ECFMG Home > Publications > 2003 Information Booklet > Clinical Skills Assessment

The 2003 USMLE application materials are no longer valid. The current application materials for USMLE Step 1 / Step 2 CK and CSA are the 2004 editions. If you wish to apply for these exams, you must use the 2004 Information Booklet and application materials.

CLINICAL SKILLS ASSESSMENT

The Clinical Skills Assessment (CSA^®) evaluates your ability to gather and interpret clinical patient data and communicate effectively in the English language. The skills evaluated by the CSA include obtaining a relevant medical history, performing a focused physical exam and composing a written record of the patient encounter. The CSA also requires that you demonstrate proficiency in spoken English and appropriate interpersonal skills as evaluated by the Standardized Patients you encounter in the test stations.

Description

The CSA consists of ten, eleven, or twelve stations, ten of which are scored; in each station you will encounter a Standardized Patient (SP), a lay person trained to realistically and consistently portray a patient. Standardized patients respond to questions from examinees with answers appropriate to the patient being portrayed and will react appropriately to physical examination maneuvers. In each encounter you will be allowed fifteen minutes to interact with the SP and ten minutes to compose the written record of the encounter. You will be expected to proceed through each encounter with an SP as you would with a real patient.

The CSA is administered in morning and / or afternoon sessions as scheduled throughout the year. Breaks are provided at various points in the exam. The duration of the CSA, including orientation, testing and breaks is approximately eight hours. The CSA is administered only in English.

The cases used in the CSA represent the types of patients that would typically be encountered during the core clinical clerkships included in the curriculum of medical schools accredited by the LCME in the United States. These clerkships include:

• Internal Medicine
• Surgery
• Obstetrics & Gynecology
• Pediatrics
• Psychiatry
• Family Medicine

The cases constituting any CSA reflect a balance of these disciplines, although not every discipline will necessarily be represented on every assessment. There is also a balance of genders, ages and ethnicities among the SPs on any assessment.

Test Development Committee

The cases for the CSA are developed by a Test Development Committee composed of practicing physicians and medical educators who are experienced in working with standardized patients. Committee members who author, review and validate all cases used in the CSA represent a diverse spectrum of generalists and specialty physicians in the United States.

Ownership and Copyright of Test Items and Materials

All cases and materials used in the CSA are owned by ECFMG and are copyrighted. Distribution or reproduction by any means of CSA test cases and materials without the express written authorization of ECFMG is prohibited and infringes on the rights of ECFMG. Appropriate legal action will be taken when any such infringement occurs.

Eligibility

Prerequisite Examinations

Both Medical School Students and Graduates must have passed USMLE Step 1 and satisfied the English language proficiency requirement before being registered for the CSA.

If ECFMG does not have your Step 1 score (or its equivalent) at the time your complete application is received, the application will be rejected.

If you have not satisfied the English language proficiency requirement, you must request that ETS send your TOEFL score directly to ECFMG. You must also submit a TOEFL Acceptance Request Form and payment to ECFMG. (See Test of English as a Foreign Language.) Your CSA application will be held up to three weeks from the date of receipt in order for your TOEFL score to be accepted. If your TOEFL score is not accepted within this three-week period, your CSA application will be rejected.

If you are applying for the CSA on-line and have not satisfied the English language proficiency requirement, your TOEFL score must be accepted by ECFMG no later than three weeks after the date that your Certification Statement is received.

Education

The education requirements for the CSA differ depending on whether you are a medical school student or a medical school graduate.

Medical School Students

To be eligible for the CSA, you must be officially enrolled in a medical school located outside of the United States and Canada that is listed in the International Medical Education Directory (IMED) of the Foundation for Advancement of International Medical Education and Research (FAIMER), both at the time that you apply and at the time that you take the assessment. In addition, the "Graduation Years" in IMED for your medical school must be listed as "Current" at the time you apply and at the time you take the assessment. You must also be within twelve months of completing the full didactic curriculum at the time that you take the assessment. Your Medical School Dean, Vice Dean or Registrar must certify your current enrollment status on the application. This certification must be current; the official must have signed the application within four months of its receipt by ECFMG. As soon as you graduate and receive your medical diploma, you must send two photocopies of your medical diploma and one full-face photograph to ECFMG (see Provision of Credentials and Translations). The photograph that you send must be current; it must have been taken within six months of the date that you send it. A photocopy of a photograph is not acceptable.

Medical School Graduates

To be eligible for the CSA, you must be a graduate of a medical school located outside of the United States and Canada that is listed in the International Medical Education Directory (IMED) of the Foundation for Advancement of International Medical Education and Research (FAIMER). Your graduation year must be included in the medical school's IMED listing. You must have had at least four credit years (academic years for which credit has been given toward completion of the medical curriculum) in attendance at a medical school that is listed in IMED. The signature of the official who certifies your status as a graduate on the application must be current; the official must have signed the application within four months of its receipt by ECFMG.

You must send two photocopies of your medical diploma at the time of application if you have not sent the diploma to ECFMG previously (for example, with an application for a previous exam, such as Step 1 or Step 2). The name on your medical diploma must match exactly the name you entered on your application, or you must submit legal documentation that confirms the name on your medical diploma is (or was) your name. (See Name on Medical Diploma.) You must send one full-face photograph with the copies of your diploma. The photograph that you send must be current; it must have been taken within six months of the date that you send your application. A photocopy of a photograph is not acceptable. If your medical diploma has not yet been issued, you must submit with your application a current photograph and a letter signed by your Medical School Dean, Vice Dean or Registrar that confirms you graduated from medical school, have met all requirements to receive your medical diploma and states the date (month and year) that your medical diploma will be issued. You must then send the photocopies of your medical diploma to ECFMG as soon as your diploma is issued. (See Provision of Credentials and Translations)

Applicants who, as of June 30, 1998, had met all ECFMG certification requirements in effect through this date (regardless of whether their Standard ECFMG Certificates had been issued) are not required, but are permitted, to take the CSA.

Application Process

ECFMG offers the CSA throughout the year. There is no deadline for submitting your application to register for the CSA. However, in planning the timing of your application, you should consider deadlines imposed by the National Resident Matching Program and graduate medical education programs. See Applying to Graduate Medical Education Programs. Applicants for the CSA are required to read the appropriate edition of the ECFMG Information Booklet.

To apply for the CSA:

• Submit an on-line application using ECFMG's Interactive Web Application (IWA). You can access IWA on this website. ECFMG typically processes on-line applications within ten calendar days of receipt of the completed Certification Statement, or



• Complete a paper application (Form 706) and send it to ECFMG by mail (or courier service). You can download Form 706 from this website or request a copy from ECFMG (see How To Obtain This Publication). ECFMG typically processes paper applications within four weeks of receipt.

You may not register using a letter, postcard or e-mail message. All photographs, signatures and seals / stamps must be original. You cannot register by faxing your application or sending photocopies to ECFMG.

Detailed application instructions are included with the CSA application. Follow these application instructions carefully and answer all questions completely. You should review these instructions before you begin working on the application. Some of the necessary items require advance planning. These items include photographs, official signatures and additional documentation, such as copies of your medical diploma if you are a medical school graduate. If your application is not complete, it will be rejected.

Once ECFMG receives your complete application and payment and determines that you are eligible (see Eligibility), ECFMG will send your notification of registration, which includes information on scheduling the CSA. You can check the status of your CSA application on-line using OASIS.

Fee

The Clinical Skills Assessment fee is $1,200 (U.S. dollars / Fee subject to change).

You must send full payment of the assessment fee at the time of application. If you do not include full payment, your application will be rejected. See Payment.

Examinees with Documented Disabilities

Reasonable accommodations will be made for CSA examinees with disabilities who are covered under the Americans with Disabilities Act (ADA). To apply for test accommodations, you must obtain a copy of the packet entitled Guidelines and Questionnaire: Requests for Test Accommodations for Examinees with Disabilities Taking the Clinical Skills Assessment. This packet is available on this website and from ECFMG, upon request. Your request for accommodations, including the completed Questionnaire and supporting documentation, must be received at ECFMG no later than your application for the CSA. If you apply on-line, you must submit this information at the time you submit your completed Certification Statement.

Scheduling

You must schedule your CSA within four months of the date indicated on your notification of registration. You must take the CSA within twelve months of the date indicated on your notification of registration. If you do not meet these deadlines, you will lose your payment for the assessment, and you will need to reapply, including payment of the assessment fee, to take the CSA. Once you have scheduled a date for the CSA, you may not change it.

In recent years, demand for CSA testing spaces in the months preceding the National Resident Matching Program (NRMP) has exceeded the number of testing spaces available. Eligible applicants are strongly encouraged to apply for and take the CSA as early as possible.

Important Note: It is solely the responsibility of the applicant to complete the CSA in time to meet deadlines imposed by the NRMP and / or GME programs. Since the number of applicants seeking to complete the CSA may exceed the spaces available in time to meet those deadlines, there is no guarantee that sufficient spaces will be available for all applicants to meet deadlines imposed by the NRMP and / or GME programs. ECFMG assumes no liability of any kind if an applicant does not complete CSA in time to meet NRMP and / or GME program deadlines.

Admission Permit

Once you schedule your CSA, ECFMG will mail your admission permit to your ECFMG address of record. The admission permit will confirm the date, time and location of your assessment. You must present this admission permit at the Clinical Skills Assessment Center on your scheduled assessment date.

Clinical Skills Assessment Centers

The CSA is administered at the following locations:

Information on the location of your assessment will be available during the scheduling process.

The Clinical Skills Assessment Centers are secured facilities. Once you enter the secured area of the Assessment Center for orientation, you may not leave that area until the CSA has been completed.

You may not use cellular telephones or beepers at any time during the CSA. The Clinical Skills Assessment Centers cannot accommodate relatives or guests during the assessment. Luggage cannot be stored in the centers.

Travel Status for CSA

You are responsible for making the necessary travel and accommodation arrangements. If you are neither a U.S. citizen nor U.S. resident, you are responsible for obtaining appropriate travel documents (passport, visa, exit permits, etc.), as required. If you are traveling from a distant location, you should consider arriving a day or two before your CSA in order to be rested for the assessment.

Preparation

Since the CSA evaluates general clinical proficiency in cases commonly encountered and / or representing important medical conditions, knowledge gained from clinical experiences should be adequate to manage the test cases. When you are registered to take the CSA, ECFMG will send you the CSA Candidate Orientation Manual and Candidate Orientation Video, which describe the content and form of the assessment. The Candidate Orientation Manual is also available on this website. In addition, each assessment begins with an on-site orientation to the CSA.

Scoring and Score Reporting

Scoring Components of the CSA

Within each case, the specific skills being documented and assessed are:

• the ability to elicit an appropriate history;
• the ability to perform an appropriate, focused physical exam;
• demonstration of interpersonal skills appropriate to a physician-patient interaction;
• generation of a legible, organized, complete and accurate written record of the encounter; and
• proficiency in spoken English.

Minimum Passing Score on the CSA

A minimum score is required to pass the CSA for ECFMG certification. This minimum passing score is based on achieving a specified level of proficiency. The minimum passing level is reviewed periodically and may be adjusted at any time.

Reporting of Results

A report of performance on the CSA consists of a pass / fail designation. ECFMG will mail this report to your ECFMG address of record approximately six to eight weeks after your assessment date. You can check the status of your CSA score report on-line using OASIS. ECFMG reserves the right to delay the reporting of scores if additional data and / or analyses are required to assure the validity of the test scores. To avoid misinterpretation and to protect the privacy of examinees, ECFMG will not provide results by telephone, fax or e-mail to anyone, including examinees. If you do not receive your report of performance on the CSA, you must send a written request for a duplicate report of performance to ECFMG.

Score Rechecks

CSA scores are based on checklists and score sheets completed by the standardized patients at the time of the assessment, as well as subsequent scoring of the written records by medically-qualified raters. Standard procedures ensure that the score reported for each examinee is an accurate reflection of the answers marked on the checklists and score sheets. A change in score based on a recheck is an extremely remote possibility. However, a request for a recheck of the checklists and score sheets will be honored if you submit a CSA Examinee Request for Score Recheck (Form 751) and payment for this service to ECFMG. Form 751 and additional information are available on this website and from ECFMG, upon request.

Testing Conditions, Validity of Scores and Irregular Behavior

ECFMG administers the CSA in conformity with the policies and procedures of the CSA program. If a situation arises in which, in ECFMG's judgment, the integrity of the process is jeopardized, ECFMG reserves the right to invalidate all or part of an exam, to withhold scores, or to take any other appropriate action for the purpose of ECFMG certification. In order to ensure the validity of scores that are reported and the meaningfulness of ECFMG certification, it is ECFMG's policy that it will not report a score which it has determined to be indeterminate. To designate a score as indeterminate means that the score achieved may not represent a reasonable assessment of the examinee's knowledge or competence as sampled by the exam, based upon statistical analyses or otherwise.

Falsification of the exam application, submission of any falsified documents to ECFMG, submission of any falsified ECFMG documents to other agencies, or the giving or receiving of aid in the examination as evidenced either by observation at the time of the examination or by statistical analysis of an examinee's answers and those of one or more other participants in that examination, or engaging in other conduct that subverts or attempts to subvert the examination or ECFMG certification process, may be sufficient cause for ECFMG to bar an individual from the examination, to terminate participation in the examination, to withhold and / or invalidate the results of the examination, to withhold a certificate, to revoke a certificate, or to take other appropriate action.

In all cases when the USMLE Committee on Irregular Behavior or the ECFMG Committee on Medical Education Credentials has taken an action with respect to an examinee, or the CSA Committee on Irregular Behavior has made a finding of irregular behavior, an annotation will be included in the ECFMG Status Report and ECFMG Certification Verification Service (CVS) Report.

Representative Examples of Irregular Behavior

Reexamination and Reapplication

For the purpose of ECFMG certification, there is no limit on the number of attempts to pass the CSA. If you fail the CSA and wish to retake it, see Retaking the CSA for ECFMG Certification below.

Once you pass the CSA, your passing performance is valid for three years from the date passed (your CSA date) for the purpose of entering a program of graduate medical education. After passing the CSA, you may only retake it to revalidate your CSA date for an additional three-year period. See Retaking the CSA to Revalidate the CSA Date.

Retaking the CSA for ECFMG Certification

If you have not passed the CSA, you may continue to take the CSA until you pass it. If you fail the CSA, you should consider obtaining more formal training in those areas in which you did not meet CSA standards before retaking the CSA. Refer to your CSA score report for information on the areas in which you did not meet CSA standards.

For each attempt on the CSA, you must submit an application and assessment fee. Additionally, there are specific, minimum waiting periods between CSA attempts. Please note that these waiting periods will change for examinees who fail the CSA on or after February 1, 2003.

If Your Most Recent CSA Fail is before February 1, 2003
If your most recent failing attempt on the CSA is before February 1, 2003, you must wait at least three months before retaking the CSA, regardless of the number of times you have failed the CSA.

If Your Most Recent CSA Fail is on or after February 1, 2003 If your most recent failing attempt on the CSA is on or after February 1, 2003, the period of time you must wait before retaking the CSA depends on the total number of times you have failed the CSA, as described below. For purposes of calculating the waiting period, all failing attempts on the CSA are counted, regardless of whether they took place before or on / after February 1, 2003.

• If you have failed the CSA a total of one time, you must wait at least three months from the date of your most recent CSA fail before retaking the CSA.



• If you have failed the CSA a total of two times, you must wait at least six months from the date of your most recent CSA fail before retaking the CSA.



• If you have failed the CSA a total of three or more times, you must wait at least one year from the date of your most recent CSA fail before retaking the CSA.

Example 1
An applicant who failed the CSA on August 5, 2002 and November 15, 2002 applies to take the CSA for the third time. The applicant may schedule a third assessment for a date after February 15, 2003.

Example 1 Explanation
Because the applicant's most recent failing attempt is before February 1, 2003, the applicant must wait only three months from the most recent CSA fail, or until after February 15, 2003, before retaking the CSA. The new waiting periods do not apply, since the applicant's most recent fail is before February 1, 2003.

Example 2
The applicant in Example 1 fails the third CSA attempt, which takes place on February 20, 2003. The applicant may schedule a fourth assessment for a date after February 20, 2004.

Example 2 Explanation
Because the applicant's most recent CSA fail is after February 1, 2003, the new waiting periods do apply. Since the applicant has failed the CSA a total of three times, the applicant must wait at least one year from the date of the last CSA fail, or until after February 20, 2004, before retaking the CSA.

Although you cannot retake the CSA during the applicable waiting period, you can reapply for the CSA, provided your application is received no more than three months before the end of the waiting period. If your application is received more than three months before the end of the waiting period, it will be rejected.

Retaking the CSA to Revalidate the CSA Date

Passing performance on the CSA is valid for three years from the date passed for the purpose of entering a program of graduate medical education. If you wish to revalidate your CSA date for an additional three-year period, you must pass a subsequent CSA. You may revalidate your CSA date before or after you are certified by ECFMG. Refer to Revalidation of the Certificate.

You must submit an application and assessment fee for each attempt to revalidate your CSA date. The waiting periods described above also apply to applicants who take the CSA to revalidate the CSA date. However, failing attempts on the CSA that occurred before your most recent CSA pass are not counted in calculating the waiting period between revalidation attempts.

Example:
An applicant passed the CSA on March 5, 2000 after failing the CSA twice before. On March 20, 2003, the applicant retakes the CSA to revalidate the CSA date but fails the CSA. The applicant may schedule another assessment for a date after June 20, 2003.

Explanation:
Because the applicant's failing revalidation attempt on the CSA is after February 1, 2003, the new waiting periods do apply. However, since the applicant is taking the CSA for purposes of revalidation, attempts on the CSA that occurred before the applicant's most recent CSA pass on March 5, 2000 are not counted. The applicant is considered to have one CSA fail (March 20, 2003) and may retake the CSA after a three-month waiting period, or after June 20, 2003.

Although you cannot retake the CSA during the applicable waiting period, you can reapply for the CSA, provided your application is received no more than three months before the end of the waiting period. If your application is received more than three months before the end of the waiting period, it will be rejected.

Additional Information

For detailed information on the CSA, including information on test regulations and test accommodations, refer to the CSA Candidate Orientation Manual. ECFMG sends this publication to applicants when they are registered for the CSA. The current edition of this publication is also available on this website.