFMG certification. Graduates of international medical schools still need to hold an ECFMG certificate or successfully complete a Fifth Pathway program, and meet other existing requirements, in order to register for Step 3. A passing performance on the ECFMG CSA or on Step 2 CS will not be a requirement to register for Step 3 through June 30, 2005. Effective July 1, 2005 international medical graduates will be required to have passed either the ECFMG CSA or Step 2 CS before registering for Step 3.

Don't medical schools already require clinical skills for graduation?

Medical schools vary in the ways they teach clinical skills and the standards they use to evaluate them. The clinical skills exam will establish a national standard that all students will need to meet before they practice medicine. Some US students still graduate without ever being observed in clinical settings. During recent field trials, 20 percent of the fourth-year students who completed a survey said they had been observed interacting with a patient by a faculty member two or fewer times. One in 25 said they had never been observed by a faculty member.

Why is this additional test necessary?

The test protects patient safety by asking physicians in training to meet a minimum national standard for clinical and communication skills. A large body of literature has shown that poor communication skills and interpersonal and general clinical skills are related to a higher incidence of malpractice suits, lower treatment compliance by patients and decreased patient satisfaction.

The previously required three Steps of the USMLE measure medical knowledge and analytical skills through multiple-choice questions and computer-based case simulations. The medical community has always recognized the distinct differences between the cognitive skills needed by a physician to recognize and understand diseases and conditions and the clinical and communication skills needed to diagnose and treat patients and consult with colleagues. Medical educators, clinicians and state licensing authorities consider both sets of skills equally important.

The best multiple-choice examinations cannot adequately assess clinical and communication skills. Research shows that a small but significant number of examinees who pass the multiple-choice exams lack the basic clinical and communication skills necessary to practice medicine.

How much does the clinical skills examination cost students?

The fee for June 1, 2004 through June 30, 2005 administrations of Step 2 CS was set at $975.00 for US and Canadian medical school students and graduates. This figure is based on the actual costs required to administer the exam -- operating the test centers; paying standardized patients; developing patient cases; developing examinee registration and scheduling systems; and assuring accurate results through rigorous training, quality assurance, and equating processes. The fee charged to take the examination is as close to the actual cost of administering the exam as is fiscally prudent. Fee information for international medical graduates is available at the ECFMG website.

When did the clinical skills examination become part of the USMLE program?

The two organizations sponsoring the USMLE introduced the skills test in mid-2004.

How is clinical skills examination be administered?

The examination is administered at regionally located centers operating year round. Staff members have evaluated a variety of delivery models, including multiple medical school centers operating for brief periods throughout the year, and have concluded that the fixed site model is the least expensive, most equitable, and most sound method for delivery of the clinical skills examination. Sites are located in Philadelphia, Los Angeles, Chicago, Houston and Atlanta.

Where does the clinical skills examination fit in the sequence of USMLE Step examinations?

Clinical Skills (CS) is one of two components of the USMLE Step 2. The other component, which is the previously existing version of Step 2, is the Clinical Knowledge (CK) component. Eligible US and Canadian medical school students/graduates are allowed to take Step 1 and each of the two components of Step 2 in any sequence. International medical school students and graduates seeking ECFMG certification must pass Step 1 prior to taking Step 2 CS. Additional information on ECFMG requirements for certification can be found at the ECFMG website.

How will performance on the clinical skills examination be reported?

Performance on the USMLE Step 2 CS exam is reported as pass or fail. Examinees are required to pass: (1) an integrated clinical encounter consisting of an assessment of data gathering skills, including history taking and physical examination, and an examinee-recorded patient note; (2) an assessment of communication/interpersonal skills; (3) an assessment of spoken English proficiency. Passing performances on all three of these are necessary to obtain the overall designation of passing on Step 2 CS.

Examinees who fail receive performance profiles, which reflect relative strengths and weaknesses across the sub-components of Step 2 CS. As stated in the USMLE Bulletin, examinees eligible to take Step 2 CS and CK may take those components in any sequence. The Step 2 CS and CK components are administered and scored separately from each other and results will be reported separately. Retake policies for Step 2 CK are described in the USMLE Bulletin. See the USMLE Bulletin for further information on scoring and score reporting for Step 2 CK and for preliminary information on scoring and score reporting for Step 2 CS.

As experience is gained with the CS component of Step 2, modifications may be made to the scoring and reporting processes. Subsequent changes, if any, will be reported on the USMLE website.​