allergies, social history, family history, and physical exam. The examinees will then state up to 3 differential diagnoses relating to the simulated patient's symptoms, and tests or procedures to investigate the simulated patient's complaints. The examinees should also list pertinent positive and negative findings to support each potential diagnosis. The examinees will not recommend any specific treatments in the note in contrast to a true clinic SOAP note (i.e., IV fluids, antibiotics, or other medications). Over the course of an 8-hour exam day, the examinees complete 12 such encounters. Examinees are required to type patient notes on a computer. USMLE Step 2 CS replaced the former ECFMG Clinical Skills Assessment (CSA) effective June 14, 2004. The last administration of the ECFMG Clinical Skills Assessment (CSA) took place on April 16, 2004. When the CSA first started it was strictly for Foreign Medical Graduates while US graduates were not required to do it. That was considered a double standard in the US medical licensing process. Later the CSA was replaced with the USMLE step 2 CS and became inclusive to all medical graduates. Grading The test was graded on a pass/fail basis, without any numerical score associated with it (as opposed to the other parts of the USMLE series). Examinees were scored on three separate subcomponents: Communication and Interpersonal Skills (CIS), Spoken English Proficiency (SEP), and Integrated Clinical Encounter (ICE). Each of the three subcomponents must be passed in a single administration in order to achieve a passing performance on Step 2 CS. Communication and Interpersonal Skills (CIS) - includes assessment of the patient-centered communication skills of fostering the relationship, gathering information, providing information, helping the patient make decisions, and supporting emotions. CIS performance is assessed by the standardized patients, who record these skills using a checklist based on observable behaviors. Spoken English Proficiency (SEP) - includes assessment of clarity of spoken English communication within the context of the doctor-patient encounter (for example, pronunciation, word choice, and minimizing the need to repeat questions or statements). SEP performance is assessed by the standardized patients using a global rating scale, where the rating is based upon the frequency of pronunciation or word choice errors that affect comprehension and the amount of listener effort required to understand the examinee's questions and responses. Integrated Clinical Encounter (ICE) - includes assessments of both data gathering and data interpretation skills. Scoring for this subcomponent consists of a