Step 2 CS Exam Overview

The Step 2 Clinical Skills (Step 2 CS) portion of the Step 2 exam assesses whether you can demonstrate the fundamental clinical skills essential for safe and effective patient care under supervision. There are three subcomponents of Step 2 CS:

  • Integrated Clinical Encounter (ICE)
  • Communication and Interpersonal Skills (CIS)
  • Spoken English Proficiency (SEP)

Examination Content

Step 2 CS uses standardized patients (ie, people trained to portray real patients in the examination). You are expected to establish rapport with the patients, elicit pertinent historical information from them, perform focused physical examinations, answer patient questions, and provide counseling when appropriate. After each patient interaction, you will record pertinent history and physical examination findings, list diagnostic impressions, and outline plans for further evaluation, if necessary. The cases cover common and important situations that a physician is likely to encounter in common medical practice in clinics, doctors' offices, emergency departments, and hospital settings in the United States. There are three subcomponents of Step 2 CS.

Integrated Clinical Encounter (ICE):

  • Data gathering - patient information collected by history taking and physical examination
  • Documentation - completion of a patient note summarizing the findings of the patient encounter, diagnostic impression, and initial patient workup

Communication and Interpersonal Skills (CIS)

  • Questioning skills
  • Information-sharing skills
  • Professional manner and rapport

Spoken English Proficiency (SEP)

  • Clarity of spoken English communication within the context of the doctor-patient encounter

Test Length and Format

Step 2 CS has twelve patient cases. You will have fifteen minutes for each patient encounter and ten minutes to record each patient note. If you do not use the entire fifteen minutes for the patient encounter, the remaining time will be added to the time you have to record the patient note. The testing session is approximately eight hours. Step 2 CS cases must be taken in the order presented. After you exit the case or session, or when time expires, you can no longer review test items or cases, change answers, or collect additional information.

Eligibility Criteria

To be eligible for Step 2 CS, you must be in one of the following categories at the time of application and on the test day:

  • A medical student officially enrolled in, or a graduate of, a US or Canadian medical school
  • A medical student in a program leading to the MD degree that is accredited by the Liaison Committee on Medical Education (LCME)
  • A medical student officially enrolled in, or a graduate of, a US medical school leading to the DO degree that is accredited by the American Osteopathic Association (AOA)
  • A medical student officially enrolled in, or a graduate of, a medical school outside the United States and Canada and eligible for examination by the ECFMG

Do USMLE scores reflect an individual's clinical skills?

Standardized patients are frequently used to assess a medical student's clinical skills, including history taking, performing the physical examination, and interpersonal skills. There has been concern that medical school faculty may not be well suited to document these skills during routine evaluations because they infrequently observe students actually performing a history and physical secondary to time restraints and because the criteria by which students are judged may vary between different physicians. In part, this was the stimulus for the creation of the Clinical Skills portion of the USMLE Step 2. This raises the question of whether the USMLE adequately assesses one's clinical skills.

A 2005 study examined the relationship of performance on the Step 1 and Step 2 CK tests with performance in standardized patient situations in PGY1 year internal medicine residents. The results of both USMLE tests were found to correlate with each other (ie, students who performed well on Step 1 tended to perform well on Step 2). However, both tests had very low correlation with performance on a standardized patient evaluation. Despite being the more clinically oriented exam, Step 2 was no better correlated with standardized patient performance than Step 1.

However, the findings of a 2003 study comparing program director ratings of residents to their performance in medical school yielded somewhat contradictory results. This study found a correlation between class rank and Step 1 and Step 2 scores with program director rankings of skills during residency. This discrepancy is potentially attributable to the fact that what standardized patient exams assess may differ from what residency program directors value in a resident. Taken together, these studies imply that students with higher GPAs or test scores likely have the intelligence and motivation to acquire more of the clinical skills needed to become excellent physicians, although higher test scores do not by themselves mean that a student will have better clinical skills.


Paolo A, Bonamino G. Measuring Outcomes of Undergraduate Medical Education: Residency Directors' Ratings of First-year Residents. Academic Medicine Issue: 78(1), January 2003, p 90–95

Rifkin WD, Rifkin A. Correlation between Housestaff Performance on the United States Medical Licensing Examination and Standardized Patient Encounters. The Mount Sinai Journal of Medicine 72(5); January 2005, pp. 47-49.

Can test anxiety contribute to failing the USMLE and what strategies are available for lessening anxiety?

Medical school can create a lot of stress. Medical students average in the 85th percentile of the general population for overall stress level. The stress in some students may be related to exams primarily, particularly important exams such as the USMLE. Testing may produce enough anxiety to qualify as an actual psychological condition known as debilitating test anxiety. This may contribute to USMLE failure in a certain subgroup of students. One aspect of this anxiety may result in under-preparation for the exam due to avoidance and/or procrastination. Students may also be overwhelmed with such a high level of anxiety during the test that attention and memory are affected. Many students may have experienced similar feelings associated with testing during high school or college but were able to get by as that material was less difficult.

There are techniques available to help students with debilitating test anxiety improve both their test preparation and level of anxiety during the test. Progressive muscle relaxation consists of sequentially tightening and relaxing major muscle groups in an attempt to facilitate relaxation. Systematic desensitization consists of forcing the student to attempt to remain calm while picturing the days leading up to and including the examination. It may even be helpful to practice a behavioral rehearsal, which may consist of simply imagining the test day itself or physically visiting and sitting within the actual test room. Psychoeducational techniques such as testing oneself before and after studying certain material may help to reinforce that progress is being made during the studying process. A 2004 study demonstrated that students who participated in techniques such as these had a higher pass rate on retaking the exam than the general retake population. While students may attempt to utilize these techniques on their own, working directly with a psychologist may be beneficial for some.


Powell DH. Behavioral Treatment of Debilitating Test Anxiety Among Medical Students. Journal of Clinical Psychology 60(8), 2004, 853-865.

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