What To Bring (& What Not To Bring)
Important: 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.
On the day of your examination you must bring:
- The Scheduling Permit you received when your registration was completed
- Your Confirmation Notice
- An unexpired, government-issued form of identification that includes a photograph and signature. (i.e current driver’s license or passport)
- Lab coat and stethoscope (not required, but strongly recommended, as there will be a limited supply available at the test center)
Each test center contains locked storage. You will be able to place personal items that you might need during breaks or during the exam at your seat in the orientation room. 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.
*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.
Please bring only necessary personal items with you to the center. You may not possess pens, 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.
If you have a medical need for an item during your USMLE administration, a list of approved personal items is available.
Bulletin: Testing contains more information about the rules and regulations during the test.
What to Wear & When To Arrive
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.
- All examinees will be required to remove eyeglasses for visual inspection by the test center administrators. These inspections will be brief and will be performed during the check-in process.
- Jewelry, except for wedding and engagement rings, is prohibited.
- Hair accessories are subject to inspection. Examinees should not wear ornate clips, combs, barrettes, headbands, and other hair accessories. Examinees wearing any of these items on test day may be asked to store such items in their locker.
The time you should arrive at the test center is listed in the Confirmation Notice you will print after scheduling your appointment.
Proper Behavior – Testing Regulations and Rules of Conduct
You cannot discuss the cases with your fellow examinees, during breaks or at any time.
Conversation among examinees in languages other than English about any subject is strictly prohibited at all times, including during breaks. Test center staff will be with you to monitor activity. To maintain security and quality assurance, each examination room is equipped with video cameras and microphones to record every patient encounter.
The USMLE program retains the right to remove any examinee from the examination who appears to represent a health or safety risk to the standardized patients or staff of a clinical skills evaluation center. This includes, but is not limited to, examinees who appear ill, are persistently coughing or sneezing, have open skin lesions, or have evidence of active bleeding. Examinees who are not feeling well are encouraged to seek medical advice prior to arrival at the center and, if consistent with medical advice, should consider rescheduling the date of their examination. This can be done at the website of your registration entity.
Clinical skills evaluation center staff monitor all testing administrations for the Step 2 CS examination. You must follow instructions of test center staff throughout the examination. Failure to do so may result in a determination of irregular behavior. The USMLE Bulletin of Information provides a complete description of irregular behavior and the consequences of a finding of irregular behavior.
Irregular behavior includes any action by applicants, examinees, potential applicants, or others when solicited by an applicant and/or examinee that could compromise the validity, integrity, or security of the USMLE examination process.
1. On-Site Orientation
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.
2. The Patient Encounter
Your Step 2 CS administration will include twelve patient encounters. These include a very small number of nonscored patient encounters, which are added for pilot testing new cases and other research purposes. Such cases are not counted in determining your score. You will have 15 minutes for each.
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. Continuing to engage the patient after the announcement to stop has been made may be considered irregular behavior, will be reported to the USMLE, and could jeopardize your continued participation in the USMLE program.
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.
The Standardized Patient & 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.
When you enter the room, you will usually encounter a standardized patient (if not, you will be asked to communicate with a standardized patient over the telephone). By relating to the patient in a patient-centered manner, asking 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, as well as begin to develop an effective physician-patient relationship.
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 information you need to obtain in each encounter will be determined by the nature of the patient’s problems. Your approach should be focused. You will not have time to do a complete history and physical examination, 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 learn during the encounter.
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.
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.
Synthetic models, mannequins, or simulators provide an appropriate format for assessment of sensitive examination skills such as genital or rectal examination. Specific instructions will be provided in cases where this is necessary.
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.
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.
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.
- To place the call, press the yellow speaker button.
- 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, press the yellow speaker button.
- 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.
3. The Patient Note
Immediately after each patient encounter, you will have 10 minutes to complete a patient note. If you leave the patient encounter early, you may use the additional time for the note. You will be asked to 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. Examinees will not be permitted to handwrite the note, unless technical difficulties on the test day make the patient note typing program unavailable.
Patient notes are rated by licensed, board-certified 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.
You should record pertinent medical history and physical examination findings obtained during the encounter, as well as your initial differential diagnoses (maximum of three). The diagnoses should be listed in order of likelihood. You should also indicate the pertinent positive and negative findings obtained from the history and physical examination to support each potential diagnosis.
While it is important that a physician be able to recognize findings that rule out certain serious or life-threatening diagnoses, the task for Step 2 CS examinees is to record only the most likely diagnoses, along with findings (positive and negative) that support them.
Finally, you will list the diagnostic studies you would order next for that particular patient. If you think a rectal, pelvic, inguinal hernia, genitourinary, female breast, or corneal reflex examination, or a throat swab, would have been indicated in the encounter, list it as part of the diagnostic studies. Treatment, consultations, or referrals should not be included.
A program for practicing typing the patient note is available in the Practice Materials