USMLE Step 2 Clinical Skills (CS) Exam

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.

1. What is the Step 2 Clinical Skills Exam and what is its purpose?
   
2. What is the CS exam like?
   
3. When will administration of the exam begin and where will it be given?
4. What will be the cost of the exam to examinees?
   
5. When can examinees register for the exam?
   
   • Timing
   • Eligibility periods
   • Schedule a testing appointment
   • How test dates become available
6. Are these costs allowable in a student's cost of attendance?
   
7. What are the options for including exam fees in the COA in the third versus the fourth year?
   
   • Issues to consider
   • Fees to reschedule an exam administration
8. What standard expenses can be included in COA?
   
   • Exam costs
   • Travel costs
   • Other considerations
9. When does professional judgment come into play?
   
10. What are the options in terms of awarding and disbursing the funds to examinees?
    
    • Options for awarding
    • Options for disbursing
    • Issues to consider
11. What remediation is available for test failures?
    
12. How do you report the cost of the exam to the government and military programs to ensure it and related expenses are covered?
    
13. Will examinees who qualify for vocational rehabilitation assistance, have their assistance increased to cover the cost of the exam and remediation if necessary?
14. 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:

1. Unpredicted travel expenses such as not getting an exam CSEC closest to the school.
2. An extra night's stay in a hotel to get a better airfare.
3. Re-examination of the exam if passage is required for medical school graduation.
4. Attending remediation/board review classes.
5. Attending preparatory classes.
6. Purchasing study guides and/or books.
7. 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.
8. 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:

1. Institutional funds: Add the fee to the budget and package as when packaging institutional funds.
2. Campus-based aid: Add the fee to the budget and package as when packaging need-based campus-based aid programs.
3. 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.
4. Private loans: If an examinee has exceeded the Stafford aggregate limits, increase the examinee's eligibility for private loans.

Options for disbursing:

1. Institutional funds: Restrictions are not the same on disbursement of institutional funds as with federal funds.
2. Campus-based aid: Disbursement restrictions apply to any federal funds awarded (i.e. Perkins).
3. 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.
4. Private loans: Restrictions are not the same on disbursement of private loans as with federal funds.

Issues to consider:

1. 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?
2. 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:

1. Work with promotions committee to establish a policy on second or third failure reexaminations and the associated costs (if passage is required for graduation).
2. Use of professional judgment - with proper documentation is strongly recommended in regard to any examinees that are enrolled at least half-time.
3. 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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1. For the purposes of this document, examinee refers to medical examinees or graduates of medical schools.

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