What it takes to fail step 2 cs

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I've been freakin out guys. Since I took that test all I can do is flashback the insane amount of things I forgot. I'm an IMG, English my first language.

Has anyone else had this experience?

I know this is everywhere in this forum, but most are a little outdated and I'd like to know about recent experiences.

Thank you.

I think it takes a pretty poor performance to fail. I didn't prepare at all, other than reading through the general description, and was pretty fast w/ the patients and I passed w/ a pretty good margin.

I am IMG too. Everybody have flashbacks after CS, because you think there were the some questions you think you must have asked... But focused history and examination is the key... If ran out of the time, didn't do closure in many cases and didn't do important counseling-than chances of failure increases. Otherwise people are failing in data-gathering which may happen if you did't ask specific questions or didn't write in patient notes.
I completed all cases in 12-13 minutes, just asked what was necessary and did focused PE only, passed with above borderline performance.

I understand your concern, but don't sweat it. You probably did a lot better than you think you did.
I seriously thought I might have failed it too, there were so MANY things I forgot to ask or to do. (i was coming off of 3 months of nonclinical electives, and i spent 1 day preparing for it -read FA) but i passed.
if you asked generic h&p qs, did focused exams, summarized, addressed pt's concerns, washed your hands before exam, wrote decent notes..you ll be fine.

What it takes to fail CS? Swearing at the SP would be an excellent start.

Very reassuring to hear these comments lol. I've been doing subspecialty research for 10 months and felt like a fish out of water for this exam after not seeing a patient for nearly a year. Definitely have been flashing back and wondering 'why didn't i ask this? or do that exam manoeuvre? or order this test? And I'm a us med student...

I think I spent wayy too much time on psychosocial things too because FA kept hammering home 'empathize with patient' and similar issues.

I took CS a few weeks ago (closer to the beginning of the reporting period), and thus have had a long time to mull over everything I didn't do during the test day...and I've still got another month of agonizing to go. I've already matched into a program I'm thrilled about, and am terrified that failing CS will throw four years of med school down the drain.

.

Hi

I took my Step 2 CS, 3 weeks ago, I can't stop thinking about a bunch mistakes I did
I was good prepare, but I was nerves and that didn't help

These are the things I did wrong ( not because I didn t know, just because the stress)

I forgot ROM in 2 cases as a part of PE
I forgot abdominal percussion in all cases
I forgot to ask about menopause symptoms in one case ( was one important DD )
In 2 PN I was not able to complete all 5 DD , ( just 4 )
Im sure I have many typing mistakes .

Things Im sure I did Righ in all the cases

Knock , draping , use gloves, etc.
I did most of the right questions ( FA ) for each case
Paraphrase, Summarize
Closure
Counseling

I would like to know your honest feeback about my chances to pass or fail the exam

Thanks

Originally Posted by officedepot

oh I'm sure you passed.

But to anyone who will read this later the above post illustrates why you should just take step 2 cs after ck but before any major break in your schedule. It'll just be sooooo much easier this way and you won't have to worry about it again.

Not necessary. I've had upperclassmen tell me take whichever is better according to your schedule. Especially since getting CS dates are a problem for IMG's, people might consider taking this before the CK. Performance on the CS is not entirely affected by CK (unless you really suck at diagnosing, and forgot everything from Step 1)

Ugh, we're about a week and a half away from the next score release block and I am freaking out. Ever so often, I'm hit with another reminder of the question I forgot to ask, the PE step I didn't do, the finding I forgot to document, etc. Regardless of the outcome, stressing over these results has definitely made me a headcase.

I think I'm generally fairly competent with patient encounters, but nerves + being away from clinic for 4 months + not being able to go back into the room = befuddled mess. I was trying to balance the objective of hitting all the checkboxes in FA, and trying to make the encounter as natural as possible.

As one user posted a while back, SDN is a love-hate relationship -- comforting to see other people who seemed to make big omissions and still pass, but horrible to find students who made fewer errors and failed. It's going to be a long 12 days...

I'm FREAKING out!!!

Update: Felt like I forgot to complete several exam maneuvres and include important things in my differential + note. Comfortably passed.

Your medical accuracy is just one of about 8 parts. If you do everything else well, you should be fine

Originally Posted by Levosimendan

I would like to know your honest feeback about my chances to pass or fail the exam

If you showed up and spoke English during the exam you will pass.

Originally Posted by tundri

I'm FREAKING out!!!

Hei, Tundri, where is feedback?
Did you pass cs?

You hear a lot of "I forgot to check the PMI on CVS exam on one patient who complained of abdo pain, but inspected, palpated and auscultated and still SOMEHOW managed to pass" on these threads.

I felt dismal after mine - I had an extensive list of miniscule errors and passed with high performance in all areas. Nearly everyone who takes the exam subsequently entertains the idea that they may have failed because nobody has a perfect run.

What does it take to fail? I don't mean to insult anyone who has failed, but abysmal English, total cluelessness and racial slurs would probably do it. During one of my rotations, I told a Senior Resident I was concerned about my upcoming Step 2 CS, to which he responded "do you speak Enlgish". I said yes, to which he responded "congratulations, you passed". I think that sums it up.

Moved to another thread

Purely out of curiosity: has anyone else been told that chewing gum during Step 2 CE is a bad idea? I like to chew gum because it helps keep me awake and alert, but if chewing gum is a major no-no on this test I'll forgo it.

lame question, but do people fail step 2 cs for not removing the gown and instead listening to the heart through the gown?

Originally Posted by rattailmd

lame question, but do people fail step 2 cs for not removing the gown and instead listening to the heart through the gown?

Absolutely do not do that. Not sure if it is a critical fail, but its poor form regardless and you will get dinged for it.

Originally Posted by rattailmd

lame question, but do people fail step 2 cs for not removing the gown and instead listening to the heart through the gown?

Always listen on skin! Come on even first years know that ;p

Originally Posted by sylvanthus

Absolutely do not do that. Not sure if it is a critical fail, but its poor form regardless and you will get dinged for it.

Crap. I listened through the gown on every patient. It seemed stupid to expose the patient for no reason. A thin gown does not make a significant difference in being able to hear. I hope that they would not fail people for such a stupid reason.

Originally Posted by Wilf

Crap. I listened through the gown on every patient. It seemed stupid to expose the patient for no reason. A thin gown does not make a significant difference in being able to hear. I hope that they would not fail people for such a stupid reason.

I dunno if they'll fail you but it's really poor form. Always. Listen. On. Skin. Always.

Can any 4th years or beyond weigh in on how important something so trivial as auscultating on skin is? Surely when the vast majority of attendings listen through clothes thicker than gowns, it won't fail us.

Originally Posted by Wilf

Can any 4th years or beyond weigh in on how important something so trivial as auscultating on skin is? Surely when the vast majority of attendings listen through clothes thicker than gowns, it won't fail us.

Idk about failing you, but as far as CS is concerned, you're better off auscultating on the skin whether or not your attendings do. There's no point in risking failing because you didnt take 5 secs to untie the gown. (again, idk for sure if they fail you for that)
I took CS in august and I auscultated on the skin, under the gown. I didn't have to remove/untie the gown for certain pts if they were thin and there was enough space for my hand to go under the gown smoothly, but the point is: auscultate on the skin
hope that helps (and I dont mean to freak Wilf out.. I'm sure you did fine.. people hardly fail CS if they can speak English properly and are nice to the pts)

Originally Posted by Wilf

Can any 4th years or beyond weigh in on how important something so trivial as auscultating on skin is? Surely when the vast majority of attendings listen through clothes thicker than gowns, it won't fail us.

unfortunately this will count against you pretty significantly. it is very important to auscultate directly on skin in CS. you're right that in real life it is very common to auscultate over clothes but in the exam you're supposed to demonstrate that you know the "proper" way to do things.

The reason you should do auscultation on the skin is to avoid hearing clothes rubbing against skin and think it is lung sounds/heart sounds. I frequently do the exam on the lower lung lobes directly on the skin esp. when patient has pulm. hypertension etc.

I auscultated over the gown on one of my 12 patients, because I didn't really think there was any need to auscultate at all with him and couldn't be bothered to undo his gown. I'll probably only lose points on that if auscultation was a required action. For the other 11 I auscultated on skin.

Originally Posted by skinMD

unfortunately this will count against you pretty significantly. it is very important to auscultate directly on skin in CS. you're right that in real life it is very common to auscultate over clothes but in the exam you're supposed to demonstrate that you know the "proper" way to do things.

How can anyone here possibly know "how much" this will hurt you? Why're you guys making this poor guy/girl feel like s/he has failed when no one knows exactly what it takes to fail? (Other than not speaking English)

To Wilf: no one here has any idea. I doubt anyone has seen the grading rubric and if they don't claim they have, don't listen to them. My guess is you're fine. I normally listen over the gown as well, but luckily remembered to go skin during the exam. You're not a failure for listening over a sheet; don't let these guys freak you out.

Did you guys check orthostatics and do a tilt test in patients with syncope or dizziness? Or can you just write that as part of the workup in your note?

Another "I just took it and I think I failed" post:

So I ran out of time on about 8 of the 12 stations. I wasted way too much time on H+P on all of those pretty much, and I was either unable to finish even a halfassed closure and/or had to drastically cut my exam short (e.g. didn't do any of the special maneuvers for knee pain, or not doing heart/lungs/belly for half the things) for those stations. I was reading up on how it's scored and it seems like the ICE component score lumps together the patient note with the exam checklist. If my notes are solid (or as good as they could be given the ****ty physical exam parts of them), how likely am I to fail if I only hit 50% of the exam checklist?

And yes my exams were bad, not just being anal about percussing (which I did about 0 times the whole day anyway )

Originally Posted by krps85

Another "I just took it and I think I failed" post:

So I ran out of time on about 8 of the 12 stations. I wasted way too much time on H+P on all of those pretty much, and I was either unable to finish even a halfassed closure and/or had to drastically cut my exam short (e.g. didn't do any of the special maneuvers for knee pain, or not doing heart/lungs/belly for half the things) for those stations. I was reading up on how it's scored and it seems like the ICE component score lumps together the patient note with the exam checklist. If my notes are solid (or as good as they could be given the ****ty physical exam parts of them), how likely am I to fail if I only hit 50% of the exam checklist?

And yes my exams were bad, not just being anal about percussing (which I did about 0 times the whole day anyway )

Well, there is nothing you can change by worrying about it. Just try not to think about it too much but have a plan of attack ready in case you have to take it again. While you can still remember, write all this down and what you can do better. If you need to retake, it will just take 1 week of prep. Your scores won't be back before match results come out anyways, so quit worrying about it. Many many people fail one of the steps. Not the end of the world.

Yeah you're definitely right that worrying doesn't change anything, including the match. The timing is unfortunate though since if I found out I failed at the end of April I don't think I'd have time to get my retake score in time for graduation and start of intern year. I'm really kicking myself now about not scheduling it earlier.

So I just wanted to post my experiences with this horrible, useless exam.

First things first, I got my score back today, and i PASSED. I took the exam all the way back in November and had to wait an anxiety filled 3 months for my score. I only prepped 2 days for the exam (and honestly, I think that is enough if you are an AMG - I'm a U.S. MD with 230's step 1 & 2, but it doesn't hurt to prep more, I just used FA which I think is the way to go.

The encounters were pretty standard with regards to topics, I felt like I had good flow (wasn't nervous), got pretty much everything I wanted to get done/ask without feeling rushed, and I left almost every encounter at least 2-4 mins. early.

Nevertheless, I "always" realized I forgot something minor (which usually involved the HPI) and was kicking myself afterwards. I pretty much maxed out the HPI box.

Things I made sure I did during every encounter: Smile, introduce myself and refer to patient by their name, wash hands, ask to remove drape when necessary, do heart & lungs on every patient, ellicit signs when appropriate (e.g., murphys, psoas, etc.), 3 complete neuro exams, counsel (smoking/alcohol/safe sex), summarize and ask if they have any other questions/concerns, go over my plan, and ask again if they have any questions/concerns (be prepared for the "challenge" questions), max out the DDx

Things that I did NOT do and probably should've: I was not overly empathetic (sorry NBME lol, but it doesn't feel natural feel for me to be "heartbroken" that a patient has a cold so I just didn't, and I don't remember ever saying "I'm sorry you feel this way/have this" although i did make sure I ask if they have any questions/concerns, I actually forgot to list the vitals on some of my patients when it was pertinent and at first I may have listed PE findings when I thought my patient was making a noise with his mouth to mimic a murmur, fill-up supporting findings in the DDx section, and lastly, my biggest gripe with the exam: list pertinent NEGATIVES to SUPPORT your DDx (yes, it actually asks you to do this next to you DDx, I didn't list any because I've never done so in real life and didn't know it was a requirement and it really feels counter-intuitive, although I absolute made sure I went through the pertinent negatives in the HPI/ROS).

In a nutshell: This test blows and its a waste of your time. Nevertheless, you don't want to fail. So, at least give yourself a 2 days (i.e. a weekend of dedicated prep in FA) to give yourself a good start. Some of the encounters are completely unnatural, but you just gotta play the game. Make sure you probe with your questions because some of the SPs aren't too bright (e.g., has your had a h/o illnesses? - No, has your child had a h/o [insert infection]? - Yes, 5 times in the past year). I completely tanked one of the T-cons, because the patient wasn't giving me anything, but in retrospect, it was my fault because with these SPs they may just say no unless you ask them EXACTLY the right question - lesson learned).

Oddly enough, I felt way more anxious about this exam than any other exam, ever, probably because you can never get it "all" done in the alotted time, I only prepped for 2 days and because it is fairly subjective. Anyway, I passed with above borderline (middle range) performance and I'm officially DONE. Best of luck to everyone. PM me if you have any questions.

I'm giving my 2 cents.

I'm a soon to be AMG and got his score back today. I took the test early december and it had been about 3 months since I had an actual patient encounter on test day. I studied about an hour the night before the exam and then I got distracted and ended up watching sunday night football. It was also in the middle of interview season so I was kind of tired at that point.

The first patient encounter I forgot to put out the leg stand when asking the patient to go supine to do an abdominal exam. I realized it during the encounter too and just moved on. I think I was really fishing for some zebras throughout most of my encounters because they all seemed too straight forward. I don't think any of the patients were trying to mimic a murmur. Maybe they did and I didn't pick it up.

I think for every encounter I probably forgot to do something. One lady had mono and I probably should have checked for spleen size. I did make sure to end the encounter with what I thought it was, what test or what the next step was, and treatment. Also I tried my best to act empathetic but I probably wasn't going to win any academy awards for my performance.

Just be sure to introduce yourself, put on gloves, and care. Throw in a few, "I'm glad you came here for that. I would be concerned in your situation as well." Write a decent note.

PM me for any other questions. Good luck!

Just got my score back today. Passed with high performance on all three areas.

I took my test in early December and it's been the worst month and a half of my entire med school life. I just kept thinking nonstop about all the mistakes I made - I forgot to wear gloves for one of the patients; I had many encounters that I had no preparation for from the FA book; fgt to to MMSE on a patient that called for it; forgot many important things on history; forgot important PE manuevers. I kept thinking about different scenarios if I failed the test - it just drove me absolutely insane. It definitely blows having to wait 6 weeks to get your results. To everyone freaking out here, I feel your pain. But rest assured, I like your chances of easily passing this test. It takes a LOT to fail this test. Good luck!

EDIT: I agree with the post above. Act extremely friendly and PCM. Make sure you have the time to summarize and explain the next steps at the end. This stuff goes a long way.

I have a feeling that Comlex PE is harder to pass than USMLE CS. I say this because PE pass rate is 95% and we don't have IMGs, because only DOs can take COMLEX. I read somewhere the pass rate for CS is 98% and one in four IMGs fail CS.

Originally Posted by cheruka

I have a feeling that Comlex PE is harder to pass than USMLE CS. I say this because PE pass rate is 95% and we don't have IMGs, because only DOs can take COMLEX. I read somewhere the pass rate for CS is 98% and one in four IMGs fail CS.

Straight from the USMLE website I found this information on pass rates for 1st-time takers of Step 2CS. It is from 2010-2011 and is the most recent thing they report.

98% for US/Canadian MD students
88% for US/Canadian DO students
79% for all students who are not from US/Canada

here is the data

so, not to antagonize, but if the Comlex PE pass rate is 95%, it actually implies that 2CS is more difficult. 95 out of 100 DO students pass PE, while only 88 out of 100 DO students pass 2CS. Also, due to selection bias of DO students who want to do allopathic residencies, the DO students who are higher achieving from an academic standpoint are the most likely to try to complete the USMLE Step series.

Originally Posted by rattailmd

lame question, but do people fail step 2 cs for not removing the gown and instead listening to the heart through the gown?

for the record: i listened to all 12 patients over their gowns (i. completely. forgot.) and passed with flying colors. I suppose so long as you do everything else you're supposed to, it's not an automatic fail

I took my test in late December and got my scores back last week. Passed in all three subject areas with high performance in two of the three. During my test I:

-did not counsel anyone on alcohol abuse and smoking cessation
-asked all my questions at once (i.e. any nausea/vomiting/diarrhea/fevers/chills instead of asking each one separately)
-made a patient with knee pain get up and walk
-put down supporting physical exam findings in only 1 of cases
-routinely went back and asked questions that I had forgotten either during the physical exam or during another part of the history

Be polite, empathize, and you should be fine.

All right guys, after some time has passed I started remembering stuff I did right and wrong during my exam.. will post it right now so that you can benefit from it.. and tell me what you think.

What I did wrong

Got nervous in the first 2 cases, the second case I tried to show good empathy to my patient, she was overly serious and I couldnt steal a smile
Wore gloves in all my patients, with 3 of them I removed their glasses and then forgot to change gloves.
did extremely focused Physical exams + general exams. (I didnt do CV and Chest exam in all patients like almost everyone does...)
did focused Neuro exams.
During 1 of my encounters I already had finished my summary and closure and then the pt asked me a challenging question; while I was answering time ended and had to leave saying "got an emergency have to leave"
In a phone encounter forgot to ask some past medical history questions.
during some of my encounters I felt I was talking to fast.. eventho the patients didnt show any signs of struggling to understand me, 1 patient asked twice "what?" I do have a fairly good english, but nervousness + time pressure were against me I suppose.
In some pts eventho I asked CAGE questionnaire i forgot to put in on the PT (FML, lol)


What I did right.

Smiled, introduced myself by name, my role in the clinic and What I was gonna do.
Asked for permission before every PE maneuver.
Explained what I was doing and what I was finding.
Asked for permission to write notes.
Said sorry, this must be tough, I see several times.
While wearing my gloves asked for anything else.. extra concerns etc, the superbowl game happened 1 day before, so I tried to have a conversation while putting my gloves, either that or tried to talk about the weather (a storm was gonna hit)
Asked pretty much everything on first aid + extra ROS.
ASked CAGE questionnaire on every patient that required it.
Counseled on every patient about everything (sex, smoking, drugs, alcohol, depression)
Congratulated patients on things they did right.
Offered support and understanding several times during the encounter while trying not to sound like a repeating machine or a clown.

Lets see IF I will pasS!

Two questions:

1) any advise on the physical exams? Im using FA to get ready and there is no way I can do a full HEENT and Neuro exam, while listening to heart and lungs in 5-6 mins. Any advise?

2)Any advice on writing the patient notes in 10 mins? I'm always going over by 1-2 mins

Originally Posted by Nola Doc

Two questions:

1) any advise on the physical exams? Im using FA to get ready and there is no way I can do a full HEENT and Neuro exam, while listening to heart and lungs in 5-6 mins. Any advise?

2)Any advice on writing the patient notes in 10 mins? I'm always going over by 1-2 mins

1) I did heart and lungs on every patient. I always asked for permission (i.e., I'm going to listen to your heart if thats OK"). I definitely did NOT do a full HEENT on (I think) any of my patients. Occasionally, did ask to look in mouth/ears/nares, but never a complete exam. I did do a full Neuro exam 3 times (may have left out reflexes/pin prick here and there) but for the most part it was complete. They really do stress a FOCUSED exam, so other than heart and lungs, if the complaint is abdominal, that was the only extra system I did and I occasionally mentioned in the work-up (do pelvic/GU exam, etc.). For headaches/neck pain, vision problems, I almost always ended up doing a full Neuro exam (unfortunately). I'm not sure if I did an MMSE.

2) I made sure my notes were squared away, so I left every encounter 2-4 minutes ahead of time. I am not sure of your own level of comfort, but I think practicing doing an focused H&P in under 10 mins is a good way to go. I did my best to not "rush" the patient by not interrupting, summarizing, and asking about other questions/concerns a few times during the interview so they have plenty of time to get it "all out."

I'd recommend leaving at the 10-12 min. mark so you can really knock out the note (provided you hit the high points). FYI, i scored mid-range in 2/3 and aced the english proficiency (lol).

Just realized that among other minor mistakes I didn't ask a single SP about surgery history or allergies. How much will that hurt?

Originally Posted by Nola Doc

Two questions:

1) any advise on the physical exams? Im using FA to get ready and there is no way I can do a full HEENT and Neuro exam, while listening to heart and lungs in 5-6 mins. Any advise?

2)Any advice on writing the patient notes in 10 mins? I'm always going over by 1-2 mins

Hi, will try to help you out since I already did my exam.

FA PE is completely impossible... there is no way in hell you can do everything they tell you to do along with a good history taking.. it is just impossible.
My advice would be to do a focused PE , If something has to be sacrificed in this exam I believe it is PE, Closure+counseling must be done always.

Regarding the Patient note, Try to use mnemonics and contractions, instead of putting bowel sounds positive all 4 quadrants put something like BS (+) all 4Q, and use the practice software in the USMLE website and time yourself.. practice practice and practice is the key

Originally Posted by SandStud

Just realized that among other minor mistakes I didn't ask a single SP about surgery history or allergies. How much will that hurt?

Prob not much, but we dont know how we will be punished by these mistakes because we took the exam with the increased difficulty.. all that matters is wait and pray.

Originally Posted by XPaeZX

Regarding the Patient note, Try to use mnemonics and contractions, instead of putting bowel sounds positive all 4 quadrants put something like BS (+) all 4Q

be VERY careful with this and i recommend the exact opposite! there is a list of approved abbreviations and though not comprehensive (i.e. abbreviations not on there will be accepted) you should err on the side of writing everything out fully because you don't want someone to not understand your note. "BS" is actually a good example of a horrible abbreviation you should avoid. Does it mean breath sounds? bowel sounds? you don't want the reader to be uncertain about any part of your note because they likely won't spend time pondering what you meant. if you are a proficient typist this should not be an issue.

Originally Posted by skinMD

be VERY careful with this and i recommend the exact opposite! there is a list of approved abbreviations and though not comprehensive (i.e. abbreviations not on there will be accepted) you should err on the side of writing everything out fully because you don't want someone to not understand your note. "BS" is actually a good example of a horrible abbreviation you should avoid. Does it mean breath sounds? bowel sounds? you don't want the reader to be uncertain about any part of your note because they likely won't spend time pondering what you meant. if you are a proficient typist this should not be an issue.

I know, I followed the approved abbreviations they put during the exam, plus some others found on first aid, writing in abbreviations will save time but as you say it is better to do it the correct way, and when in doubt it is better to spell the entire word.
I was just giving an example, writing in abbreviations will save time.

Thanks for the quick replies. I was thinking of leaving that pertinent negative out and just type "negative, except as stated above" in order to save time. Also, do we have to have physical findings to support our DD, or can I get away with just having supporting info under Hx findings?

Originally Posted by Nola Doc

Thanks for the quick replies. I was thinking of leaving that pertinent negative out and just type "negative, except as stated above" in order to save time. Also, do we have to have physical findings to support our DD, or can I get away with just having supporting info under Hx findings?

If you dont have supporting findings then dont put them and just write the history findings