New CS Performance Standards to Further Increase IMG Failures

January 14, 2013 by · Leave a Comment
Filed under: USMLE Step 2 CS 

As of January 1, 2013 the USMLE has raised the level of performance standards required for passing the USMLE Step 2 CS examination. According to the latest information posted at their website(, these higher passing requirements apply to the CIS(Communication & Interpersonal Skills) and the ICE(Integrated Clinical Encounter) components of the CS exam; the passing level for the SEP(Spoken English Proficiency) has not changed. This increase in performance requirements comes on the heels of changes to the structure of the Step 2 CS instituted this past June of 2012 which already broadened the criteria standards for passing CIS, and revised the format for patient note writing.

Since the USMLE has not yet released performance data for 2012, there is no way to quantify how the structural changes to the exam enacted last June have already affected passing rates for the second half of the year. We do know that passing rates among foreign and international graduates has steadily risen over recent years from 70% in 2008 to 77% in 2011. Based on the historic difficulty that IMGs have had with passing the CIS component, as well as added challenges now incorporated into the exam itself, it’s safe to assume that passing rates have undoubtedly already fallen. And now USMLE predicts that failures for first time foreign and international graduated will increase 18% beyond those estimated for the second half of 2012. Failures among those trained in American medical schools are expected to increase by 3%.

Needless to say, these latest changes are expected to have sweeping consequences for foreign and international graduates who are now planning to take the CS exam. Even assuming that passing rates for IMGs held at 77% for 2012(which is unlikely), the latest USMLE predictions maintain that approximately 4 in 10 will now fail under current performance standards.

Whether the new performance requirements(as well as the expansion of CIS criteria) represent an attempt to regulate the numbers of IMGs who will acquire residencies in the U.S. is anybody’s guess. Past increases in standards for passing the CS have generally had significant adverse effects on the passing rates for foreign graduates while having minimal impact on those from American schools. The bottom line is that those who study medicine outside of the U.S. will need to prepare longer and harder than ever before to clear the CS. Not only will they need to put in more preparation time, but they will also need to be more selective with choosing study sources and live instruction programs with which to prepare. Since instituting my Step 2 CS Review workshops in 2005, I have been amazed(and dismayed) at the proliferation of CS programs and those professing to be “experts” at preparing medical graduates for the exam. All too often students are attracted by the promise of abundant case practice, but are provided with little instruction which is often misguided, and assessed by inexperienced instructors and standardized patients. Furthermore, the more popular preparation books continue to offer the same faulty instruction with little or no consideration for the expanded CIS requirements.

It is more important than ever to get sound advice and quality expert feedback regarding your test taking performance before going forward, but be sure to ask questions about any program that you are considering, and find out about the experience of the instructors as well as that of the SPs before putting your money down.


Changes to the USMLE Step 2 CS Present New Challenges for IMGs

August 15, 2012 by · Leave a Comment
Filed under: USMLE Step 2 CS 

Beginning in June of 2012, the USMLE( U.S. Medical Licensing Examinations) has added new criteria for two of the scoring components of the Step 2 Clinical Skills exam. The changes include an expanded format for patient note writing which will now limit the differential diagnoses section to allow for up to three impressions, but will require the examinees to support each choice with history and physical exam findings collected during the patient encounter. Presumably, the component of data gathering will now be assessed by evaluating findings listed on the patient note rather than by SP checklists completed after each encounter.

The more significant changes, however, involve the CIS (Communication & Interpersonal Skills) component of the exam, which traditionally has posed the most difficulty for international and foreign medical graduates. In expanding on the former CIS subcomponents which assessed Professional Manner and Rapport, Questioning Skills and Information Sharing, USMLE has now restructured its evaluating criteria requiring examinees to demonstrate competence in the following areas: Fostering the Relationship, Gathering Information, Providing Information, Making Decisions, and Supporting Emotions. To implement these changes, USMLE has re-trained its standard patient evaluators, and has created new cases designed to further challenge test takers in these areas. Examinees will now be expected to take a more “patient centered” approach with their cases by encouraging patients to fully express specific concerns regarding their problem, and to share more responsibility with overall health decisions. An ability to genuinely communicate empathy to the patient when appropriate has become a higher priority as well. The goal is to create a more cooperative “partnership” with patients by establishing a trusting and comfortable environment, by evaluating and addressing the health needs and concerns of the patient, by providing education, and through gaining consensus with the patient for carrying out future plans.

While it is still too early to determine how these changes to the exam will impact passing rates for foreign graduates, it can be expected that CIS failures will increase. At the heart of the problem is the fact that many overseas institutions continue to focus almost exclusively on the “medical” component of patient care with little or no emphasis on the value of interpersonal communication. Cultural differences also make it difficult for many foreign trained doctors to feel comfortable with addressing the emotional impact of health problems on patients. Interestingly, in many foreign countries, expressions of caring and compassion by doctors are often interpreted as an over-compensation for an inadequate knowledge of medicine. In my experience with preparing foreign graduates for the CS, perhaps the biggest challenge has been in overcoming cultural indifference, and even resistance, to the concept of empathy. All too often, doctors follow the advice given in the “popular” preparation manual and simply recite “hollow”, scripted sounding statements which lack any sense of sincerity or genuineness. In all likelihood, these types of superficial, “cookie cutter” responses will no longer be adequate for communicating sensitivity and authentic concern. Language barriers also stand to significantly limit foreign test takers’ ability to spontaneously converse with patients about concerns and issues not directly related to the medical investigation aspect of the encounters.

Unfortunately, most of the preparation sources currently available cannot adequately address the specific obstacles that the changes to the CS exam present to foreign graduates. The most widely used cs prep book (you know the one) which, in my opinion, promotes unnatural, robotic behavior as a substitute for genuine caring and concern, has now become all but obsolete. Because new case challenges will now require examinees to not only listen more attentively but also to respond appropriately and empathically to a host of unforeseen issues, they can no longer rely on the usual group of standard “catch all” phrases (“I can understand your concern”) which may have been acceptable in the past. Sound communication skills begin with a sincere willingness to imagine what the patient is experiencing and demonstrating interest and compassion through non-verbal behaviors as well as with words. Any successful preparation for passing the USMLE Step 2 CS exam must start with a healthy understanding and appreciation for these concepts.


USMLE Step 2 CS – Live Practice Methods for Patient Interaction

November 18, 2010 by · 1 Comment
Filed under: USMLE Step 2 CS 

Arguably the most critical part of the USMLE Step 2 CS (Clinical Skills) exam is the personal interaction between the patient and doctor. During the Step 2 exam each candidate is required to perform in 12 patient encounters. Unlike the Step 1 and Step 2CK examinations, this particular exam is where medical knowledge and clinical skills are applied together during simulated real-world experiences.  If it seems daunting, and you feel apprehensive, you are not alone.

The overall exam involves collecting data, making some preliminary decisions about diagnosis and work-up, and completing a patient note. But establishing the appropriate interpersonal relationship between doctor and patient is where many IMGs have the most difficulty.  Such stress can also diminish a test candidate’s ability to apply their analytical skills, knowledge and training, and too often limits their ability think and communicate clearly. This is especially true for foreign doctors who must overcome additional obstacles including language and differences in cultural norms with regard to personal interaction.

The general consensus among experts in the field is that international medical graduates, especially those who struggle with spoken English proficiently, have the most difficult time navigating the various requirements of the Step 2 CS exam. Learning written English for academic study is very different from conversing during real (or even simulated) human interaction in the clinical environment. The burdensome task of translation from a native language to a less familiar one also requires extra time which can make it more difficult for examinees to finish the cases. Combine that particular difficulty with the added stress of being evaluated by the patients themselves on so many different sets of criteria, and the CS exam can be exceedingly challenging.

How does one overcome these difficulties? There are three ways; practice, practice and more practice! For any exam in any field, preparation is a key factor. However, possessing sound medical and even clinical ‘knowledge’ alone is not enough to pass the USMLE Step 2 CS exam. Examinees must be able to demonstrate a comfort level with themselves as well as with the standardized patients who assess them. They must be familiar with what to expect and how to best establish patient rapport through appropriate verbal and non-verbal communication. Perhaps the best way to accomplish this is to practice these interpersonal skills in a supervised environment with professional SPs and instructors who are experienced with the exam, and can provide valuable feedback for improving performance deficits.

Supervised practice with personalized feedback has proven to be particularly helpful for foreign medical graduates who face these additional challenges of cultural and language obstacles when preparing for the exam. In fact, the latest statistics indicate that passing rates among IMGs and foreign graduates improve dramatically with this kind of preparation component, where specific areas of weakness can be identified and corrected.  These types of programs also boosts student confidence through the positive reinforcement of appropriate clinical behaviors, and help to reduce the anxiety and nervousness which so often is responsible for failure. Unfortunately, all too many  test takers continue to rely on the popular cs preparation books and online sources which often provide faulty advice and cannot address individual areas of needed improvement.

Many candidates choose to find practice partners or get involved with a study group of doctors who are all preparing for the exam. They meet and practice on each other to hone their clinical skills and develop a familiarity with the exam. This may be good in the sense that it is, in fact, practice. However, without accurate and knowledgeable input from someone who understands the assessment criteria, it may become an exercise in futility. Many come to realize, only after failure, that a more professional and expert approach is warranted for such an important exam.

The best advice may be to consider a Step 2 CS training workshop that combines instruction with live full case practice and feedback. Review classes that utilized specially trained professionals who have experience in standardized patient education as well as clinical skills assessment, will usually provide the most comprehensive approach for success.  This will also allow for a more focused and productive practice experience leading up to the exam.

The USMLE Step 2 CS exam can be a formidable and trying exam. For international students, this is especially true. Getting involved with a study group is a good step, but seeking out professional training classes or workshops that specialize in live practice and individualized feedback with professionally trained SPs is the most optimal method of preparation. Doing so will greatly improve one’s chances of passing the step 2 cs exam the first time.


February 17, 2010 by · 3 Comments
Filed under: General 

Hello and welcome to the Step 2 CS Review blog!  For thousands of medical graduates who are hoping to pass the USMLE Step 2 CS exam in the upcoming months, making a decision as to the best way to prepare for a favorable outcome can feel like a daunting task. The stakes for successfully completing this requirement on the first attempt are high indeed! For those of you who have already secured a residency, it may be mandatory to pass your exam before a specified time deadline.  For many of you, however, who are seeking a residency during the next year, the reality of having to retake any of the USMLE licensing examinations may present a serious setback – one which can delay your medical career for an entire year!

The most current USMLE pass rate statistics for step 2 cs show that, while American and Canadian graduates continue to pass 97% of the time, pass rates for foreign graduates have fallen from 74% in 2007, to 70% in 2008. And these numbers are actually just the latest indication of a declining trend in foreign graduate pass rates which began in 2004.

So why is this happening? We do know that, in 2007, USMLE increased the difficulty for passing the CIS (Communication & Interpersonal Skills) and SEP (Spoken English Proficiency) components of the step 2 cs exam. It is estimated that these components combined now account for the majority of foreign graduate failures. And aside from the obvious cultural advantage given to American medical students, most now also benefit from curriculum based standardized patient programs which are specifically designed to prepare them for the USMLE Step 2 CS examination. In many domestic medical schools, students are required to pass a simulated step 2 cs examination before graduating, and are offered remedial help when standards are not met.

My sincere intention in launching this blog is to offer useful, exam oriented advice for successfully approaching the step 2 cs, and to also address some of the specific test taking issues and obstacles common to IMGs. Having personally assessed thousands of simulated patient encounters over the past nineteen years (the last eight yrs. preparing foreign grads for the USMLE Step 2 CS), it has been my experience that most CS failures are a result of faulty preparation approaches, and inadequate investment in practice. All too often, we see doctors at our two-day workshops who are retaking the step 2 cs exam because they simply followed “bad” advice. Unfortunately, much of the misguided information and instruction that, in my opinion, is responsible for poorer test scores is being provided by some of the most widely used and “well regarded” preparation sources.

In the days and weeks ahead, I will be adding postings with which I hope to address a variety of topics dealing with the USMLE Step 2 CS and the recommended preparation approaches. I also look forward to hearing from you, and welcome your comments and questions. As you know, there are literally hundreds of different cases which the USMLE draws from for CS examination purposes. For this reason, I would ask that your questions be limited to more universal aspects of the exam rather than to specific medical presentations. I must also request that this forum not be used for purposes of promoting ones services, or for making negative comments about any person, group or institution.