How do you fail the USMLE Step 2 CS?

If you’re a North American allopathic medical student, with difficulty. And yet several hundred students fail their first attempt at this “English” test every year. SDN and the like are full of stories about students with massive Step 1 scores who fail Step 2 CS, which makes anyone reading think that no one is safe (or that people who do extremely well on MCQ tests are robots [or both]).

You can always finds the passing rates for USMLE Step exams from performance data. Here are the passing rates for the most recent two years (note the section breakdown at the end):

Examinees from US/Canadian Schools 2010 – 2011 2011 – 2012
Number Tested Percent Passing Number Tested Percent Passing
MD Degree 18,294 98% 17,118 97%
1st Takers 17,852 98% 16,662 97%
Repeaters 442 91% 456 92%
DO Degree 67 88% 46 87%
1st Takers 67 88% 45 87%
Repeaters 0 N/A 1
Total 18,361 98% 17,164 97%
Examinees from Non-US/Canadian Schools 2010 – 2011 2011 – 2012
Number Tested Percent Passing Number Tested Percent Passing
1st Takers 11,899 79% 11,515 80%
Repeaters 3,143 67% 2,265 65%
Total 15,042 77% 13,780 77%
2010-2011 2011-2012
All US / Canadian Schools 98 99 > 99 98 99 > 99
All Non US / Canadian Schools 87 89 95 86 89 97

* Please note that neither of these years takes into account the new changes in the differential diagnosis section of the patient note, which began in June 2012. It’s not known at this time how the change (detailed below) has affected passing rates, if at all.

If you try to look up Step 2 CS tips, a lot of the traffic online is from foreign students. Most US allopathic students tend to ascribe to the “it’s an English test” belief and leave their review to a quick read through of First Aid for the USMLE Step 2 CS and their cumulative experience with standardized patients/OSCEs/etc. For the vast majority of students, that seems to be working out just fine. Then again, over 300 US MD students in 2011 failed. The rate for DOs is worse. No one wants to be that guy; it’s also an expensive mistake. Here is the breakdown of the sections and the skills they test.

So start by reading the USMLE Step 2 CS manual; follow up by giving First Aid a good eyeballing. Just know that on game day, you can forget to do a lot of things. Everyone leaves the test (and each encounter for that matter) with a list of things they forgot to ask. That’s okay. If you have a solid framework, then the individual elements you forget here and there don’t add up. The goal is not to do everything; the goal is to do a reasonable and relatively thorough job.

Spoken English Proficiency (SEP)

Contrary to popular opinion, SEP is the least likely cause for failure across all groups. Now, the wrinkle here is that all non-US schools are grouped together, which means that native-speaking IMGs (e.g. the Caribbean schools) and non-native speakers are all-lumped together. Less than one percent of US/Canadian of grads fail this portion.

Communication and Interpersonal Skills (CIS)

So one in a hundred people fail CIS, which is essentially a failure of acting. It can be hard to get into character. You have to pretend to be a doctor, you have to “be” compassionate, you have to ask questions like they’re real patients, deal with their emotions, help them make choices, and answer their special brain-buster questions (they all have one): am I going to die, what’s going to happen to me, can I run in my race tomorrow, should I take ginseng? Be professional: introduce yourself, wash your hands, open-ended followed by direct interviewing, explain your logic, offer closure. If you can pretend this is a real person, then you’ll do well on this portion.

Integrated Clinical Encounter (ICE)

2% of people fail ICE (which is nearly 2/3 of all failures). ICE is the combination of data gathering (asking questions of patients and doing an appropriate physical exam) and data interpretation (your note). Data gathering isn’t just about getting the diagnosis—it’s about [fake] patient care. You need to know if people are smokers, if people are drinkers, if they do either to excess. You need to ask the review of systems that helps you figure out that the patient with the yeast infection actually has undiagnosed DM2.

The best way to prepare for the note is to look through First Aid and the official Step 2 CS manual. Getting a feel for these notes will help you be efficient when it counts, even if you don’t spend any time actually writing them in preparation. These notes are not hard (sample outline), but you need to think about writing under pressure and time constraints, which you are likely not used to doing. You need to have differentials on hand for common complaints (headaches, chest pain, abdominal pain, vertigo, syncope, etc).

As of 2012, you also need to understand which factors in the history and physical go along with which diagnosis. This new element is surely designed to give some people trouble, but chances are if you know what questions to ask, you also know which answers go where. On the plus side, you only have to write up to three items on your differential instead of five, which is much better, since sometimes you’d rack your brain trying to get to five reasonable diagnoses for a clear-cut case. Most resources for the exam have not taken this change into account yet, but you need to be aware of the change. When in the exam room, you need to be tailoring your differential based on your history and physical anyway; now, you simply have to be able to account for the rationale you’re already using intuitively.

A word about scheduling

It’s also worth noting that the delay in registration and the difficulty in getting last minute spots means that you should register for Step 2 CS as soon as you can. If you take it in the summer or early fall of fourth year, you would have time to fail, re-register, and take it again before rank lists are due. Taking it in the winter means you may need to pass it on the first try in order for some programs to rank you. How much does failing hurt you if you’re one of the unfortunate few? There’s no way to know. Some program directors have clearly stated they don’t care about the test. That said, without a pass on record by match time, some may not be interested in giving a spot to someone who might not be able to start on time.

The itch between your shoulder blades

Even though the vast majority of students pass this exam, the fact that it’s not possible to brute-force your way through a few thousand questions, know you’ll pass, and just wonder exactly how your score will turn out is unnerving. Even after taking it, nearly everyone wonders if they’ll pass in a way that is often more irritating than for Step 1 or Step 2 CK. It’ll be a huge relief when you find out you passed (and that your English proficiency is above-average).

Still, for those who have done their share of OSCEs and a night or two with First Aid, taking it seriously and doing your best in and of itself is probably enough for almost everyone. Don’t blow it off. The SPs can smell a poor sport.

Updated July 2013.


  1. This test is just a way for the educational industrial complex to make more money. The education industry in this country has ballooned out of proportion. Practicing doctors who graduated in the top of their class in other English speaking countries with 240+ USMLE scores have failed this English exam. I believe this exam is a symptom of what is wrong with this country — over educating and mis-allocation of funds. Enacted in 2004, this exam is just another way for the fat cat medical industry to over bill and underperform. I say the top medical schools in this country and top residencies start saying that they do not require this exam anymore and save this country hundreds of millions of dollars in test fees, transportation and human resource fees.

  2. I agree with Angry Student! This exam is so unfair. I know some total morons that passed, and brilliant people that didn’t. It’s just wrong!

  3. It’s a real joke, this CS! I got near maximum on CIS and ICE and fail with SEP. How can I get that information to score on CIS and ICE but through communication.

  4. Joker, I’m sorry to hear about your crappy experience. I think most people agree that CS is a crummy test that doesn’t really meaningfully test much of anything.

    SEP, though, is graded differently than what you alluded in your comment. Failing SEP doesn’t mean you weren’t able to obtain information from the SPs; it means that the SPs had to work hard in order to understand you (more or less). The official packet says this:

    The SEP subcomponent includes assessment of clarity of spoken English communication within the context of the doctor-patient encounter (for example, pronunciation, word choice, and minimizing the need to repeat questions or statements).

    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.

    This is also separate from information gathering and patient centered communication skills, which fall under the CIS category. Data gathering is also reflected in the ICS component through the physical exam checklist and the patient note. I’m not trying to validate the failure you received, just clarifying the grading scheme for other readers.

  5. can you shed some light (with a practice sample if you have it) on how to write the note in less than 10 min?

    • Finishing quickly is a combination of medical knowledge, practice, and practical/logistical skills. Examples are in First Aid Step 2 CS, which you should read if you haven’t. In particular, memorize the differential and workup portions for common complaints. You should be able to rattle off what to do next for most common issues (i.e. you don’t want to have to spend time “thinking” of what you need to do; you could reason through these issues, but it’s better to just know them. These are common complaints).

      Practice writing a few of these notes (there are blank templates in FA) so that you get a feel for approaching them the same way every time. Unlike in FA though, you can save more time by writing in fragments/phrases. You don’t need flowery prose or full sentences. Be curt, especially when it comes to things like pertinent positives/negatives. For example: Complains of 1 day of worsening gradual onset throbbing frontal headache, currently 7/10. No prior episodes. Endorses photophobia, phonophobia. Denies nausea, vomiting. Worse when standing, better when lying in darkened bedroom. No treatments attempted.

      You can use + or – and commonly accepted abbreviations. Your physical exam should be mostly abbreviations. NC/AT, PERRLA, EOMI, RRR, CTAB, NT/ND, +BS, 2+ DTR, etc. Only use detail for systems relevant to the complaint.

  6. I think the OSCEs my school had me go through prepared me well enough… I could only practice a handful of cases from the First Aid book and I still managed to pass!

    I think the most important thing, as you mention, is to be complete in your encounter. You’re gonna forget stuff, but that’s OK.

  7. thank you. will i pass if i walk in with only 3 ddx in mind for a given cc (ie for ‘headache’ i think of migraine, sinusitis, meningitis) and only focus on asking questions to rule in or out those ddx? or, do i have to be ready to explore a multitude of diagnoses as they suggest in CS (ie trigeminal neuralgia, subarachnoid hemorrhage). should i know the specific maneuvers to deal with shoulder or knee joint complaints? for the note in the physical exam section, do i write out all the vitals? i don’t know how to speed up in the note, especially when the 3 ddx section asks for history and physical exam info that will support AND refute the listed ddx?

    how do you suggest i break my time apart for the patient encounter, from reading the doorway info to walking out to write my note?

    if you were to ask a patient with a cc of headache about family history, would you ask ‘any medical problems in the family’ or would you ask ‘any family history of headaches’? is it a general question or one tailored to the cc?

    for meds, do i ask if they are taking any OTC and prescription and herbal? or can i save time but not forfeit points by simply asking ‘are you taking any medicines’?

    some cc ask for a neuro exam but there is no time to do the whole thing! how do you do an abbreviated neuro exam?

    did you do heart, lungs, and abdominal exams on every patient (regardless of cc)? if so, how did you do it? did you only listen in the aortic and pulmonic valve areas and listen on 2 spots posteriorly for the lungs and just press on the belly for abdomen? i am not understanding how to do all of this in 15 min?

    thank you for this site. your advice is so helpful.

    • 1) Depends. I’d know a few more, better to know things that make sense for acute vs chronic, infectious, life-threatening. If someone complains of one year of episodic headache with n/v/photophobia, it would be silly to put subarachnoid on there. Things like trigeminal neuralgia usually only come up in specific sets of symptoms and don’t need to be part of the default differential (e.g. migraine, tension, analgesia abuse, cluster)
      2) Physical exam is mostly a sham. You don’t need to do that stuff really, just test strength, sensation, etc. Pretend to assess laxity sure, but it’s not important.
      3) Yes do vitals
      4) For the note, be brief. Migraine +episodic, chronic, no neuro deficit, etc
      5) For all history, including FH, start broad and then tailor. Ask in general, then double check they don’t have certain things you’d be worried about. Otherwise they don’t always give it to you.
      6) I would ask about supplements as well as about smoking, alcohol, drugs.
      7) Focused neuro exam means you don’t test everything. So if someone comes in with carpal tunnel, you’re not testing cerebellar function, you don’t need to test lower extremity strength, etc.
      8) A majority of patients. If the case is a twisted ankle, you don’t really have to. But for more general complaints yes. Generally, I do all areas but listen very quickly in each. Two beats in each valve area. Four spots for the lungs. Put the stethoscope on the belly for one second for bowel sounds and palpate quickly. Would only percuss for belly pain.


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