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.

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.

DL