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 usmle.org 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|
|Examinees from Non-US/Canadian Schools||2010 – 2011||2011 – 2012|
|Number Tested||Percent Passing||Number Tested||Percent Passing|
|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.