The cases that make up each administration of the Step 2 CS examination are based upon an examination blueprint. An examination blueprint defines the requirements for each examination, regardless of where and when it is administered. The sample of cases selected for each examination reflects a balance of cases that is fair and equitable across all examinees. On any examination day, the set of cases will differ from the combination presented the day before or the following day, but each set of cases has a comparable degree of difficulty. The intent is to ensure that examinees encounter a broad spectrum of cases reflecting common and important symptoms and diagnoses. The criteria used to define the blueprint and create individual examinations focus primarily on presenting complaints and conditions. Presentation categories include, but are not limited to, cardiovascular, constitutional, gastrointestinal, genitourinary, musculoskeletal, neurological, psychiatric, respiratory, and women's health. Examinees will see cases from some, but not all, of these categories. The selection of cases is also guided by specifications relating to acuity, age, gender, and type of physical findings presented in each case.
Your Step 2 CS administration will include eleven or twelve patient encounters. These include a very small number of non-scored patient encounters, which are added for pilot testing new cases and other research purposes. Such cases are not counted in determining your score. The examination session lasts approximately 8 hours, and two breaks are provided. The first break is 30 minutes long; the second break is 15 minutes long. You may use the restrooms before the exam and during breaks. A light meal will be served during the first break, and there are vending machines available for drinks. You may also bring your own food, provided that no refrigeration or preparation is required. Smoking is prohibited throughout the center.
When you enter the room, you will usually encounter a standardized patient. By asking this patient relevant questions and performing a focused physical examination, you will be able to gather enough information to develop a preliminary differential diagnosis and a diagnostic work-up plan. You will be expected to communicate with the standardized patients in a professional and empathetic manner. As you would when encountering real patients, you should answer any questions they may have, tell them what diagnoses you are considering, and advise them on what tests and studies you will order to clarify their diagnoses. You should interact with the standardized patients as you would with any patients you may see with similar problems. The only exception is that certain parts of the physical examination must not be done: rectal, pelvic, genitourinary, female breast, or corneal reflex examinations. If you believe one or more of these examinations are indicated, you should include them in your proposed diagnostic work-up. You should perform physical examination maneuvers correctly and expect that there will be positive physical findings in some instances. Some may be simulated, but you should accept them as real and factor them into your evolving differential diagnoses. You should attend to appropriate hygiene and to patient comfort and modesty, as you would in the care of real patients.
An announcement will tell you when to begin the patient encounter, when there are 5 minutes remaining, and when the patient encounter is over. In some cases you may complete the patient encounter in fewer than 15 minutes. If so, you may leave the examination room early, but you are not permitted to re-enter. Be certain that you have obtained all necessary information before leaving the examination room.
Immediately after each patient encounter, you will have 10 minutes to complete a patient note. Note: If you leave the patient encounter early, you may use the additional time for the note. You will be asked to handwrite or type (on a computer) a patient note similar to the medical record you would compose after seeing a patient in a clinic, office, or emergency department. You should record pertinent medical history and physical examination findings, as well as your initial differential diagnoses. Finally, you will list the diagnostic studies you would order next for that particular patient. If you think a rectal, pelvic, genitourinary, female breast, or corneal reflex examination would have been indicated in the encounter, list it as part of your diagnostic workup. Treatment, consultations, or referrals should not be included in your workup plan.
The patient note is considered a communication tool; poor legibility or spelling errors that interfere with the patient note rater's ability to comprehend the note may have a negative impact on your score. If your handwriting is difficult to read, you should probably type your patient note. The patient note is considered a communication tool; poor legibility or spelling errors that interfere with the patient note rater's ability to comprehend the note may have a negative impact on your score. If your handwriting is difficult to read, you should probably type your patient note.
Scoring: USMLE Step 2 CS is a pass/fail examination. Examinees are scored in three separate subcomponents: Integrated Clinical Encounter (ICE), Communication and Interpersonal Skills (CIS), and Spoken English Proficiency (SEP). Each of the three subcomponents must be passed in order to achieve a passing performance on Step 2 CS.
The ICE (Integrated Clinical Encounter) subcomponent includes assessment of:
- Data gathering: patient information collected by history taking and physical examination
- Documentation: completion of a patient note summarizing the findings of the patient encounter, diagnostic impression, and initial patient work-up
Data gathering is scored by checklists completed by the standardized patients. The checklists are developed by committees of clinicians and medical school clinical faculty and comprise the essential history and physical examination elements for specific clinical encounters. The patient note is scored by trained physician raters
The CIS (Communication & Interpersonal Skills) subcomponent includes assessment of:
•Questioning skills (eg, use of open-ended questions, transitional statements, not interrupting the patient)
•Information-sharing skills (eg, avoidance of jargon, responsiveness to patient questions or concerns, provision of counseling when appropriate)
•Professional manner and rapport (eg, concern for patient's comfort and modesty, examinee's attention to personal hygiene, expression of interest in the impact of the illness)
CIS performance is assessed by the standardized patients using rating scales. The domains included in these scales are, in part, based upon the scales used in the Clinical Skills Assessment (CSA) of the Educational Commission for Foreign Medical Graduates, with enhancements based upon national consensus statements on essential communication skills and upon review of other commonly used rating forms.
The SEP( Spoken English Proficiency) subcomponent includes assessment of:
•Clarity of spoken English communication within the context of the doctor-patient encounter (eg: 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.
Eligibility: Both medical school students and graduates must have passed the USMLE Step 1 to take Step 2 CS. TOEFL is no longer required after implementation of Step 2 CS in June, 2004.
Eligibility Period: A 12-month period of your choice. You must schedule your CSA within four months of the date on your notification of registration. You must take CS within 12 months of the date indicated on your notification of registration
Fees: The fee for Step 2 CS is $ 1,200. Step 2 CS is administered at regional Clinical Skills Evaluation Centers (CSECs) in Atlanta, Chicago, Houston, Los Angeles, and Philadelphia in the United States. You will not choose a CSEC when you complete the application. Once registered, you will select a CSEC, subject to availability, when you schedule your testing appointment. If you are unable to keep your testing appointment at the CSEC you select, you can reschedule for a different center, subject to availability, for a fee.
Step 2 CS is administered in both morning (AM) and afternoon (PM) sessions. Although you will select your test date and center, you will not be able to choose your test session. When you confirm a testing appointment, you will be assigned to either an AM or PM session. A PM session is assigned if, for that test date and center, AM sessions have been filled and PM sessions have been opened. When reviewing available test dates, you will be informed whether AM or PM sessions are currently being assigned for each date, and you can continue to check available dates for one offering your preferred session. Before you confirm a testing appointment, you will be informed once again whether an AM or PM session will be assigned.
Retaking the exam: If you reapply for Step 2 CS, the eligibility period assigned to you will be adjusted, if required, so that it does not begin during the sixty-day period after your last attempt. Additionally, you cannot take the same Step or Step Component more than three times in any twelve-month period. For Step 2 CS, attempts at the former ECFMG CSA count toward this limit. If you do not take an exam during your assigned eligibility period, you must reapply, including payment of the appropriate fee(s), if you wish to take the exam. In this event ECFMG cannot process a subsequent application for this exam until two weeks after the end of the eligibility period for the exam you did not take.
Books Recommended for Step 2 CS:
a) Mastering the Objective Structured Clinical Examination and the Clinical Skills Assessment
b) Kaplan Medical USMLE Step 2 Clinical Skills
c) Lecture Notes on Clinical Skills
d) Textbook of Physical Diagnosis: History and Examination
e) First Aid for the USMLE Step 2 CS
f) NMS Review for the Clinical Skills Assessment Exam
g) Bates' Pocket Guide to Physical Examination and History Taking
Step 2 CS Courses Available:
a) USMLE-World Step 2 CS Course
b) 5-Day Prep USMLE Step 2 CS - Kaplan
c) 1 Day USMLE Step 2 CS Prep - Kaplan
d) 1-Day USMLE Step 2 CS Simulated Exam - Kaplan
e) History Taking Workshop - Kaplan
f) Exam Master USMLE Step 2 CS Online
g) FALCON Physician Reviews - USMLE Step 2 CS
h) 6 days USMLE Step CS - Kaplan
i) Physical Exam Workshop - Kaplan
Score Rechecks for Step 1 & Step 2 CK: For Step 1 / Step 2 CK, standard procedures ensure that the scores reported for you are an accurate reflection of the responses recorded by the computer on the exam date. A change in score based on a recheck is an extremely remote possibility. However, a request for a recheck will be honored if you submit a Request for Recheck of Score on USMLE� Step 1 and Step 2 CK (Form 265) and the fee for this service to ECFMG. Your request must be received at ECFMG no later than ninety days after your score report release date.
USMLE Step 3
STEP 3 assesses whether you can apply medical knowledge and understanding of biomedical and clinical science essential for the unsupervised practice of medicine, with emphasis on patient management in ambulatory settings. Step 3 provides a final assessment of physicians assuming independent responsibility for delivering general medical care. Step 3 emphasizes selected physician tasks, namely, evaluating severity of patient problems and managing therapy. Assessment of clinical judgment will be prominent.
- Clinical problems involve mainstream, high-impact diseases. Provision is made for less common but important clinical problems as well.
- Test items and cases are patient centered, starting with a description of a clinical encounter (vignette). Both the multiple-choice items and case simulations pose action-related challenges that require clinical decisions or judgment.
- Emphasis is on ambulatory patient encounters; however, inpatient encounters of significant complexity and reflecting contemporary trends also are represented.
- Provision is made for incorporating applied basic science concepts, especially as they relate to justification for prognosis or management. It is assumed that basic science and clinical fundamentals have been assessed adequately in the prerequisite Step 1 and Step 2 examinations.
It is a two-day computerized test in clinical medicine consisting of mulitiple-choice questions and computer-based case simulations (CCS). You must complete each day of testing within 8 hours. The first day of testing includes approximately 350 multiple-choice questions divided into blocks of 25 to 50 questions that have to be completed within 30 to 60 minutes. There is a maximum of 7 hours of testing on the first day, plus 45 minutes of break time and a 15-minute optional tutorial. The second day of testing includes approximately 150 multiple-choice questions and computer-based case simulations (CCS). The questions are divided into sets of 25 to 50 questions; each set takes from 30 to 60 minutes and must be completed within 3 hours. After answering the multiple choice questions there is a CCS tutorial for which a maximum of 30 minutes is allowed. The CCS tutorial is followed by approximately 9 case simulations using new, proprietary simulation software called PRIMUM. The case simulations are presented in 1 or more cases per block and 3 hours, 45 minutes are allotted for them. The allotted break time for the second day is also 45 minutes. Taking Step 3 before residency is critical if the IMG is seeking H1B visa and is a bonus that can be added to the application for residency. Step 3 is also required for a full medical license in the US and can be taken during residency for this purpose.
Step 3 Specifications:
Physician Task:
1) 8 -12 % Obtaining History and Performing Physical Examination
2) 8 -12 % Formulating Most Likely Diagnosis
3) 8 -12 % Evaluating Severity of Patient�s Problems
4) 8 -12 % Applying Scientific Concepts and Mechanisms of Disease
5) 45-55 % Managing the Patient
i) Health Maintenance
ii) Clinical Intervention
iii) Clinical Therapeutics
iv) Legal and Ethical Issues
6) Clinical Encounter
7) 20-30% Initial Work-ups
8) 55-65% Continued Care
9) 10-20% Emergency Care
Eligibility: Most states require that applicants have completed one, two, or three years of post-graduate training (residency) prior to applying for Step 3 and permanent state licensure. The exceptions are the 11 states: Arkansas, California, Connecticut, Florida, Louisiana, Maryland, Nebraska, New York, South Dakota, Texas, Utah, Washington & West Virginia, which allow IMGs to take Step 3 at the beginning of or even before residency. So if you don�t fulfill the prerequisites to take Step 3 in your state of choice, simply use the name of one of the 11 states in your Step 3 application. You can take the exam in any state you choose regardless of the state that you mentioned on your application. Once you pass Step 3, it will be recognized by all states.
Basic eligibility requirements for the USMLE Step 3 are as follows:
•Obtaining an MD or DO degree (or its equivalent) by the application deadline
•Obtaining an ECFMG certificate if you are graduate of a foreign medical school or successfully completing �fifth pathway� program (at a date no later than the application deadline)
•Meeting the requirements imposed by the individual state licensing authority to which you are applying to take Step 3.
Application materials: Step 3 applications can be found online at
www.fsmb.org and must be submitted to FSMB. Step 3 is administered only in the US.
Eligibility Period: A three month period of your choice.
Fees: The fee for the 2005 Step 3 is $625 for all state medical boards with the exception of those boards listed below.
Iowa $675
Mississippi $725
South Dakota $775
Vermont $660
Retaking: In the event you failed the test, you can reapply and select an eligibility period that begins at least 60 days after the last attempt. You cannot take the same Step more than three times in any 12-month period.
Test Delivery: The NBME software, known as FREDTM, will replace the Prometric software in USMLE Step 3 in the fall of 2004. Installation of FRED for USMLE Step 3 will be phased in over several weeks in October 2004. If you schedule to take the Step 3, with a test date during the month of October, you should familiarize yourself with both the Prometric test delivery software and FRED.
The FRED software allows you to highlight and strike out item text as well as create annotations to items. Please note that the annotation feature allows you to record brief notes to yourself about individual items; it is not intended as a way to communicate to USMLE staff members. There is no additional time granted for use of the additional features provided by FRED, so you should closely monitor examination time when using these features.
The change to the FRED software will be accounted for in scoring the examination results, so that scores will be comparable to the Prometric software. Because of this change, along with other changes in the Step 3 test item pool, it will be necessary to delay the reporting of scores of some examinees for an additional 3-4 weeks beyond the normal turnaround period. The normal turnaround period for Step 3 examinees is 4 to 6 weeks. All efforts will be made to minimize these delays.
Score Reporting: The score report consists of two scores- a two digit and a three digit score. Both scores reflect your overall performance on the examination. The number of test items you answered correctly is converted to two equivalent scores, one on a 3-digit score scale and one on a 2-digit score scale. Both scales are used for score reporting purposes. The new minimum passing score for Step 3 is 184 implemented in April, 2004.
Statistics: For 2000 and 2001, the pass rates for first-time takers from LCME-accredited US and Canadian medical schools were 95% and 94%, respectively, whereas for non-US graduates/students, the pass rate is 61%. For 2002 and 2003, the pass rates for first-time takers who were graduates of MD-granting US and Canadian medical schools were 95% for both years, whereas, for non-US graduates/students, the pass rate is 68%.
Books Recommended:
a) Crush Step3: The Ultimate USMLE Step3 Review
b) NMSReview for the USMLE Step 3 (Book + CD-ROM)
c) Appleton & Lange's Review for USMLE Step 3
d) Medical Boards Step 3 Made Ridiculously Simple
e) Kaplan Medical USMLE Step 3 Q book
f) Blueprints Computer-based Case Simulation Review: USMLE Step 3
g) Mosby's USMLE Step 3: Comprehensive Review
h) Swanson�s Family Practice Review
i) Washington Manual of Medical Therapeutics
Step 3 Courses available:
a) Center-Prep USMLE Step 3 - Kaplan
b) Live Prep for USMLE Step 3 - Kaplan
c) Med Pass USMLE Step 3 - Kaplan
d) Deluxe Prep USMLE Step 3 - Kaplan
e) UMKC Institute for Professional Preparation
MCQs and CCS for Step 3:
a) USMLE-World
b) Q bank USMLE Step 3 - Kaplan
c) Kaplan Medical USMLE Step 3 Q book
d) Exam Master On-Line - USMLE Step 3
e) American Family Physician Clinical Quiz
