Why take a prepatory course for USMLE Step 2 CS exam/Comlex PE exam?

Don W. Penney MD.MSC.FACEP.
Neurological Surgeon

Step 2 CS exam 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.

Although all medical schools curriculums have courses teaching clinical skills, often instruction varies from institution to institution. Some of these courses are taught in a didactic fashion, while others involve standardized patients, simulators and real patients in hospitals and clinics associated with a medical school.
Since their original development, OSCEs (Observed Structural Clinical Evaluation) have become one of the main methods of assessing clinical competence in undergraduate medical education. Without question, OSCEs are more reliable than traditional methods of assessing clinical competence such as the long case.
The overarching philosophy in OSCEs is that all candidates are presented with the same clinical tasks, to be completed in the same timeframe and are scored using structured marking schemes. (Ulster Med J 2011)

Step 2 CS success requires medical student candidates to exhibit a minimal competency in four components; biomechanical, humanistic, data gathering and proficiency in the English language. Candidates must pass all four components of the exam.

Step 2 CS exam requires competency in the following areas:

  • Communication and professionalism skills (e.g. breaking bad news)
  • History taking skills (e.g. taking a history from a patient presenting with acute chest pain)
  • Physical examination skills (e.g. performing a respiratory examination)
  • Clinical-reasoning skills (e.g. interpreting clinical data and then prescribing therapy on a drug chart)
  • Practical/technical skills (e.g. insertion of a peripheral venous cannula)

Failure in any one component including humanistic can result in an overall failure on the CS exam, requiring a re-take, and a failure reflected on their transcript; which can reduce the student’s chance at a residency match.

As the director and lead instructor in IMGC, Advanced Medical Course; I have observed students who have been unsuccessful on the STEP 2 CS and Comlex PE exam, as a result of a number of common problems and misconceptions.
The problems that I have identified include:

  • Students who have not adequately prepared for the exam with practice in the OSCE format on standardized patients
  • Examinees who have delayed taking their CS exam late in the third or fourth year and after acquiring bad habits in their clinical rotations
  • Students who have not been trained in the proper format of the SOAP note submission and not receiving constructional criticism of the SOAP note by a physician mentor
  • Students who have obtained their undergraduate medical education in foreign medical schools, taught by instructors not familiar with the USMLE 2CS/Complex PE standards.
  • Lastly, students who failed to remediate after a failure and scheduling too soon a re-take without proper instruction.

The training students receive in IMGC’s AMC Course, addresses all potential problem areas. Over the course of 1 month, students are taught all clinical skill sets including Vitals, Head (ENT), Eye, Cardiovascular, Respiratory, Abdominal, Upper and Lower Extremity musculoskeletal and the neurological exam. Students are trained by the course director with years of experience in both allopathic and osteopathic medical schools.

Class sizes are kept small so that there is one on one training with immediate feedback. In addition, SOAP note submissions are critiqued with the advice given on strengthening weekly.Students are also provided with differential diagnoses for the most common CS/PE presenting complaints. In addition, participants are instructed in the proper format for developing a management plan for these diagnoses.

Lastly, In addition to the detailed training participants receive, tuition for the course also includes BLS and ACLS certification, a requirement in the US for hospital privileges.

Step 2 CS exam is a one day exam, held in multiple US cities. It is a pass/fail exam, and all components need to be completed successfully in order to obtain a pass. The exam is designed to reflect a medical evaluation in a doctor’s office, emergency department or clinic. Standardized patients involved in the exam undergo months of training in preparation for their participation in the exam. One source of failure by students taking the exam is not treating the standardized patient as a real patient but as an actor or actress. The medical student candidate is expected to gather a history (data gathering) appropriate for the presenting complaint, and performing a physical exam felicitous to the complaint. During the timed patient encounter the candidate is expected to communicate in a professional and compassionate manner. On the conclusion of the exam, the examinee is expected to advise the patient of their management plan and answer any questions.

In the July 2017 meeting, the USMLE Management Committee voted to increase the required minimum passing level for all three Step 2 CS subcomponents: Communication and Interpersonal Skills (CIS), Spoken English Proficiency (SEP), and Integrated Clinical Encounter (ICE). Because numerical scores are not reported for Step 2 CS, the decisions of the Management Committee were reported in terms of the potential impact on examinees, using data from previous exams.

Historically, the failure rate on Step 2 CS has been low. Annual first-attempt passing rates for North American medical students ranged from 91% to 97% between 2004 and 2016, according to the USMLE. However, as noted, in 2017 the USMLE Management Committee announced an increase in the passing standards after the routine review of examinee performance that it performs every 3 to 4 years. The USMLE announcement noted that if the new standards had been applied to the scores of earlier examinees evaluated under the previous standards, the national passing rate would have been three percentage points lower.
Passing the Step 2 CS examination is required for licensure. Soon after its introduction in 2004 many schools introduced changes to their curriculum to better prepare students for the examination. Furthermore, just 5 years after its introduction, the Step 2 CS examination was identified by residency program directors as the sixth most important criterion in their process for selecting residents. They ranked it more important than medical school class rank, membership in A O A, and medical school research experience.9 Students who fail and need to repeat the exam must pay a second fee, and many also face significant additional expenses for travel and lodging because of the limited number of testing sites.

Fam Med. 2019; 51(6):483-499.

Considering the high risk stakes with this important exam, students are encouraged to carefully evaluate their clinical acumen prior to taking this exam. The IMGC’s Advanced Clinical Medicine course is offered in Atlanta, multiple times a year; with the next scheduled course to commence November 11, 2019.
“Failure to plan, is a prescription for planning to fail”

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