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Step 3 CCS Questions

Discussion in 'Step III' started by FutureProof, 10.02.11.

  1. FutureProof

    FutureProof

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    Hello,

    I had some questions regarding the CCS. I was practicing them for the first time today on the NBME website practice material and I found it quite confusing.

    Questions:

    1. Once you read the prompt, do you always do a focused physical exam next? I know at times the case may need to treat first but I have noticed when I first go to treat or order (e.g. IV fluids for hypotension) and then go to the physical it says my orders will be canceled

    2. When you start ordering tests and treatment. Are you graded on the order listing them when you go to order for the first time. E.g. DKA pt, I want finger stick glucose but also want to start fluids but also want a chemistry panel and UA, should I be listing them in a specific order?

    3. Once I am done ordering my tests and treatment, here is where I am a bit lost. Do I just go to the clock and press on "when next result ready" ? When I do this often I just get back one result. Am I supposed to then keep pressing it to get my other results ? Is there a time frame I should be typing in to get all my results? e.g. 1 hr? 30 mins?

    4. When wanting to re-assess patients' for example blood pressure or vitals or electrolyte or glucose level, do we RE-order these things? For example, I put a chest tube in for a pneumothorax after seeing it on the first chest x ray, do I then go and re-order another one?

    5. When wanting to re-assess patient's well being do I go to physical and order interim report? What I am having trouble with is at what points I should check on the patient? (In the real world its so much easier, this program is quite odd to me)

    6. Once the patient is doing better, and lets say they are in an inpatient setting, and all my work up is done, do I just end the case or do I just sit there and wait for a prompt to come again to say something else? Do I schedule inpatient patients for follow up or is this just for outpatient visits?

    Thank you very much, any advice and tips are very much appreciated
  2. OveractiveBrain

    OveractiveBrain

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    ALWAYS do a physical. Usually complete. Only sometimes focused (in emergencies). Its a safe bet. Do the physical before you do anything else.

    No. Get ER labs all at once. Don't advance the clock. Get CBC, CMP, UA, ECG, CXR, Glucose, SpO2 on EVERYONE. +/- CT scan, +/- MRI, +/- something else. You can always cancel these later if you dont want them, and they take like 6 hours to come back, and each prompt will allow you to stop the clock. Put them all in at once.

    What you CANNOT do is call consultants. If you don't have everything done for teh consultant they will give you something useless. Even, then, consultants are terrible. Guy has appendicitis. I call surgery. "Continue medical management." I order Ex-Lap case ends with me the winner.

    I just select some time in the future. Like 3 weeks from today. When I get a test result that actually shows something, I say "stop the clock!" This is dangerous if you don't know what you're doing, but its totally OK.

    I hope you would do this in real life too. So, yes. It is ok to reorder tests to confirm what you've done is right. You can order vitals q4 or q1, or whatever. You don't have to physically do them yourself.

    Usually no. If you are doing this then you've probably missed something. if you are hoping to gain extra information from a repeat physical, you aren't going to get it. I did not have a single practice case nor a single real case that involved long term care beyond "do the right thing this visit." Though i did have a patient stay in the hospital (so i got a physical exam in the AM). You DONT have to reassess the patient every time you do an intervention.

    This isn't a test on social work. Just get the case done. The case will end when you've done it right, or you killed the patient. Do not stop prematurely. When you've succeeded, the program will stop the case for you. This is why you do the Uworld cases. You have to get an understanding for when "winning" has occurred. If you THINK you've done everythign for the patient, and you haven't, it WILL let you continue. Continuation means you aren't done. Ending means winning. Or failing. But since you're a doctor and not an idiot, generally it means winning. Failing means "got a brain biopsy" instead of "gave tylenol for headache."

    This is, by far, the easiest part of this exam. Practice well and this can save your score. You can easily make up a garbage performance on the MCQ to save your pass. Don't **** it up!
  3. FutureProof

    FutureProof

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    First off, I want to thank you for taking time from your busy schedule to write such an informative reply to my questions. I am very truly indebted, thank you!

    Do you think if I do the UW cases and the First Aid ones in the back of the book and the 6 practice ones on the nbme one I will be fine? I am a us medical grad, I finished all of UW QBank, did the practice test on nbme at my test center, went through all of Kaplans Master the Boards.

    I hadn't heard of this Archer website, wasn't sure if it was worth it or not, my test is on the 17th/18th.

    I guess one thing I was missing and not paying attention to was the time it takes to get a test back that is listed once you order a test. I was not look at that at all. Should I then just forward the clock to that many hours to get the results?

    My other question is I did not understand what you meant by "stop the clock" when you get something. How do you do that? or do you mean you do a mental note and see what else needs to be done from the results you have gotten?

    Also, I am having trouble at what point to transfer the patient lets say to the wards or ICU.

    e. g. I have a pt with DKA, I do the slew of labs, give insulin, fluids, K. Do I then move the clock forward to get my results or should I at this point transfer patient and then get my results at this new location?

    Will any of my tests cancel if I move the patient or any of my ongoing interventions?

    Also, lets say a patient needs surgery. E.g. dissecting aortic aneurysm, I let's say have transferred the pt, and made him NPO, iv normal saline, type and cross, foley for urine output, and then i do a surg consult, and then i get the prompt surgery is not scheduled, continue with medical management. What else is there to do that point? Do i just end the case?

    Thank you again, I am sooooo grateful !
  4. haresh

    haresh

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    I received my score report 2 weeks back and astonished to know that I failed again. This is my second time. I have done Uworld cases thrice so far. My CCS ended up very low. And i have had the same problems that many of you are having with Uworld software . I know why score can come down when surgeon does not accept or because of the wrong report times for tests in UW. It is unfortunate that this UWorld course is too much promoted here though there are fatal errors in that software. I am going to practice on exam software (Primum) from now and may be will try other courses.

    If I had not seen a post on this forum, I would have repeated UWorld software committing the same errors . See the post below and you will know why we could be getting low score on CCS though practicing Uworld twice or thrice : http://forums.studentdoctor.net/showthread.php?t=738730

  5. OveractiveBrain

    OveractiveBrain

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    Bro, honestly, from your writing, the issue isnt the software or the test. Its your language barrier. You don't speak english well. I doubt you can even fully read the vignette in the case.

    I promise you. It is not Uworld software. It is not a hard test. It is you. Keep studying, keep learning, try it again. If you do not accept the fault onto yourself you will never get passed this test. Blaming anything other than yourself makes you feel good but does not get at the root of the problem.

    I would have failed CCS if I didn't use the UWorld cases. It taught me that cases ending early is a good thing. It taught me that I had to order the right test in the right way in order to get what I wanted to happen to actually happen. Its algorithmic except for the one or two tests that are extra and the one or two interventions that are extra and pertain specifically to the diagnosis.

    Edit: The thread you referred to is full of people who don't speak english bitching about how they didnt pass. Some people have been banned. Some people have been banned and allowed to return. The entire thread is garbage. Its harsh, I know. You want to practice in the United States. We have no national language, but our licencing exams are in english. LEARN ENGLISH.
  6. haresh

    haresh

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    To "overactive" brain :

    Your answer confirms my suspicion. Even a brainless fellow can understand it from all your posts. Out of your 100 posts, a minimum 50% are filled with extra-hard support for UW. They are also filled with hateful attack against anyone that criticizes UW. You are definitely the most overactive usmleworld promoter on this forum - you exude hatred against people who blame UWorld. It is people like you that should be permanently banned . In fact, you should be arrested for conspiring this way. Which of the following disgusting errors in UW software are you trying to support? Read the thread again. It is a honest opinion from people who were cheated by UW hired agents like you. Writing stupid english filled with hateful remarks does not make you great. Education should teach you manners and courteous attitude. You may be good in English but your dirt-filled post shows that you are no different from a homeless person on the road. Your profile picture confirms your homelessness...that unshaved, unkept appearance perfectly matches your writing!

    Which of the following errors in UW can you deny? If you do dreadful mistakes like these, would not you fail?

    The post that I quoted above says , "
    The problem with USMLE WORLD software is that there are many mistakes in the interaction and it does not guide on what to do to get a higher score. It also does not tell what things are most crucial to score higher on the CCS. I have done this and I find there are some critical mistakes in UW which can lower the CCS score. For example, UW software does not accept patients for surgery when surgery is required. The software is not properly designed to accept the patient when an appropriate surgery is ordered. This error can misguide us to think as if there is no need for surgery and this can cost us the entire case on the exam. I did cases on USMLE CD and when there is an indication for surgery, the surgeon will accept the patient and a window pops up saying " patient will be scheduled for surgery. Continue with medical management". We should then type the name of the surgery itself along with pre-op orders.

    Other mistake is the timing of emergent surgery is totally wrong on UW when you compare with the real USMLE CD. For example on UW, emergent laparotomy takes 24hrs, which is not emergent. This is wrong. You can practice this on USMLE CD. In reality, Stat laporotomy takes only 2 hours. If you pick up case number 1 on usmle CD and order "laporotomy" and choose "stat" and then check report time. It says with in 2 hours of order time, it will be done.
    If you are practicing on USMLE World software, please remember there are hundreds of errors especially in critical aspects like this where this software can clearly misguide us with respect to report times and time taken to complete an order. This leads to confusion.

    There are other critical mistakes on UW software like timing of CT in ER settings. CT scan stat in the ER takes 4 hours to come back on UW software where as it takesx only 30 minutes to come back on the USMLE CD. This shows that UW software has no time sense with respect to ER case scenarios where simulated time is crucial. If you have a stroke patient who presented in the ER with in 30 minutes, you can not wait for 4 hours to read the CT head result. If that is the case, you lose the valuable 3 hour window to administer thrombolytic in a CVA patient. UW software reports CT head in ER setting after 4 hours. Practicing cases on such software can obviously screw up our analysis i.e; waiting for four hours for a CT head when tpa was to be given with in 3 hours in a ischemic CVA patient.

    CT head takes only 30 minutes if ordered as "STAT" in the ER setting on the USMLE CD. So, clearly UW is giving erroneous "report times" which can mess up the case approach. I think it is better to work on the USMLE CD software to clear your doubts regarding this simulated time."

    Let us assume you end up with a stroke in the emergency room - how would you like getting a CT head result 3 hours after presentation? How can you support these errors? Stop cheating others. Learn to be humble and later, you can concentrate on english. If you continue to sin, you will soon perish in hell.
    Last edited: 10.13.11
  7. Gute

    Gute

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    I agree with overactive...UWORLD is not the problem. Uworld provides a framework and a basic order to approaching a case and goes over the basic things you must do in certain clinical scenarios.

    overactive is correct, the software is really looking for you to go on the right track for the initial steps of a case. CCS cares more that you ordered taht CT scan than getting to the tpa decision. They know that in the real world, the radiologist is paging your butt about the large hypodensity on noncon CT for ischemic stroke. you might get some gravy points if it lets you keep going and you pick tpa if it is appropriate...but I'll tell you, my cases were no where near getting to that high level of decision....especially one like that where the evidence is only recent that that therapy should be given.

    Let me tell you something: you aren't failing Step 3/CCS because Uworld doesn't have the timing for a laparotomy or a CT scan correct. If you are taking the real test and that results of a ct or laparotomy come back sooner, then guess what? your management will be dictated for you based off of those results. If you can't figure out what to do without Uworld's help, its not their problem. Their approach wasn't designed for people without real world experience.

    if you don't have the clinical judgement to make basic decisions without having studied the exact timing down to the minute on uworld for each specific scenario that could come up on CCS, then you probably aren't ready for unsupervised practice of medicine.

    If you are so inexperienced to need this much help with CCS before taking the test, you are not ready to take Step 3. Do more observerships. Do more clerkships. Do an intern year before taking this test. Don't expect that uworld or any other product you pay for can just make up for the judgement you will gain from work.
  8. haresh

    haresh

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    You guys are totally confusing people here and you are giving a deviant approach to people who come here for honest opinion. If some of you are working for UW, you must ask them to fix the software to prevent these errors. Or you all need to repeat your intern year. Your answer reflects severe lack of knowledge of the stroke protocol in the USA ( real world). The issue is clear - tpa must be given with in 3 hrs of acute CVA. To give tpa, a CT scan result must be read before 3 hours so tpa criteria is met. If you do not know this, vist a near-by ER and check their stroke protocol. If Ct comes after 3 hours, you can not give tpa because simulated time ( patient time) moved past three hours. If you do not give tpa with in 3 hrs of onset, you will get a zero score for that case. There is no role for tpa in acute thrombotic CVA after 3 hours of symptom onset. CCS tests your clinical management not just ordering a CT scan which even a nurse can do. We are expected to know the criteria for giving tpa in a stroke case. By giving wrong report times, UW software moves past the allowed simulated time and the entire case changes. Clinical judgment mandates you to give tpa in 3 hours not anytime you like!!! Know this simple issue first! I am just starting to understand these issues better after I stopped following UWorld.

    You said, "If you are taking the real test and that results of a ct or laparotomy come back sooner, then guess what? your management will be dictated for you based off of those results." I agree with that and that is exactly what I am referring to. Go to primum software at www.usmle.org and download the orientation material. Select case 1 and order a CT scan of head...it takes 30 minutes of patient time to get the result not three hours!!!! Now, do you see how the entire management will change and how your understanding of management guidelines will be affected if UW software gives these serious errors ? You will lose the understanding of importance of "simulated time" in management decisions, you will lose the case management principles, you will lose the importance of timing in critical cases in the ER!! Do I need to say more?

    Same problems with surgical cases and following guidelines with procedures in UW CCS. I find it much easier doing practice on software at www.usmle.org because the report times are similar to what you see in the ER. It is much easier to navigate the case when you stick to the guidelines. There is a critical problem with UW CCS , accept it! If you work for them, ask them to change this software to reflect exact times in real life ER or to reflect report times that are at least close to the official software at www.usmle.org. It is ok to sell an inferior product but do not sell something that harms people!

    Some people here seem to be lingering on the forum for three to four years. Have not they started their practice or work in residency? How do they find time to just come here and post irrelevant topics like these. Very suspicious.
    Last edited: 10.15.11
  9. Gute

    Gute

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    I do not work for uworld, but used their products along with others. In general their products were superior in my opinion.


    Maybe you need to check your knowledge base before saying I should repeat intern year and accuse of me of ignorance of stroke protocol in America. You say "there is no role for tpa..after 3 hours of symptom onset," but the ECASS 3 trial demonstrated a benefit for tPA at up to 4.5 after onset of ischemic stroke symptoms, and this 4.5 hour time frame is used by major academic medical centers.

    tPA can also be given by intraarterial administration in some patients after the 4.5 hour window has passed.

    Like I said before, you aren't going to fail the CCS portion of step 3 because Uworld's timing isn't exactly the same. You will fail if you lack the knowledge and the judgement to practice correct medicine. Part of this involves adapting to different scenarios: this is the point of CCS instead of just multiple choice questions.
  10. haresh

    haresh

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    Sir Gute! I am not here to argue with you but just making a point how most of us in initial stages of preparation are being taught a deviant approach by this error-filled heavily-advertised UW software. Whatever trial you are quoting suggests an extended benefit until 4.5 hours but that does not mean you wait and watch for the stroke to progress for 3 hours for a crazy reason of not being able to get CT read in 3 hours!! Intrarterial is fine but it is for people who come late to ER after stroke onset. If the poor patient was prompt in getting to ER with in 30 minutes, it is not justified to delay the tpa or resorting to invasive intra-arterial approach just because UW software ( like a lazy ER doctor) is negligent in getting the CT within 3 hours.
    JCAHO standards call for getting the CT read in 45 minutes of arrival in ER
    ( not 3 hours).
    Here is a stroke protocol template that meets JCAHO standards :
    http://www.beaconcollaborative.org/assets/files/Stroke_Tool_Kit/CPMC-Stroke-PnP.pdf

    Anything that is being done just because you are negligent confers harm to the patient in the form of a progressive stroke and is a failure on that case. In real life, we could be shot for committing such mistakes.

    Also, do you know how much importance is given for "timely management" of acute stroke? This means we are expected to keep "simulated time" as low as possible in acute stroke by the time tpa is administered. Each 15 minute delay could be a reduction in CCS score. Does UW teach this anywhere? If they make critical errors like this what is the kind of message they are conveying...does not the message mean it is ok to wait for CT head for 3 hours? Unacceptable!

    Do you follow up-to-date? The following are the words from the world-famous most widely consulted up-to-date in medicine . It says "TIME IS BRAIN"! You wait three hours, patient loses more brain to ischemia! Give tpa in less than 60 minutes, you get good score in CCS. At 4.5 hours, below average score. After 4.5 hours, zero score!

    Reference from up-to-date:
    Treatment timeline — "Time is brain": the sooner intravenous alteplase treatment is initiated after ischemic stroke, the more likely it is to be beneficial. Eligible patients should be treated as quickly as possible within the appropriate 3 or 4.5 hour time limit. To achieve the earliest treatment, current guidelines recommend that the elapsed time to the start of alteplase infusion should be ≤60 minutes from the time of patient arrival in the emergency department . The following in-hospital timeline is suggested as a goal for all patients with acute ischemic stroke who are eligible for treatment with intravenous alteplase:

    Evaluation by physician - 10 minutes
    Stroke or neurologic expertise contacted, ie, stroke team - 15 minutes
    Head CT or MRI scan - 25 minutes
    Interpretation of neuroimaging scan - 45 minutes

    Start of treatment - 60 minutes from arrival


    Please do not punish patients with negligence and fatal errors! Now, would you please let me know who lacks the clinical judgement and time sense in treating emergency room patients?
  11. Gute

    Gute

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    Obviously time is brain, but if you dont have the CT result your hands are tied because it could be a hemorrhagic stroke. uw probably should have the CT come back sooner, but in the real world, CT scans don't get read at precise intervals. You gotta use judgement and do the best thing you can given the limitations of the information you are provided.

    The best call is to give tPA as soon as you know it is safe and indicated, but you were clearly incorrect that 3-4.5 hours out is outside the window.
  12. haresh

    haresh

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    Again, I am not here to argue with people who do not understand the concept behind "simulated time" in the CCS cases. This is clearly the reason why most people are failing in CCS portion even after repeating this error filled UW software three times. Simulated time is crucial and managing it well is important. By reporting results very late, UW is conveying a fatal point that it is "ok" to delay in the ER in critical setting. As we practice more on the software, we lose the concept of software navigation and the judgement in critical case scenarios.
    Surgery is a huge problem also. Surgeons will not accept in UW even if there is indication. This conveys a message to us that it is "ok" to order the name of the surgical procedure on primum software even if surgeon does not accept. Not everyone knows correct indications for surgery and if surgeon does not accept it is not acceptable to put surgery name with out first meeting the criteria for surgery. Surgery is invasive and putting such orders with out having an idea about navigation and how things will work on "Primum software" is a serious issue. The flaws in UW are definitely a reason why many people are failing the exam. At least, this is true for people with average knowledge. Some people may have great IQ to neglect the UW errors and move on in their own way. But for most people, this erroneous method that they practice on UW will stick and they do the same errors on the exam.
  13. NKJN

    NKJN Member

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    Hi Haresh, I see that you are very passionate about warning people about the UWorld CCS software errors. I definately dont work for uworld. I can understand your frustration about legitimate errors in a software that people endorse heavily. However, if the program's only flaws are incorrect simulated time for 2/52 clinical senarios and failure to "accept" an obvious surgical candidate, that still shouldnt cause you to fail the real thing. Even IF uworld is flawed when it comes to simulated time, that would not cause me to question my medical knowledge. Yes, you're right about the 3 hr window for tpa, and yes, you're right, in real life a stat head CT should come back much sooner so you know whether you're treating an ischemic or hemorrhagic stroke. However, I still dont understand why messed up simulated time on uworld would cause you to fail; if the simulated time is correct on the real software, then I imagine you'll get your head CT back when you're supposed to, order your tpa, save your patient's life and be done with it. Same with the surgery consult case; on the real exam, if you know it's appendicitis, you'll get your surgery consult, they will accept the patient for surgery, u do your orders and it's all good. What's the problem? The errors you point out are not "critical" or "dreadful" or "fatal" at all.


    Actually it does. like another poster pointed out, when you review the case, there's a chart with 3 columns; on the L = ALL the things you must do/order to get ALL points; middle column = stuff u do/order that doesnt hurt nor help your score; R column = stuff that if you do/order WILL cost you points. Further more, it lists the general guideline as to how to manage your time, when to order things, which things are emergent orders, what can wait, when to transfer patients to ward/ICU, etc.

    How so?? Again, I understand that its frustrating dealing with a flawed software, but why should that make you question your clinical judgement on the real exam? Besides, you yourself said that when you used sound clinical judgement in the official USMLE cd, everything was fine:

    ...Sooo if you understood the USMLE software, put in the correct orders in the appropriate amount of simulated time, why did you still fail the exam? I'm not trying to be a smart a**, but i just dont get how you are blaming uworld for your failures when you claim that you were fine doing the official USMLE software.

    Again, still dont understand. The simulated time for a stat ex lap is wrong in uworld, ok fine... but it's correct in the USMLE cd...which you used...but you still failed and are blaming uworld??


    You only listed the same 2 errors over and over...that is not "hundreds" like you claim. I think you got tripped up by the few errors on uworld, which caused you to miss the big picture and purpose of the exam (twice). You clearly got confused by the uworld software, (and rightfully so when it came the head CT in the stroke case), but since such flaws are not present in the real USMLE software, you should've been ok on the real exam if you know your medicine.

    Wow I'd hate for MY doctor to ignore common sense and sound clinical judgement and medical knowledge just because a software suggested otherwise. When in doubt, look it up. Should there be a discrepancy between what uworld says and what the literature says, bring this to uworld's attention. Laziness (rope memorization of a software) should never replace a physician's ability to use his or her brain!


    I'm sorry that you got so hung up on the few uworld flaws that you were second guessing yourself too much on the real exam.

    Anyway, I saw that you finally passed the thing, so congrats. I'm sure this whole process sucked for you, but hopefully you (and others) can learn from your mistakes. Uworld may not be perfect for ccs, and I thank you for the heads up. However, it certainly seems to be helping the vast majority of ppl I've spoken to about the exam, so I'm gonna stick with it.

    Best of luck to you.
    Last edited: 02.03.12
  14. haresh

    haresh

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    NKJN, the very fact that you spent your whole day writing that post tells me who you are!
    I am not against any software but I was trying to give facts about this flawed software that some people here are promoting. So, now you are accepting all these errors. But earlier I was attacked by one UW promoter here for just giving my opinion. So, what does it tell you?
    If you are scheduled for surgery and surgeon does not accept, UW is giving an impression to test taker that it is fine to put a surgery consult even when it is not accepted by surgeon. That is what you do in UW software. But when surgeon does not accept there may not be an indication for surgery as per what I learned. If test taker gets misguided and puts in wrong consult and then writes the procedure name even when surgeon rejected, he will fail. This is what some people did..just GOOGLE and see how people failed using this wrong UW approach. I wrote three errors? Do you want more? I will start posting everyday one if you would like to know more errors.

    In CCS, the simulated time is fundamentally, very crucial. UW fails to convey that message and fails to convey the message of following emergency management guidelines by seriously skewing wrong report times and the case goes wrong when you do not understand these guidelines. You can use your judgement and pass on the exam but why practice on a flawed software if you are going to use your judgement anyway? Double effort of doing wrong approach first and then taking time to correct yourself on the Primum software?

    I want you and everyone to understand that there are alternatives out there and people need not practice on outdated and flawed UW software by paying them a fee. So, you are telling us to buy that software, practice it, follow the errors and self-correct ourselves each and every time it misleads us. Amazing ! why should I buy that flawed software in the first place and why should I put in so much effort to understand it's errors? Does it make any sense to us except that UW will make money at our expense? Moreover, this UW software is extinct now because of new CCS changes.

    I was not second guessing. I improved a lot and i actually passed with a very high score this time. I am ready to answer anyone's CCS challenges and let us see if you UW promoters can compete with me here with all the errors you are used to :)

    Just open your eyes and google "USMLEWORLD CCS ERRORS". People are talking about them everywhere on how it is poorly impacting their performance. Just GOOGLE!!! GOOGLE does not lie!
  15. raymon

    raymon

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    Haresh's posts are so true
    With all the mis-guidance, UW is sending us to the exam in a very wrong direction. It is so sad to see it is still well-promoted by hired workers on many forums.

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