IMG Perspectives

The Importance of Being Earnest (with Step 2 CS)

By Sasmit Sarangi

The Step 2 Clinical Skills (CS) exam is a fundamental step toward the process of residency. The basic purpose of the exam is to assess the core clinical competence of a future physician in the context of a typical clinic visit as seen in a US hospital. IMGs are often lulled into a false sense of security by the format of this exam, which stresses absolute fundamentals. However, in my opinion, and based on my experience, the Step 2 CS is perhaps the single most important exam in the current residency application process.


Over the last few years, the number of residency applicants has risen very rapidly. As an applicant, it is important to not have any obvious deficiencies in your application. Such deficiencies could lead to the exclusion of your application as programs cannot be expected to go through the complete applications of thousands of applicants. As a result, IMG candidates with a second attempt on Step 2 CS are not considered by a huge number of programs. I have to admit that this is based on my own experience as an applicant who failed Step 2 CS on his first attempt. My failure to pass the exam on my first try severely limited the number of programs that would even consider me for an interview.

Looking at the performance statistics for IMGs on Step 2 CS, one might draw the conclusion that this is a limited problem. For example in 2011-2012, 77% of all IMGs passed the Step 2 CS exam. It is important to keep in mind that in January 2013, the minimum passing performance in the components of Communication and Interpersonal Skills (CIS) and Integrated Clinical Encounter (ICE) were raised. This change has been predicted to decrease the passing rate of IMGs by a very significant 18%. While no data is officially available for 2013, this change would likely mean a predicted IMG passing rate of below 60%.

I, personally, did not take the CS exam lightly at all. I practiced a significant variety of sample cases and worked on writing a clinical note in the allotted time. During the day of the actual exam, I felt that I had managed to satisfactorily demonstrate my clinical skills. In spite of my best efforts, I received a marginal failing level on the CIS subcomponent. This was a huge shock to my efforts towards securing a residency position, and I spent several weeks agonizing over what I could have done differently. I had to retake the exam quickly because the application dates were fast approaching. It was immensely stressful to quickly prepare and retake an exam when I wasn’t sure what I should do differently.

Thankfully, I managed to pass comfortably on my second attempt and reassure myself regarding my interpersonal skills. If any of you are currently preparing for Step 2 CS, it is important to thoroughly practice cases, particularly with someone who has already passed Step 2 CS. If you unfortunately fail, know that you are not alone and try to get feedback from others about what you could have done differently. There are a lot of things that I could further discuss regarding the exam but in the interest of keeping this post focused, I would encourage everyone to post their questions and comments below. I will try to help you to the best of my abilities.

Click here for more info about Step 2 CS

Categories: IMG Perspectives

14 replies »

  1. I agree with several points on your post.

    1) False sense of security, everybody I had talked to said that after passing Step 1 and 2 CK, step 2 CS would be just a requisite. Some IMGs that I know took the step 2 CS first and passed it without a problem. However, nobody really warned me about the changes expected in 2012-2013 regarding the CSI scoring.

    2) Patient-centered interview is the most significant change in my opinion for the current Step 2CS and all IMGs should become familiar and master this before taking Step 2CS.

    3) My main problem right know is about practicing and networking. I do not know anybody right know that might be taking the exam soon and also is difficult to “simulate” the patient’s encounters.


  2. It is really difficult to organize a practice session if you don’t know someone. Perhaps skype can be your friend in getting practice with someone who has passed the exam recently. As you said the most important is to focus on your patient interview skills.


  3. Hey ! I prepared well for the exam. I passed in ICE and SEP but failed in CIS. I got an asterix for CIS,meaning I had a really low score. I dont really know how that happened though. I did FA thoroughly, practiced over skype and in person…

    I was excited of thinking i’d be applying this year, but this result has shocked me and I still have to give my other steps.

    Do you suggest reval ? Because I dont know why I was on the lower end of CIS. I wasn’t that bad. I’m pretty sure.


  4. Hi Kagman,

    We are in the same boat. Would you like to talk about?.

    Let me know, we can talk by skype.

    All the best,



  5. Hi guys.Am in the same boat.Rofranco and Kagman, if u guys can hit me bk. Bombed my ICE.Didnt think it was that bad despite my rather speedy, disorganized PN. Tot d PN wasn’t that awful. Don’t know if re-eval of any use at this point. My Centre was Philly.


  6. It is great that you guys are using this forum to link up. I would advise increasing eye contact and minimizing notes to increase your CIS score. Ultimately practice with your peer group is vital (try to find someone who has passed already).


  7. I just got my grade back. I was almost certain I failed the exam because In about 4 cases I ran out of time closing. I attribute it to being super tired (no sleep) and I asking way too many questions on ROS and not doing a focused PE. For ROS and PE I had a system and had to follow it. ROD I had about 20 questions from head to toe and almost on all pts I did heent, resp, cvs exam. The good thing was that with my system I was always able to elicit additional information (more points) and discover a diagnosis. However my recommendation is to have a system for ROS and do a “focused PE”. Had I done a focused PE I would have had time for closure on those patients and increased my Score even further. Nonetheless I passed.

    Just keep in mind that this is a points exam. Be empathetic, make sure you greet properly. (CIS points). Get a good HPI (first aid is good for this). Have a ROS that you ask every patient. Do a focused PE (a guy comes in with lower leg pain, don’t waste time palpating thyroid gland like I did). And practice your note on the usmle website (another tip is to do an IM core/elective prior to cs because you will be used to writing notes like I had been). Try to close, it’s free points (“this what you said, this is what I think you have, do you have any questions?). Keep eye contact. Pat the patient on the shoulder if you feel he needs it (or show him empathy verbally). If you do all this you will have racked up a lot of points.

    You must practice with a person. I repeat, YOU MUST practice with a person. I practiced with a medschool buddy and then practiced with my GF. She wasn’t available all time so we did it over Skype for 2-3 days. Total study time I did for cs was 1-2 weeks. Some recommend longer and I do too.

    I used first aid and usmle world cases.

    Good luck to everyone taking the exam.


  8. hi guys i got my resutl today and i did not pass. the ICE component. It shows from low to borderline. I am planning to apply this year. I already took the token and started on my application. Should i apply this time? and now the date for having ones result out by oct something is sept 7 th which is too early to take an exam and there is no availability of vacancy in any center. Pls some advice would be good. thank u.


  9. Hello I plan to take cs exam in January. I have not studied for steps or step 2 ck. I need some advice, will that make a difference on my score. Should I reconsider taking my step 1 before my cs exam.


  10. I just got my CS results and was shocked that I failed. I am an IMG studying in Europe but grew up in North America. My ICE and SEP scores were off the higher end of the charts with asterisks, it was my CIS score that was borderline. The whole time throughout the test, I felt good about how things were going (and I don’t usually feel that way!), and I made sure to tick off everything I had read is part of the CIS score. My patients seemed happy with me, and even the difficult ones seemed to get on board in the end. Afterwards, I thought the only way I would fail is through my ICE score, maybe I hadn’t asked enough questions or done a focused enough exam, and maybe my note was too rushed. And then I see it’s my CIS, when all throughout medical school and in all my North American electives, my communication and interpersonal skills were the first things I would be praised for by my preceptors. It is just absolutely mind-boggling. Being an IMG, with not stellar step 1 scores, this score has just destroyed my chances, and my self-esteem, which wasn’t too high to begin with. I am also applying to Canada (which has far fewer spots so that is pretty much out), and had to complete a similar clinical exam that was introduced this year, and was pleasantly surprised at how well I scored on that. At the time, I felt that exam was much more difficult than the CS. CS may very be the first exam I felt good about! And in med school, my rank is strong and my strengths are clinicals. Is it worth rechecking the grade? I don’t see how the score will change if they simply re-tally the marks. I cannot understand for the life of me how this has happened. I honestly thought my downfall would be knowledge. I had read First Aid and Kaplan Core Cases, and used Uworld material online, and gave myself several weeks to prepare and practice. I guess I feel exactly how you all describe!


    • Hi Bex,

      I feel the exact same way as you, and I also marginally failed the CIS component with high marks in the other two. All my life, I have been praised for my communication and interpersonal skills, I never would have guess this would have ruined me in the end. I’m sorry that you also went through this. Do you mind me asking how you’re doing now…were you able to match?


  11. Got cs scores yesterday: failed in SEP. Xms was on 15th October, Houston. I am an non US IMG with 240s step scores. I did my entire education in English medium and never thought English would ever fail me a test. cIS is high and ICE touches FA and thoroughly practised with friends who passed with high performance in SEP.Not sure what to do? Does rechecking help?


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