AMG at top medical school, failed Step 2 CS!

[medblazer21]

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I guess I'm in the bottom 4% of people who fail the exam.

The reason I failed was the ICE portion. My interpersonal skills and english were graded very highly.

I did badly on both the "patient note" portion as well as the "data gathering" section. I really wish they would give me a more detailed score breakdown, because data gathering is both history and physical so I dont know if one was worse than the other or not.

The patient note section was graded as borderline pass/fail. I thought my notes were OK, I didnt realize they were so bad.

Looking back, I can understand how I failed:

1) I had a depression patient and only asked 2 of the SIGECAP questions.

2) I didnt have any alcoholics, but I had about 5 people who said they had 1-2 drinks per week and I didnt ask CAGE questions on any of them. I thought CAGE was just for people who identified a heavy drinking habit, not 1-2 drinks per week.

3) I asked most of the LIQOR questions related to each complaint, but I didnt consistently ask all of them.

4) I didnt get an OB/GYN history on every woman. I only asked for those with abdominal pain or STD complaints.

5) I didnt get a detailed sexual history on every patient, only the abd pain or STD patients. If a pt told me they were married, I just left it at that, and didnt ask about sexual orientation, sex with same gender, # of sexual partners in last year, etc.

6) For physical exam, I didnt elicit any specific signs (i.e. Homans, Kernigs, Murphy, Dix-Hallpike, etc). I was able to do basic CV, lung, abd exams on every pt regardless of complaint, and for the neuro patients I was able to do about 95% of the neuro maneuvers.

7) I think I might have lost points for not doing some of the PE maneuvers exactly right. For example on lung exam I listened to 4 positions on posteriorly and 2 positiosn anteriorly, its possible SP didnt give me credit for it because I didnt listen to 6 and 4 respectively.

8) I didnt do any inguinal lymph nodes or femoral pulses on anybody, even for those with CV, GI or STD complaints.

9) On the patient note, I wrote all physical exam findings as normal. I thought that they were just checking to make sure I did all the maneuvers, I didnt realize they were looking for REAL physical exam findings on the patient, even though it had nothing to do with their diagnosis (i.e. gastritis patient with mildly diminished extremity position sensation).

10) On the patient note and history taking, my ROS was very very limited. For example if they had a headache I asked about nausea, vomiting, diplopia, stiff neck but didnt ask about a bunch of other stuff such as dizziness, vertigo, gait difficulty. And I didnt ask ANYTHING about other systems such as leg swelling, rhinorrhea, cough, diarrhea, etc.

11) Had a depression patient and didnt do a MMSE. Did you guys do this on all neuro/psych patients or just the standard AO x 3 stuff?

 

[arthrodisiac]

didnt do mmse, though before i entered the room i thought i should do it, and as i left i was pissed i forgot.

if i heard alcohol i did cage, although it took up at least a minute, which caused me to run out of time a few times.

i definetely didn't get obgyn histories on all of the women, i dont even think i did a full one on the obgyn patient.

i didnt do inguinal or femoral.

i think i said everything was normal unless they faked a complaint...said ouch when i did palpation...positive impingement sign, etc.

sorry dude

 

[Hard24Get]

Hmm, I came here as a result of your post. I still dont see what you did that was so bad. They said to do a focused exam. So I understand sigecaps, but CAGE on people with 1-2 drinks on the weekend etc? I didn't do any of the stuff you didn't do, so if that's why you failed then I guess I definitely failed. Thought, it doesn't seem justified to me? 😕 why do a sexual history, etc on someone with an unrelated complaint?

I guess I'm in the bottom 4% of people who fail the exam.

The reason I failed was the ICE portion. My interpersonal skills and english were graded very highly.

I did badly on both the "patient note" portion as well as the "data gathering" section. I really wish they would give me a more detailed score breakdown, because data gathering is both history and physical so I dont know if one was worse than the other or not.

The patient note section was graded as borderline pass/fail. I thought my notes were OK, I didnt realize they were so bad.

Looking back, I can understand how I failed:

1) I had a depression patient and only asked 2 of the SIGECAP questions.

2) I didnt have any alcoholics, but I had about 5 people who said they had 1-2 drinks per week and I didnt ask CAGE questions on any of them. I thought CAGE was just for people who identified a heavy drinking habit, not 1-2 drinks per week.

3) I asked most of the LIQOR questions related to each complaint, but I didnt consistently ask all of them.

4) I didnt get an OB/GYN history on every woman. I only asked for those with abdominal pain or STD complaints.

5) I didnt get a detailed sexual history on every patient, only the abd pain or STD patients. If a pt told me they were married, I just left it at that, and didnt ask about sexual orientation, sex with same gender, # of sexual partners in last year, etc.

6) For physical exam, I didnt elicit any specific signs (i.e. Homans, Kernigs, Murphy, Dix-Hallpike, etc). I was able to do basic CV, lung, abd exams on every pt regardless of complaint, and for the neuro patients I was able to do about 95% of the neuro maneuvers.

7) I think I might have lost points for not doing some of the PE maneuvers exactly right. For example on lung exam I listened to 4 positions on posteriorly and 2 positiosn anteriorly, its possible SP didnt give me credit for it because I didnt listen to 6 and 4 respectively.

8) I didnt do any inguinal lymph nodes or femoral pulses on anybody, even for those with CV, GI or STD complaints.

9) On the patient note, I wrote all physical exam findings as normal. I thought that they were just checking to make sure I did all the maneuvers, I didnt realize they were looking for REAL physical exam findings on the patient, even though it had nothing to do with their diagnosis (i.e. gastritis patient with mildly diminished extremity position sensation).

10) On the patient note and history taking, my ROS was very very limited. For example if they had a headache I asked about nausea, vomiting, diplopia, stiff neck but didnt ask about a bunch of other stuff such as dizziness, vertigo, gait difficulty. And I didnt ask ANYTHING about other systems such as leg swelling, rhinorrhea, cough, diarrhea, etc.

11) Had a depression patient and didnt do a MMSE. Did you guys do this on all neuro/psych patients or just the standard AO x 3 stuff?

 

[Tiki]

Hmm, I came here as a result of your post. I still dont see what you did that was so bad. They said to do a focused exam. So I understand sigecaps, but CAGE on people with 1-2 drinks on the weekend etc? I didn't do any of the stuff you didn't do, so if that's why you failed then I guess I definitely failed. Thought, it doesn't seem justified to me? 😕 why do a sexual history, etc on someone with an unrelated complaint?

I didn't do the majority of those things either (except the CAGE and SIGECAPS) and I passed.

 

[babycatcher08]

i really dont know how you failed. now, i think i definitely failed.

 

[lord_jeebus]

How long were your notes? I remember listing a lot of pertinent negatives.

 

[Rogue_Leader]

I remember that for my notes (did mine on computer), I always maxed out the HPI box. The PE box only had 5-6 lines of stuff, and I always wrote the vitals. I always tried to fill out 5 differentials and 5 tests, and I'll admit that some of them tended to be a reach just to try and get points.

 

[nevercold]

Hopefully I passed. I found that every case was very easy to figure out or to get to a point where a particular test or couple of tests would give you a diagnosis among a few possibilities. A focused history and physical were all that was needed for just about every case and all that is really appropriate in a 15-minute encounter.

Let's be honest, half of the country has a chronic disease or two and most patients come to clinic on like 7-8 meds with 5-6 problems and a ton of behavioral changes needed. If you're seeing this patient for the first time, you would *never* *EVER* schedule only a 15-minute visit. It would be 30 minutes at a minimum to be sure you could gather all the information. Some doctors schedule 45-minutes for new patients. And that's what this is--it is a NEW patient visit even though we're focusing on one problem.

I definitely asked the questions and did the exams I needed to come to a conclusion or decision tree about the presenting complaint and I'd be happy to defend that to the NBME if they think I didn't do enough.

As many people have pointed out, some elements are not appropriate even though First Aid says to do them. "I may have a glass of wine if we go out to dinner on the weekend, but that's it" does not warrant a CAGE questioning. In fact, the patient would be more likely to be insulted by it in reality than anything. Sexual history on someone who comes in with an acute sports injury is completely irrelevant and an inappropriate use of everyone's time in a 15-minute visit. That's why you go for yearly physicals, to run through all of those issues.

Jeez, I'm all fiery here or something. Guess I'll stop my rant 🙂

 

[MeowMix]

Good luck with your retake. This exam is not at all an automatic pass for AMGs; 5-10 people from my school failed last year.

Wanted to comment on a few of your conclusions about your CS results; I'm not sure I agree with some of them. I used FA only and thought it was very good, though I was convinced I failed CS until the day I got my results.

1) I had a depression patient and only asked 2 of the SIGECAP questions.
- this was my first case and I totally blew it, don't think I asked any of the SIGECAPs, although I was empathetic. And I blew the ddx in my note.

2) I didnt have any alcoholics, but I had about 5 people who said they had 1-2 drinks per week and I didnt ask CAGE questions on any of them. I thought CAGE was just for people who identified a heavy drinking habit, not 1-2 drinks per week.
- every SP said 1-2 glasses of wine/wk and I was so disoriented (b/c it is so unreal) that I didn't ask any CAGE questions except maybe one pt where it seemed necessary

4) I didnt get an OB/GYN history on every woman.
5) I didnt get a detailed sexual history on every patient
I'm sure I didn't do this either, except where it seemed relevant. There isn't enough time

6) For physical exam, I didnt elicit any specific signs (i.e. Homans, Kernigs, Murphy, Dix-Hallpike, etc). I was able to do basic CV, lung, abd exams on every pt regardless of complaint, and for the neuro patients I was able to do about 95% of the neuro maneuvers.
That's way more than I did.

7) I think I might have lost points for not doing some of the PE maneuvers exactly right.
I certainly didn't do mine perfectly either.

8) I didnt do any inguinal lymph nodes or femoral pulses on anybody, even for those with CV, GI or STD complaints.
I think I did these where appropriate.

9) On the patient note, I wrote all physical exam findings as normal.
This is where I wonder if you lost a lot of points. Did you write "normal" or did you write specifically, HEENT: TM clear, OP clear, no LAD, sclerae clear, PERRL, EOMI? Did you use abbreviations not on their approved list? I did not have a single pt with a true abnormal finding.

10) On the patient note and history taking, my ROS was very very limited.
I did do very detailed ROS, although I also missed a lot of things.

11) Had a depression patient and didnt do a MMSE.
Didn't do MMSE on anyone, got too disoriented by the unrealness of the SPs.

 

[jdh71]

This is a test of "check-marks". You either asked a question or did and exam or you didn't. There is no checking between the note and the camera in the room. The camera is there for simulated patient protection. Bottom line . . . if you forgot something in the history and physical, you PUT it in your note. Organize your note damn it! Label your sections - make sure they are all there! HPI, ROS, PM/PSHx, SocHx, Meds/Allergies, etc . . . your graders are looking for these section specifically. Memorize a whole ROS for everything, do you best on focused questions and then hit them with pertinent ROS Q's - all you are doing is picking up points. Simulated patients have no clue you are being unorganized, they have to leave a checkmark if you asked a question. Remember heart in 4 places (ask women with large breasts to kindly move themf or you), lung in 4 places in back, two up front - that nothing more than points.

I recommend First Aid.

Make it hard for them to fail you by playing the system against them (and I say "against," because the test appears rigged against certain types of personalities - more on that if you want to PM me)

 

[Arsenic]

This is a test of "check-marks". You either asked a question or did and exam or you didn't. There is no checking between the note and the camera in the room. The camera is there for simulated patient protection. Bottom line . . . if you forgot something in the history and physical, you PUT it in your note. Organize your note damn it! Label your sections - make sure they are all there! HPI, ROS, PM/PSHx, SocHx, Meds/Allergies, etc . . . your graders are looking for these section specifically. Memorize a whole ROS for everything, do you best on focused questions and then hit them with pertinent ROS Q's - all you are doing is picking up points. Simulated patients have no clue you are being unorganized, they have to leave a checkmark if you asked a question. Remember heart in 4 places (ask women with large breasts to kindly move themf or you), lung in 4 places in back, two up front - that nothing more than points.

I recommend First Aid.

Make it hard for them to fail you by playing the system against them (and I say "against," because the test appears rigged against certain types of personalities - more on that if you want to PM me)

one of my classmates when he was taking CS in atlanta went into the room but couldnt find the drape that is normally on the stool. he opened the door, told the proctors and they brought him a new one. like 2 encounters later one of the proctors comes up to him and tells him that they had reviewed the tape and that the SP had actually hidden the drape from him in the room! 😱 they told him not to worry that they had filed an incident report with the NBME and that the encounter with that pt wouldnt be graded. insane. just another reason why the camera is in the room, the protection goes both ways.

 

[theCamel]

i didn't listen anteriorly to any lung fields on anybody
forgot completely to do abd exam on one pt entirely
no abnormal findings on anybody
didn't document cardio/pulm on one pt note

is there this much room for error, or is there a big chance i failed??

 

[Lauraaa]

Hi Guys,
Sorry I posted this on another thread but maybe it belongs here too -

Did anyone take CS before taking CK and have any problems with that? I'm going to be in a place for the next 3 weeks where I don't have good access to internet and so won't be using USMLE world during that time. I thought it would be a good time to use for studying first aid for CS and taking the exam after match day, but I might want to reconsider doing that if anyone had a bad experience taking CS first...

 

[Rogue_Leader]

Hi Guys,
Sorry I posted this on another thread but maybe it belongs here too -

Did anyone take CS before taking CK and have any problems with that? I'm going to be in a place for the next 3 weeks where I don't have good access to internet and so won't be using USMLE world during that time. I thought it would be a good time to use for studying first aid for CS and taking the exam after match day, but I might want to reconsider doing that if anyone had a bad experience taking CS first...

I took the CS 4 months before taking the CK, it's not a problem so long as you've finished the big 6 clerkships (med, surg, psych, peds, OB/Gyn, family), neuro helps but I didn't have it done before taking the exam. For the most part, you already have all the medical knowledge you need for the exam, and preparation is moreso about making sure you can hit all the requsite elements of the patient encounters in a succinct manner and getting comfortable with planning your questions and physical exam on the fly without needing to stop and think. 3 weeks is a hell of a long time to study for the CS, and I think you'll find that you'll have no benefit for taking that long to study for it. I'd say that you should take some CK material with you as well, because I don't think it's possible to spend 3 weeks studying for the CS. (You'll get everything you need from FA after 3 days spending 2 hours a day reading it).

 

[kitsens]

x

 

[Lauraaa]

I took the CS 4 months before taking the CK, it's not a problem so long as you've finished the big 6 clerkships (med, surg, psych, peds, OB/Gyn, family), neuro helps but I didn't have it done before taking the exam. For the most part, you already have all the medical knowledge you need for the exam, and preparation is moreso about making sure you can hit all the requsite elements of the patient encounters in a succinct manner and getting comfortable with planning your questions and physical exam on the fly without needing to stop and think. 3 weeks is a hell of a long time to study for the CS, and I think you'll find that you'll have no benefit for taking that long to study for it. I'd say that you should take some CK material with you as well, because I don't think it's possible to spend 3 weeks studying for the CS. (You'll get everything you need from FA after 3 days spending 2 hours a day reading it).

Thank you! another question for those who have taken it -
Did you guys write on the note for the differential or in the work up section the reason for including diagnoses and tests or did you just list them like in First Aid?

Thanks...

 

[Rogue_Leader]

Thank you! another question for those who have taken it -
Did you guys write on the note for the differential or in the work up section the reason for including diagnoses and tests or did you just list them like in First Aid?

Thanks...

Just list them. Your notes should be exactly like how they're presented in FA, aside from how you can only list a max of 5 differentials and 5 tests.

 

[medblazer21]

Thanks so much for your posting Medblazer. It's really helped me feel less isolated during this crisis.

Similar situation. Did well on OSCE, fairly well on Step 1 and CK. Reputable med school. Middle of the road student. I can "come up" with reasons I didn't pass the first time, but it is purely speculation. Many who seemed to have the same concerns passed the exam. I failed in the integrated clinical encounter portion. My data-gathering was atrocious. Absolute bottom of the curve which I cannot understand.

All said. I didn't study at all the first try and don't recommend that to ANYONE! Not to mention, it had been several months that I had seen a patient in the outpatient/urgent care type setting.

Take this exam seriously for 2 days at least. You must look at First Aid and visualize how the cases will manifest during the real exam. It is critical to devise a strategy to pick up as many points as possible. Use mnemonics if you need them. Take the test early for those in third year. Get it out of the way, and in the event you fail, there will be time to retake.

Took the retake. Waiting on the rescore. Scared ****less. Ironically, after the retake I have far more fear of failing and continue to "second guess" and lament the things I missed during the exam. Hopefully this is a sign I knew what I was doing this time with exam. 🙂

Good luck everybody.

Thanks for sharing your story. Do you mind giving more details about why you think you failed? You can PM me if you dont want to talk publicly about it. Also, where did your score averages fall on the chart? My data gathering was off the charts bad, my patinet note was mostly in the "borderline" region.

 

[gleep and gloop]

Thank you! another question for those who have taken it -
Did you guys write on the note for the differential or in the work up section the reason for including diagnoses and tests or did you just list them like in First Aid?

Thanks...

Nah, there's really no room for this. For almost every one of my patients, I was maxed out on the HPI section and was having to delete things as time ran out to put in more important points. There's definitely no room for justifying your differential. And in the space where you actually list each diagnosis, you only get one short line for each one.

 

[medblazer21]

Alright so I took my retake the other day, and I'm still worried.

I used all the mnemonics this time which I failed to do last time. So I think I got at least a few more points off that.

I used LIQORAAAFPPPT and PAMHUGSFOSS and TOADDESS mnemonics. They are helpful, I asked every single one of the questions related to those, and it doesnt leave you enough time to ask a lot of ROS-related questions or do a real thorough physical exam. I found that many of the cases I was starting the physical exam right around the 5 minute mark which is much later than I started the first time I took the test.

I still blew a couple of cases. One SP answered YES to 4 of the SIGECAP questions even though it was clear at the end of the case that his symptoms were not related to depression. It kinda ticks me off, because it caused me to waste a lot of valuable time working up depression when he had several different complaints and I didnt have enough time to cover all of them because he falsely got me off track on the depression stuff.

I think that depression should only be considered in patients who answer YES to the guilt/worthlessness question or if they had a suicide attempt. I noticed on at least 5 other SPs that they also answered YES to the "change in mood" question which forced me to ask SIGECAP which wasted time. I think too many of them are overthinking the question and ad-libbing instead of sticking to their script. They are thinking as an actor "since I have weight loss, or general fatigue, or ____________ then I should probably feel down about it as well."

Forgot to do dix-halpike on a dizziness patient, and didnt have time to check orthostatics.

Overall I think I got probably 30% more history than the first attempt. Physical exam overall probably about the same.

Honestly I'm not sure if thats enough to change from a fail to a pass or not. I dont feel real good about it though. If I fail it again, I'm going to throw out all the mnemonics and just memorize a list of questions SPECIFIC to every complaint.

For example, next time I have a dizziness patient, I'm only going to ask LIQORAAAFPPPT and PAM questions (ignore HUGSFOSS and all of the TOADDESS) and just ask all the dizziness-related ROS questions, and then do dix-hallpike, and then check orthostatics, full cardio exam, full neuro exam, do all the counseling BS, and ONLY THEN if I have time go back to fill in the details of the social history.

The physical exam on a dizziness case takes at least 8-10 minutes to do everything. I think its by far the most difficult case to cover everything on time.

 

[flumazenil]

can you please tell me what these mnemonics all stand for..toadess..pamhugfoss..etc

 

[gleep and gloop]

But if this is really a "checklist" sort of test like First Aid and others say, then it's much more high yield to spend time asking more detailed history and ROS questions than it is to do single, time-intensive PE maneuvers like Dix-Hallpike or orthostatics. Personally, in the one case I had where I felt orthostatics were warranted, I wrote them as an order in the note.

Best of luck this time around - I'm sure you'll pass without a problem.

Alright so I took my retake the other day, and I'm still worried.

I used all the mnemonics this time which I failed to do last time. So I think I got at least a few more points off that.

I used LIQORAAAFPPPT and PAMHUGSFOSS and TOADDESS mnemonics. They are helpful, I asked every single one of the questions related to those, and it doesnt leave you enough time to ask a lot of ROS-related questions or do a real thorough physical exam. I found that many of the cases I was starting the physical exam right around the 5 minute mark which is much later than I started the first time I took the test.

I still blew a couple of cases. One SP answered YES to 4 of the SIGECAP questions even though it was clear at the end of the case that his symptoms were not related to depression. It kinda ticks me off, because it caused me to waste a lot of valuable time working up depression when he had several different complaints and I didnt have enough time to cover all of them because he falsely got me off track on the depression stuff.

I think that depression should only be considered in patients who answer YES to the guilt/worthlessness question or if they had a suicide attempt. I noticed on at least 5 other SPs that they also answered YES to the "change in mood" question which forced me to ask SIGECAP which wasted time. I think too many of them are overthinking the question and ad-libbing instead of sticking to their script. They are thinking as an actor "since I have weight loss, or general fatigue, or ____________ then I should probably feel down about it as well."

Forgot to do dix-halpike on a dizziness patient, and didnt have time to check orthostatics.

Overall I think I got probably 30% more history than the first attempt. Physical exam overall probably about the same.

Honestly I'm not sure if thats enough to change from a fail to a pass or not. I dont feel real good about it though. If I fail it again, I'm going to throw out all the mnemonics and just memorize a list of questions SPECIFIC to every complaint.

For example, next time I have a dizziness patient, I'm only going to ask LIQORAAAFPPPT and PAM questions (ignore HUGSFOSS and all of the TOADDESS) and just ask all the dizziness-related ROS questions, and then do dix-hallpike, and then check orthostatics, full cardio exam, full neuro exam, do all the counseling BS, and ONLY THEN if I have time go back to fill in the details of the social history.

The physical exam on a dizziness case takes at least 8-10 minutes to do everything. I think its by far the most difficult case to cover everything on time.

 

[Hard24Get]

Hmm, I came here as a result of your post. I still dont see what you did that was so bad. They said to do a focused exam. So I understand sigecaps, but CAGE on people with 1-2 drinks on the weekend etc? I didn't do any of the stuff you didn't do, so if that's why you failed then I guess I definitely failed. Thought, it doesn't seem justified to me? 😕 why do a sexual history, etc on someone with an unrelated complaint?

BTW, I passed 😀

 

[medblazer21]

BTW, I passed 😀

Congrats!

i'm still waiting for the score to come back on the retake

goddamn this test!

 

[samgobigs]

I guess I'm in the bottom 4% of people who fail the exam.

The reason I failed was the ICE portion. My interpersonal skills and english were graded very highly.

I did badly on both the "patient note" portion as well as the "data gathering" section. I really wish they would give me a more detailed score breakdown, because data gathering is both history and physical so I dont know if one was worse than the other or not.

The patient note section was graded as borderline pass/fail. I thought my notes were OK, I didnt realize they were so bad.



9) On the patient note, I wrote all physical exam findings as normal. I thought that they were just checking to make sure I did all the maneuvers, I didnt realize they were looking for REAL physical exam findings on the patient, even though it had nothing to do with their diagnosis (i.e. gastritis patient with mildly diminished extremity position sensation).



Medblazer: First let me say that in my CS exam, I did a lot of similar things to you, in that I asked very similar questions (or lack of), while I still passed. What I suspect caused you to fail was the patient note. You mentioned that you "wrote all physical exam findings as normal." The problem is that they don't want you to write "NORMAL EVERYTHING" -- they mentioned this specifically in the orientation video if you can remember--.

They want to know that you actually performed the relevant physical examination technique, and the result was normal.

Writing something like "CVS is normal" is different than "CVS: JVP not elevated, heart sounds dual, no murmur, no heaves, thrills. Point of maximal impulse 5th Left intercostal space, mid-clavicular line, no peripheral edema etc etc"

Does this make sense? If you apply this to every exam system, you should pass. You sound like you have read first aid, and you know what you are doing, but just go over how they write the Patient notes.

Also, one other note, how did you do your counseling part?