ECFMG Clinical Skills Assessment / USMLE Step 2 CS

The purpose of ECFMG’s CSA is to test your medical communication skills, English proficiency, medical history, physical exam and diagnostic skills. In this article, we have included some useful tips on bedside manners, communication skills and strategies to help you pass the Clinical Skills Assessment. ECFMG’s CSA is a one-day exam that lasts for approximately 8 hours. You will be given about 10 patients to examine. You will have the opportunity to interact with them for 15 minutes each. You will then have 10 minutes to write a brief medical case history, physical findings, differential diagnosis and treatment plan. 

You will be given 2 breaks. The first break is 30 minutes long and is given after the fourth patient encounter. The second break is 15 minutes long and is given after the eighth patient encounter. This is a live test given at ECFMG centers in Philadelphia, PA and Atlanta, GA. ECFMG’s CSA exam will be replaced by USMLE Step 2 CS (Clinical Skills) in June 2004. Learn more about the new USMLE Step 2 CS . Completing CSA is a requirement for ECFMG certification, along with USMLE Step 1 and Step 2. To participate in the ERAS / NRMP match and join a medical residency program, you must have a valid ECFMG certificate.  

ECFMG’s CSA assessment areas 

• Relevant history

• Focused physical exam

• Interpersonal skills & developing a rapport with the patient

• Medical communication skills

• English proficiency - written and spoken English 

What type of patients will you get in the CSA? 

Since ECFMG’s CSA tests your clinical and bedside skills at a basic level, you will most likely get patients with common disease conditions like Hypertension, diabetes, Myocardial infarction. However, their presentation to you will be “symptom based”. So your preparation should also be symptom based. Common symptoms that current Residents see in real life, in their medical residency clinics, include chest pain, shortness of breath, abdominal pain, diarrhea, seizure, headache, side effects of medications, vaginal bleeding, vaginal discharge, wrist pain, back pain, knee, shoulder pain, diffuse muscle pain, weakness etc.,

You will be scored on 10 patient encounters for ECFMG CSA test. However, the number of patients you see may vary from 10 to 12. The additional cases are “experimental” and will not affect your score.

Tips for better communication with patients.

ü Establish and maintain eye contact with the patient

ü Talk slowly and clearly

ü Use short sentences

ü Refer to the patient by last name “Mr. Smith”.

ü Don’t call patients by their first name, unless asked to do so.

ü Talk with a pleasant face. Don’t take a history with a frown on your face.

ü Deliver your sentences in a polite and soft manner.

ü Don’t use a rough or annoyed tone in your conversation.

ü Listen without interrupting or cutting off patients

ü Show interest in what the patient is saying, with nonverbal body language, such as nodding or leaning forward while seated.

ü Reassure patients about concerns, but don’t promise any miracle cures. 

CSA history taking – the patient interview.

Pay attention to the patient info presented on the door. Write down the vitals and the presenting chief complaint of the patient. You can review this with the patient once you are inside the room.

Knock on the door before you enter the room.

Once you enter the room, shake hands with the patient and introduce yourself. “Good morning Mr. Smith, I am Dr. Tintin. Can you tell me what brings you to the Emergency room” or “How can I help you today” or “What can I do for you”.

Before you begin anything, tell the patient that you will first take a medical history, then do a physical exam and then answer any questions that he might have and discuss the treatment plan.

Start your medical history taking by encouraging the patient to tell you more about his chief complaint. “Mr. Smith, can you tell me more about your chest pain”. Then ask follow up questions on areas missed by the patient.

Never interrupt the patient or cut him off in mid sentence. Listen attentively to what he has to say. While it is ok to write notes when the patient is talking to you, try to maintain eye contact, even when you are writing.

When taking the history, pull up a chair and sit down. Don’t stand over the patient. This has several advantages. Patients are more comfortable when you are at the same eye level as them. You can also sit comfortably for the duration of the history taking. It is also easier to write notes in a sitting position. 

Have one format for the history and physical exam that you are used to. This will ensure that you don’t miss anything vital. Commonly missed questions are about the patient’s current medications and medication allergy. These are vital components in your history. Use the sample patient history given in ECFMG’s CSA candidate orientation manual to guide your history taking.

You must read ECFMG’s CSA candidate orientation manual several times and pay close attention to the evaluation criteria outlined. You must also be familiar with the CSA orientation video.

If the patient tells you that he has pain, in addition to taking a full history on pain, you should ask him to rate his pain on a scale of 1 to 10, 10 being the worst. Pain is now considered to be the fifth vital sign.

How you ask the question is more important than what the question actually is. For example when asking about sexual orientation, don’t ask, “ are you a homosexual”. That can be insulting to the patient. Instead start by saying that you will be asking some personal questions, which you ask to all your patients. You don’t mean to offend him…then ask “ do you usually have sex with women, men or both”

If the patient is depressed or crying, offer him a box of tissues and empathize with him. You can also briefly touch his hand or his shoulder to show that you care and support him.

Don’t waste time re-measuring the patient’s blood pressure and other vital signs. Just use the one provided to you in the CSA question. However, examination of the pulse for any irregularity (atrial fibrillation) must be done.

Communicating with the patient is a vital component of the CSA exam. Do not use any medical terms. It is important that you speak slowly and clearly to the patient, especially if you have a heavy foreign accent. Remember that the patient will grade you on this.

Be very clear on the questions that you ask the patient. Use simple and plain English. Keep your sentences short.

It is important to develop a rapport with the patient. The simplest way is to pay close attention to what the patient has to say and being a good listener. You can also crack some jokes if you can. However, act professional at all times. Don’t try to act like a teenager. Remember that you are a physician.

During the CSA physical examination.

Wash your hands with soap and warm water prior to examining the patient. Make sure you dry your hands properly. If your hands are cold, rub them to warm them prior to putting them on the patient’s body.

Pay attention to keeping the patient comfortable at all times. Prior to examining him, explain to him that you are about to examine him. Get his consent by asking him “is it ok with you”. Once he gives you permission, you can proceed.

When you ask the patient to lie down, extend the leg support of the examination table, to make him comfortable. 

Use drapes to cover areas of the patients body that you are not examining. You can then shift the drapes to other areas. Maintain your patient’s modesty at all times.

When examining the patient, use proper techniques to elicit physical signs. The patient has been taught these techniques and he will grade you. Be gentle. Do not poke or push too hard.

Do not do a rectal, breast, pelvic or genito-urinary or corneal reflex examination on the patient. You are exempted from these for ECFMG CSA exam purposes. However, if you feel that the patient needs these, you can write it down under investigations.

Counseling and concluding the patient encounter.

At the end of the history and physical, inform the patient about what you think is the reason for his symptoms. You do not have to give one specific medical diagnosis. You can discuss with him two or three likely differential diagnosis that you are considering and tell him that you need to run some blood tests and imaging before narrowing it down to one specific medical diagnosis. You will have to explain the nature of these tests to reassure the patient.

You are expected to answer all questions that the patient has. If you are asked a difficult question, and don’t know what to answer, tell the patient that, at this time you don’t have more information on that question. Reassure him that when you see the test results, you or one of your colleagues will get back to him with more information. You can also tell the patient that you will get back to him after discussing with your attending physician.

Before you end the encounter, offer a final chance for him to clarify any doubts he may have. “Do you have any other questions for me, Mr. smith?” is a good way of phrasing this.

You can then conclude the interview by telling the patient “it was a pleasure meeting you”.

Writing the CSA patient note (medical record) .

Once you are sure that you have finished your patient encounter, exit the room and proceed to your desk. Start writing your patient note (medical record) on the CSA formatted paper provided.

Take time to record the patient’s history legibly. Don’t write too much. Try to economize on the words and stick to conveying medical information. Write less, but convey more information.

Recently, ECFMG has begun giving CSA examinees, a choice to enter the patient note on a computer. This will take care of the legibility problem if you have a bad handwriting. You can also save space and write more. However, if you don’t know how to type fast, this may be a disadvantage. In any case, you can give the computer a try for your first patient. If you don’t like it, you can switch to writing by hand. 

When writing the patient’s history and physical examination, you must include both, relevant positive findings and important negative findings.

Write a brief list of medical differential diagnosis, in order of priority, starting with the most likely. Aim to write at least five.

You must also write relevant medical investigations that will help you to make the final diagnosis. If you are not sure what investigations to order, look at your list of differential diagnosis and order investigations to “rule in” or “rule out” the list. 

You will not be required to write treatment plan or medication orders.