USMLE Step 2: Clinical Knowledge and Clinical Skills

Step 2 has two components to it: Clinical Knowledge (CK) and Clinical Skills (CS). Both CK and CS must be taken during the fourth year of medical school. Some residency programs want to see that one or both have been taken before offering an interview, but all residency programs require that CK and CS are completed before ranking students for the Match in February.

The CK portion of the test is a multiple choice exam very similar to Step 1 in both format and grading. However, rather than testing basic science knowledge, Step 2 CK questions are more designed to test the ability to evaluate symptoms, establish a diagnosis, and manage disease. Regardless of the question stem, the variety of questions is rather limited:

• Which of the following diagnostic tests can most likely establish this patient's diagnosis?
• Which of the following is the most likely cause of these findings?
• Which of the following is the most likely finding on physical exam?
• Which of the following is the most likely diagnosis?
• Which of the following is the most appropriate next step in management?
• Which of the following is the most appropriate intervention?
• Which of the following would be the best initial treatment in this patient?
• Which of the following is the most appropriate pharmacotherapy for this patient?

The CS portion of Step 2 is quite different. It is an 8-hour pass/fail exam that makes use of standardized patient-actors to evaluate clinical skills in a simulated clinical setting. There are 12 patient encounters, each one lasting 15 minutes with an additional 10 minutes afterward to write a note summarizing the encounter. In the 15 minute encounter, we're expected to obtain a full history from the patient and perform a focused physical exam that addresses the patient's presentation. The patient note written in the 10-minute post-encounter is meant to be just like any note I would write on a real patient, though parts of the note are standardized for the purposes of grading.

The CS exam is only administered in five locations nationwide: Atlanta, Chicago, Houston, Los Angeles, and Philadelphia. Because of the nature of the CS exam, the grading is necessarily complicated. Scoring is separated into three "subcomponents": 1) Integrated Clinical Encounter, 2) Communication and Interpersonal Skills, and 3) Spoken English Proficiency.

The ICE subcomponent is graded by checklists. Observers behind a one-way mirror check off physical exam maneuvers and such, and the patient note is reviewed to see if it incorporates certain information that the creators of the test deem important. The CIS subcomponent is necessarily based on subjective feedback from the standardized patient, though I have no idea what criteria or grading rubric they use. The SEP subcomponent is obviously not an issue for people who speak English fluently.

As part of the end-of-third-year ICC, everyone in my class took a five-hour CAPE exam to prepare for the USMLE Step 2 CS. A lot of effort was put into making this practice exam as close to the real thing as possible. Except for the CAPE exam being 5 hours instead of 8, and 10 patient encounters instead of 12, I think that this experience did a great job of preparing me for what the CS test experience will be like.