Sunday 26 August 2012

Importance of USMLE Step 2 CS score attempts in Program Interviews

Step 2 CS is an important exam for residency applicants. While American medical graduates do not have any issues passing this exam, many international and foreign medical applicants fail this exam for multiple reasons. Similar articles in the past have dealt with issues like which are the best programs for applicants with attempts in Step 1 and how Step 1 and Step 2 CK score affect interview invitations.

Reasons for failing and importance of Step 2 CS: 
Difficulty with accent, spoken English, customs, problems with comprehension of the standardized patient and unfamiliarity with the medical conduct and bedside manners in US, all contribute to high failure rate in IMGs. Step 2 CS is a pass/fail exam so it is important to clear this exam prior to applying for residency. It is one of the required examinations to get ECFMG certified which in turn is mandatory for residency application, matching and eventually state licensing to practice medicine in US. 

Using data analyzed from the program directors survey an NRMP publication (2012), program specialties were arranged in the order of importance they place on passing step 2 CS when considering applicants for interviews. The results, shown in figure 1, were indeed surprising. 

Fig 1: % of programs that consider step 2 CS result in inviting applicants for  residency interview, Source: NRMP

1. Highly competitive programs like dermatology, ENT (OTO), ortho, plastic etc did not place much importance on step 2 CS results 
2. Radiology which is competitive and a favorite for foreign trained radiologists was also at the bottom. 
3. Pathology, pediatrics and psychiatry programs (79, 82 and 83% respectively) used step 2 CS scores when considering applicants for interview 
4. Resounding majority of family medicine programs(91%) considered step 2 CS scores when inviting applicants for interviews. 

The fact that highly competitive programs like Derm, Ortho, ENT etc do not stress much importance in USMLE step 2 CS pass/fail score may be as a result of a combination of factors. They are inherently very difficult residencies to get into with the bar for selection placed very high in other areas (AOA, research, contacts?, networking). All applicants are American graduates with almost 100% pass rates for USMLE step 2CS, which makes considering this exam a criterion less important.     

Radiology may not place much importance on this exam for the simple reason, this is a clinical skills exam and radiology is not a clinical skills field. The irrelevance of step 2 CS for radiology may reflect in its low importance as a factor to grant interviews. 

Looking at FM, IM, pediatrics and psychiatry, FM tends to place the most importance on step 2 CS scores. Thus if you have failed in this exam, it may not be a good idea to apply to FM as vast majority (91%) of programs are going to take your 2CS score into account. There may be other things in your resume, which may help you gain an interview mitigating the effect of a failed step 2 CS but a lot of FM programs seem to place importance on this result. 

Though the difference between IM, FM, Peds, psych, path and neuro are small, they may still be important enough to consider which programs you are going apply to if you have an attempt on your USMLE step 2 CS. 

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National Resident Matching Program, Data Release and Research Committee: Results of the 2012 NRMP Program Director Survey. National Resident Matching Program, Washington, DC. 2012.


  1. thank you for this great post ... I'm an IMG 2011 graduate , step1 249, step2 268, cs passed on second attempt :(
    do you think that my application will be filtered out ... what are my chances in IM

    1. while it may be possible that the program sets the PDWS software to filter out applicants by step 2 CS results. most common scenario is step1 and step 2 scores. you may still get a few interview based on your good scores in those exams. just be prepared to say and explain why you failed CS and what you have done to rectify it.

    2. Hey IMG.... I am in a similar situation. I have an attemot in cs exam and have scores of 256 and 257. Kindly tell me how you fared in the residency applications. Your words will help me preapre for what i need ot face.. Thank you

  2. hello dr
    i have a unique situation whe
    i finished 1 patient encounter and then left
    the exam because i was too nervous just
    got scared and left and was feeling unwell
    now my report will
    show "Incomplete Attempt" i really could
    have finished the exam and passed but i dont
    know what happened. i have
    232/231 Scores on Step 1 + 2 CK (all first attempt)
    and 1 month US experience elective
    during which i got a strong US LoR
    i intend to apply to pediatrics. Im very sad
    and worried about this incomplete attempt
    will I get filtered out because of this?
    It's not the same as fail :(
    thank u so much...need ur advice

    1. ideally there should be no irregularities in your scores and that is the best case scenario. You should appear for the exam again and this time pass the CS. you can and make every attempt to explain your incomplete attempt because if you dont, it will certainly affect your chances. This incomplete attempt will affect you a little but buff up on your other aspects of the application and you will do just fine. good luck!

  3. by the way this is for Step 2 CS
    im going to do it again this time soon
    I am still student and will be fresh grad
    when I apply
    need Visa

    1. see above. good luck. it is not as bad as you think. focus on passing this time and apply. good luck!

  4. hi...i failed cs twice... my scores are 219 & 234 in step 1 & step 2...what are my chances if i retake the cs exam... plz give ur opinions on it...

    1. Failing CS twice is tough to overcome. You need to surmount this challenge and then have a good honest explanation as to why you failed. Folks with multiple attempts (more than 2) have an exponentially lower chance of getting interviews.YOu need to focus on passing this crucial exam and also improving your overall application

  5. Is there a section in the ERAS application itself that shows the number of attempts? I failed CS on first attempt. I passed with on my second attempt. My school's MSPE only shows that I passed and not the number of attempts. How do residency programs know? My application is yet to be sent by the way.

    1. the PWDS (program directors work station ERAS database is accessible by PWDS) which the programs use can filter out applicants based on many criteria and number of attempts is one of them.

  6. Hi, I failed CS on my first attempt and will not have the scores from my second attempt until after applications open. Can I apply to programs without CS scores? and if I can, will they see my first failed attempt?

    1. If you apply with an incomplete application at the time of the deadline (sept 15), it is highly likely that your chances will diminish significantly. however, your best bet is under the current circumstance is to still apply and when your scores are cleared, your application will be updated.

  7. I have a question, can i apply for residency this september? I failed my cs exam today,I m very sad, but i moved on and i will re take in october but my result will not be out till december. I already took step one passed and step two passed.
    another question I have is, do i need to graduated from medical school before i apply in september, becasue i m still doing my electives, i m from carribean school. i will not get medical diploma till november. please let me know . thanks

    1. i think I may have replied to your question on the other post that was deleted. to reiterate in brief, applying with a partial application is a big gamble. you will mostly miss out on a lot of programs that need your file complete by September 15th before they start sending out interview invitations. the answer to if you should apply is dependent on if you can afford to apply this year.

      applying with full deck of cards is better than applying with partial deck better than not applying at all.
      Good luck!

  8. Hi! Thanks for your very informative blog.

    I noticed the quiz you have up utilizes 2-digit scores; with the changes made to Step 1 scoring, some students who score well with 3-digits still have a "low score" reflected by the 2-digit score. Any idea about this?

    Also, is it wise to apply on Sept 15 with Step 1 (240) and CS but no CK yet (will be in mid-Oct). I'm also planning to write Step 3 in March/April. Much thanks in advance.

    1. Hi Nasism, I have revised the quiz to reflect some updated changes. Ideally you need everything complete. But you have a good step 1 score, so it may be okay applying with incomplete application and take your chances. As and when your scores are available, your application will be updated.

  9. Thank u very much, but what about step 2 ck always talk about step 1 and CS attempt,but what about attempt in ck. my step 1( 240) cs first attempt passed and ck 239 second attempt. I want to apply for Neurology.
    I am IMGs gyraduated 2 years ago and doing a Neurology research in USA now , what do you think.advise me please, how the step 2 ck attempt affect my match chance in Neurology.

    1. An attempt in Step 2 CK is as bad but a good thing about your case is that you had an attempt in step 2 CK but scored well on second attempt. It will affect your chances some, but likely not the end of the road type deal.

  10. Hi Thank you for the information.
    I am a caribbean grad with 209 and 208 in Step 1 and CK respectively. I have 2 attempts on Step 2 CS. I am an IMG graduated in 2010. I have 2 months of USCE in psychiatry and 2 months in IM. please guide me if I should try for IM or psych?, anything is ok for me. I am planning to write step 3 in july and do 1 month of research in neurology. I have strong LORs too.
    Please help me what I should apply for IM or psych and what can I do to get interviews. I dont want to give up.
    Thank you

  11. Hi, Thank you for great guide.
    One of my friends is an IMG, and an internal medicine specialist. She failed her CS today. First attempt step 2 & 1 (254, 240). 3 months US experience in IM. One publication in Medical education. Medical school graduation: 2005. Residency graduation: 2011. Need visa.
    How is her chance for IM?

  12. Hi,
    Thanks for this very useful site.
    I am an IMG from India, I have 211 in step 1 and 220 in CK, I just got my CS result and I failed, very disheartening for me.
    I have 2 months observership and may get an opportunity for a research assistant job for a year.
    What do you think my chances are next match after I pass CS next attempt? Should I continue or give up?

  13. Hi, Thanks for this great blog.
    My date for the USMLE step 2 cs is on July 28, I am afraid I will not be ready for it so soon, I want to apply for this year matching, will it lower my chances for getting interviewed if I will take the exam on the end of November instead?
    thank's for the information,

  14. This comment has been removed by the author.

  15. Dear Dr. thank you so much for your helpful guidance, I am non-US grad from Caribbean school and need visa sponsorship. I achieved a score of 242 on step I and 233 on step II ck on first attempt but failed on my first attempt on step 2 cs when I took it in April 2014. I am scheduled for my second attempt in Dec 2014. What are my chances of matching this year. Also if I did not match this year what are my chances of matching next year if I have my step III done by May 2015?

  16. Hey! I have heard that it's really difficult for the img to pass the step 2cs. Is it true? I an considering to go for USMLE, but the idea of getting stuck at step 2cs freaks me out.
    Thank you in advance


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