Knock! Knock! The Patients You Will Encounter on the Clinical Skills Examination

The United States Medical Licensing Examination (USMLE®) does not disclose the exact cases you will experience in the USMLE Step 2 CS examination. They do provide a general overview of what you may expect when you knock on the door and enter the examination room.

The cases you experience on the examination are not designed to be overly challenging or to trick you. Many cases are family medicine or internal medicine-oriented and written with the tone of patients you will regularly encounter as a physician. All of the patients you meet with can have their concerns addressed in the time allotted and no patient’s case is designed to be unpassable.

Below are some of the types of patient scenarios and encounters you may experience when you knock on the exam room door:

The Straight-forward Patient

Most encounters focus on illnesses you may experience regularly in the course of practice of family medicine or internal medicine. These patients present with abdominal pain, joint pain, fever, and other common ailments. These patients are willing and ready to answer your questions during the history interview, will complete your physical exam requests, and are eager to hear your diagnoses and plans.

The Impatient Patient

While most patients will be compliant, some patients may be a little impatient with you as the physician. Some may complain of having had to wait so long to meet with a doctor. Others may want to know why you have to ask so many questions about their illness. Some may even tell you to hurry up with the physical exam. These types of encounters are assessing your ability to navigate the encounter and control the path of the conversation and physical exam. Do not let these patients escalate your mood. Calmly explain to them the role of the history and physical. Take into account the patient’s feelings that they are uncomfortable and express your sincere desire to provide them quality care.

The Patient with a Fear of Disease that Runs in the Family

You may experience a patient who has started to show symptoms of an illness that runs in the family. This may be a cancer or heart disease that was the cause of death of an immediate family member. You may find from your history and physical examination that your differential diagnoses include the illness the patient is concerned about. These types of encounters are assessing your ability to deliver the diagnosis to the patient in a manner that addresses their concerns and validates their feelings. Do not offer them false assurance or provide them a definitive prognosis. Those conversations are more appropriate for a follow-up visit. For these patients, focus on your diagnostic studies and help the patient understand how they will help you confirm a diagnosis.

The Telephone Encounter

The landscape of medicine has changed. Patients are now able to receive care for common illnesses from physician’s assistants and nurse practitioners at convenient care clinics. Patients can even complete video visits with their primary care physicians for similar illnesses. The telephone encounter requires that your entire interaction with the patient (or informant for pediatric telephone cases) take place by telephone. Telephone encounters assess your ability to demonstrate your knowledge and show empathy using only your voice. Feel free to ask your patient (or informant) to complete basic physical exam maneuvers and report back to you. For example, “look in the mirror and take a few deep breaths. Did your nostrils widen more than normal?” In the telephone encounter you may find it appropriate to inform the patient they will need to visit the clinic for an in-person physical examination. This is acceptable and expected.

The Patient Who Has Something More to Show You

Medical records and images are increasingly going digital. X-ray sets are now able to be instantaneous and delivered to a physician’s table for prompt evaluation. A recent addition to the clinical skills examination is imagery that is provided on a tablet device. The images may include x-rays, electrocardiogram printout, photo of a rash, among other items. Your patient will present this to you at a specific time during your history interview. The exam center staff will provide you an orientation to the device so that you are aware of how to use it should a patient provide one to you. This patient is assessing your ability to comprehend the image, manipulate the image on the device, and draw interpretations that can be used in your interaction with the patient. Keep in mind that some diagnostic images, like an x-ray or EKG, may show normal findings.

You are expected to perform at the level of a first-year resident physician. The exam is assessing your ability to navigate a timed-visit with a patient, your clinical knowledge, and your ability to development a rapport with your patient and demonstrate your ability to care for them. You are not expected to perform perfectly but should leave you patients feeling comfortable and confident that they received care from a competent physician.

Becker’s USMLE® Step 2 CS Assessment and GuideMD include up-to-date content including patients like each of those listed above. Becker’s USMLE® Step 2 CS curriculum is regularly being updated by the clinical skills staff to provide students with challenging and forward-thinking patient scenarios to help you perform at your best on exam day.

Taylor Gothard on Linkedin
Program Manager, Clinical Skills at Becker