Read Helen’s story about her experience of the USMLE Step 2 Clinical Skills exam, and the preparation that Kaplan offers for this exam. All International Medical Graduates must gain ECFMG (Educational Commission for Foreign Medical Graduates) certification to work or train as a Doctor in the US. To do this you must take the USMLE Step 1, Step 2 Clinical Knowledge and Step 2 Clinical Skills. Our USMLE Step 2 Clinical Skills student explains the process from her experience. Read on to find out more.
The USMLE is divided into three parts, the USMLE Step 1, Step 2 Clinical Knowledge, Step 2 Clinical Skills and the Step 3. The USMLE Step 1 and Step 2 CK are full day exams of MCQs, the Step 1 tests basic science and the Step 2 Clinical Knowledge, clinical medicine. Both of these exams can be taken in the UK. The USMLE Step 2 Clinical Skills and Step 3 are taken in the US.
All US medical graduates as well as foreign medical graduates take the same exams. One cannot work in the USA without passing the USMLE Step 1 and Step 2. The USMLE Step 3 can be taken whilst in a residency program (equivalent to specialist training program), but many overseas graduates choose to take it before taking up a post.
Why did I choose the USMLE?
There were many international students who took the course in medical school. I never really thought about it then, but before MMC in 2007, when I was unsure what was happening, I was advised by a previous consultant to take the USMLE exams. He graduated overseas and knew many people who worked in the USA. He explained that the training programs are well structured and the trainee is the central focus in the US system. I was successful getting on to specialist training in the UK, but felt that having the USMLE would open doors for me in the future, particularly for fellowships. I spent 3 months revising about 2 hours a day for the USMLE Step 1 and Step 2 CK exams, mainly just doing MCQs. There were many peers and consultants who couldn’t understand why I was doing this exam.
The USMLE Step 2 CS Exam
Having completed the MCQs, I then moved onto the Clinical Skills exam. I failed the first time. Return flight, hotel and cost of exam ($1200) down the drain. I didn’t give the exam the respect that it deserved. The exam is divided into 3 parts, Communication Skills, Spoken English Proficiency and Integrated Clinical Encounter (Patient history, examination, and patient note.) I thought it would be just like OSCEs in medical school. There are no ‘real patients’ in the exam, with no ‘real’ signs. They are all ‘standardised patients’ who are actors, they mark your examination and communication skills. They use a tick box to record what questions you ask, what exam manoeuvres were performed, communication skills and spoken English. A medical doctor marks your patient note. There are no doctors observing you in the room to check that the clinical examination is performed correctly, or to clarify why certain areas of the history are important. It is just you and the standardised patient.
The Clinical Skills Course, Kaplan Centre, Newark, New Jersey
Having failed the first time (I passed on communication skills and spoken English, but failed on the ICE, therefore failed the whole exam), I realised that I had to learn how to do it the American way. I also bought a Kaplan book to prepare for the CS exam. There are several preparation courses available through Kaplan, I could only afford to get the time off and pay for the practice simulated exam.
The course provided practice with 12 patient interactions, portraying patients who had cancer (breaking bad news), health maintenance check- ups, acute abdomen, chest pain etc. Patients would pretend the setting was outpatients, ‘the office’ or the Emergency Room. After each encounter lasting 15 minutes, there are 10 minutes to write a patient note. This is to record elements from the history and physical examination, 5 possible diagnoses, and further investigations. After these interactions we were given detailed feedback in a small seminar and breakdown for performance in each area for each patient encounter.
During the practice I scored poorly on the patient note especially. I was really worried as I had the real exam 2 days after the practice exam. The overseeing doctor there was very supportive and informative. My provisional diagnosis was correct most of the time, but I really fell down on the ICE. It is primarily a tick box exercise for the SP, and any variation from the ‘expected order’ would not be anticipated by the SP. They are trained to mark key questions and key manoeuvres. Profiles such as TFTs and LFTs, U and Es etc are not permitted. The American students are ‘trained’ to use a specific mnemonic in ‘quick fire mode’ after a few open questions to start. I was concerned that this may come across a bit regimented, but I was told that they SPs are expecting it to be that way. They also place a big emphasis on closure of the encounter and patient counselling. If somebody smokes, there are points for suggesting seeing a smoking cessation councillor and advising about diet. There is a lot to cover in 15 minutes. In the practice exam I often felt pushed and ran out of time.
How much did it cost? Do I recommend this course?
The Kaplan USMLE Step 2 CS Practice Exam cost $999. I enquired about the preparation in September for a course on the 12th December. There were no places available at this time, but luckily more space became available and I was booked on. One needs to plan months in advance. For the actual exam you need to book about 4 months in advance, and as I experienced the Kaplan preparation options fill up very quickly.
It is a lot of planning to co-ordinate them both together but it saves on 2 trips to the US. This course was invaluable and well worth it. I am not sure whether I have passed this time, but I have really taken their advice on board and really tried to focus on their set mnemonics and how to do it the American way for this exam.
I did find that the real exam was rather false and not really a reflection on one’s knowledge, but that is the way they do it. I think I was in blissful ignorance when I failed the first time. There are specific points for correctly draping the patient, retying the gown, counselling, closure, attention to patient comfort and empathy and washing hands for at least 15 seconds etc. The SP also expects a brief summary and is looking out for transition statements. This practice exam really prepared me for the exam 2 days later. I was in no doubt this time as to exactly what was expected of me.
Helen emailed Kaplan on 1st February, informing us that she had passed her exam.
Who is the course for?
I would recommend this course for those people who have graduated outside the US and are planning to sit the CS exam. Despite some negativity on occasion, I am still glad that I chose to do this exam. There are well structured fellowship programs in the US, with a great emphasis on trainer responsibility. US residents work in excess of 80 hours each week with less annual leave, but really get their money’s worth when it comes to learning and training.