Another Step 2 CS Freakout

[buonassezia]

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I know this thread has been rehashed a million times, but I keep waking up with horrific memories of more awful things I sailed by and forgot on CS. They seem orders of magnitude too terrible to pass. And yet I did many things very well, and I am hoping to get some sense of what people think of these mistakes. It would be so sad to fail this exam, and will definitely be a long time worrying.

Here's the breakdown. For what it's worth, did well on my school's mock CS, but then was away from clinicals for a while and skills seemed to atrophy. Was really not "on" the day of the test. Forgot major things. Timing became more of an issue than it ever was. Generally stunk.


- Case 1: Was finishing the PE as time was called. Didn't perform special maneuvers (likely non-critical in the case). Didn't give impression, differential, or plan at all. Thanked patient and left the room. Some sections of the note may have been unfinished(?), I forget; at least short sections of notes throughout the day, which varied from note to note, went unfinished.

- Another early case: honed in on some key history and findings that pointed to a good top diagnosis, but didn't have many alternatives in mind. Note was thorough until the differentials, where 2nd dx was terrible/wrong, and then totally didn't see the "Workup" section at the bottom, I was so nervous. I had great ideas for what to put, but missed the section altogether and it was left blank.

- Another case: In retrospect, this was a clear, pretty classic presentation of something life-threatening that I missed and didn't even put on the differential, discuss, ask questions about, or test for. This is inexcusable. I have no idea what I was thinking. My differentials and questions were all very reasonable, but the #1 was completely absent and escaped my mind. What on Earth?

- Another case: This was one where I think I understood the 'general category' of diagnosis and key findings, but missed critical history. Took too long with the history and the 5 min warning was called, so moved on to the exam. There was a critical category of history I didn't even touch which was absolutely monumental in this case, and I didn't even touch upon. I'm sure I missed all the relevant counseling associated with that, as well. Told the patients the tests we would perform and then only wrote some of them in the note before time was called.

- Another case: Did a good MSK exam but forgot to do CRITICAL special maneuvers. I have no idea where my brain was. Got a very good exam but then documented the exam last in the note, and ran out of time and wrote hardly any of the key findings on exam.

- Another case: could not remember the name of a diagnosis and described it/made it up in the note--how embarrassing!

- Did not check any JVD for anyone although it was warranted

- Many otherwise thorough notes but with incomplete portions that varied from note to note

Lastly, what I did well: established excellent rapport with the patients, introduced myself, maintained a professional demeanor, listened attentively. Answered questions, including challenge questions, seemingly well, and demonstrated empathy. In the past have done well in these regards, but my concerns are primarily in the ICE domain.

This is unbelievably scary. Please weigh in with your thoughts. Thank you very much.

 

[H Y F R]

Wish I could give my opinions, but I take mine tomorrow, so I'm a bit nervous too. For what it's worth, most people pass, with some having more major mistakes than you have posted. Treat yourself to a nice meal, hang with friends and loved ones, and just forget about the whole damn thing for now. You'll find out soon enough how you did. And I'm praying you passed.

 

[buonassezia]

Wish I could give my opinions, but I take mine tomorrow, so I'm a bit nervous too. For what it's worth, most people pass, with some having more major mistakes than you have posted. Treat yourself to a nice meal, hang with friends and loved ones, and just forget about the whole damn thing for now. You'll find out soon enough how you did. And I'm praying you passed.

thank you! you're awesome, and best of luck! keep going and no matter how an encounter goes, clear your mind and move on to the next. you will succeed! 🙂

 

[Redoxify]

I know this thread has been rehashed a million times, but I keep waking up with horrific memories of more awful things I sailed by and forgot on CS. They seem orders of magnitude too terrible to pass. And yet I did many things very well, and I am hoping to get some sense of what people think of these mistakes. It would be so sad to fail this exam, and will definitely be a long time worrying.

Here's the breakdown. For what it's worth, did well on my school's mock CS, but then was away from clinicals for a while and skills seemed to atrophy. Was really not "on" the day of the test. Forgot major things. Timing became more of an issue than it ever was. Generally stunk.


- Case 1: Was finishing the PE as time was called. Didn't perform special maneuvers (likely non-critical in the case). Didn't give impression, differential, or plan at all. Thanked patient and left the room. Some sections of the note may have been unfinished(?), I forget; at least short sections of notes throughout the day, which varied from note to note, went unfinished.

- Another early case: honed in on some key history and findings that pointed to a good top diagnosis, but didn't have many alternatives in mind. Note was thorough until the differentials, where 2nd dx was terrible/wrong, and then totally didn't see the "Workup" section at the bottom, I was so nervous. I had great ideas for what to put, but missed the section altogether and it was left blank.

- Another case: In retrospect, this was a clear, pretty classic presentation of something life-threatening that I missed and didn't even put on the differential, discuss, ask questions about, or test for. This is inexcusable. I have no idea what I was thinking. My differentials and questions were all very reasonable, but the #1 was completely absent and escaped my mind. What on Earth?

- Another case: This was one where I think I understood the 'general category' of diagnosis and key findings, but missed critical history. Took too long with the history and the 5 min warning was called, so moved on to the exam. There was a critical category of history I didn't even touch which was absolutely monumental in this case, and I didn't even touch upon. I'm sure I missed all the relevant counseling associated with that, as well. Told the patients the tests we would perform and then only wrote some of them in the note before time was called.

- Another case: Did a good MSK exam but forgot to do CRITICAL special maneuvers. I have no idea where my brain was. Got a very good exam but then documented the exam last in the note, and ran out of time and wrote hardly any of the key findings on exam.

- Another case: could not remember the name of a diagnosis and described it/made it up in the note--how embarrassing!

- Did not check any JVD for anyone although it was warranted

- Many otherwise thorough notes but with incomplete portions that varied from note to note

Lastly, what I did well: established excellent rapport with the patients, introduced myself, maintained a professional demeanor, listened attentively. Answered questions, including challenge questions, seemingly well, and demonstrated empathy. In the past have done well in these regards, but my concerns are primarily in the ICE domain.

This is unbelievably scary. Please weigh in with your thoughts. Thank you very much.

Hey,

Know that you're not alone. I'm freaking out too. Took mine recently and felt ok walking out and even during it. But every morning i wake up remembering more stuff I did wrong/didn't do/didnt say.

Either ways, just try to focus on what's next. There's nothing we can do about it now.

 

[Nabin]

Haven't given mine but I want to wish you all the best. I have read much worse experiences and people have passed. So, I don't think there is an iron hand scoring the test. Anyways, keep calm, relax and hope for the best.

 

[Psai]

Every time I left a room I was like damn I forgot to check the thyroid, forgot to look for JVD, forgot to ask about family history, etc.

 

[rodmichael82]

I made more mistakes than you and passed CS with higher performance on every section. Seriously don't sweat it. 95 % of the people pass this exam and you would have to do something ridiculous to be part of the failing 5 %

 

[uacom_ms2]

96% of AMG pass on their first attempt. That means approximately 1 out of every group of 24 fails. There was some dude in my group who asked one of the proctors if he had to wash his hands before touching the patients. Therefore, I am in the clear. It was probably some other guy who failed, not you.

 

[uacom_ms2]

[deleted]

 

[psychM4]

Hi all,
another question about CS 🙂
I keep freaking out over minor details, such as:
- can I write the history as one big paragraph instead of bullet points, as in "HPI (...). Patient has a past medical history of hypertension and diabetes. No surgical history. No allergies or medications. Patient does not drink alcohol, smoke, or do illicit drugs. etc.
- I also never described the patient: "Patient is in NAD, etc." Does this have much of an impact?

I made many other mistakes, but those have been mostly covered in other threads so I won't repeat.

I appreciate any input!

 

[beastie87]

I know this thread has been rehashed a million times, but I keep waking up with horrific memories of more awful things I sailed by and forgot on CS. They seem orders of magnitude too terrible to pass. And yet I did many things very well, and I am hoping to get some sense of what people think of these mistakes. It would be so sad to fail this exam, and will definitely be a long time worrying.

Here's the breakdown. For what it's worth, did well on my school's mock CS, but then was away from clinicals for a while and skills seemed to atrophy. Was really not "on" the day of the test. Forgot major things. Timing became more of an issue than it ever was. Generally stunk.


- Case 1: Was finishing the PE as time was called. Didn't perform special maneuvers (likely non-critical in the case). Didn't give impression, differential, or plan at all. Thanked patient and left the room. Some sections of the note may have been unfinished(?), I forget; at least short sections of notes throughout the day, which varied from note to note, went unfinished.

- Another early case: honed in on some key history and findings that pointed to a good top diagnosis, but didn't have many alternatives in mind. Note was thorough until the differentials, where 2nd dx was terrible/wrong, and then totally didn't see the "Workup" section at the bottom, I was so nervous. I had great ideas for what to put, but missed the section altogether and it was left blank.

- Another case: In retrospect, this was a clear, pretty classic presentation of something life-threatening that I missed and didn't even put on the differential, discuss, ask questions about, or test for. This is inexcusable. I have no idea what I was thinking. My differentials and questions were all very reasonable, but the #1 was completely absent and escaped my mind. What on Earth?

- Another case: This was one where I think I understood the 'general category' of diagnosis and key findings, but missed critical history. Took too long with the history and the 5 min warning was called, so moved on to the exam. There was a critical category of history I didn't even touch which was absolutely monumental in this case, and I didn't even touch upon. I'm sure I missed all the relevant counseling associated with that, as well. Told the patients the tests we would perform and then only wrote some of them in the note before time was called.

- Another case: Did a good MSK exam but forgot to do CRITICAL special maneuvers. I have no idea where my brain was. Got a very good exam but then documented the exam last in the note, and ran out of time and wrote hardly any of the key findings on exam.

- Another case: could not remember the name of a diagnosis and described it/made it up in the note--how embarrassing!

- Did not check any JVD for anyone although it was warranted

- Many otherwise thorough notes but with incomplete portions that varied from note to note

Lastly, what I did well: established excellent rapport with the patients, introduced myself, maintained a professional demeanor, listened attentively. Answered questions, including challenge questions, seemingly well, and demonstrated empathy. In the past have done well in these regards, but my concerns are primarily in the ICE domain.

This is unbelievably scary. Please weigh in with your thoughts. Thank you very much.

This sounds exactly like what I have been going through... Took CS during a sub-I after being awake for >24hrs (okay, I napped on the bus..) bc I didn't want to pay for another permit. Bad move? We'll see. This test and all the awful mistakes I made keep me awake at night. Literally. It's distracting me from preparing for interviews properly. Some things I did:
-Forgot to wash my hands, maybe a few times. More often than not I washed when hands when I entered the room, not immediately before the PE. If that doesn't count then I don't get any credit...
-Completely left off an entire workup section
-Wrote some pretty weak notes
-Did a PE on a std pt who was there for a med check. To be fair, the guy was there to talk about outpatient meds but immediately told us he wanted to discuss 'the little blue pill' so a cardiac exam isn't unreasonable, I think.
The list goes on. I'm terrified I failed. It's comforting at least to know that I'm not alone. Hang in there. Statistically speaking, we both passed. Still, someone has to be in that 2-4%.. Ugh.

 

[buonassezia]

This sounds exactly like what I have been going through... Took CS during a sub-I after being awake for >24hrs (okay, I napped on the bus..) bc I didn't want to pay for another permit. Bad move? We'll see. This test and all the awful mistakes I made keep me awake at night. Literally. It's distracting me from preparing for interviews properly. Some things I did:
-Forgot to wash my hands, maybe a few times. More often than not I washed when hands when I entered the room, not immediately before the PE. If that doesn't count then I don't get any credit...
-Completely left off an entire workup section
-Wrote some pretty weak notes
-Did a PE on a std pt who was there for a med check. To be fair, the guy was there to talk about outpatient meds but immediately told us he wanted to discuss 'the little blue pill' so a cardiac exam isn't unreasonable, I think.
The list goes on. I'm terrified I failed. It's comforting at least to know that I'm not alone. Hang in there. Statistically speaking, we both passed. Still, someone has to be in that 2-4%.. Ugh.

Sounds very familiar. The nightmares will pass and you will truly be able to forget about it for a while. I will update once I (finally) figure out the outcome! Hang in there!!

 

[buonassezia]

Hurray! I just wanted to update everyone that I passed.

This test should not be taken lightly in one's preparation, but a number of mistakes seem to be permissible without outright failing the test.

As a warning, I did receive near-borderline CIS score breakdown on the exam, although this has always been an area in which I have excelled in school OSCEs and patient interactions. I also thought I hit the interpersonal skills out of the park during the exam day, and left the test worrying that I had failed in terms of ICE score. (I thought I spent too much time empathizing with the patient and not figuring out accurately what was going on with them).

I have no idea what contributed to this odd CIS domain weakness, and will really have to reflect on it. As I tended to run out of time on encounters, I likely did not answer all of the patients' questions well. I probably missed some of the key counseling. Otherwise, in my preparation, I practiced and practiced greetings, empathic phrases (although they also tend to come naturally), challenge question responses, summarizing, briefly guiding patients through the physical exam, appropriate draping and asking permission, and hand washing; I replicated these habits on test day.

I promise, I'm not one of those cold or clueless, non-empathic people who nonetheless thinks they're fine. I tend to have an intuitive and inherently warm and nurturing personality, and this domain is (usually) truly my main strength. I am much more frequently told I'm "too nice" and I really 1. would be a great Pediatrician, and/or 2. Should just be brusque and get on with the businessy tasks of medicine rather than spending time on patient reassurance and communication. No joke. I think I finally struck a good balance of the two in the second half of third year...

I will add more thoughts as they come to mind about why this might have been a lower area of performance, in case it can help in anyone else's preparation. Don't ignore the CIS portion at all!!!


That said, if you took it and are freaking out that you definitely failed, you still probably didn't.

<3

Updated:
I think the most lacking sections in my CIS performance occurred as I rushed to finish each encounter. I described my impressions, differentials, and briefly outlined the diagnostic tests (without using medical jargon) and the next steps, but often ran out of time to elicit questions, allay patients' concerns, and clarify any confusion about next steps. This is probably key. Also probably missed counseling opportunities. Be sure to leave enough time at the end of the encounters, as these pieces are likely significant. It's not enough just not to be a robot.

 

[buonassezia]

Advice for your CS preparation:

Work on establishing routines such that necessary portions of the encounter (introduction, hand washing, asking permission to do the physical exam) become SO HABITUAL you could do them in your sleep.

At the beginning of EVERY SINGLE encounter you practice, develop the habit of introducing yourself briefly, confidently, and with good eye contact ('Hi, Mr./Ms. [___]? Nice to meet you. I'm _______, a fourth-year medical student. I'll be discussing with you your medical history and concerns, and performing a brief physical exam.'). Sit down and make eye contact with the patient, and ask 'What brought you in today?' or whichever favorite open-ended opening question you prefer (but stick to the same one every time). Do this EVERY single time you practice, and it will become a worthwhile habit you carry with you for the rest of your medical career. Practice it until it is coming out of your ears and you are doing this in your sleep. A few other students I know who didn't have a scripted way to begin often spooked on test day, forgot to introduce themselves, or otherwise felt lost and uncomfortable from the start.

Likewise, every time you are wrapping up the history portion, summarize briefly and ask, 'Do you have anything else to add?' And 'Do you have any questions for me?'. Then say, 'I would like to move on to the physical exam now. Is that ok with you?' (pause for response). 'Ok, please sit on the examining table. I'm going to wash my hands now.' (wash hands). Practice this little piece ad nauseum, too, so it becomes completely rote and you never forget.

* * *

The CIS section is apparently challenging and quite a lot is expected of you. But if you have these basic routines in place so that you don't even have to think about them on test day, you can dedicate your much-needed attentional real estate to attending to the patient's questions, mood, and consideration of diagnosis. Be sure to counsel and save ample time at the end for questions, clarifications, and discussion of differential and plan with the patient.

* * *

Also, if you're here post-test day and didn't do these things, and think you've failed, again, you still probably didn't. 🙂

 

[downthedrain]

Good to hear that you passed. I'm definitely nervous and I don't find out until Feb! This whole process is stupid. I feel like I definitely had some major issues, but for the most part, I knew what was going on with the patient the entire time and tried my best to handle the situation like I had in previous OSCE exams. Crossing my fingers I guess.

 

[uacom_ms2]

I never seriously thought I failed, but I did get some occasional agitation thinking about the 'what ifs' - what if some SP didn't like the looks of me and gave me a low score, what if I was part of a "fail quota", what if I have to explain to programs why my otherwise excellent application has a fail on this exam.

My school has decent clinical training, and my clinical evaluations have been excellent, so to prepare for this exam I only had to skim First Aid for a couple of days before. Results: my ICE was great, CIS was still all in the "higher performance" category, but it was only a few blocks away from dipping into the shaded "borderline" area. I think this is because I looked at my notes too much and wrote too much. My memory is bad in patient encounters, unless I write things down I forget and it doesn't get documented in the computer. Although I made lots of eye contact, the SPs are trained to dock you points if you look at your notes too much. My advice for those who have yet to take this exam and like/need to jot down notes, is to learn to write without looking at the page, which apparently can be done, but I've never been able to do well.

 

[mona1324324]

I know this thread has been rehashed a million times, but I keep waking up with horrific memories of more awful things I sailed by and forgot on CS. They seem orders of magnitude too terrible to pass. And yet I did many things very well, and I am hoping to get some sense of what people think of these mistakes. It would be so sad to fail this exam, and will definitely be a long time worrying.

Here's the breakdown. For what it's worth, did well on my school's mock CS, but then was away from clinicals for a while and skills seemed to atrophy. Was really not "on" the day of the test. Forgot major things. Timing became more of an issue than it ever was. Generally stunk.


- Case 1: Was finishing the PE as time was called. Didn't perform special maneuvers (likely non-critical in the case). Didn't give impression, differential, or plan at all. Thanked patient and left the room. Some sections of the note may have been unfinished(?), I forget; at least short sections of notes throughout the day, which varied from note to note, went unfinished.

- Another early case: honed in on some key history and findings that pointed to a good top diagnosis, but didn't have many alternatives in mind. Note was thorough until the differentials, where 2nd dx was terrible/wrong, and then totally didn't see the "Workup" section at the bottom, I was so nervous. I had great ideas for what to put, but missed the section altogether and it was left blank.

- Another case: In retrospect, this was a clear, pretty classic presentation of something life-threatening that I missed and didn't even put on the differential, discuss, ask questions about, or test for. This is inexcusable. I have no idea what I was thinking. My differentials and questions were all very reasonable, but the #1 was completely absent and escaped my mind. What on Earth?

- Another case: This was one where I think I understood the 'general category' of diagnosis and key findings, but missed critical history. Took too long with the history and the 5 min warning was called, so moved on to the exam. There was a critical category of history I didn't even touch which was absolutely monumental in this case, and I didn't even touch upon. I'm sure I missed all the relevant counseling associated with that, as well. Told the patients the tests we would perform and then only wrote some of them in the note before time was called.

- Another case: Did a good MSK exam but forgot to do CRITICAL special maneuvers. I have no idea where my brain was. Got a very good exam but then documented the exam last in the note, and ran out of time and wrote hardly any of the key findings on exam.

- Another case: could not remember the name of a diagnosis and described it/made it up in the note--how embarrassing!

- Did not check any JVD for anyone although it was warranted

- Many otherwise thorough notes but with incomplete portions that varied from note to note

Lastly, what I did well: established excellent rapport with the patients, introduced myself, maintained a professional demeanor, listened attentively. Answered questions, including challenge questions, seemingly well, and demonstrated empathy. In the past have done well in these regards, but my concerns are primarily in the ICE domain.

This is unbelievably scary. Please weigh in with your thoughts. Thank you very much.

Hey, I realize this is an old post - but how did you do on your ICE component? I have some similar mistakes and I'm very worried about my ICE component. I missed critical history for 2 of my cases, and one critical diagnosis each in another 2 cases. :/