The USMLE Step 2 consists of two separate exams: USMLE Step 2 Clinical Knowledge (CK) and USMLE Step 2 Clinical Skills (CS). The latter has been cancelled permanently. Step 2 CK tests your theoretical clinical knowledge. Acing this test can help you get into some of the most competitive residencies out there! In this blog, you will learn what USMLE Step 2 CK is, the exam format and content, Step 2 CK question formats, and how you can ace this challenging exam!
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What is USMLE Step 2 CK?
The United States Medical Licensing Examination Step 2 Clinical Knowledge (USMLE Step 2 CK) evaluates your ability to apply medical knowledge, skills, and understanding of clinical science important for the delivery of patient care under supervision and includes an emphasis on health promotion and disease prevention. Step 2 CK is designed to ensure examinees' devotion to and understanding of the principles of clinical sciences and basic patient-centered skills that are the foundation of the safe and competent practice of medicine. Essentially, this exam tests your readiness to enter medical practice as a supervised, rather than an autonomous, professional. In addition to testing your clinical knowledge and theoretical knowledge of clinical skills, Step 2 CK will prepare you for the OSCE elements of your licensing examinations, i.e. Step 2 CS. Students typically write the Step 2 CK exam in the fourth year after completing the majority of their clerkship rotations.
USMLE Step 2 CK Exam Format
This is a one-day examination. The entire test is divided into 8 60-minute blocks and administered in one 9-hour session. There is a variety of test forms – the number of questions in each section of Step 2 CK will vary but will not exceed 40. The total number of questions on the exam will not exceed 318. The examination also includes a 45-minute break, as well as a 15-minute optional tutorial. Note that you can end up getting a total of 1 hour of break by skipping the 15 minute tutorial if you download and practice the interface/tutorial in advance of the test. You can also increase your breaks if you finish a block of test questions before the allotted time expires. In this case, you can use the left-over time to prolong your break. It is also important to note that you can end up getting a total of 1 hour of break by skipping the 15-minute tutorial if you download and practice the interface/tutorial in advance of the test. To get familiar with the test format and software, practice with the exam Tutorial and Practice Test Items before your test date to get familiar with Step 2 CK question formats: single multiple-choice questions, sequential set of multiple-choice questions, a scientific abstract, and items with audio or video findings. Keep reading this blog to learn more about each question type.
USMLE Step 2 CK Content
This portion of USMLE Step 2 includes questions that assess system-based practice, patient safety, legal/ethical issues, and professionalism. All USMLE exams are designed based on the integrated content outline, so make sure you go over this document before you start studying. As you can see from the outline, the content of the exam is structured according to general principles and individual organ systems. CK questions are organized into one of the 18 major categories, depending on whether they focus on concepts and principles that are applicable across organ systems or within individual organ systems. Below, you will find a table outlining content weighting. Sections focusing on individual organ systems are also subdivided into normal and abnormal processes, including principles of therapy. In most instances, knowledge of normal processes is evaluated in the context of a disease process or specific pathology. Remember, while not all topics in the content outline will be included in every USMLE examination form, generally, content coverage is comparable among the various exam forms. Additionally, although the tables below provide you with an estimated weighting of each content area, the percentages are subject to change at any time.
Each Step 2 CK exam form will cover content related to the following disciplines. An additional reminder: the amount of content from each discipline varies based on the exam form:
In addition to testing your theoretical clinical knowledge, Step 2 CK also evaluates your physician competencies and practical knowledge. Each test question is designed to assess one of the following competencies:
USMLE Step 2 CK Question Formats
Single-Item Questions
This traditional, most frequently used multiple-choice question format consists of a vignette and question followed by three to twenty-six responses that are organized in an alphabetical or logical order. The responses are lettered (A, B, C, D, etc.) and you are required to select the one best answer to the question. Keep in mind that other options may be partially correct, but there is only one best answer. This means that you need to read the vignette, the questions, and all the response options very carefully before you choose your answer.
Sample Single-Item Question
A 32-year-old woman with type 1 diabetes mellitus has had progressive renal failure over the past 2 years. She is not yet on dialysis. The examination shows no abnormalities. Her hemoglobin concentration is 9 g/dL, hematocrit is 28%, and the mean corpuscular volume is 94 m3. A blood smear shows normochromic, normocytic cells. Which of the following is the most likely cause?
A. Acute blood loss
B. Chronic lymphocytic leukemia
C. Erythrocyte enzyme deficiency
D. Erythropoietin deficiency
E. Immunohemolysis
F. Microangiopathic hemolysis
G. Polycythemia vera
H. Sickle cell disease
I. Sideroblastic anemia
J. β-Thalassemia trait
(Correct answer is D)
Sequential Item Sets
This question format presents you with a single patient-centered vignette with two or three consecutive questions about the patient problem. Each question is related to the vignette presented but is testing a different point of the patient problem. You must choose the one best answer to each question. It’s important to remember that once you answer the first question, you must click “proceed to next item” to view the next question related to the vignette. Once the next question appears on the screen, you will not be able to change the answer to the previous question, even though the patient-problem is still the same. The questions are designed to be answered in sequential order, so pay attention to what you’re being asked and the answers you select. Single-item questions and sequential item sets are similar in format and intent, as you need to choose the correct answer for questions that are presented to you. However, just keep in mind that sequential item sets take more concentration and time, because you need to pay attention to each question separately and how each question is related to previous question items and the patient problem. While you only need to answer one question related to the patient problem in a single item type, the sequential item sets are a bit longer and more complicated.
Sample of Sequential Item Sets Question Type
A 35-year-old woman is brought to the emergency department because of worsening pain and swelling of her right knee for the past 2 days. She has been taking acetaminophen for the knee pain during the past 2 days, but the pain is worse today. She has not had any trauma to the knee or any previous problems with her joints. She is otherwise healthy and she currently takes an oral contraceptive. She is sexually active and has a 10-year-old son who lives with her. She is a receptionist at a local hotel and she tells you she must stand often while working. She is 160 cm (5 ft 3 in) tall and weighs 52 kg (115 lb); BMI is 20 kg/m2. The temperature is 37.9°C (98.9°F). The right knee is erythematous, swollen, and tender; there is pain on movement. No other joints are affected. X-ray of the knee shows an effusion but no structural abnormalities of the joint.
Which of the following is the most appropriate next step in diagnosis?(
A) Arthrocentesis of the knee
(B) Blood cultures
(C) Complete blood count
(D) MRI of the knee
(E) Urine cultures
(Correct answer is A)
Arthrocentesis is done. The synovial fluid is cloudy. Gram stain is negative. Analysis of the synovial fluid shows a leukocyte count of 120,000/mm3 and 90% neutrophils. Which of the following is the most appropriate additional test on the synovial fluid?
(A) Culture for bacteria
(B) Glucose measurement
(C) Polarized light microscopy
(D) Protein level
(Correct answer is A)
Abstract Format
The abstract format questions include a summary of an experiment or clinical investigation presented in a manner commonly encountered by physicians, e.g., as an abstract that accompanies a research report in a medical journal. Examinees must interpret the abstract to answer questions on various topics, including:
- Decisions about care of an individual patient
- Biostatistics/epidemiology
- Pharmacology/therapeutics
- Use of diagnostic studies
If you would like to review a sample of this question type, please follow this link.
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Exam-Taking Tips
The amount of information this examination covers can be overwhelming, but Step 2 CK tests more than your clinical knowledge. In addition to preparing for the content you will encounter in the exam, you should also work on your exam-taking strategies. As you go through practice questions, make it your habit to perform the following strategies to increase your exam endurance and stress management:
- Read each question carefully. You need to understand what is being asked of you exactly. Remember that your ability to pay attention to detail and use common sense are also being evaluated. If necessary, read the vignette and its question several times to take note of any details. You will need to address the patient problem and the questions that follow precisely, so make sure you comprehend your task.
- Try to generate an answer before you look over the responses that are offered to you. Coming up with solutions of your own is a great way to train yourself to face any possible scenarios you will face in Step 2 CK. Rather than rely on the response list, you can train yourself to deduct the correct course of action independently. Once you decide how to answer the question, you can choose the answer that best corresponds to your solution.
- Undoubtedly, you will run into patient problems and questions that will stump you. If you cannot come up with your own answer, go ahead and read each option carefully. If you cannot identify the best answer from the get-go, start by eliminating the clearly incorrect options. Select the option you deem most correct out the remaining options.
- Remember to always choose an answer, even if you are not certain whether you choose the right option. There is no penalty for guessing but unanswered questions are automatically counted as wrong answers.
How to Prepare for USMLE Step 2 CK
USMLE Step 2 CK consists of a series of multiple-choice questions (MCQs) prepared by an exam committee composed of faculty members, teachers, investigators, and clinicians. All committee members are recognized experts in their respective fields. As we mentioned above, the test evaluates your ability to identify and perform principles of clinical science that are considered important for the practice of medicine as a supervised medical professional in postgraduate training. The content outline that I include in the section above is not meant as curriculum development or a study guide but rather models the range of challenges that will be met in the actual practice of medicine. The outline provides a flexible structure for test construction that can readily accommodate new topics, emerging content domains, and shifts in emphasis. Keep in mind that the categories and content coverage are subject to change.
To prepare for USMLE Step 2 CK, focus on broad-based learning that forms a strong understanding of concepts and principles in the basic and clinical sciences. Here are some study strategies you should implement:
Do Well on Your Subject Exams. Medical students generally must take a SHELF exam after each major rotation, which tests their knowledge of the material in that rotation. These comprehensive exams share the content of USMLE Step 1 and USMLE Step 2 CK. They will help you identify your strengths and weaknesses before you take the actual exam. Doing consistently well on each SHELF exam means that a student will be well prepared by the time the Step 2 CK comes around. For IMG students, who do not take the shelf exams, sufficient time should be dedicated to reviewing the material from each of these core rotations (as specific questions may come up). Keep in mind, that while the SHELF and USMLE exams may have similar content, USMLE examinations and the scoring process are independent from the SHELF exams.
Start Your Review Early. I cannot stress this enough. As you start medical school, you should keep your USMLE Steps in mind. Cramming for any of your USMLE exams a few weeks before the test date is not going to result in a good score. To ensure success in your Step 2 CK, form good study habits to retain new content and immerse yourself in your studies starting your first year at medical school. Get used to studying the content of Step 2 CK as soon as you start your medical school rotations – set aside a few hours each week to go over content you covered in clerkships. Reviewing your materials every week will solidify your knowledge base. If you follow this advice, instead of cramming for your exam a couple of months before your test date, you will be simply reviewing your notes and study materials, rather than learning new content or trying to recall content you learned 1 or 2 years ago.
Focus on Clerkships. Once you pass your USMLE Step 1, a lot of the clinical knowledge you will want to retain, and implement will be covered in clerkship rotations in your program. Clerkship years are difficult; in addition to the strenuous amount of work and learning, students tend to have less free time to relax, eat, or even sleep. On top of that, many students start to worry about the residency match, potential career choices and doing well on their Step 2. While you can allow these worries to pop up in mind from time to time, we strongly urge you to focus on the content material you will be presented with in each rotation – this will be the key to your success in USMLE Step 2, both CK and CS. Approach each clerkship rotation as if you are seriously considering this specialty as a potential career choice. Learn, understand, and memorize all the basics needed to perform in that field of medicine. Not only will this allow you to hone your clinical skills, but you will be able to assess your fit for each specialty honestly because you gave 100% to each rotation. The rotations you go through are certainly there to prepare you for the exams, but they are also there for you to try out different specialties and gain theoretical and practical knowledge enough to function as a supervised practitioner. Tip: the main six clerkships: Pediatrics, Psychiatry, Family Medicine, Internal Medicine, Surgery, and OB/GYN make up nearly all of the content on the Step 2 CK examination. It would be wise to pick out an accessible/easy to read resource like “Step up to Medicine” and use the UWorld Qbank during rotations to help solidify knowledge.
Practice Tests. Many students swear by the UWorld practice tests. The UWorld makes a great question bank. Subscribing early to the UWorld question bank soon after concluding Step 1 (and beginning clinical rotations) is a wise move. However, the UWorld practice tests themselves have been reportedly inconsistent for students in terms of predicting their scores. We would emphasize the quality of the question bank itself rather than the practice tests. Additionally, the AAMC offers a series of USMLE practice tests, which are actually old test forms and may more accurately reflect the exam and predict your scores.
Whether you choose UWorld or AAMC practice test, take it as many tests as possible. Don't forget to make notes about the content you struggle with. Based on your initial practice tests, you can create a study schedule that will help you navigate the content outline I linked to in one of the above sections. Remember, having a study schedule can prevent you from getting lost in all the content you need to cover for the exam. Taking practice tests has another big advantage: you will get a sense of how much time you need to answer different question types. Remember, this is a timed exam, so you must keep in mind the time limit you’re provided with. After doing hundreds of practice questions, you will develop a sense of how long each question should take you.
FAQs
1. How do I apply for USMLE Step 2 CK?
Students and graduates of LCME- or AOA- accredited programs should apply for Step 1, Step 2 CK, and Step 2 CS by following the instructions on the NBME website. International medical graduates should apply for Step 1, Step 2 CK, and Step 2 CS by following the instructions on the ECFMG website.
2. How much does it cost to apply for USMLE Step 2 CK?
The fee for the graduates of medical schools in the United States and Canada is $645. International medical graduates must pay $965 for this Step.
3. When should I take USMLE Step 2 CK?
Typically, students take USMLE Step 2 CK and CS in their fourth year of medical school.
4. What does USMLE Step 2 CK assess?
This exam assesses your ability to apply medical knowledge, skills, and understanding of clinical science and prepares you for medical practice under supervision. While much of basic science concepts will be tested in Step 1, foundational science knowledge will often be needed to answer questions on Step 2 CK, even if the question is focused on diagnosis or management. You will find that foundational science knowledge will be covered in all USMLE examinations as it is needed both for licensure examinations and for lifelong learning that continues beyond assessments and tests.
5. When will I get my score?
Scores for Step 2 CK are released each Wednesday. Usually, it takes about three to four weeks from the test date for the score to be released. However, many factors may delay an individual score release. Usually, these are quickly resolved and the score is released in the next weekly cycle. Your registration entity will notify you via email when your score becomes available. When released, your scores will be posted to your registration entity's secure website, either NBME or ECFMG.
6. What is the passing score for Step 2 CK?
The current minimum passing score is 209.
7. Can I retake a Step that I passed to raise my score?
If you pass a Step or Step Component, you are not allowed to retake it.
8. How much of each content area appears on the examination?
Though the amount of content in each area varies on each test. The following percentages provide a guideline about how much content in each area is on the examination:
Medicine 50-60%
Surgery 25-30%
Pediatrics 20-25%
Obstetrics & Gynecology 10-20%
Psychiatry 10-15%
9. What should I do if I fail my Step 2 CK exam?
Don’t panic. You will be able to re-take the exam. Before you schedule a new test date, ensure that you review the exam content thoroughly. The Step examinations are highly integrative, and you should plan to review all content areas. In prioritizing which areas to review, you should take into account both the representation of that content area on the examination (based on the % items per exam next to the content area label) and your relative performance in that content area. Remediation strategies focused solely on relatively weak areas of performance are unlikely to be the most effective for failing examinees. In most cases, failing scores are best remediated through attention to all content areas.
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