Which USMLE Step 2 CS exam center is IMG friendly?

(This article was originally published 6/16/08)

One of the most common questions I get from my students is; “Which CSEC location is best for me?” (CSEC - Clinical Evaluation Examination Center) As with anything in life, there are varying opinions on this topic. You may hear opinions from friends, colleagues or online. It all depends on who you ask, you will hear different answers.Each person means well, but who is telling you what is right for you? How is one able to discern the truth? Well, the best way is; put your "scientist hat" on. Let's look at the facts and come to a logical conclusion. That’s what I hope to do with this post.

The Logical Approach: First, consider the source of your information. There are 2 factors at play here. 1) Your source may be "word of mouth". A first hand experience anecdote from someone you know. There may be some reliability to that source. 2) Internet rumors; I don't need to mention by default information from such a source is largely speculative. Here’s another observation; have you noticed that it always seems to be IMGs that are quite opinionated regarding the subject of which center is better than the other? Are these judgements based on hard evidence, research or being an authority on the subject? I doubt it. It's funny, I never really hear from an AMG that's all that concerned about it. Hmmm.

IMG Friendly?: Some have even attempted to label certain CSEC locations as "IMG friendly" over others. IMG friendly?? The truth is: 

This is a completely FALSE mindset. Here's why:

As you are aware, there are just five CSEC locations worldwide. Philadelphia, Chicago, Atlanta, Houston, and Los Angeles. The order in which I listed them denotes the general demand each center receives from exam applicants. These are the centers that tend to attract more IMGs than AMGs versus the others. (Although all 5 centers can hold the same capacity) This means that Philadelphia tends to receive more demand for IMG registrations versus Los Angeles. Why is this? We all know how difficult it is to get a date you prefer on short notice in Philadelphia, so we'll use it as an example. With proximity to the eastern seaboard, the major cities such as Toronto, Boston, NJ and NY have major international airports, which are gateways into the US. In addition, many tend to have family members or family in those cities. Therefore Philadelphia offers better transportation access to IMGs logistically. Now it's no mystery as to why there's a lot more buzz and attention regarding the Philadelphia center, compared to any of the other four. Not only do more IMGs take the exam in Philadelphia, IMGs tend to intermingle with one another and are interconnected through one another from medical school, libraries, prep centers and now, even more than ever; through the internet. The connections between IMGs are tighter than those with AMGs. Many will share the story of their experience and this gets the rumor mill going. 

The buzz: Rumors are rampant on online USMLE discussion forums and within peer groups. Personally I've seen and heard this topic come up over and over all this years. It's created quite a lot of concern. It's understandable because the USMLE/match phase of life is nerve-racking to say the least. At times you can get caught up in the panic of it all and even forgo common sense. Now don’t get me wrong, forums can be great places to be. They can be EXCELLENT resources of information that provide you great tips and support. But as with anything, there are pros and cons. With freedom of speech comes an opportunity for negative information to influence us. You may wonder who or why someone write or say something negative? You know why, it's the way of the world. There is a minority of the world that tend to be malicious, bitter or looking to trip up others sadistically. Sometimes they are just plain bored with no life. We call them trolls. Actually what I tend to see more commonly is another type of person. Imagine scoring 99 on Step 1 and 2 CK on a first attempt only to get the shocked by the score report of an unsuccessful attempt on the 2 CS. Unbelievable? Trust me, it happens! Imagine you're a person who has never experienced the concept of failure before. And in a shock and denial stage, how could you ever naturally accept blame for it? Disappointment needs to be consciously coped with before moving on. In many cases a person will deal with it in a negative manner. Constantly replaying flashbacks of what could have been different. They can't see where they went wrong. Inevitably blame is projected on someone else. They miss the simple truth they have to face: They didn't know which criteria were important for the exam and which weren't. Maybe they didn't take the exam as seriously as other steps. Maybe they didn't actively engage in live practice. Whatever the case, they can’t come to grips that they just were not prepared for this exam. They will then go and vent online, spreading rumors and fear to other prospective exam takers. All about the staff, the SPs and how there was some conspiracy theory against them. I've heard it all.

The way it really works: So where did this “IMG friendly center” term come from? Is there really such a thing? Yes there IS such a thing as an "IMG friendly residency program". This is because residency programs pick AMGs over IMGs in most cases. They are not treated as equals and a bias exists, but there are understandable reasons for this. (though you may not agree, but this is subject matter for a different article.) I'm sure you know, some programs hardly take ANY IMGs while other programs take many. These are IMG friendly. This concept CANNOT be applied of exam centers though. It just not designed that way. They don't differentiate an IMG from an AMG. You don't go into the exam wearing your name tag, you are a number. Just as it is for your other steps. How you perform is up to you. SPs are not medical people and they are not part of the "system" that are trying to "screw you". The USMLE, NBME and CSEC are all sophisticated operations. You have to understand that they take medical licensure VERY seriously. Think about it; they are participating in certifying you for a limited license to work under supervision one day. This is serious business and not to be taken lightly. Therefore they have very strict regulations. Their SPs and physician raters are thoroughly trained and regulated by a quality assurance program. They have cameras, proctors and security in place to ensure everything runs in a controlled and regulated manner. The CSEC periodically reviews the design of the exam and makes changes and improvements. They put in a lot of work to ensure standards of uniformity throughout all 5 centers. Yes, this is all far from perfect. It is quite a subjective exam in many ways and we are humans after all. But realize that every measure is taken to limit bias and deviance from a defined standard.

Many IMGs have come from a country where life and culture is different. Past experiences may create a cynical mindset. A feeling that authorities are not to be trusted. Others may feel insecure; being that they are new to American culture. They may feel they don't fit in naturally with other Americans due to a perception of race, culture, skin color, religion or accent. Because of this, they may perceive one of the centers to be unfriendly, racist or corrupted. These claims are hard to believe. Yes, I'm sure anything can happen in an extreme, isolated incident. But it has to be more rare than the number of stories I've heard. CSECs are subject to US law to not discriminate towards anyone for any of these reasons. Remember that you are protected. And of course they have an invaluable reputation to uphold as well as ethics and integrity.

Proctors: You may have heard; “The proctors were rude, they were not friendly”. Sure, maybe they were friendly, maybe they weren't. The real question is; Is that what they are there for? Are they really required to be friendly towards you? The answer is no. Perhaps an examinee you heard from received an "irregular behavior" claim and that has made them bitter. But who’s fault is that? The rules can't bend and proctors must enforce them at all times. Let's put it this way; If you were to cross paths with a police officer, would he/she be required to be friendly towards you at all times? They put on a serious authoritative demeanor on purpose. The problem with being nice is that certain types of people are likely to take advantage of that. Proctors need to be able to instruct and warn examinees in an assertive manner. This is how they must behave in order to be effective. Understanding that will help you appreciate that in actuality, they act professionally.

SPs: You may have heard “The SPs there were not friendly or cooperative”. They may or may not be friendly. Again, who said they are supposed to be? They are ACTORS. The way they act or talk is not supposed to be taken personally. It is all part of the encounter! An SP cries or gets angry. It's not about you. It's about the case. Some sensitive types tend to take things the wrong way and then they think it will influence the outcome of the exam. It can if you let it. The truth is the SP is your friend not your enemy! It's you yourself that can become your worst enemy. There are appropriate responses to all these kind of challenges seen on the exam. And yes, there is a WRONG way to handle them. You have to expect these possibilities and come up with a planned strategy NOW. Not on exam day expecting to "wing it". Trust me things won't go as smoothly as you think with that kind of plan.

The "Ivy League" Effect: There are some that say that some of the top tier American medical schools are in closer geographical proximity to certain CSEC locations than others, such as Philadelphia and Chicago. This factor suggests that IMGs will face stiffer competition with their American counterparts. In another words, you'd expect students from Yale or Harvard to take the exam at the Philadelphia center and expect hardly any "Ivy Leaguers" at Houston. This is logical reasoning, and there may be SOME truth to it. But I'd still argue that this point is still debatable. SPs are trained to score each examinee independently and to not compare one examinee to another. But before cynics come after me, I will say that I agree that with this type of exam; it is impossible to ensure there is zero bias involved in all situations. Naturally an SP's mind may subconsciously compare one examinee to another, although this may not be their intention, this is only human. In general, an untrained 4th year American student (even those that are not from Ivy League schools) will tend to have the edge over a non-American IMG in terms of CIS and SEP. Which is exactly why a review course is essential. But the point here is that the proportion of IMGs that take the exam at a particular center does not give it "IMG friendly" status. YOU have to be the "friendly IMG".

The Placebo Effect: Some people tell me "OK I agree with you, that all makes sense". Some even say they they knew all about this, or deduced it on their own, but truthfully there is some level of irrational fear they can't shake. They ask "I get it but can I just switch and take my exam in Houston? No real reason why, I don't know. I'd just feel better that way. Is it a good idea?" OF COURSE! If it helps give you gain the peace of mind that you need and you can financially afford to do so, why not? If it can't hurt, then more power to you. Do what makes you feel better. Yes, it may be just a placebo effect but that just may be what's best in your case. You now know the truth that has been discussed here, just keep it in the back of your mind. 

Jet-Lagged: So you STILL feel the need to fly to a CSEC that is located on the opposite side of the country? Maybe it's because you didn't get the exam date you wanted. Well here is one more thing you need to consider, unless you haven't already: Time zones. The continental US is quite a large land mass and has 4 time zones. So if you choose the LA center and you are from NYC or if you choose Philadelphia and you are from Seattle, be aware of the differences in time zones. This can mean that at 8am when you show up at the Philadelphia CSEC it can feel like 5am to YOU! Or if you happen to have an afternoon session at LA. towards the end of the exam you are going to feel like it is 1am; you will not survive! Obviously you can't expect to adapt overnight if you fly in the day before. How much coffee do you plan to drink? It will end up being more bad for you than good. Yes of course, all of this will have an impact on your performance, did you ever consider that? Therefore choosing a center that is located closer to you is better; not only from a distance and cost standpoint, but also for your circadian rhythm. This is also one of the reasons I tell IMGs, who reside outside the US, to plan their trip to the US carefully. If at all possible try to avoid an abbreviated and abrupt "fly-in--fly-out" schedule. It creates an exhausting, high pressure, high risk and high stress situation on top of jet-lag that is best avoided and just not a good idea. 

The Answer: In closing, let’s put this question to rest once and for all. “Which CSEC location is IMG friendly?”. The truthful answer is “They ALL are!!!” The bottomline is that if you are really confident and PREPARED for the Step 2CS exam you wouldn't even ask such a question. Yes you may be nervous, you can't help it, it's natural. Transform that negative nervous apprehension into more of an eager, excited, form of anxiousness. Your attitude should be "Give me ANY case! Anywhere. I am ready!" With this attitude you can thrive in all circumstances and in any exam center. This is my aim for you.

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