Step 2 CS and CSA Tips

Pam Shaw MD
January 10, 2013

Dont panic. You are well-
prepared
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 patients15 min encounters
Knock in room after 10 minyou
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
patient10 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 patients 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
Dont interrupt your patient!
Dont 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
Dont 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 examsgoes in write
updo 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
Dont 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?
Dont 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 patients
problem(s).
Physical examination: Describe any
positive and negative findings
relevant to this patients 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 patients 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