advice after failing ICE on CS

[step2cs01]

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So I got the 4/9 stars in the borderline zone for ICE, just one shy of passing. Yeah, quite a punch in the gut. (AMG, scored fine on Step1/CK).

CIS/SEP were mid to high. Given that ICE is basically the PE check points and Global score on note, these are my thoughts about what happened that day:

1. Kept finishing early (3-5 min early) consistently because rushed through the encounter due to time worry.
2. Noticeably felt my PE's were too short and once or twice missed doing exam on a part of CC.
3. Always put 3 ddx, even though some were pretty weak and just wanted to fill up the space.
4. Felt supporting evidence at times was pretty weak for likely appropriate diagnoses
5. kept citing same pertinent negative Exam evidence over and over bc thought it was ok to do that since mostly all normal findings
6. Did not ask sexual history on some adult patients
7. missed some pertinent q's (related to feeling of poor supporting Historical evidence).



All in all, i may have missed some points on the PE but seems to me the NOTE is what caused me to fail. I'm not sure if that is a result of missing information translating to poor supporting evidence or just poor ddx listed. I think the 'diagnostic tests' were appropriately conservative overall. And I'm guessing stuff like challenge questions/closing well is part of CIS score, so not giving that as much attention.

Any feedback would be tremendous, I have to retake this within the month. I'll plan to go thru FA again and practice more so I'm fluid on test day and don't choke on PE/rush like I did first time. Since I haven't been doing any rotations I'll do some CK review also to bring back some clinical reasoning ability.

 

[Patho_logical]

Hey,

I completely understand how you're feeling. I had the same thing happen. Borderline failed the ICE. I'm an AMG, Other step scores were all fine, good grades on clinical rotations. This test is way too subjective and very much not an assessment of medical knowledge or social skills but whatever.

Here's what I did differently the second time around. You can find mnemonics online for hpi and ROS. I used these on my second attempt. I did OLDCARTS for hpi and the PUBSAWED stuff for ROS. (Google it if you don't already know it). I think that really helped me to cover the history really well. Just put a check mark or an 'X' by the ROS items as you ask them. It goes fast. That's really all I changed on data gathering.

On physical exam, I listened for 3 seconds at each spot (read somewhere that you need to listen for that long), I basically did heart, lungs, abdomen on everyone. I'm sure your physical is probably not what failed you.

As for your note, that's where I felt like I might have failed the first time too (but who knows, honestly?) I think the best thing is to get the First Aid. Read a case. Then set a timer on your phone and type a note. I would give myself 9 minutes to type it then compare it to the sample in First Aid. If it was close I would feel pretty good about it. The ones that I left out a lot on kind of stuck in my head as important bits of info to include for such cases.

Here's what my prep looked like for the second attempt:
I first wrote and re-wrote out my mnemonics for the history.
After I had those down, I set a timer for 13 minutes and faked an encounter. I literally started the timer and read the "doorway info" page; jotted down any significant vitals and the patient name and age, then knocked on my bedroom door and walked in then pretended I was interviewing someone and doing a physical exam. I felt really stupid, but it helped me tremendously with getting the feel for how long I have. It sounds like you left the room early a lot and maybe didn't get to be as thorough as you could have been. If nothing else, ask the SP if they would like to tell you anything else that they forgot about. Couldn't hurt. So after my fake interview and physical (check in first aid to see if you did all or most of the physical exam it says to do for the case) with my ghost patient I would leave the room and sit down at my computer with the online note writer already open, start my timer for 9 minutes, type a note, and compare it to the note in FA. Check my Ddx and my work up. And that was that. I did that for probably 10-15 cases. And read all the cases and mini cases at least once. That was about it. It wasn't anything crazy. Prepped easily in a couple week's time. Passed with very high scores in all sections.

ALSO: Read the bulletin from usmle about how it's scored. It seems like a bunch of useless info but there are important sections in it. You should be able to google search and find it. It's just a pdf that explains the exam but it helped me apparently.

Good luck! I hope you get this thing behind you. It caused me a ton of stress. You'll get through it.

 

[downthedrain]

Ugh, you guys are making me nervous about this. I feel like I definitely put things in my note with poor support. Also, there were things in the physical exam that I missed and only realized when I walked out of the room. I felt like I was OK because I spent at least 5mins at the end explaining what I thought was going on and what I was going to do as well as telling patients to stop smoking, cut back on caffeine, etc, but now I'm really nervous cuz it seems like you guys all did that too. Crap!

 

[Patho_logical]

Ugh, you guys are making me nervous about this. I feel like I definitely put things in my note with poor support. Also, there were things in the physical exam that I missed and only realized when I walked out of the room. I felt like I was OK because I spent at least 5mins at the end explaining what I thought was going on and what I was going to do as well as telling patients to stop smoking, cut back on caffeine, etc, but now I'm really nervous cuz it seems like you guys all did that too. Crap!

I wouldn't worry if it's done and you're just waiting for scores. It would be pointless. You most likely passed. I was probably just very unfortunate in how mine was graded. I'm sure the 2/12 that were not graded were my best cases. If you did the counseling on most you should be fine. I felt like I did pretty decently the first time and failed. But honestly I didn't feel much better the second time and I was all the way in the higher performance area on the score report. So I really think it just depends on who grades your notes and the mood they are in that day. The CS is a largely subjective test, and I think it's pretty unfortunate that it is set up the way it is. Also, I hate that it is milked for all its worth in terms of making the NBME money. But I guess that's how it goes. We pay thousands of dollars to take tests and we are allowed to practice medicine after a few years. I'm sure you did fine. Try not to worry about it! Good luck!