TOSCE: Tulane Objective Structured Clinical Examination for senior medical students to assess
history taking, physical exam techniques, communication and interpersonal skills. The purpose
is to assure that all students possess and can demonstrate an appropriate level of clinical skills
and behaviors prior to graduation. TOSCE is taken in May or June of a student’s final year of
medical school at Tulane.
USMLE Clinical Skills exam: Uses standardized patients to test the examinees’ ability to gather
information from patients, perform physical examinations, communicate their findings to patients
and colleagues, and decide the next course of action for diagnosis. The Tulane SOM Dean’s
Office states that students must take and pass the Step 2 CS Exam before January of their final
year of medical school.
Common USMLE CS Misconceptions: You may have already heard from older students,
residents, and staff that “you’ll be fine. You just need to speak English and wash your hands”.
We recommend more prep than remembering to wash your hands. Please see some of our
recommended strategies below.
How to Prepare
● Points to Remember
○ The goal of both exams is to take a good history and physical exam while
communicating pertinent findings and next steps to the patient. Please take note
that making a definitive diagnosis is NOT a goal of these exams.
○ The standardized patient encounter for both TOSCE and CS typically includes a
focused physical exam, geared toward the patient’s chief complaint. You can
show off your amazing head-to-toe exam skills to your medicine attending on the
wards, but it is not necessary for these encounters.
○ Patient Interaction:
■ Make and maintain good eye contact with patients
■ Smile when you enter the room and introduce yourself
■ Keep your emotions in check. An angry doctor does not a pass make.
● USMLE Clinical Skills exam website: http://www.usmle.org/step-2-cs/
○ Practice materials including sample patient notes: http://www.usmle.org/practicematerials/
● First Aid CS: http://www.amazon.com/First-USMLE-Step-FourthEdition/dp/0071760504
Review of book:
*Skim the cases during the few days before the exam. It is a good review for
working through differentials if it has been awhile since you took Medicine. It’s
really to help you with the patient note writing part of the exam. Some of the
cases are weird, like diagnosing Creutzfeldt-Jacob Disease. As we said
before, diagnosis is not the goal; it’s the process of getting to a few most likely
diagnoses.
Day of the Exam
● Strategy in the Exam Room: 15 minutes
○ Introduction
■ Look at the Instructions
■ Knock on the door before opening
■ Ask for the patient by name
■ Introduce yourself and your role
■ Wash your hands/Use hand sanitizer
○ Chief Complaint→ Pertinent History
■ Review of Systems if necessary/good on time
■ Is there anything else that the patient wants to address today?
○ Past History
■ Medical History
■ Surgical History
■ Gynecological and Obstetric History (women)
■ Social History (include sexual history)
■ Family History
■ Medication List
○ Physical Exam
■ Focused Exam based on the history taken from patient
■ It is not necessary to complete a full physical examination.
■ Inform the patient before doing exam maneuvers.
○ Formulate a differential diagnosis
○ Next steps/Closing
■ Tell the patient your plan
● Additional Exams you would like to do: Breast, Pelvic, Prostate,
Rectal
● Lab tests
● Imaging
■ Ask the Patient what questions they have and let them know they can
contact you with any additional questions that may arise.
■ Inform the patient about the follow-up appointment
● Strategies for Writing the Patient Note: 10 minutes
○ Review and familiarize yourself with the note format from the USMLE CS
website: http://www.usmle.org/practice-materials/step-2-cs/patient-note.html
○ Physical Exam: your note should include both pertinent positives and negatives
○ Formulate at least 2 differential diagnoses. The most likely one should be listed
first. Provide supporting history and pertinent physical exam findings (positives
and negatives) to receive full points.