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USMLE Step 2 Clinical FAQ's
Frequently Asked Questions
Beginning with the Class of 2005, every medical school graduate
will be required to take and pass USMLE Step 2 Clinical Skills (CS)
Exam in order to gain licensure to practice medicine. The following
compilation of Frequently Asked Questions should address some of
the concerns financial aid officers have about this requirement.
Large excerpts of this document are taken directly from the USMLE
Web site. For more information, visit the USMLE
or NBME Web site.
- What is the Step 2 Clinical Skills Exam and what
is its purpose?
- What is the CS exam like?
- When will administration of the exam begin
and where will it be given?
- What will be the cost of the exam to examinees?
- When can examinees register for the exam?
- Are these costs allowable in a student's cost of
attendance?
- What are the options for including exam fees in
the COA in the third versus the fourth year?
- What standard expenses can be included in COA?
- When does professional judgment come into play?
- What are the options in terms of awarding and
disbursing the funds to examinees?
- What remediation is available for test failures?
- How do you report the cost of the exam to the
government and military programs to ensure it and related expenses
are covered?
- Will examinees who qualify for vocational rehabilitation
assistance, have their assistance increased to cover the cost
of the exam and remediation if necessary?
- Related Web Resources
1. What is the Step 2 Clinical Skills Exam
and what is its purpose?
Purpose Statement. Step 2 CS assesses whether an examinee
can demonstrate the fundamental clinical skills essential to safe
and effective patient care under supervision. These clinical skills
include taking a relevant medical history, performing an appropriate
physical exam, communicating effectively with the patient, clearly
and accurately documenting the findings and diagnostic hypotheses
from the clinical encounter, and ordering appropriate initial diagnostic
studies.
2. What is the CS exam like?
Description of Step 2 CS: Step 2 CS is a one-day test that
mirrors a physician's typical workday in a clinic and other settings.
Examinees will examine eleven or twelve "standardized patients"—people
trained to portray real patients. These include a very small number
of non-scored patient encounters, which are added for piloting new
cases and other research purposes. Such cases are not counted in
determining an examinee's score. Examinees will typically be given
15 minutes for these encounters, and during the encounters, they
are expected to establish rapport with the standardized patients,
elicit pertinent historical information, perform focused physical
exam, communicate effectively, and document findings and diagnostic
impressions. After each encounter, examinees will record a patient
note, including pertinent history and physical exam findings, diagnostic
impressions, and plans for further evaluation if necessary. The
cases will cover common and important situations that a physician
is likely to encounter in common medical practice in clinics, doctors'
offices, emergency departments, and hospital settings in the United
States.
3. Where are the test sites?
The locations and expected dates of availability for the Clinical
Skills Evaluation Centers (CSECs) are:
- Philadelphia, Pennsylvania
- Atlanta, Georgia
- Los Angeles, California
- Chicago, Illinois
- Houston, Texas
4. What will be the cost of the exam to examinees?1
An exam registration fee of $1007 will be assessed for sitting
for the CS. This is in addition to the $470 fee for the Step 2 Clinical
Knowledge exam (CK). Additional fees will be charged for rescheduling
exams, re-sitting for the exam in the event of failure, etc. ( See
Question 7 for further details.)
5. When should examinees register for the exam?
Timing: There is no deadline for submitting
an application to register for Step 2 CS. However, in planning the
timing of an application, refer to the section on Eligibility
Periods on the USMLE Web site for information on how Step 2
CS eligibility periods are assigned. Examinees should also consider
deadlines imposed by their school, the National Resident Matching
Program (NRMP), and graduate medical education (GME) programs. Finally,
both schools and examinees should recognize that demand for test
dates/centers at certain times during the year may exceed the number
of testing spaces available.
Eligibility Periods. Examinees registered
for Step 2 CS are assigned a 12-month eligibility period
beginning on the date their registration information is entered
into the Step 2 CS scheduling system.
To schedule a testing appointment, an examinee must select
a test date and a test center. The test date selected
must fall within the eligibility period. Step 2 CS is administered
in both morning (AM) and afternoon (PM) sessions. Examinees will
not be able to choose the test session. Once a testing appointment
is confirmed, examinees will be assigned to either an AM or PM session.
A PM session is assigned if, for that test date and center, AM sessions
have been filled and PM sessions have been opened. The scheduling
system will indicate for each date whether AM or PM sessions are
currently being assigned. Examinees can continue to monitor available
dates for locations offering preferred sessions. Before confirming
a testing appointment, the examinee will again be informed whether
an AM or PM session will be assigned.
How Test Dates Become Available:
- Test dates are opened so that dates will be available throughout
a 12-month eligibility period.
- Additional test dates are opened, according to demand. These
dates are opened to maximize operational efficiency at all centers
and may not reflect examinee demand for particular test dates
and/or centers.
- Testing appointments are available on a first-come, first-served
basis. It is possible that examinees will not be able to obtain
a testing appointment for the preferred time period and/or center.
- The earliest available test dates for each center will conform
to the center's expected opening date.
- The availability of testing appointments will change on a daily
basis as result of examinee scheduling, rescheduling and opening
of additional test dates.
- It is possible that testing appointments will become available
for a time period and/or center that an examinee prefers after
the examinee has scheduled an appointment for a different time
period and/or center. In this event, examinees may change their
scheduled test date and/or center for a fee.
- Although examinees can monitor available test dates for a preferred
time period and test center, availability is not guaranteed.
Registered examinees must take the exam during their eligibility
period; if the exam is not taken during the eligibility period,
examinees must reapply and pay the entire exam fee in order
to take the exam.
6. Are these costs allowable in a student's
cost of attendance?
According to an e-mail received in fall 2003 from the Department
of Education, costs associated with tests that are required as
part of the academic program can be included in a examinee's
cost of attendance (COA). Therefore, as long as a student is required
to sit for or demonstrate a passing score before graduation, it
is possible to include the exam fees in the examinee's COA.
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7. What are the options for including exam
fees in the COA in the third versus the fourth year?
Medical schools that require sitting for or passing these exams
should reflect upon the ideal time for examinees to register and
take the exam. It would be advisable for schools to consider whether
to establish a deadline date for examinees to sit for the exam,
especially if passing the exam is an academic requirement and a
passing score must be received prior to graduation. Some schools
may want to set their initial deadline date sufficiently early to
allow for a repeat administration, should an examinee fail the initial
exam. Another issue to consider is whether test results will be
expected or required by residency programs, as when an examinee
sits for the exam and receives their test results may impact the
residency selection process. The options available are as follows:
- Several schools have indicated they include registration fees
in an examinees' third year as registration for the exam and for
specific test sites is being handled by USMLE on a first-come,
first-served basis. By encouraging examinees to register early,
schools may help examinees to reduce travel costs. As a result,
the exam costs will span two academic years: the exam fee in the
third year COA; and the actual travel costs during the fourth
year.
- Other schools may encourage their students to register for the
exam at the start of the fourth year so the exam fee and the travel
costs are in the same academic year and COA.
Issues to consider:
- Rescheduling fees and penalties exist for examinees that schedule
an exam without full knowledge as to their personal availability.
While there is no fee to cancel a scheduled testing appointment,
fees are due at the time of rescheduling. Step 2 CS rescheduling
fees are based on the date the appointment is cancelled, using
Eastern Standard Time in the United States. Fees
to reschedule increase as the scheduled test date approaches.
- If cancelled more than 14 calendar days prior to a scheduled
test date, there is no fee to reschedule.
- If cancelled during the 14 day period prior to a scheduled
test date, the fee to reschedule is $150.
- If a scheduled testing appointment is missed without canceling,
the fee to reschedule is $400.
Some rescheduling of the exam by examinees may be unavoidable,
for example, due to illness, death in the family, etc. Financial
aid officers will need to determine how they will handle this
expense if it occurs. Examinees who are ill will be encouraged
to seek medical advice prior to arrival at the center. They should
request a change in their exam date to protect the health and
safety of the standardized patients and exam staff.
- Examinees will not necessarily have control over their test
CSEC. They can attempt to select a specific test center, however,
due to the anticipated demand throughout the country, it may be
necessary for examinees to sign up for a CSEC not geographically
close to the school to sit for the exam during a desired time
period.
- Examinees will not be able to select a test session (AM versus
PM). Morning sessions will first be filled before any afternoon
sessions are opened. Thus, it may be necessary for examinees to
stay in a hotel close to the testing center the evening prior
to the exam and possibly after the exam.
8. What standard expenses can be included
in COA?
As stated in Question 6, required educational
expenses can be added to the standard COA. When building budgets,
however, remember that the cost(s) should be reflected in the year
in which the expenses are incurred. This should be a factor in deciding
when and by how much budgets are increased, and whether to increase
over a two-year span.
Exam costs: The cost of the exam is
$975.
Travel costs: Schools may choose to increase
budgets on a case-by-case basis, adjusting the COA to reflect actual
expenses. However, schools that expect most examinees to take the
Step 2 CS at one CSEC may prefer to standardize the travel and hotel
costs by allowing an average travel allowance and other associated
costs and equally increasing every budget. Documenting the average
travel expense to the nearest CSEC, one night's stay in a modest
hotel (or two nights, depending on CSEC location,) and appropriate
per diem expenses along with standard budget-building methodology
should be sufficient. Some campuses may want to verify expenses,
while others may feel that research on an average amount added for
travel is sufficient. Schools may survey students who have taken
the exam in order to include a realistic amount for travel in the
COA.
Other considerations: Financial aid offices
should include their policy on Step 2CS in their Policy and Procedures
handbook, describing the scope and amount of the expenses considered
allowed, whether the costs are standard, or adjusted to actual expenses,
whether to collect receipts or document in budget building methodology,
and whether exceptions will be made. For example, the standard budget
allowance may include travel to the nearest location, one night
at a modest hotel and incidental expenses (cab-fare, meals etc.)
However, what about the examinees who present other options (e.g.
flying to another CSEC because family members live near-by and can
help with other costs, combining the CSEC visit with other activity,
etc.)? What about the examinee who must re-take the exam or change
the date? Having thought these options out will assure that all
examinees are treated in an equitable manner.
9. When does professional judgment come into
play?
Financial aid professionals have the authority to use professional
judgment (PJ) in circumstances they determine warrant exceptions
to their normal policies. In November 1993, NASFAA published an
excellent monograph, "Professional Judgment in Eligibility
Determination and Resource Analysis," that outlines a variety
of situations warranting the use of professional judgment. In the
case of the Step 2 CS exam, there are several opportunities to use
PJ. They are:
- Unpredicted travel expenses such as not getting an exam CSEC
closest to the school.
- An extra night's stay in a hotel to get a better airfare.
- Re-examination of the exam if passage is required for medical
school graduation.
- Attending remediation/board review classes.
- Attending preparatory classes.
- Purchasing study guides and/or books.
- Unexpected circumstances prevent an examinee from taking the
exam as scheduled (i.e. significant illness or death in the family,)
after funds have already been disbursed.
- Other circumstances.
Each of these issues can be addressed using PJ to legitimately
increase an examinee's budget, allowing for additional financial
aid. Reviewing each circumstance on a case-by-case basis is typically
the norm. It is mandatory to document each case when the decision
to approve the variation and increase the examinee budget has been
made.
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10. What are the options in terms of awarding
and disbursing the funds to examinees?
Options for awarding:
- Institutional funds: Add the fee to the budget and package
as when packaging institutional funds.
- Campus-based aid: Add the fee to the budget and package
as when packaging need-based campus-based aid programs.
- Stafford loans: Increase the examinee's eligibility for
unsubsidized loans. Some schools have a higher COA during the
third year which exceeds the Stafford aggregate limit. If an examinee
would be eligible for Stafford loans in the fourth year, a school
may not want to add the fee until then.
- Private loans: If an examinee has exceeded the Stafford
aggregate limits, increase the examinee's eligibility for private
loans.
Options for disbursing:
- Institutional funds: Restrictions are not the same on
disbursement of institutional funds as with federal funds.
- Campus-based aid: Disbursement restrictions apply to
any federal funds awarded (i.e. Perkins).
- Stafford loans:
- Full academic year (third year): If the fee is added
to the third year budget, examinees can apply for the fee
as they would normally apply for financial aid, and funds
would be disbursed in equal disbursements.
- Next academic year (fourth year): If the fee is added
to the fourth year budget, examinees can apply for the fee
as they would normally apply for financial aid, and funds
would be disbursed in equal disbursements.
- Private loans: Restrictions are not the same on disbursement
of private loans as with federal funds.
Issues to consider:
- What happens if a school disburses funds in the third year for
both Step 2exams and the CS portion is not taken until the fourth
year?
- If you disburse money to examinees before the exam, how do
you manage a mishandling of the funds?
11. What remediation is available for test
failures?
Each school that requires passage of the exam for graduation will
need to work closely with their academic counterparts to establish
policies that address concerns over remediation. A hierarchy should
be established as to who has final authority over decision-making
in this regard. If a school is going to require passage, they should
also consider the tools and resources that examinees will need in
order to accomplish this objective. Discussion as to when and how
funding is applied and how many times sitting for the exam will
be allowed should also be decided. Options and suggestions are listed
below:
- Work with promotions committee to establish a policy on second
or third failure reexaminations and the associated costs (if passage
is required for graduation).
- Use of professional judgment - with proper documentation is
strongly recommended in regard to any examinees that are enrolled
at least half-time.
- School financial aid offices need to coordinate with Registrars
to work out alternative enrollment for independent study if the
examinee is off-site.
12. How do you report the cost of the exam
to the government and military programs to ensure it and related
expenses are covered?
Each of the branches of the HPSP program has responded with varied
answers.
- Air Force: The examinee will be reimbursed for the cost
of the exam only. Reimbursement will be made to the examinee using
the existing reimbursement method.
- Navy: Reimbursement for the cost of the exam will be
made to the examinee upon proof of payment and proof of the successful
completion of exam. Therefore, actual examinee reimbursement may
be one year or more from the date of fee payment.
- Army: Schools are advised to contact their local recruitment
office with inquiries.
If required for graduation, the NHSC
will cover the Step 2CS exam fee and will include a limited amount
of funds for travel to the CSEC. This travel allotment will be given
to all examinees in the fourth year, regardless of the location
of CSEC or location of school. When completing the Cost Worksheet,
schools have been instructed to include the Step 2 CS exam fee as
a third-year expense. The travel allotment will automatically be
given and should not be listed on the Cost Worksheet.
13. Will examinees who qualify for vocational rehabilitation
assistance, have their assistance increased to cover the cost of
the exam and remediation if necessary?
It is possible that Vocational Rehabilitation will cover the cost
of the exam, as it is included in the examinee cost of education.
Examinees should check with their personal vocational rehabilitation
counselor.
14. Web Resources
USMLE Web site: www.usmle.org
Per Diem rates for different cities: www.gsa.gov/Portal/gsa/ep/contentView.do?contentId=17943&contentType=GSA_BASIC
Test Sites: www.usmle.org/step2/step2cs/CSECAddresses.htm
Hotel Discounts for Testing: www.aamc.org/meetings/clinicalskills/hotelrates
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- For the purposes of this document, examinee refers
to medical examinees or graduates of medical schools.
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