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How to Prepare for USMLE Step 2 CS

Preparing for the USMLE Step 2 CS can be frustrating. You know it’s graded pass/fail and there’s a high pass rate, so you don’t want to spend too much time studying and take too much time away from other pursuits.

But at the same time, it’s expensive, requires travel for many students, the pass rate has been dropping slightly, and so no one wants to deal with taking it more than once.

Here I have assembled the most important pieces of advice I like to provide to students who are thinking about or preparing for Step 2 CS.

First, a quick recap of what you’re preparing for: 12 Standardized Patient Encounters with 15 minutes for the Clinical Encounter and 10 minutes for the Patient Note.

Your overall score will be based on these three competencies: Integrated Clinical Encounter (ICE), Communication and Interpersonal Skills (CIS) and Spoken English Proficiency (SEP).

1) Before the Step 2 CS Exam: Studying

First Aid for Step 2 CS should be the primary resource (it should take 12 hours of studying to get though this book). As you read the book, use each case as a flashcard. In other words, read the brief clinical prompt, and then come up with 3 differential diagnoses and write them down along with a sample workup before you go any further.

For example:

  • 55 Female presenting to the emergency room with chest pain -> You might write down:
  • MI, PE, pericarditis
  • Also write down a brief list of potential diagnostic tests, for example:
  • ECG, CXR, CT-PE.

Only then should you flip the page, read the history and the exam and the rest of the case. Afterwards, look at the answer key and the sample note, and focus specifically on the differentials and elements of the workup that you missed.

Do this for every case, until you can read the prompts and know you will be able to produce a solid list of differentials and workup for all of the chief complaints.

2) Before the Step 2 CS Exam: Practicing

If at all possible, find a practice partner or two and simulate the encounter with them. Ideally you have a third partner who can keep time and give feedback about time management, communication skills, etc.  Run as many cases as you can (First Aid cases are perfect) to simulate the timing and after the case is finished, write down your 3 most likely differentials and commit to a workup before you look at the answer.

Also, as funny as this may sound, remember that being human gets you points on this exam. When you practice before your test, remember to flex your empathy muscle and make sure your “patient” feels heard and supported. Practice PEARLS in each of your patient encounters:


3) During the Step 2 CS Exam: Before You Open the Door

Here’s a technique that’s very helpful and increases efficiency during the encounter: Before you step into the room, look at the chief complaint on the door, and do the same thing you did when studying First Aid: write down 3 potential differentials — and a couple of potential diagnostics.  All of this should be extremely quick, and shouldn’t take more than 30 seconds total. These will help guide the history and exam and get you thinking of pertinent issues to cover.

For example:

  • Prompt on the door says: 55 year old Female with chest pain
  • 3 quick differentials -> MI, PE, pericarditis
  • Potential workup: ECG, CXR, CT Chest.

Now you will be more likely to ask about important topics like recent immobilization, history of cancer, recent viral illness, hemoptysis, or dyspnea on exertion.  On the physical exam, you will look for edema, signs of DVT, etc.  Depending on where the history takes you, the workup can shift accordingly.

For example, if the pain is pleuritic and radiates to the shoulder, and the patient had a recent viral illness, consider adding an echocardiogram if you think pericarditis is the most likely diagnosis.

4) During the Step 2 CS Exam: Taking The History

For the actual exam, some specific tips:

You need to memorize a skeleton to structure the history-taking, because you NEED to cover every category, even if superficially, with every patient, just like in real life, different categories will yield richer information with different patients.

Here are the basics:

  • Chief Complaint (CC)
  • History of Present Illness / Review of Symptoms (HPI / ROS)
  • Past Medical & Surgical History (PMH / PSH)
  • Social History (SHx) -> living situation / drugs-alcohol / sexual history / smoking
  • Family History (FHX)
  • Medications / Allergies

All of these must be addressed with every patient, and should be recorded in your note, even if very briefly. This is the basis of the first part of the encounter.

Before you dive into this, you need to open the encounter. 

Here’s a basic outline:

  1. Go into room
  2. Clean hands
  3. Introduce yourself, “Hi, my name is ____.  I’ll be taking care of you today.  What brings you in?”
  4. Pt: “XYZ”
  5. You: “Is there anything else you wanted to address today?”
  6. Pt: “ABC”
  7. You: “That sounds very important.  I’m glad you came in today.  Could you tell me more about XYZ?”

Let the patient speak as much as possible, and use as few questions as you can.  “Could you tell me more about the pain?” ends up being much more efficient than “Did the pain radiate anywhere?” – although of course if it’s an important question and the patient has already elaborated, it’s perfectly appropriate to finish with a few quick and direct questions. Continue to work your way through the skeleton as above. Make sure you’ve covered all of the elements mentioned above before you move on to the exam.

5) During the Step 2 CS Exam: Physical Exam

Always examine the heart and lungs, even if very briefly.

Then move on to examine the system of interest to the chief complain, eg abdomen, shoulder, neurologic etc.

In other words, the exam should consist of listening to the Heart/lungs + “1” depending on the chief complaint.

6) During the Step 2 CS Exam: Closing the Visit

After the exam, you must “close” the encounter with some kind of compassionate statement that acknowledges the patients’ frustration and thanks them for taking the time to come in today.

  • “I’m so sorry you’re dealing with this back pain, it sounds really frustrating”
  • “I’m not completely sure what’s causing it, so I’d like to order a few tests to address the most likely cause.”
  • “Thanks again for your time. I’m very glad you came in today to get this taken care of.”
  • “Did you have any other questions?”

7) During the Step 2 CS Exam: Writing the Note

After the encounter, you should write the note backwards.

This way, you will enter the 3 most likely differentials and workup first, and leave the remaining time to fill in the history and exam in a way that reflects your differential and plan.

Now, if you do this, you will run out of time when entering minutiae about the negative review of systems or exam maneuvers that were negative, or details of the family history these are far less important anyway.

This is far better than running out of time before you’ve had a chance to put some thought into the differential and the plan.  Therefore, write it backwards and enter the differential and workup first.

The USMLE website also offers some very helpful example notes.

Want some more in-depth perspective on Step 2 CS? Take a look at my colleague’s Starter Guide to Rock Step 2 CS.