First Aid for USMLE Step 2CK.pdf

INTRODUCTION

The United States Medical Licensing Examination (USMLE) Step 2 allows

you to pull together your clinical experience on the wards with the numerous

“factoids” and classical disease presentations that you have memorized over

the years. Whereas Step 1 stresses basic disease mechanisms and principles,

Step 2 places more emphasis on clinical diagnosis and management, disease

pathogenesis, and preventive medicine.

The Step 2 exam is now composed of two parts:

■

The Step 2 Clinical Knowledge examination (Step 2 CK)

The Step 2 Clinical Skills examination (Step 2 CS)

■

The USMLE Step 2 CK is the second of three examinations that you must

pass in order to become a licensed physician in the United States. The com-

puterized Step 2 CK is a one-day (nine-hour) multiple-choice exam.

Students are also required to take the Step 2 CS, which is a one-day live

exam in which students examine 12 standardized patients. The goal of the

Step 2 CS is to ensure that students from more than 1600 medical schools

worldwide, with varying curricula and educational standards, can collect and

interpret a history, perform a physical exam, and communicate with patients

at a comparable level. For more information on this examination, please refer

to First Aid for the USMLE Step 2 CS. Information about the Step 2 CS for-

mat and about eligibility, registration, and scoring can be found at

www.nbme.org.

The information found in this section as well as in the remainder of the

book will address only the Step 2 CK.

USMLE STEP 2 CK—COMPUTER-BASED TESTING BASICS

How Will the CBT Be Structured?

The goal of the Step 2 CK is to

apply your knowledge of

medical facts to clinical

scenarios you may encounter

as a resident.

The Step 2 CK is a computer-based test (CBT) administered by Prometric,

Inc. It is a one-day exam with 368 questions divided into eight 60-minute

blocks of 46 questions each. A new form of testing software called FRED is

now being used by the USMLE. FRED is different from the Step 1 exam you

took in that you can now highlight and strike out test choices as well as make

brief notes to yourself. During the time allotted for each block, the examinee

can answer test questions in any order as well as review responses and change

answers just as in the Step 1 exam—but examinees cannot go back and

change answers from previous blocks. Once an examinee ﬁnishes a block, he

or she must click on a screen icon to continue to the next block. Time not

used during a testing block will be added to your overall break time, but it

cannot be used to complete other testing blocks. Expect to spend up to nine

hours at the test center.

Testing Conditions: What Will the CBT Be Like?

Even if you’re familiar with CBT and the Prometric test centers, FRED is a

new testing format that you should access from the USMLE CD-ROM or

Web site (www.usmle.org) and try out prior to the exam.

If you familiarize yourself with the FRED testing interface ahead of time,

you can skip the 15-minute tutorial offered on exam day and add those min-

utes to your allotted break time of 45 minutes.

For security reasons, examinees are not allowed to bring personal elec-

tronic equipment into the testing area—which means that digital watches,

watches with computer communication and/or memory capability, cellular

telephones, and electronic paging devices are all prohibited. Food and bever-

ages are prohibited as well. Examinees are given laminated writing surfaces

for note taking, but these must be returned after the examination. The testing

centers are monitored by audio and video surveillance equipment.

You should become familiar with a typical question screen (see Figure

1-1). A window to the left displays all the questions in the block and shows you

the unanswered questions (marked with an “i”). Some questions will contain

ﬁgures or color illustrations adjacent to the question. Although the contrast

and brightness of the screen can be adjusted, there are no other ways to ma-

nipulate the picture (e.g., zooming, panning). Larger images are accessed

with an “exhibit” button. The examinee can also call up a window displaying

normal lab values. You may mark questions to review at a later time by click-

ing the check mark at the top of the screen. The annotation feature functions

like the provided erasable dry boards and allows you to jot down notes during

Annotate

Highlight and

strike-

through

Time

status

Mark

question

Lab

values

Exit

Highlighting

Marked

question

Annotated

question

Strike-through

Incomplete

question

FIGURE 1-1. Typical FRED Question Screen

Keyboard shortcuts:

A–E—Letter choices.

Enter or Spacebar—Move to

next question.

Esc—Exit pop-up Lab and

Exhibit windows.

Alt-T—Countdown timers

for current session and

overall test.

the exam. Play with the highlighting/strike-out and annotation feature with

the vignettes and multiple answers.

You should also do a few practice blocks to get a feel for which tools actu-

ally help you process questions more efﬁciently and accurately. If you ﬁnd

that you are not using the marking, annotation, or highlighting tools, then

keyboard shortcuts can save you time over using a mouse.

What Does the CBT Format Mean for Me?

The CBT format is the same format as that of the USMLE Step 1. If you are

uncomfortable with this testing format, spend some time playing with a Win-

dows-based system and pointing and clicking icons or buttons with a mouse.

The USMLE also offers an opportunity to take a simulated test, or practice

session, at a Prometric center. The session is divided into three one-hour

blocks of 50 test items each. The USMLE Step 2 CK sample test items (150

questions) that are available on the CD-ROM or on the USMLE Web site

(www.usmle.org) are the same as those used at CBT practice sessions. No

new items will be presented. The cost is about $42 for U.S. and Canadian

students but is higher for international students. The student receives a

printed percent-correct score after completing the session. No explanations of

questions are provided. You may register for a practice session online at

www.usmle.org.

How Do I Register to Take the Exam?

Information on Step 2 CK format, content, and registration requirements can

be found on the USMLE Web site. To register for the exam in the United

States and Canada, apply online at the National Board of Medical Examiners

(NBME) Web site (www.nbme.org). A printable version of the application is

also available on this site.

The preliminary registration process for the USMLE Step 2 CK is as fol-

lows:

■

Complete a registration form and send examination fees to the NBME

(online).

Select a three-month block in which you wish to be tested (e.g.,

June/July/August).

■

Attach a passport-type photo to your completed application form.

■

Complete a Certiﬁcation of Identiﬁcation and Authorization Form. This

must be signed by an ofﬁcial at your medical school (e.g., the registrar’s of-

ﬁce) to verify your identity. This is a new form and is valid for ﬁve years, al-

lowing you to use only your USMLE identiﬁcation number for future

transactions.

■

Send your certiﬁed application form to the NMBE for processing. (Appli-

cations may be submitted more than six months before the test date, but

examinees will not receive their scheduling permits until six months prior

to the eligibility period.)

■

The NBME will process your application within four to six weeks and will

send you a ﬂuorescent orange slip of paper that will serve as your schedul-

ing permit.

■

Once you have received your orange scheduling permit, decide when and

where you would like to take the exam. For a list of Prometric locations

nearest you, visit www.prometric.com.

■

■ Call Prometric’s toll-free number or visit www.prometric.com to arrange a

time to take the exam.

■ The Step 2 CK is offered on a year-round basis except for the ﬁrst two

weeks in January. For the most up-to-date information on available testing

days at your preferred testing location, refer to www.usmle.org.

Your orange scheduling permit will contain the following important infor-

mation:

■ Your USMLE identiﬁcation number

■ The eligibility period in which you may take the exam

■ Your “scheduling number,” which you will need to make your exam ap-

pointment with Prometric

■ Your candidate identiﬁcation number, or CIN, which you must enter at

your Prometric workstation in order to access the exam

Prometric has no access to the codes and will not be able to supply these

numbers. Do not lose your permit! You will not be allowed to take the Step 2

CK unless you present your permit along with an unexpired, government-

issued photo identiﬁcation that contains your signature (e.g., driver’s license,

passport). Make sure the name on your photo ID exactly matches the name

that appears on your scheduling permit.

Because the exam is

scheduled on a “ﬁrst-come,

ﬁrst-served” basis, you should

be sure to call Prometric as

soon as you receive your

scheduling permit!

What If I Need to Reschedule the Exam?

You can change your date and/or center within your three-month period with-

out charge by contacting Prometric. If space is available, you may reschedule

up to ﬁve days before your test date. If you need to reschedule outside your

initial three-month period, you can apply for a single three-month extension

(e.g., April/May/June can be extended through July/August/September) after

your eligibility period has begun (visit www.nbme.org for more information).

This extension currently costs $50. For other rescheduling needs, you must

submit a new application along with another application fee.

What About Time?

Time is of special interest on the CBT exam. Here is a breakdown of the

exam schedule:

Tutorial

15 minutes

60-minute question blocks (46 questions per block)

8 hours

Break time (includes time for lunch)

45 minutes

Total test time

9 hours

The computer will keep track of how much time has elapsed during the

exam. However, the computer will show you only how much time you have

remaining in a given block. Therefore, it is up to you to determine if you are

pacing yourself properly.

The computer will not warn you if you are spending more than the 45

minutes allotted for break time. However, you can elect not to use all of your

break time, or you can gain extra break time either by skipping the tutorial or

by ﬁnishing a block ahead of the allotted time.

If I Leave During the Exam, What Happens to My Score?

You are considered to have started the exam once you have entered your CIN

onto the computer screen. In order to receive an ofﬁcial score, you must ﬁn-

ish the entire exam. This means that you must start and either ﬁnish or run

out of time for each block of the exam. If you do not complete all the blocks,

your exam will be documented on your USMLE score transcript as an incom-

plete attempt, but no actual score will be reported.

The exam ends when all blocks have been completed or time has expired.

As you leave the testing center, you will receive a written test-completion no-

tice to document your completion of the exam.

What Types of Questions Are Asked?

■ Almost all questions on the Step 2 CK are case based. A substantial

amount of extraneous information may be given, or a clinical scenario

may be followed by a question that could be answered without actually re-

quiring that you read the case. It is your job to determine which informa-

tion is superﬂuous and which is pertinent to the case at hand.

■ Subject areas vary randomly from question to question.

■ Most questions have a single best answer , but some matching sets call for

multiple responses (the number to select will be speciﬁed). The part of the

vignette that actually asks the question—the stem—is usually found at the

end of the scenario. From student experience, there are a few stems that

are consistently addressed throughout the exam:

■ What is the most likely diagnosis? (40%)

■ Which of the following is the most appropriate initial step in manage-

ment? (20%)

■ Which of the following is the most appropriate next step in manage-

ment? (20%)

■ Which of the following is the most likely cause of...? (5%)

■ Which of the following is the most likely pathogen...? (3%)

■ Which of the following would most likely prevent...? (2%)

■ Other (10%)

■ Note the age and race of the patient in each clinical scenario. When eth-

nicity is given, it is often relevant. Know these well (see high-yield facts),

especially for more common diagnoses.

■ Be able to recognize key facts that distinguish major diagnoses.

■ Questions often describe clinical ﬁndings instead of naming eponyms

(e.g., they cite “audible hip click” instead of “positive Ortolani’s sign”).

■ Questions about acute patient management (e.g., trauma) in an emer-

gency setting are common.

The cruel reality of the Step 2 CK is that no matter how much you study,

there will still be questions you will not be able to answer with conﬁdence. If

you recognize that a question is not solvable in a reasonable period of time,

make an educated guess and move on; you will not be penalized for guessing.

Also keep in mind that 10–20% of the USMLE exam questions are “experi-

mental” and will not count toward your score.

How Long Will I Have to Wait Before I Get My Scores?

The USMLE reports scores three to four weeks after the examinee’s test date.

During peak times, however, reports may take up to six weeks to be scored.

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