Borderline performance on CCS

[Catch22]

---

Members don't see this ad.

I just got back my Step 3 scores, and I failed by a point...I'm just baffled because i thought I nailed all of the ccs cases, only to see on my scoring that I had borderline performance on that section. All of my cases ended early (8-10 minutes in), and i thought they were easy. Am i missing something key to doing well on this section? Does anyone have any suggestions?

 

[commander]

sorry to hear that.
did you do all the usmle world cases? CCS could be the determining factor because I know it pulled down my results.

I just passed and I also thought I did well on ccs, but it was borderline. but I knew ahead of time that I was not prepared for the ccs.
I knew all the cases too, but I am sure they grade for little things that are easily missed.
for example, all unstable patients --> pulse oximetry, oxygen, iv lines, then perhaps focused physical.
and other things like reassurance, counseling patient. It turns out, I missed stuff like that in the easy cases.

 

[Catch22]

Thanks for your reply. I did all of the CCS cases on UW, the sample caes given from USMLE itself, as well as reading through the cases in the back of First Aid. I for sure did all of the suggestions you mentioned (pulse ox, continuous bp monitoring on unstable patients) as well as counseling...I truly feel like i ordered the right tests. I know i over managed one patient, and 2 of my patients were "going to go home" after my H&P (wtf?!?)....i didn't know what to do in that scenario so I admitted them to the hospital (hence the over management)...but it seems like people have killed patients and still did OK. I feel like there are style points that I am missing and not "playing the game correctly." thoughts?

 

[imable24]

Out of curiosity, how was your performance on the mcqs?

What was your UW average going into the exam?

CCS is only 25% of the overall exam, i think.

 

[cerebra]

Thanks for your reply. I did all of the CCS cases on UW, the sample caes given from USMLE itself, as well as reading through the cases in the back of First Aid. I for sure did all of the suggestions you mentioned (pulse ox, continuous bp monitoring on unstable patients) as well as counseling...I truly feel like i ordered the right tests. I know i over managed one patient, and 2 of my patients were "going to go home" after my H&P (wtf?!?)....i didn't know what to do in that scenario so I admitted them to the hospital (hence the over management)...but it seems like people have killed patients and still did OK. I feel like there are style points that I am missing and not "playing the game correctly." thoughts?

I am in the same boat as you, missed by 4 points and the CCS was the worst. The critical issue is the dangerous errors on USMLEWORLD software. I believe as we are practicing on this much talked about course, we are getting used to the approaches that can kill patients. It is important to practice on the true exam software to know the navigation times and to play the game correctly. This post is an eye opener for me : http://forums.studentdoctor.net/showthread.php?t=738730

How are you approaching the exam this time? Please share

 

[Gute]

I am in the same boat as you, missed by 4 points and the CCS was the worst. The critical issue is the dangerous errors on USMLEWORLD software. I believe as we are practicing on this much talked about course, we are getting used to the approaches that can kill patients. It is important to practice on the true exam software to know the navigation times and to play the game correctly. This post is an eye opener for me : http://forums.studentdoctor.net/showthread.php?t=738730

How are you approaching the exam this time? Please share

sorry but you are not failing because UW has the CT's take too long relative to the real test.

 

[Catch22]

Out of curiosity, how was your performance on the mcqs?

What was your UW average going into the exam?

CCS is only 25% of the overall exam, i think.

My MCQ performance was passable (not great, however), UW avg in mid
50's. CCS being 25% is a good portion of the grade, and enough to make or break your score, in my opinon....If the test were just MCQ I would have passed!!!! My CCS cases were easy, which is why I'm so confused at my score being so borderline...sinusitis, hypothyroidism, pregnancy...all one step management. I thought the CCS would bring my score UP!! Could I possibly be missing somethign else in the case? I just don't want to make the same mistakes over again and not pass for not knowing to press up up down down left right left right B A B A select start. Frustrated!

 

[OveractiveBrain]

My MCQ performance was passable (not great, however), UW avg in mid
50's. CCS being 25% is a good portion of the grade, and enough to make or break your score, in my opinon....If the test were just MCQ I would have passed!!!! My CCS cases were easy, which is why I'm so confused at my score being so borderline...sinusitis, hypothyroidism, pregnancy...all one step management. I thought the CCS would bring my score UP!! Could I possibly be missing somethign else in the case? I just don't want to make the same mistakes over again and not pass for not knowing to press up up down down left right left right B A B A select start. Frustrated!

Check out the Uworld cases again. When you're done, read what's in the left column. If you didn't do ALL of it, you missed points. Then, read the what's in the right column. If you did ANY of it, you missed ALOT of points. You have to remember to move patients to do locations at the right time. You have to always do a physical exam as the first thing (but select focused exams when emergent, followed by a complete exam later), then diagnostics labs as the second thing.

Since it was the reason you failed Step 3, its likely you have a major system error in your CSS workflow. Analyzing the natural steps to get the right answer might help. I know you probably know this intuitively, but on the exam, it must be robotic and methodic. Actually, in order to pass you must think like what ER doctors are chastized for thinking like. "Abdominal Pain = Belly Labs" "Chest Pain = Chest Pain labs." This type of thinking makes you look like a peon, replaceable, and down right foolish. On the Step 3, it gives you a win.

History --> Physical --> Regular Labs --> Focused Labs --> Treatment
(maybe treatment before focused labs if emergent)
(don't forget to transfer a patient)

Decisions at each step
1. History: none, done for you
2. Physical: complete (nonemergent) focused (emergent), do a complete later
3. Regular Labs: CBC, CMP, +/- CXR, ECG,
4. Focused Labs: patient, location, and severity dependent
- Pap, GC, Chla, Wet Mount, KOH Prep (vaginal discharge)
- KUB, CT scan, Lactate, Amylase, lipase (belly pain)
5. Treatment: patient, location, and severity dependent

If you went from "runny nose --> sinusitis --> abx" but didn't do a decent workup, then you probably lost points. You know, things like Centor critieria, monospots, rapid streps, bacterial culture, those things matter. If you didn't do the monospot or the rapid strep, and just treated, you probably got dinged in the "critical fail" category. If you knew "antibiotics" but didn't know which to pick or the right route, you probably got dinged in the critical fail" category.

Again, I'd check Uworld and thoroughly read the closing statements and all the things that the test expects you to do in the complete win category.

P.S. Up Up Down Down Left Right Left Right B A start. There isn't a second BA, and why would you play two player on Step 3?

 

[Gute]

Actually, in order to pass you must think like what ER doctors are chastized for thinking like. "Abdominal Pain = Belly Labs" "Chest Pain = Chest Pain labs." This type of thinking makes you look like a peon, replaceable, and down right foolish. On the Step 3, it gives you a win.

Since you brought it up....the History and Physical is just not sensitive or specific to rule out life-threatening things that ER docs "excessively test" for. Being robotic and algorithmic in your approaches may make you look like a peon, but in the real world you look like a jackass if you don't rule out an important item on the differential. e.g. I've seen pt's with lower quadrant abd pain who had PNA, who looks like a peon when that gets missed?

 

[OveractiveBrain]

Since you brought it up....the History and Physical is just not sensitive or specific to rule out life-threatening things that ER docs "excessively test" for. Being robotic and algorithmic in your approaches may make you look like a peon, but in the real world you look like a jackass if you don't rule out an important item on the differential. e.g. I've seen pt's with lower quadrant abd pain who had PNA, who looks like a peon when that gets missed?

I'm not going to get into this argument. I think you missed the point, so, as to not confuse the OP, I'll make it explicit. The point is, get the chief-complaint-labs (and all of them) if you want to win at the test. And oh yeah, do a history and physical.

 

[Catch22]

Check out the Uworld cases again. When you're done, read what's in the left column. If you didn't do ALL of it, you missed points. Then, read the what's in the right column. If you did ANY of it, you missed ALOT of points. You have to remember to move patients to do locations at the right time. You have to always do a physical exam as the first thing (but select focused exams when emergent, followed by a complete exam later), then diagnostics labs as the second thing.

Since it was the reason you failed Step 3, its likely you have a major system error in your CSS workflow. Analyzing the natural steps to get the right answer might help. I know you probably know this intuitively, but on the exam, it must be robotic and methodic. Actually, in order to pass you must think like what ER doctors are chastized for thinking like. "Abdominal Pain = Belly Labs" "Chest Pain = Chest Pain labs." This type of thinking makes you look like a peon, replaceable, and down right foolish. On the Step 3, it gives you a win.

History --> Physical --> Regular Labs --> Focused Labs --> Treatment
(maybe treatment before focused labs if emergent)
(don't forget to transfer a patient)

Decisions at each step
1. History: none, done for you
2. Physical: complete (nonemergent) focused (emergent), do a complete later
3. Regular Labs: CBC, CMP, +/- CXR, ECG,
4. Focused Labs: patient, location, and severity dependent
- Pap, GC, Chla, Wet Mount, KOH Prep (vaginal discharge)
- KUB, CT scan, Lactate, Amylase, lipase (belly pain)
5. Treatment: patient, location, and severity dependent

If you went from "runny nose --> sinusitis --> abx" but didn't do a decent workup, then you probably lost points. You know, things like Centor critieria, monospots, rapid streps, bacterial culture, those things matter. If you didn't do the monospot or the rapid strep, and just treated, you probably got dinged in the "critical fail" category. If you knew "antibiotics" but didn't know which to pick or the right route, you probably got dinged in the critical fail" category.

Again, I'd check Uworld and thoroughly read the closing statements and all the things that the test expects you to do in the complete win category.

P.S. Up Up Down Down Left Right Left Right B A start. There isn't a second BA, and why would you play two player on Step 3?

Thanks for the feedback...I'm in an non-clinical specialty so this makes everythign that much more difficult. I thought i was casting a wide enough net on my differential, but I am probably just missing the details (ie, route of admin, timing of stuff) enough to effect my score.

I'm assuming you've taken step 3 already? Do you have any advice on how to close out cases once you've hit the 5 min mark? I guess it can't hurt to schedule routine preventive procedures (colonoscopy, mammo) months/year into the future..? On an emergent case, I get the standard O2, pulse ox, blood pressure, cardiac monitor, and IV access...after that do you "wait for results" (who waits for pulse ox results in real life?!?!) or go ahead with a focused exam?

 

[Catch22]

Since you brought it up....the History and Physical is just not sensitive or specific to rule out life-threatening things that ER docs "excessively test" for. Being robotic and algorithmic in your approaches may make you look like a peon, but in the real world you look like a jackass if you don't rule out an important item on the differential. e.g. I've seen pt's with lower quadrant abd pain who had PNA, who looks like a peon when that gets missed?

I see what you're saying, but unless I am completely off base, it seems as though Step 3 bascially GIVES you the diagnosis on the H&P (with maybe 1-2 additional differentials that are easily sifted out on the orders you chose). I don't think they are that evil as to make you go through a million permutations on a computed simulated exam in order to figure out that LLQ pain is actually PNA...or are they?

 

[Gute]

I see what you're saying, but unless I am completely off base, it seems as though Step 3 bascially GIVES you the diagnosis on the H&P (with maybe 1-2 additional differentials that are easily sifted out on the orders you chose). I don't think they are that evil as to make you go through a million permutations on a computed simulated exam in order to figure out that LLQ pain is actually PNA...or are they?

no but they'd want you to get the CXR in an abd pain case as part of the ER workup.

 

[OveractiveBrain]

Thanks for the feedback...I'm in an non-clinical specialty so this makes everythign that much more difficult. I thought i was casting a wide enough net on my differential, but I am probably just missing the details (ie, route of admin, timing of stuff) enough to effect my score.

I'm assuming you've taken step 3 already? Do you have any advice on how to close out cases once you've hit the 5 min mark? I guess it can't hurt to schedule routine preventive procedures (colonoscopy, mammo) months/year into the future..? On an emergent case, I get the standard O2, pulse ox, blood pressure, cardiac monitor, and IV access...after that do you "wait for results" (who waits for pulse ox results in real life?!?!) or go ahead with a focused exam?

Whoa whoa whoa. Major red flags everywhere here.

What are you talking about months/years into the future? They want you to "get the diagnosis" and "do the intervention." There's no health maintenance scheduling, there's no shotgun approach. You should already know what the diagnosis is just from the history and physical, then you do routine stuff, get some imaging, and choose the intervention that's appropriate. When you've done the right thing, the case ends.

Always History --> Physical --> Orders. Always. You LOSE points for ordering tests before doing the exam.

Yes I've taken step 3, and rocked css. The cases should be done in 30 minutes EACH. I finished mine in 3-5 minutes EACH. You really need to do UWORLD CSS cases and read through the end. You need to FEEL the way it supposed to go. If you keep waiting for more information or you keep watchign the clock go by, it means YOU HAVEN'T DONE SOMETHING YOU WERE SUPPOSED TO.

 

[cerebra]

sorry but you are not failing because UW has the CT's take too long relative to the real test.

Yes, you can fail when you make such very critical error. This is what they are talking about when it comes to errors in USMLEWorld ccs software.
The example in the link I gave http://forums.studentdoctor.net/showthread.php?t=738730
describes a CVA patient who does not get CT reports back in 3 hours on UW software. So, how will you approach this case when you can not even get Ct report within 3 hours. Thrombolytics should be given within 3 hrs of onset of CVA - if that is not done, tpa has no role. The entire concept changes because of these errors on UW. It is a shame.

If you do not give tpa within 3hrs of CVA symptoms in the ER, it is a failure on that case. What do you mean by "we can not fail"? Navigation is everything on Step 3 CCS . If there are serious errors in navigation and simulated time, we lose it all. There are many more concepts which are presented in a deviant way in UW CCS software because of the errors people discussed here. It is a shame that I used this software only to practice my cases last time.

Many people are encouraging to use only Primum software and practice many hypothetical CCS cases on this software. In fact, even ********** workshop has shown case demonstrations only on primum software not on a duplicate software that is not reproduced correctly. Primum is the exam software that we will take our test on and obviously, will respond accurately to our orders when practicing. It can be downloaded from www.usmle.org .

 

[vandu]

I was wondering if anyone had a clue as to how many erorrs in ccs are pardonable, I forgot to do a physical examination in 1 case (inpatient setting with shortness of breath) and forgot ASA in STEMI but did everything else right on that case. Will these mistakes cost me the whole exam? any thoughts?.

 

[gasblaster]

Whoa whoa whoa. Major red flags everywhere here.

What are you talking about months/years into the future? They want you to "get the diagnosis" and "do the intervention." There's no health maintenance scheduling, there's no shotgun approach. You should already know what the diagnosis is just from the history and physical, then you do routine stuff, get some imaging, and choose the intervention that's appropriate. When you've done the right thing, the case ends.

Always History --> Physical --> Orders. Always. You LOSE points for ordering tests before doing the exam.

Yes I've taken step 3, and rocked css. The cases should be done in 30 minutes EACH. I finished mine in 3-5 minutes EACH. You really need to do UWORLD CSS cases and read through the end. You need to FEEL the way it supposed to go. If you keep waiting for more information or you keep watchign the clock go by, it means YOU HAVEN'T DONE SOMETHING YOU WERE SUPPOSED TO.

Bumping this old thread.

On UWorld, the way they have it listed on the "Scoring" and "Clock Management" section for each case is that they want you to put in "Emergency orders" before doing the Physical Exam. Like put in pulse ox, cardiac monitor, blood pressure monitor, IV access, etc which will then go through as you do the physical exam (so the timing of both overlap).

Wondering which way it should be done?

 

[Margo]

Bumping this old thread.

On UWorld, the way they have it listed on the "Scoring" and "Clock Management" section for each case is that they want you to put in "Emergency orders" before doing the Physical Exam. Like put in pulse ox, cardiac monitor, blood pressure monitor, IV access, etc which will then go through as you do the physical exam (so the timing of both overlap).

Wondering which way it should be done?

I used the UW "scoring" and "clock management" guidelines for the real test: worked well.
Emergency orders are needed in the ER setting if the pt presents in acute distress or crashing. In this case, you're right: start IV access, cardiac monitor, pulse ox, suppl O2 etc. Then do a focused PE. In the office setting, do PE first. UW CCS experience is very much like the real test. I did not second-guess UW recommendations.

 

[gasblaster]

I used the UW "scoring" and "clock management" guidelines for the real test: worked well.
Emergency orders are needed in the ER setting if the pt presents in acute distress or crashing. In this case, you're right: start IV access, cardiac monitor, pulse ox, suppl O2 etc. Then do a focused PE. In the office setting, do PE first. UW CCS experience is very much like the real test. I did not second-guess UW recommendations.

Thank for the clarification.

And one other thing if you don't mind. On the real thing, for the final order screen that comes up, what are you doing with that? For instance, if it ends in in the middle of you giving inpatient antibiotic treatment, do you still leave everything on (monitors, admission orders, treatments, etc) and then add in counseling or something?

 

[Margo]

Thank for the clarification.

And one other thing if you don't mind. On the real thing, for the final order screen that comes up, what are you doing with that? For instance, if it ends in in the middle of you giving inpatient antibiotic treatment, do you still leave everything on (monitors, admission orders, treatments, etc) and then add in counseling or something?

You're welcome. For inpatients: some cases would end as soon as I ordered a surgical procedure or a consultation. In the last few min, I'd order pre-op stuff (type&screen, NPO, IVF etc) and cancel any unnecessary orders. If you are in the middle of giving a pt abx treatment, I'd leave everything on. Adding in counseling is helpful, if you have the time: not sure how much that adds to your score. Overall, no drastic changes. Take a closer look at UW clock management section for each case: I found it to be the most helpful. CCS is really straightforward once you see the pattern.