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Step 2 CS and CSA Tips
Pam Shaw MD
January 10, 2013
Don’t panic. You are wellprepared
You have had lots of SP experiences that
have prepared you for the test
CSA is a good trial run-dates for CSA in
KC are May 29, 31, and June 3, 5, 7, 10, 12,
14, 18, 25
Residency program directors rate our
students’ skills highly
We have a high pass rate for CS
BUT……
CS changes for 2013
 One of the recommendations emerging from the
Comprehensive Review of USMLE (CRU) process is that
USMLE consider ways to further enhance the testing methods
used in the Step 2 Clinical Skills (CS) examination. these
enhancements were implemented in mid-2012.
 The Step 2 Committee decided to increase the performance
levels required to receive a passing outcome on two of the
three Step 2 CS subcomponents: Communication and
Interpersonal Skills (CIS) and Integrated Clinical Encounter
(ICE). There will be no change to minimum passing
requirements for the Spoken English Proficiency (SEP)
subcomponent of Step 2 CS at this time.
 The change means that the passing rate would be changed by
3% based on last years results
What is CS?
 Step 2 of the USMLE assesses the ability of
examinees to apply medical knowledge,
skills, and understanding of clinical science
essential for the provision of patient care
under supervision, and includes emphasis
on health promotion and disease prevention.
Step 2 ensures that due attention is devoted
to the principles of clinical sciences and
basic patient- centered skills that provide the
foundation for the safe and effective practice
of medicine.
What is CS?
Step 2 CS uses standardized patients to
test medical students and graduates on
their ability to gather information from
patients, perform physical examinations,
and communicate their findings to
patients and colleagues.
Step 2 CS: 3 components
 Integrated Clinical Encounter
 Data gathering (with SP) scored by checklist
 Documentation (or note)scored by physicians-this
changed last year
 Communication and Interpersonal Skills (SP
scored)
 This also changed last year
 Spoken English Proficiency (SP scored)
 Must pass all three to pass exam
Step 2 CS Test Sites
Chicago
Los Angeles
Atlanta
Philadelphia
Houston
Step 2 CS
 12 patients—15 min encounters
Knock in room after 10 min—you
have 5 left
5 pts-30 min lunch break-4 pts-15
min break-3 pts
Once you leave the room, you are
done
 Post-encounter note after each
patient—10 min
 Approximately 8 hours
Step 2 CS
No PDAs or phones
Only white coat and stethoscope and
blank paper
Exam is confidential so sharing of
information is taboo
You must be on time to be able to sit for
the exam
Step 2 CS: Possible types of
encounters
Acute, chronic cases
Counseling vs. PE cases
Follow up lab results
Telephone case
Peds cases with child out of room
Cases with a simulator
Changes to the assessment of
Communication and Interpersonal Skills
(CIS)
 The CIS subcomponent of Step 2 CS has been
redesigned to assess a fuller range of
competencies.
 Beginning June 17, 2012, the Communication and
Interpersonal Skills (CIS) scale will focus on five
functions:
1. Fostering the relationship
2. Gathering information
3. Providing information
4. Making decisions: basic
5. Supporting emotions: basic
Fostering the Relationship
Expressed interest in the patient as a
person
Treated the patient with respect
Listened and paid attention to the patient
Gathering Information and
Providing Information
Encouraged the patient to tell his/her
story
Explored the patients reaction to the
illness or problem
Provided information related to the
working diagnosis
Provided information on next steps
Making Decisions-Basic
 Elicited the patient’s perspective on the
diagnosis and next steps
 Finalized plans for the next steps
 Advanced skills are still being developed
Supporting Emotions-Basic
Facilitated the expression of an implied or
stated emotion or something important to
him/her
Advanced skills to be determined
And lastly, helping patients with behavior
change
Communication and
Interpersonal Skills
 Questioning skills – examples include:
 use of open-ended questions, transitional
statements, facilitating remarks
 avoidance of
- leading or multiple questions, repeat questions
unless for clarification, medical terms/jargon
unless immediately defined, interruptions when
the patient is talking
 accurately summarizing information from the
patient
Communication and
Interpersonal Skills
 Information-sharing skills – examples
include:
 acknowledging patient issues/concerns and
clearly responding with information
 avoidance of medical terms/jargon unless
immediately defined
 clearly providing
- counseling when appropriate
- closure, including statements about what
happens next
Communication and
Interpersonal Skills
 Professional manner and rapport – examples
include:
 asking about expectations, feelings, and concerns of the
patient; support systems and impact of illness, with
attempts to explore these areas
 showing consideration for patient comfort during the
physical examination; attention to cleanliness through
hand washing or use of gloves
 providing opportunity for the patient to express
feelings/concerns
 encouraging additional questions or discussion
 making empathetic remarks concerning patient
issues/concerns; patient feels comfortable and
respected during the encounter
Communication and
Interpersonal Skills tips
 Introduce yourself every time
 Call pt. Ms. or Mr. or ask!
 Open-ended questions
 Transition statements
 Don’t interrupt your patient!
 Don’t use jargon (eg. Say high blood
pressure, not hypertension)
 Empathize
Communication and
Interpersonal Skills tips
 Partner with the patient
 Ask the pt what they think/want to do
 Ask the pt if they have questions (and answer
them)
 Explain what you think and want to do. Make
sure your pt is ok with the plan!
 Counsel pt if appropriate
 Closure
 Provide hope, follow-up plan
Spoken English Proficiency
For most, should not be an issue, if you
are concerned, please touch base in
student counseling or with Student Affairs
Integrated Clinical Encounter
Components
History taking
Full history
Physical exam
Focused exam
Post-exam discussion with patient
Post-encounter note
Integrated Clinical Encounter
tips: History
 Focus on the process
 Keep diagnostic possibilities wide open
 Don’t focus on an obvious dx early
 Open-ended questions first, second and
third. You can be specific later.
 One question at a time
 Get all the concerns on the table early-“Anything else?”
Integrated Clinical Encounter
tips: History
 Ask ALL appropriate attributes of a
symptom: LOCATES
 Location
 Other symptoms
 Chronology/Timing
 Alleviating factors
 Things that make it worse
 Experience of the symptom/Quality
 Severity
Integrated Clinical Encounter
tips: History
ALWAYS ASK
Past Medical History
Medications
Allergies
Social History
Occupation, Smoking, Alcohol, Drugs,
Sex
Family History
Review of Systems
Integrated Clinical Encounter
tips: Physical exam
Focused exams
Think about your differential before you
do your exam
Wash hands every time
Technique matters
Keep your patients modestly draped
If you have questions, review before
Step 2CS
Integrated Clinical Encounter
tips: Physical exam
 ALWAYS listen with stethoscope on the skin
 Vitals given, but you may want to repeat
 No GU/breast/corneal exams—goes in write
up—do talk to your pt about these
 There may be abnormalities!
 May be real or simulated
 If you observe something abnormal, it is
supposed to be that way
Integrated Clinical Encounter
tips: Post-exam discussion with
patient
Don’t just leave the room!
Discuss differential dx with patient
Discuss your diagnostic plans with
patient (GU exam for example)
Be prepared for difficult questions
Eg. “Am I going to die?” “Did I do
something to cause this?”
Don’t let these sidetrack you from your
task
Integrated Clinical Encounter
tips: Post-encounter note
10 min per note
Character limit in each area of 250
characters
Abbreviations must be acceptable to
USMLE
Typing is required this year
You will only be handwriting anything
if computer glitch
Patient Note Entry Form
Post-encounter note
History and Physical
History: Describe the history you just
obtained from this patient. Include only
information (pertinent positives and
negatives relevant to this patient’s
problem(s).
Physical examination: Describe any
positive and negative findings
relevant to this patient’s problem(s).
Be careful to include only those parts
of examination you performed in this
encounter.
Post-encounter note
Data Interpretation
 Based on what you have learned from the history
and physical examination, list up to 3 diagnoses
that might explain this patient’s complaint(s). List
your diagnoses from most to least likely. For
some cases, fewer than 3 diagnoses will be
appropriate. Then, enter the positive or negative
findings from the history and physical
examination (if present) that support each
diagnosis. Lastly, list initial diagnostic studies (if
any) you would order for each listed diagnosis (eg
restricted physical exam maneuvers, laboratory
tests, imaging, ECG, etc.)
Quick word on telephone cases
Treat as if the patient were in the room
Take your time
Ask all your usual questions
Usually a pediatric case
Feedback before taking the exam
If you plan on taking CSA in June or July,
you need to meet with Dr. Shaw before
taking the exam
Everyone who scores in the bottom 15%
of the class will have to meet with Dr.
Shaw
CSA will be scored like the CS so it is
good feedback
Resources
More info:
USMLE® : Test Content & Practice
Materials
http://www.usmle.org/examinations/step2/
step2cs.html
Use your clerkships/faculty!
Recommended resources