Step 2 CS

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Step 2 CS Case Development
Standardized Patient-Based Examinations

The patients you will see are people trained to portray a clinical problem. This method of assessment is referred to as a standardized patient examination. Most medical school programs in the United States and Canada accredited by the Liaison Committee on Medical Education (LCME) use standardized patients for instruction; many of these institutions use standardized patients for evaluation as well.

Standardized patients have been used since 1998 in the ECFMG Certification process, and have also been incorporated into the Medical Council of Canada's medical licensure examination for Canadian and international medical graduates. The standardized patient-based testing method was established more than 35 years ago, and its procedures have been tested and validated in the United States and internationally.

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Description of the Examination

When you arrive at the test center on the day of your examination, bring the Scheduling Permit you received when your registration was completed, your Confirmation Notice, and an unexpired, government-issued form of identification that includes a photograph and signature, such as a current driver's license or passport. Your name as it appears on your Scheduling Permit must match the name on your form(s) of identification exactly. The only acceptable differences are variations in capitalization; the presence of a middle name, middle initial, or suffix on one document and its absence on the other; or the presence of a middle name on one and middle initial on the other.

If you do not bring acceptable identification, you will not be admitted to the test. In that event, you must pay a fee to reschedule your test. Your rescheduled test date(s) must fall within your assigned eligibility period.

The time you should arrive at the test center is listed in the Confirmation Notice you will print after scheduling your appointment.

Please note that, as part of the Step 2 CS registration process, you acknowledge and agree to abide by USMLE policies and procedures, including those related to confidentiality.

Please bring only necessary personal items with you to the center. You may not possess cellular telephones, watches of any type, pagers, personal digital assistants (PDAs), two-way communication devices, or notes or study materials of any kind at any time during the examination, including during breaks. These items must be stored during the examination.

Each test center contains a locked storage area with small open cubicles. Coat racks are also available. Each examinee is assigned one of the cubicles in which all personal items must be stored during the examination. Examinees are not permitted access to the cubicles at any time during the examination, including breaks. Luggage may not be stored in the center. There are no waiting facilities for spouses, family, or friends; plan to meet them elsewhere after the examination.

Wear comfortable, professional clothing and a white laboratory or clinic coat. The proctors will cover with adhesive tape anything on the laboratory coat that identifies either you or your institution.

The only piece of medical equipment you may bring is an unenhanced standard stethoscope, which is subject to inspection by testing center staff. All other necessary medical equipment is provided in the examination rooms. Do not bring other medical equipment, such as reflex hammers, pen lights, or tuning forks to the testing center. If you forget to bring a laboratory coat or stethoscope, a limited number of coats and stethoscopes are available at each test center. However, it is strongly recommended that you bring your own.

As more fully explained in the Bulletin of Information, unauthorized possession of personal items while you are in the secure areas of the testing center is prohibited, and unauthorized items will be taken away. However, in certain limited circumstances, exceptions to this policy may be made for medical reasons, provided that permission is granted in advance of test administration.If you believe that you have a medical condition that requires you to use medication, an external appliance, or electronic device in the secure areas of the test center, you will need to submit a written request. Information on how to submit a request is available in the USMLE Bulletin of Information. Examples of appliances and devices to which this policy applies include non-standard stethoscopes, (eg, electronic or digitally amplified or otherwise enhanced non-standard stethoscopes), insulin pumps, inhalers, syringes, medications (oral, inhaled, injectable), TENS units, breast pumps, hearing aids, wheelchairs, canes, crutches, and casts.

Each examination session begins with an on-site orientation. If you arrive during the on-site orientation, you may be allowed to test; however, you will be required to sign a Late Admission Form. If you arrive after the on-site orientation, you will not be allowed to test. You will have to reschedule your testing appointment and will be required to pay the rescheduling fee.

The clinical skills evaluation centers are secured facilities. Once you enter the secured area of the center for orientation, you may not leave that area until the examination is complete.

Throughout the examination day, staff members, wearing identifying name tags, will direct you through the examination. You must follow their instructions at all times.
Examination Length

Your Step 2 CS administration will include twelve patient encounters. The examination session lasts approximately 8 hours, and two breaks are provided. The first break is 30 minutes long; the second break is 15 minutes long. You may use the restrooms before the exam and during breaks. A light meal will be served during the first break. The test center is unable to accommodate special meal requests. However, you may bring your own food, provided that no refrigeration or preparation is required. Smoking is prohibited throughout the center.
Equipment and Examinee Instructions

The testing area of the clinical skills evaluation center consists of a series of examination rooms equipped with standard examination tables, commonly used diagnostic instruments (blood pressure cuffs, otoscopes, and ophthalmoscopes), non-latex gloves, sinks, and paper towels. Examination table heights are approximately 32-33 inches, and are not adjustable. Outside each examination room is a cubicle equipped with a computer, where you can compose the patient note.

There is a one-way observation window in each examination room. These are used for quality assurance, training, and research.

Before the first patient encounter, you will be provided with a clipboard, blank paper for taking notes, and a pen. There will be an announcement at the beginning of each patient encounter. When you hear the announcement you may review the patient information posted on the examination room door (examinee instructions). You may also make notes at this time. DO NOT write on the paper before the announcement that the patient encounter has begun.

The examinee instruction sheet gives you specific instructions and indicates the patient's name, age, gender, and reason for visiting the doctor. It also indicates his or her vital signs, including heart rate, blood pressure, temperature (Celsius and Fahrenheit), and respiratory rate, unless instructions indicate otherwise. You can accept the vital signs on the examinee instruction sheet as accurate, and do not necessarily need to repeat them unless you believe the case specifically requires it. For instance, you may encounter patient problems or conditions that suggest the need to confirm or re-check the recorded vital signs and/or perform specific maneuvers in measuring the vital signs. However, if you do repeat the vital signs, with or without additional maneuvers, you should consider the vital signs that were originally listed as accurate when developing your differential diagnosis and work-up plan.

You may encounter a case in which the examinee instructions include the results of a lab test. In this type of patient encounter the patient is returning for a follow-up appointment after undergoing testing.
The Patient Encounter

When you enter the room, you will usually encounter a standardized patient. By asking this patient relevant questions and performing a focused physical examination, you will be able to gather enough information to develop a preliminary differential diagnosis and a diagnostic work-up plan.

You will be expected to communicate with the standardized patients in a professional and empathetic manner. As you would when encountering real patients, you should answer any questions they may have, tell them what diagnoses you are considering, and advise them on what tests and studies you will order to clarify their diagnoses.

The elements of medical history you need to obtain in each case will be determined by the nature of the patient's problems. Not every part of the history needs to be taken for every patient. Some patients may have acute problems, while others may have more chronic ones.

You will not have time to do a complete physical examination on every patient, nor will it be necessary to do so. Pursue the relevant parts of the examination, based on the patient's problems and other information you obtain during the history taking.

The cases are developed to present in a manner that simulates how patients present in real clinical settings. Therefore, most cases are designed realistically to present more than one diagnostic possibility. Based on the patient's presenting complaint and the additional information you obtain as you begin taking the history, you should consider all possible diagnoses and explore the relevant ones as time permits.

If you are unsuccessful at Step 2 CS and must, therefore, repeat the examination, it is possible that during your repeat examination you will see similarities to cases or patients that you encountered on your prior attempt. Do not assume that the underlying problems are the same or that the encounter will unfold in exactly the same way. It is best if you approach each encounter, whether it seems familiar or not, with an open mind, responding appropriately to the information provided, the history gathered, and the results of the physical examination.
Physical Examination

You should perform physical examination maneuvers correctly and expect that there will be positive physical findings in some instances. Some may be simulated, but you should accept them as real and factor them into your evolving differential diagnoses.

You should attend to appropriate hygiene and to patient comfort and modesty, as you would in the care of real patients. Female patients will be wearing bras, which you may ask them to loosen or move if necessary for a proper examination.

With real patients in a normal clinical setting, it is possible to obtain meaningful information during your physical examination without being unnecessarily forceful in palpating, percussing, or carrying out other maneuvers that involve touching. Your approach to examining standardized patients should be no different. Standardized patients are subjected to repeated physical examinations during the Step 2 CS exam; it is critical that you apply no more than the amount of pressure that is appropriate during maneuvers such as abdominal examination, examination of the gall bladder and liver, eliciting CVA tenderness, examination of the ears with an otoscope, and examination of the throat with a tongue depressor.

You should interact with the standardized patients as you would with any patients you may see with similar problems. The only exception is that certain parts of the physical examination MUST NOT BE DONE: rectal, pelvic, genitourinary, inguinal hernia, female breast, or corneal reflex examinations. If you believe one or more of these examinations are indicated, you should include them in your proposed diagnostic work-up. All other examination maneuvers are completely acceptable, including femoral pulse exam, inguinal node exam, back exam, and axillary exam.

Another exception is that you should not swab the standardized patient’s throat for a throat culture. If you believe that this diagnostic/laboratory test is indicated, include it on your proposed diagnostic workup.

Excluding the restricted physical examination maneuvers, you should assume that you have consent to do a physical examination on all standardized patients, unless you are explicitly told not to do so as part of the examinee instructions for that case.

Announcements will tell you when to begin the patient encounter, when there are 5 minutes remaining, and when the patient encounter is over. In some cases you may complete the patient encounter in fewer than 15 minutes. If so, you may leave the examination room early, but you are not permitted to re-enter. Be certain that you have obtained all necessary information before leaving the examination room. Re-entering an examination room after leaving will be considered misconduct.
Telephone Patient Encounters

Telephone patient encounters begin like all encounters; you will read a doorway instruction sheet that provides specific information about the patient. As with all patient encounters, as soon as you hear the announcement that the encounter has begun, you may make notes about the case before entering the examination room.

When you enter the room, sit at the desk in front of the telephone.

* Do not dial any numbers.
* Push the speaker button by the yellow dot on the phone to be connected to the patient's caregiver or the patient.
* You will be permitted to make only one phone call.
* Do not touch any buttons on the phone until you are ready to end the call - touching any buttons may disconnect you.
* To end the call on a phone case, press the speaker button above the yellow dot.
* You will not be allowed to call back after you end the call.

Obviously, physical examination of the patient is not possible for telephone encounters, and will not be required. However, for these cases, as for all others, you will have relevant information and instructions and will be able to take a history and ask questions. As with other cases, you will write a patient note after the encounter. Because no physical examination is possible for telephone cases, leave that section of the patient note blank.
The Patient Note

Immediately after each patient encounter, you will have 10 minutes to complete a patient note. Note: If you leave the patient encounter early, you may use the additional time for the note. You will be asked to handwrite or type (on a computer) a patient note similar to the medical record you would compose after seeing a patient in a clinic, office, or emergency department.

You should record pertinent medical history and physical examination findings obtained during the encounter, as well as your initial differential diagnoses. Finally, you will list the diagnostic studies you would order next for that particular patient. If you think a rectal, pelvic, genitourinary, female breast, or corneal reflex examination, or a throat swab, would have been indicated in the encounter, list it as part of your diagnostic workup. Treatment, consultations, or referrals should not be included in your work-up plan.

Appendix A illustrates a blank patient note page similar to what you will be asked to complete if you write the note by hand. Appendix B illustrates a blank patient note screen similar to what would appear to examinees who choose to type their notes. Appendix C provides sample patient note styles. A program for practicing typing the patient note is available on the USMLE website.

Typically you will be able to choose, for each patient encounter, whether to write the patient note by hand or type it on a computer. Occasionally, due to technical or administration problems, the option of typing the patient note may not be available for one or more patient encounters. When this happens, examinees will be required to write their patient notes by hand. All examinees should be prepared for the possibility that they may have to write one or more patient notes by hand.

Patient notes are rated by physicians who are well trained at reading notes and can interpret most handwriting. However, extreme illegibility will be a problem and can adversely impact a score. Everyone who writes patient notes by hand should make them as legible as possible.

If you have a case for which you think no diagnostic workup is necessary, write "No studies indicated" rather than leaving that section blank.

You will not receive credit for listing examination procedures you WOULD have done or questions you WOULD have asked had the encounter been longer. Write ONLY the information you elicited from the patient through either physical examination or history taking.

When you hear the announcement to stop writing, put down your pen immediately or click "Submit" on the computer. Continuing to write after the announcement to stop will be considered misconduct. Remain seated until all examinees' patient notes have been collected.
Other Case Formats

The kinds of medical problems that your patients will portray are those you would commonly encounter in a clinic, doctor's office, emergency department, or hospital setting. Although there are no young children presenting as patients, there may be cases in which you encounter — either in the examination room or via the telephone — a parent or caregiver of a child.

In some instances you may be instructed to perform a physical examination that relates to a specific medical condition, life circumstance, or occupation. Synthetic models, mannequins, or simulators provide an appropriate format for assessment of sensitive examination skills such as genital or rectal examination, and may be used for these cases. In such cases, specific instructions regarding the use of these devices will be provided. If you encounter any case for which you decide no physical examination is necessary, leave that section of the patient note blank.