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Why medical students fail in USMLE Step 2 Clinical Skills Exam?

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Why medical students fail in USMLE Step 2 Clinical Skills Exam?

USMLE Step 2 CS exam has three components—Integrated Clinical Encounter (ICE), Spoken English Proficiency (SEP) and Communication and Interpersonal Skills (CIS). Students appearing for Step 2 CS test have to pass all the components in one sitting. As a USMLE Instructor, a lot of students tell me they did everything right in the Step 2CS encounter but still failed.

I just failed in the ICE component of the exam, should I ask ECFMG to recheck my score?

I write this to explain, how to pass the USMLE Step 2 Clinical Skills Exam in first attempt with flying colors.

Failed in Integrated Clinical Encounter (ICE)

If you fail to extract a good history and lack a good clinical acumen, it will lead to poor patient note and obviously will affect your outcome in the Step 2 CS Exam. When I coach medical students, I teach them the Simon Sinek’s “Start with Why” approach.

Why I failed in Step 2 CS because of poor approach.
How I was not able to collect the clinical information from the patient correctly
What Poor patient note, as I have nothing to write now.

My training methodology is to coach them with the help of Vital Checklists that can provide them with quick memory aid to recall all the questions.

Why is it important to ask past medical history and family history in the exam?

Most students think that past medical history and family history is to record the previous disease, inherited diseases, and recurrence of diseases. For Example, you might ask—

Have you had any heart disease?

Have you had any sugar problems?

Have you had blood pressure issues?

Have you had any disease in the family?

We ask these questions to see if there is any relevance to the presenting complaint.

Therefore, we are able to extract adequate history from the patient.

However, these are standard approaches and everyone will be following them. What makes you stand out and score great in ICE is going that extra mile.

We can use past medical history and family history not only as a clinical tool but also as a counseling tool, communication tool and also to showcase your clinical abilities and diversity of your knowledge. This will leave an everlasting impact on the patient and will also help you write an accurate and detailed patient note, thereby improving ICE scores significantly. I will explain this using an example.

After asking the above-mentioned questions, you can evaluate for 10-year cardiovascular risk and also counsel them for their healthy lifestyle habits. Counseling is the key part for the Communication and Interpersonal Skills (CIS) segment of the Step 2 CS Exam. While practicing with a study partner for Step 2 CS exam make sure to ask these questions—

  1. Smoking history,
  2. Cholesterol history,
  3. Myocardial infarction history,
  4. Stroke History,
  5. Hypertension History,
  6. Treatment of the Hypertension,
  7. Last but not the least Diabetes history.

Why is this important?

This is based on Framingham Risk Estimator 2008 Guidelines that may be remembered with the help of the following checklist—(iCrush) Diabetes.

I Male or Female
C Cholesterol-Total and HDL
R Rx for SBP
U UR Age
S Smoking Currently
H Hypertension-SBP
Diabetes Diabetes

The Endpoints assessed in Framingham General CVD Risk Score (2008) are

CHD Death, Non Fatal MI, Coronary insufficiency or angina, Fatal or nonfatal Ischemic or hemorrhagic stroke, Transient Ischemic stroke, Intermittent Claudication and heart failure.

In 2013 American College of Cardiology/American Heart Association (ACC/AHA) proposed a cardiovascular risk calculator, the first risk model to include data from large populations of both Caucasian and African-American patients. This model includes the same Framingham Risk Estimator but the difference was in the hard endpoints.

2013 ACC/AHA Hard Endpoints
1 Coronary Heart Disease Death
2 Nonfatal MI
3 Fatal Stroke
4 Nonfatal stroke

Noteworthy amongst the above-mentioned score is that the family history is missing. However, when prediction variables are used in QRISK CVD risk estimator (2007), you will note that family history and even body mass index is included. Therefore, when you are asking past medical history it is important to ask about the above-mentioned conditions, family history and their date of onset. This will help you with integrated clinical encounter (ICE), counseling, writing patient note and also the communication skills. This will also showcase your Spoken English Proficiency and clinical acumen.

It might seem overwhelming to read the medical jargon mentioned above, but when I hold Vital Checklist workshops for USMLE Step 2 CS exam, I chunk these risk calculators into easy to remember, hard to forget, practical Checklists. After practicing with standardized patients, these checklists become an involuntary reflex to your history taking and do not require brain storming during the highly stressful moment in the real Step 2 CS exam. When you enter the room, you can easily write the mnemonic on your rough sheet and ask questions accordingly, without having to think about it. It will make you sharp, precise, intellectual in front of the patient and also save a lot of time for counseling, and building a good rapport with the patient. You will not only appear confident but also nail the Step 2 CS exam in the first attempt.

Now you must be wondering if this is important for cardiovascular patients alone but I would like to emphasize that asking about histories of cancer, autoimmune diseases and allergy in the family is as important as any other history. I have explained this in great detail in my book-Vital Checklist Communication and Clinical Skills (VC3).


Disclaimer-USMLE is a registered trademark of National Board of Medical Examiners and this trademark owner does not support or endorse Vital Checklist in any manner.


Dr.Harpreet Singh MD, FACP is a Chief Executive Officer and Founder of Vital Checklist and The text, graphics, images, videos and other material contained in the videos and iCrush Website ("Content") are for informational purposes only. The Content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.
Dr. Harpreet Singh - Chief Editor
Dr. Singh MD FACP is truly a “Doctor in no hurry.” He has pledged loyalty to the noble cause of educating and empowering patients to understand their disease and fight back. He believes in giving the patients control of their health, and enabling them to understand the “Why” of their problem. He has gained wide popularity by his courteous and empathetic approach towards patient care and envisions a complete hassle free patient experience. He uses easy to remember checklists, which chunk the important facts about the disease in a day-to-day acronym. The ultimate goal is to make the patient aware of the risks and benefits of their actions, enabling them to be ready when calamity strikes, or to avoid it altogether.

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