USMLE Failed STEP 2 CS... Doesn't seem possible.

[fullmetal]

Hi everyone,

I got my score report back and it says I failed the ICE portion of the exam.

From my understanding ICE (Integrated Clinical Encounter) scores the examinee on their physical exam and their patient notes. I don't believe that it's possible that I made enough mistakes to fail this portion of the exam.

During the exam, I was very confident. Most of my patients had very non-specific symptoms (i.e. could be a variety of diagnoses), and a couple cases had some pretty specific ones (I could not think of more than one or two diagnoses).

My patient notes, in my mind, were pretty okay. My history section included a detailed HPI, ROS, PMHx, PSHx, family history, social history, sexual history (if relevant). My physical exam section was fairly standard and contained all the relevant information. For example, if I did an abdominal exam, and didn’t find anything I might write something like:

"Abdomen non-tender, non-distended. No scars, visible masses or pulsations. Normal bowel sounds. No hepatomegaly or splenomegaly. No guarding or rigidity."

I am sure that this could be a little more detailed, and again, its just an example of what I would put without any positive findings, but I do not think its anywhere near worthy of a failing grade.

I cannot imagine that my diagnoses were so off base for the examiners to give me a failing grade either. I did find it difficult to put supporting findings, as many patients had very non-specific symptoms (they answered no to most of my questions). This is not to say I didn't put any though, I offered 2-3 supporting factors for each diagnosis, even if they overlapped. My supporting physical exam findings were a little scant I suppose, however I am not sure how I would remedy this because aside from pain and the occasional faked respiratory symptom or reflex, the patient’s exam findings were negative (they are normal healthy people after all).

Diagnostic studies I felt were appropriate. I believe I listed the tests that would be most relevant to confirming or ruling out certain diagnoses. I threw in a few extra tests that may be helpful (but might not be necessary) because this is what they seemed to do in First Aid for CS.

Even considering all of this… It just doesn’t seem possible. The examiners would have to be incredibly strict. The only other thing I could think of is that I made some sort of huge mistake multiple times of which I was completely unaware. But I washed my hands before every physical exam, draped every patient, asked every patient what name they would like to be referred to by... can't think of anything glaring...

I'm feeling very cheated by all of this. The exam costs $1,600 and without any feedback I have absolutely no idea what to work on. I've practiced with many colleagues and they never noticed any glaring errors I was making. I took the practice course with Kaplan (failed that but they fail everybody).... I don't know what else I could do...

Could anyone offer some insight?

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[NCMED101]

I'm terrified, I don't understand where you could have gone wrong from what you stated. Where does your score report say your stars are at?

 

[fullmetal]

The score report actually shows most of my stars (8 of 11) in the "lower performance" section, and 3 in the "borderline performance" section.

So I must have done something wrong... but what that something is... I have no clue. I requested a score recheck, but if you look at their policy on this, they don't re-evaluate your patient interviews or patient notes, just just go back and add up all the scores from each SP and physician rater.

Can anyone who has been through this (perhaps failed CS, then managed to pass it at a later date) shed some light on what might be going on and what could be changed?

 

[lymphocyte]

The score report actually shows most of my stars (8 of 11) in the "lower performance" section, and 3 in the "borderline performance" section.

So I must have done something wrong... but what that something is... I have no clue. I requested a score recheck, but if you look at their policy on this, they don't re-evaluate your patient interviews or patient notes, just just go back and add up all the scores from each SP and physician rater.

Can anyone who has been through this (perhaps failed CS, then managed to pass it at a later date) shed some light on what might be going on and what could be changed?

I'm sorry this happened to you. It sucks.

1. I'm 99% confident that your score won't change on a recheck. I hope it does.
2. Nobody was in that room but you and the patient. Nobody else can look at the notes you submitted but the actual doctors who graded them. You're likely misremembering aspects of the patient encounter.
3. Failing Step 2CS is partly repeating mistakes across patient encounters. You very likely made the same mistakes over and over again without realising it.
4. Actual diagnoses (with exception of the first diagnosis--which is checked against a computer database, so yes spelling matters) score little compared to how you justify them.
5. Just purely based on what you posted, you probably did too much. Why so much detail with the abdominal exam? Why are you throwing in extra tests? (FA is horrendously out-dated in this regard.) Did you shot-gun the ROS? Or did you tailor it to your patient? The whole point of Step 2CS is safe and reasonable practice. It's moved a long way from checklist-medicine. I urge everybody to read the Step 2CS manual, which covers these points in detail with worked examples: http://www.usmle.org/step-2-cs/
6. Another common reason for failing ICE is documenting findings that you didn't actually find. Huge no-no.
7. I'm not saying that you actually made these mistakes. Unfortunately, nobody can say what mistakes you made. That's what's so frustrating about Step 2CS. All I can suggest is to practice, practice, practice under strict time conditions with somebody who has passed the exam with high marks. What else can you do?
8. If you have time to burn, PubMed Step 2CS (or look through my post history). There are a handful of papers that explain the above in slightly more detail--but Step 2CS is still maddeningly opaque.

Good luck OP. I hope things work out for the best.

 

[fullmetal]

Hey lymphocyte. Thanks for the response.

Your post is insightful. A few of the things you mention, I did not think about.

I definitely treated the encounter somewhat like a checklist. I go through the list of questions in my head. Especially for ROS. I was actually taught that ROS is supposed to be a sort of shotgun approach following a detailed HPI to catch any symptoms that the patient may not have mentioned. I asked the pertinent questions in my HPI. For example, if the patient had epigastric pain, a follow up question might be if its pre-prandial or post-prandial. Later in the ROS I was just like "Any headaches, any difficulty swallowing, any chest pain, any change in your bowel habits, any joint pain... etc.).

I did find it difficult to support my diagnoses with *differentiating* symptoms. For example, it was a woman with abdominal pain.. perhaps my differentials were appendicitis, diverticulitis and peptic ulcer (as an example). One of the big problems I had was that the patient didn't have any classic findings. The pain was not in the lower right quadrant. It did not start around the umbilicus. It was not related to eating, the was no hemoptysis, etc etc. Everything was very vague.

I don't believe I mis-documented or misremembered details (I mean its POSSIBLE one or two things here or there).. but it couldn't be enough to make me fail I think...

Anyway I will take your advice and read the manual and take a look at PubMed. These are great suggestions.

I am still very frustrated at this process. It feels like I am in the wizard of oz, with some all knowing being behind a curtain deciding my fate without telling me why or what I can do to change it... How am I expected to improve as a physician if I am not given the opportunity to know my mistakes?

 

[lymphocyte]

Hey lymphocyte. Thanks for the response.

Your post is insightful. A few of the things you mention, I did not think about.

I definitely treated the encounter somewhat like a checklist. I go through the list of questions in my head. Especially for ROS. I was actually taught that ROS is supposed to be a sort of shotgun approach following a detailed HPI to catch any symptoms that the patient may not have mentioned. I asked the pertinent questions in my HPI. For example, if the patient had epigastric pain, a follow up question might be if its pre-prandial or post-prandial. Later in the ROS I was just like "Any headaches, any difficulty swallowing, any chest pain, any change in your bowel habits, any joint pain... etc.).

I did find it difficult to support my diagnoses with *differentiating* symptoms. For example, it was a woman with abdominal pain.. perhaps my differentials were appendicitis, diverticulitis and peptic ulcer (as an example). One of the big problems I had was that the patient didn't have any classic findings. The pain was not in the lower right quadrant. It did not start around the umbilicus. It was not related to eating, the was no hemoptysis, etc etc. Everything was very vague.

I don't believe I mis-documented or misremembered details (I mean its POSSIBLE one or two things here or there).. but it couldn't be enough to make me fail I think...

Anyway I will take your advice and read the manual and take a look at PubMed. These are great suggestions.

I am still very frustrated at this process. It feels like I am in the wizard of oz, with some all knowing being behind a curtain deciding my fate without telling me why or what I can do to change it... How am I expected to improve as a physician if I am not given the opportunity to know my mistakes?

Things like normal VS would argue against appendicitis or diverticulitis and in favour of peptic ulcer. Reproducible tenderness to palpation in the lower right quadrant would argue in favour of appendicitis. Lack of tenderness to palpation anywhere would argue against all three. (Remember, relevant negatives and positives.) Maybe there are classic features; maybe there aren't. But reasonableness is what matters--are you a thinking doctor? (Not saying that you aren't--the test has its issues.) Somebody else posted a sample of their note on SDN for us to look at. Maybe you could do the same with your note. The whole thing would be immensely frustrating to anyone. Good luck OP.

 

[fullmetal]

Thanks lymphocyte. I will try posting a sample note later on to get it reviewed in addition to your suggestions about reading the manual and looking on PubMed. Beyond that I guess I just have to do a ton of practice and work on learning some more pertinent positives/negative for common disease processes.

And I guess also practice knowing the correct differentiating diagnostic studies.

Thanks again for all your help. Really.

 

[6yearmedstud]

dont worry about failing i spoke to the attendings at my school and they said they reserve specific spots at my school for those who failed cs so that they will match for sure

 

[Patho_logical]

Thought I'd chime in here. Haven't been to this board in quite some time (recently started residency) but saw some news about the CS and decided to check back out of curiosity.

Your story is similar to mine. I failed the ICE portion, but I think I had about 5 stars in the borderline area.

I also don't understand how I failed. My only thought that seemed valid in that regard was that I put some unlikely "rule-out" type of diagnoses on my first attempt. Later I read that you lose points for unlikely differentials. I figured if the CC is chest pain, any good doc would have MI in his differential. However, although you would consider that at least temporarily, it doesn't need to go on the CS differential I guess if it doesn't fit with the entire patient history. Other than that I really can't think of many mistakes. Forgot the work up section of one case, but I've seen several stories of people not even finishing on multiple encounters that still end up passing.

I passed on my second attempt well into the "higher performance" section with very little change. I used mnemonics for the hpi and ROS. That was about the only difference. Still collected similar data. Just did it by logical history taking before with no real system. Also of note, I had ZERO work with standardized patients between attempts. So it was all practice with note writing and the adjustments to what I included in the differential that apparently allowed me to jump from a fail to "higher performance" asterisks. Not trying to say I didn't commit mistakes that warranted a fail; however, I do have a hard time believing that.

So yeah, I paid the $1300 twice. (Must've gone up if it's now $1600...ridiculous) Also spent 4 days total with travel and probably another $300 on hotels across both attempts. It's awful. And in the end I felt (and still feel) cheated out of my money.

The good news is nobody at residency programs seemed to care too much. Most interviewers (almost all) were too old to have taken the exam. One asked me what it was. She had no idea how it worked. When I explained the differential diagnosis scoring, she seemed to think it was a bit odd as well.

Good luck on your second attempt. That passing score feels amazing. Opening the link probably caused dangerous palpitations though.

 

[Phloston]

My impression during CS was that writing a lot of info in the notes, even if good, won't yield you additional points, but won't detract either if mildly irrelevant. E.g., saying "no JVD" in an abdo case might not get you any points, but it won't lose you any.

Most of your points are going to come from the note itself. It's hard to speculate as far as what may have happened during your exam, but when you go back in there, be fast making targeted comments on the Hx/PE sections, then make sure you drill out some of the relevant DDx and supporting information.

Nevertheless I'm sorry to hear that you're dealing with this setback. You're not alone. I know someone who's had to put off the match a year because of a CS fail. And you know what? He/she is doing an MPH in the mean time. Interesting huh? CS fail now = this person will get an MPH. So there are ways to turn it positive.

 

[24blue8]

How long were you in the room with the patients? The only time I thought the complaints were vague is when I (later realized) I had completely missed the diagnosis. The majority of them had a pretty obvious one or two diagnoses. But if you miss the diagnosis and ask a bunch of questions over in left field it would seem like they had no positives or really vague symptoms.

 

[Melatonin87]

Hi everyone,

I got my score report back and it says I failed the ICE portion of the exam.

From my understanding ICE (Integrated Clinical Encounter) scores the examinee on their physical exam and their patient notes. I don't believe that it's possible that I made enough mistakes to fail this portion of the exam.

During the exam, I was very confident. Most of my patients had very non-specific symptoms (i.e. could be a variety of diagnoses), and a couple cases had some pretty specific ones (I could not think of more than one or two diagnoses).

My patient notes, in my mind, were pretty okay. My history section included a detailed HPI, ROS, PMHx, PSHx, family history, social history, sexual history (if relevant). My physical exam section was fairly standard and contained all the relevant information. For example, if I did an abdominal exam, and didn’t find anything I might write something like:

"Abdomen non-tender, non-distended. No scars, visible masses or pulsations. Normal bowel sounds. No hepatomegaly or splenomegaly. No guarding or rigidity."

I am sure that this could be a little more detailed, and again, its just an example of what I would put without any positive findings, but I do not think its anywhere near worthy of a failing grade.

I cannot imagine that my diagnoses were so off base for the examiners to give me a failing grade either. I did find it difficult to put supporting findings, as many patients had very non-specific symptoms (they answered no to most of my questions). This is not to say I didn't put any though, I offered 2-3 supporting factors for each diagnosis, even if they overlapped. My supporting physical exam findings were a little scant I suppose, however I am not sure how I would remedy this because aside from pain and the occasional faked respiratory symptom or reflex, the patient’s exam findings were negative (they are normal healthy people after all).

Diagnostic studies I felt were appropriate. I believe I listed the tests that would be most relevant to confirming or ruling out certain diagnoses. I threw in a few extra tests that may be helpful (but might not be necessary) because this is what they seemed to do in First Aid for CS.

Even considering all of this… It just doesn’t seem possible. The examiners would have to be incredibly strict. The only other thing I could think of is that I made some sort of huge mistake multiple times of which I was completely unaware. But I washed my hands before every physical exam, draped every patient, asked every patient what name they would like to be referred to by... can't think of anything glaring...

I'm feeling very cheated by all of this. The exam costs $1,600 and without any feedback I have absolutely no idea what to work on. I've practiced with many colleagues and they never noticed any glaring errors I was making. I took the practice course with Kaplan (failed that but they fail everybody).... I don't know what else I could do...

Could anyone offer some insight?

I would honestly give up on Medicine all together. So I just got my score back today and let me tell you, if I just passed this exam with high marks in every category, then there is absolutely no excuse to fail CS. I made so many mistakes that I was hesitant to even finish my ERAS application. I ran out of time on 3 of my encounters without finishing my closure and saying something like, "Oh they are paging me in the ER, I'll be back in a couple minutes to discuss your matter further." 3 encounters!!! I did not do one focused physical examination, NOT ONE, I did however do the basic 3 Respi/Cardio/GI with every encounter. I was totally off diagnosis with at least 4 encounters, and for almost 5 encounters I listed either 1 or 2 differentials. I had 2 incomplete write-ups........which made me come to the conclusion that either you are incompetent or just lack the adequate training. Oh and Let me not forget to mention that I studied by myself never practicing the physical exam on anyone other than in my rotations, something people warned me not to do but I had no option.

My only advice is to try again and if for some reason you fail it again, I would definitely choose another career path my friend. I'm just being real with you

 

[morbentfel]

I would honestly give up on Medicine all together. So I just got my score back today and let me tell you, if I just passed this exam with high marks in every category, then there is absolutely no excuse to fail CS. I made so many mistakes that I was hesitant to even finish my ERAS application. I ran out of time on 3 of my encounters without finishing my closure and saying something like, "Oh they are paging me in the ER, I'll be back in a couple minutes to discuss your matter further." 3 encounters!!! I did not do one focused physical examination, NOT ONE, I did however do the basic 3 Respi/Cardio/GI with every encounter. I was totally off diagnosis with at least 4 encounters, and for almost 5 encounters I listed either 1 or 2 differentials. I had 2 incomplete write-ups........which made me come to the conclusion that either you are incompetent or just lack the adequate training. Oh and Let me not forget to mention that I studied by myself never practicing the physical exam on anyone other than in my rotations, something people warned me not to do but I had no option.

My only advice is to try again and if for some reason you fail it again, I would definitely choose another career path my friend. I'm just being real with you

Don't listen to this negativity. I know an IMG who is now an attending pathologist and failed doubly with pass on 3rd try on step 2 ck, and a fail on step 1 also. If it's truly your passion just go over FA carefully and also the guides posted on this forum and improve next time.

 

[Melatonin87]

Don't listen to this negativity. I know an IMG who is now an attending pathologist and failed doubly with pass on 3rd try on step 2 ck, and a fail on step 1 also. If it's truly your passion just go over FA carefully and also the guides posted on this forum and improve next time.

I'm sorry to be a realist but you do have to consider your investment and time. Like I said try again but if you do fail I would try with the family business

 

[Konda]

Hi everyone,

I got my score report back and it says I failed the ICE portion of the exam.

From my understanding ICE (Integrated Clinical Encounter) scores the examinee on their physical exam and their patient notes. I don't believe that it's possible that I made enough mistakes to fail this portion of the exam.

During the exam, I was very confident. Most of my patients had very non-specific symptoms (i.e. could be a variety of diagnoses), and a couple cases had some pretty specific ones (I could not think of more than one or two diagnoses).

My patient notes, in my mind, were pretty okay. My history section included a detailed HPI, ROS, PMHx, PSHx, family history, social history, sexual history (if relevant). My physical exam section was fairly standard and contained all the relevant information. For example, if I did an abdominal exam, and didn’t find anything I might write something like:

"Abdomen non-tender, non-distended. No scars, visible masses or pulsations. Normal bowel sounds. No hepatomegaly or splenomegaly. No guarding or rigidity."

I am sure that this could be a little more detailed, and again, its just an example of what I would put without any positive findings, but I do not think its anywhere near worthy of a failing grade.

I cannot imagine that my diagnoses were so off base for the examiners to give me a failing grade either. I did find it difficult to put supporting findings, as many patients had very non-specific symptoms (they answered no to most of my questions). This is not to say I didn't put any though, I offered 2-3 supporting factors for each diagnosis, even if they overlapped. My supporting physical exam findings were a little scant I suppose, however I am not sure how I would remedy this because aside from pain and the occasional faked respiratory symptom or reflex, the patient’s exam findings were negative (they are normal healthy people after all).

Diagnostic studies I felt were appropriate. I believe I listed the tests that would be most relevant to confirming or ruling out certain diagnoses. I threw in a few extra tests that may be helpful (but might not be necessary) because this is what they seemed to do in First Aid for CS.

Even considering all of this… It just doesn’t seem possible. The examiners would have to be incredibly strict. The only other thing I could think of is that I made some sort of huge mistake multiple times of which I was completely unaware. But I washed my hands before every physical exam, draped every patient, asked every patient what name they would like to be referred to by... can't think of anything glaring...

I'm feeling very cheated by all of this. The exam costs $1,600 and without any feedback I have absolutely no idea what to work on. I've practiced with many colleagues and they never noticed any glaring errors I was making. I took the practice course with Kaplan (failed that but they fail everybody).... I don't know what else I could do...

Could anyone offer some insight?

Hello FullMetal. I registered specifically because I am in the exact situation as you are, and have been scouring the internet and fellow friends who passed (with whom I even practiced with) to try and identify where I might have gone wrong during the CS. Like you, I failed the ICE portion by having 4 stars in the borderline and the rest below that. My experience went similarly to yours, right down to reporting on the note. I am having so much difficulty identifying where I may have gone wrong.

Sure I may have made minor mistakes, we all do and I've read about people making far greater ones than mine, but I genuinely felt confident walking out of the exam. A few cases were rather vague and perhaps a bit difficult to reason under stress. But I did feel that most cases were rather straightforward enough so that I got differentials within reasonable proximity to the actual diagnosis. For example, if it was an abdomen case, I would have an idea of some differentials. I would ask typical history questions (location, intensity, radiation, character, onset, duration, alleviating, exacerbating factors, relation to meals etc) and try to establish a strong HPI. Then I would do a shot-gun ROS that focused a little more on the system involved if possible, but tried to encompass a head-to-toe approach like yourself to see if I missed anything. Then get PMH, FH, Surgical, Meds, Allergies, Social and if relevant, sexual history. I summarized in all cases, asked if I missed anything, always made time for a good closure, always counseled on ETOH/Cigarettes/Drugs and always answered the difficult question, if any.

For PE, I recall my patients all being in gowns. I can't recall if I saw an additional drape. I think they may have had a blanket on their laps, and I'd use that to cover them during an exam such as an abdominal exam (cover the pelvis for example and legs). So say it's the abdomen case, I would begin with a focused abdominal exam. Explain and ask permission, inspect, auscultate, palpate light and deep, percuss. I didn't do maneuvers like psoas or Murphy's unless I suspected the case warranted it. Then, I'd listen to the heart, and the lungs front and back. Heart in 2 areas, lungs in 4 general quadrants in the front, 6 in the back.

If it was a respiratory case, I'd inspect, palpate, auscultate front and back, tactile fremitus, percuss (I think just chest and not the back if I recall). Then, I might do HEENT (without fundoscopy) if the case warranted it, otherwise I'd listen to the heart. But I tried to be as targeted as possible, and not try to do too many systems but do one relevant system involving inspection, palpation, auscultation - and then briefly heart and lungs. If it was a CVS exam I'd go all out - carotid bruit, capillary refill, check for janeway lesions, pulses, edema, in addition to palpating the chest for tenderness, auscultating. I did forget to check PMI. I do think I may have reported my findings in CVS wrong but I'd write for example:

CVS: Chest wall without deformities, lesions, discolorations, non-tender to palpation. No cyanosis in hands, no UE or LE edema, capillary refill <2secs. Radial, pedal, posterior tibial pulses 2+ b/l. RRR, No murmurs, gallops, rubs.

I felt I had respectable diagnoses although supporting them is where I had difficulty. I would often list just 2 points, and repeat the justifying points often. I'm trying to improve on that to get enough clues to back up my DDX to have 3 for each, even if I repeat them. Just make sure it's solid evidence. Still, I thought it was reasonably supported. Often times I'd only have one PE finding to report and other times none… they were normal patients as you mentioned. A lot of times I was lacking supporting positives and negatives was when the case felt quite vague, or the answer was No a lot. But still I was able to pull together what I felt was a reasonable note that I was confident with.

I did the First Aid approach too with workups. I tried to be a little more conservative that FA, but still tried to remember all related tests that corresponded with my differentials and would help confirm or rule one in or out over the others.

I wish we had some form of feedback. I'm afraid that I really don't know where I went wrong. So far my plan is to review First Aid and practice as much as possible. I am practicing writing the notes for each practice case as I didn't do that enough the first time. Although I didn't feel it hindered me at all as I did my notes within the time constraints and everything. I just don't know. But perhaps it'll help me to be even faster so I can reflect on more supporting points?

I just have no idea where I fell short to improve. I don't feel that mistakes I made were worth a fail, but I also can't be sure what consistent mistake I must have made to fail me. Any advice or help would be appreciated. Perhaps be even more targeted in my PE and not overload it with so much information? Get more supporting details and think clinically about where they go with the DDX? And do targeting questioning towards an already suspected DDX?

 

[Everyones_a_rat]

Which test center did you write your test at?

 

[Konda]

Which test center did you write your test at?

Does that really make a difference? I've heard Philidelphia is where people have issues, but it's also where all notes are graded. I didn't take it at Philly but I failed ICE, and Philly is where all notes are graded, so it might not matter where I took it really. The test is intended to be standardized anyway I suppose… I just wish I could identify what mistakes I repeated on all encounters to fail. I'm doing a course and of course FA and practice, but I just don't understand. What is the key? Using mnemonics? I just don't know how to do the targeted questioning thing… I mean with differentials in mind it's possible, but with such general cases like fatigue it could be anything. Anemia, depression, abuse, hypothyroidism, menstrual issues, new-onset diabetes/hypoglycemia, narcolepsy/sleep apnea/some sleep issue, caffeine use/ anxiety. I suppose there are ways to use an approach to screen for all of these… but in a few minutes? IDK. I thought I had a good approach to ask open ended questions and arrive at a good differential, but since I failed ICE, I have no idea if I did anything correctly. Coming up with good DDX was difficult with general cases for me with no exam findings and general interview with no real positives sometimes. But I still felt I was in the realm of good DDX regardless, but I failed.

 

[6yearmedstud]

its ok konda i heard CS is being taken out next year by AMA petition so you won't have to pass if you reapply for match next season

 

[Konda]

its ok konda i heard CS is being taken out next year by AMA petition so you won't have to pass if you reapply for match next season

Yep, I found out before I was going to submit my ERAS that I failed. So I have no choice but to apply next year and lose a year, sadly. Hopefully I can acquire some research or something. I have always admired research and is something I missed about Undergrad (Med school is so time consuming it's difficult to research and study simultaneously). Still, it hurts so much that I'll be behind all of my friends who passed and are applying to match this year, as I should have.

I just wish I knew how to improve on ICE, and where it all went wrong. Even when they gave a more detailed breakdown (which wasn't detailed at all) it wasn't enough. But just to see ICE - FAIL and a few stars hasn't helped at all.

 

[6yearmedstud]

Yep, I found out before I was going to submit my ERAS that I failed. So I have no choice but to apply next year and lose a year, sadly. Hopefully I can acquire some research or something. I have always admired research and is something I missed about Undergrad (Med school is so time consuming it's difficult to research and study simultaneously). Still, it hurts so much that I'll be behind all of my friends who passed and are applying to match this year, as I should have.

I just wish I knew how to improve on ICE, and where it all went wrong. Even when they gave a more detailed breakdown (which wasn't detailed at all) it wasn't enough. But just to see ICE - FAIL and a few stars hasn't helped at all.

yea i was very borderline on both everything and still pass lucky as you can see but i was very confident i pass besides that i forgot to do a neurology exam on a patient that needed it and i did not counsel anyone and i forgot to finish asking full history on some patients.

 

[Red Husky]

its ok konda i heard CS is being taken out next year by AMA petition so you won't have to pass if you reapply for match next season

That is a rumor. CS not going anywhere :/
http://www.nbme.org/students/Urban-Legends/index.html

 

[Konda]

yea i was very borderline on both everything and still pass lucky as you can see but i was very confident i pass besides that i forgot to do a neurology exam on a patient that needed it and i did not counsel anyone and i forgot to finish asking full history on some patients.

I'm starting to believe that notes are heavily weighed by the differentials and more-so by justifying them, then. Because I counseled every patient, closed every case, asked all questions and had a very meaty and elegant HPI. It was having time to back up my differentials, and remembering their medical terms under time pressure (hearing loss vs. presbycusis for example) where I fell short. I rarely put pertinent negatives because I was trying to crunch in the positives and would run out of time. Only had like 3 supporting points for each DDX and failed ICE. But I had, overall, a complete note. Wrote HPI, physical findings, DDX and 2-3 justifications per DDX and tests for every note on every case. I was well-timed, but not detailed enough on the second half of the note. I never imagined that was enough to fail though.

Again it's possible my HPI wasn't as great as I thought if my line of questioning wasn't right I suppose. I remember cases being awfully vague. One or two being TOO vague, some vague enough but with respectable leads to wide differentials. I don't know. I found it challenging to do targeted questioning. I treated it like a real scenario where I'd try to be as open ended as possible and ask by logical progression based on their responses. I didn't use mnemonics the first time although I did do LIQQORAAA just by instinct for pain cases. But for example if it's a wide thing like a follow up or cough or something not pain related, the questioning pool can be rather obtuse unless you're calculating differentials in your mind DURING the interview. I was too stunned by stress, timing and writing information down to processes it all I suppose.

 

[Red Husky]

I'm starting to believe that notes are heavily weighed by the differentials and more-so by justifying them, then. Because I counseled every patient, closed every case, asked all questions and had a very meaty and elegant HPI. It was having time to back up my differentials, and remembering their medical terms under time pressure (hearing loss vs. presbycusis for example) where I fell short. I rarely put pertinent negatives because I was trying to crunch in the positives and would run out of time. Only had like 3 supporting points for each DDX and failed ICE. But I had, overall, a complete note. Wrote HPI, physical findings, DDX and 2-3 justifications per DDX and tests for every note on every case. I was well-timed, but not detailed enough on the second half of the note. I never imagined that was enough to fail though.

Again it's possible my HPI wasn't as great as I thought if my line of questioning wasn't right I suppose. I remember cases being awfully vague. One or two being TOO vague, some vague enough but with respectable leads to wide differentials. I don't know. I found it challenging to do targeted questioning. I treated it like a real scenario where I'd try to be as open ended as possible and ask by logical progression based on their responses. I didn't use mnemonics the first time although I did do LIQQORAAA just by instinct for pain cases. But for example if it's a wide thing like a follow up or cough or something not pain related, the questioning pool can be rather obtuse unless you're calculating differentials in your mind DURING the interview. I was too stunned by stress, timing and writing information down to processes it all I suppose.

Maybe you missed the vague ones entirely. Follow up, referral or medication refill patients are usually about something else that you have to get out of the SP (medication side effects, a chief complaint that they didn't tell the nurse, abuse,...) I had one patient that said follow-up on the door but when asking the patient what brought him in he shyly said something completely different. I think the SP had two scenarios. If you didn't ask him what was wrong and went on with the cc on the door he would probably never say the main cc.

I don't think the length or detail of patient note is that important. I wrote 2 ddx for most of my cases and 2 (max) supporting evidence. My notes were super short (not a fast typer!)
I did my exam last year though. Maybe things have changed.

 

[Konda]

Maybe you missed the vague ones entirely. Follow up, referral or medication refill patients are usually about something else that you have to get out of the SP (medication side effects, a chief complaint that they didn't tell the nurse, abuse,...) I had one patient that said follow-up on the door but when asking the patient what brought him in he shyly said something completely different. I think the SP had two scenarios. If you didn't ask him what was wrong and went on with the cc on the door he would probably never say the main cc.

I don't think the length or detail of patient note is that important. I wrote 2 ddx for most of my cases and 2 (max) supporting evidence. My notes were super short (not a fast typer!)
I did my exam last year though. Maybe things have changed.

This is a good and valid point. And it's entirely possible. I can't be certain that I missed the vague ones because I can't recall the exam well enough to be sure of anything I missed, if anything on those cases relative to others, based on my present knowledge. I know I would ask open ended questions. Enough that I hoped to get the main complaint. But it just wouldn't work for me. "Tell me more about that" or "Describe to me what's happening" or "My interest is in all aspects of your health, well-being and safety, so please feel free to share any information you can. As your physician everything matters to me and is held in confidence" - nothing. There must be some secret closed-end question or observation to make? I don't know.

All I can say is my thinking was stunned. I was so focused on going through the motions, getting the timing right, remembering the little nuances of offering tissues, counseling, washing hands, asking permission, that my mind felt washed out when it came to coming up with differentials. I tried to be as linear as possible - if it's Abdominal pain ask about general stuff, do a shotgun ROS (perhaps wrong in hindsight), counsel, wash hands, start with full abdomen exam, listen to heart and lungs, depending on the case maybe a HEENT, then close. I'd come out of the room and then try to synthesize the information as I wrote it in the HPI and physical. This may be a mistake as I should have a DDX throughout the interview for targeted questioning, I suppose? I don't know.

I've been studying First Aid (again) and I'm taking a course. If at some point I discover some secret thing I missed or glaring repeated error, I will share. I am on a journey to understand this exam and what I could have done wrong. It's so gray and vague. Today I got my score recheck back in the mail - a waste of money as everyone on this forum has said. And another reason I've spiraled back into the depression I'm trying to escape in order to re-take this test. Meanwhile my friends are hearing back about interviews and I'm staring at my ruined ERAS

 

[Red Husky]

Reading the open-ended questions you asked I don't think you missed the cc. All I did was I asked the SP was "what brought you in today?" and he told me the real cc. They should be very unfair not to tell you the real chief complaint if you are asking an open-ended question.

One thing that really helped me was that when I read the notes on the door, I paused 30 seconds and made 3 ddx before going in. I feel that helps with taking a more focused history and honestly 30 seconds is nothing. Sometimes I didn't even write ddx but a list of systems. Eg. Respiratory, Cardio,..
That sounds silly and I didn't see American students do that. They just knocked and went in but it really helped me. (IMG here)

 

[Konda]

Reading the open-ended questions you asked I don't think you missed the cc. All I did was I asked the SP was "what brought you in today?" and he told me the real cc. They should be very unfair not to tell you the real chief complaint if you are asking an open-ended question.

One thing that really helped me was that when I read the notes on the door, I paused 30 seconds and made 3 ddx before going in. I feel that helps with taking a more focused history and honestly 30 seconds is nothing. Sometimes I didn't even write ddx but a list of systems. Eg. Respiratory, Cardio,..
That sounds silly and I didn't see American students do that. They just knocked and went in but it really helped me. (IMG here)

I've read of people doing that (the listing of DDX). I am also an IMG btw. I didn't do that despite the suggestions because I didn't really know what to expect for the case. This time I'm trying to have a good grasp on the FA Mini-cases to try and do what you did. But for example, if it's mesenteric ischemia for Abdominal pain, I couldn't know that just from the door, but I'd need PMH to discover A-fib for example, or hypercholesterolemia and DM, and then piece it together. So I always tried to synthesize the info AFTER the encounter, like one would do in real life (sigh).

I tried hard not to ask close-ended questions unless it was a ROS. But FA seems to start with an open ended question, then go into close-ended ones immediately. I suppose that was the point. I'd ask open-ended ones and get nowhere. "Just having abdominal pain" - "yeah, that's it, started yesterday, and it hurts a lot when I move." I can tell in hindsight one had to have some DDX on their fingertips to get anywhere in the interview other than getting basic nonsense. So you get a case like fatigue… the close-ended questions and even differentials are endless. So I'm just not sure.

Sorry if I sound helpless. I think the issue is I don't know where I went wrong. Hopefully the course will help. God willing if I pass this exam I really think I might start a blog about my story and try to help encourage other students that might end up in my position. It's a nightmare but I must overcome it and find a way to pay any assistance forward. The first goal is identify where I went wrong.

 

[Red Husky]

I've read of people doing that (the listing of DDX). I am also an IMG btw. I didn't do that despite the suggestions because I didn't really know what to expect for the case. This time I'm trying to have a good grasp on the FA Mini-cases to try and do what you did. But for example, if it's mesenteric ischemia for Abdominal pain, I couldn't know that just from the door, but I'd need PMH to discover A-fib for example, or hypercholesterolemia and DM, and then piece it together. So I always tried to synthesize the info AFTER the encounter, like one would do in real life (sigh).

I tried hard not to ask close-ended questions unless it was a ROS. But FA seems to start with an open ended question, then go into close-ended ones immediately. I suppose that was the point. I'd ask open-ended ones and get nowhere. "Just having abdominal pain" - "yeah, that's it, started yesterday, and it hurts a lot when I move." I can tell in hindsight one had to have some DDX on their fingertips to get anywhere in the interview other than getting basic nonsense. So you get a case like fatigue… the close-ended questions and even differentials are endless. So I'm just not sure.

Sorry if I sound helpless. I think the issue is I don't know where I went wrong. Hopefully the course will help. God willing if I pass this exam I really think I might start a blog about my story and try to help encourage other students that might end up in my position. It's a nightmare but I must overcome it and find a way to pay any assistance forward. The first goal is identify where I went wrong.

It is so frustrating that they don't give much feedback (Just a couple of meaningless stars!)

You are right in that in real life you see the patient then make your ddx then treat but these are SPs not real patients. Making ddx list reduced my stress in there and this is a test after all. Less stress=better results. I really believe cs is not that much about medical knowledge. We have step 1 and step2ck for that. So maybe it is best to think of more complicated diagnosis after the 3,4 simple ones are ruled out. Just list the 2 most common ddx and 1 or 2 that you might miss (depression in patient with fatigue) or those that are important to rule out (ACS in middle-aged man with dyspepsia)

Lets take fatigue. I would write: Thyroid, Anemia, Depression,Cancer before going in.Now there are a dozen other ddx for fatigue but this way I knew I want to definitely look for clues for these 4. If the patient was a young woman, having anemia in my list reminded me to ask about her menstrual history in more detail. With an older patient it reminded me to ask for GIB, weight loss,.... And of course there are systems that you ask about in every patient (Like respiratory and cardio) so I would't put it up there. Some people use mnemonics and it works for them but they are not for me!

Best of luck

 

[Konda]

It is so frustrating that they don't give much feedback (Just a couple of meaningless stars!)

You are right in that in real life you see the patient then make your ddx then treat but these are SPs not real patients. Making ddx list reduced my stress in there and this is a test after all. Less stress=better results. I really believe cs is not that much about medical knowledge. We have step 1 and step2ck for that. So maybe it is best to think of more complicated diagnosis after the 3,4 simple ones are ruled out. Just list the 2 most common ddx and 1 or 2 that you might miss (depression in patient with fatigue) or those that are important to rule out (ACS in middle-aged man with dyspepsia)

Lets take fatigue. I would write: Thyroid, Anemia, Depression,Cancer before going in.Now there are a dozen other ddx for fatigue but this way I knew I want to definitely look for clues for these 4. If the patient was a young woman, having anemia in my list reminded me to ask about her menstrual history in more detail. With an older patient it reminded me to ask for GIB, weight loss,.... And of course there are systems that you ask about in every patient (Like respiratory and cardio) so I would't put it up there. Some people use mnemonics and it works for them but they are not for me!

Best of luck

Thank you. I appreciate it. Well I believe I may have discovered my shortcomings. I remember taking a long time on the HPI, often beginning my physical as the 5 minute warning went off, and spending 3 or so minutes on a rushed one. I tried to avoid this but it occurred often. I may have sacrificed too much PE to doing a closure and securing a strong CIS standing. It worked, but I failed ICE. The key seems to be a good balance of both, which I suspect I may have lacked. Working on timing a good interview but not being too detailed in the interview might be ideal to get enough PE maneuvers done as well. I also need to try and remember what I did in the PE to write in the note, which can be difficult since we're not writing while doing the PE, but I'm practicing and trying.

I'm a nervous wreck about it honestly. But I suspect this is why I failed ICE - insufficient PE maneuvers and insufficient time devoted to it. I also don't really know when symptoms are being faked knowing in my mind that it's all role-play and not real life. So this could have hindered me as well. But overall, I'm trying to be efficient with ALL parts of the encounter - Interview, PE, closure, and note.

I always read online to sacrifice PE time to doing a solid closure. I'm not so sure this was ever good advice. I believe one must gauge their performance in real-time. I did this far too often and failed ICE. If I had done the opposite, well who knows. I really think a solid PE, at least 5 minutes of it, might be warranted. It's having that extra minute for the note that's eluding me at this moment.

 

[Konda]

It is so frustrating that they don't give much feedback (Just a couple of meaningless stars!)

You are right in that in real life you see the patient then make your ddx then treat but these are SPs not real patients. Making ddx list reduced my stress in there and this is a test after all. Less stress=better results. I really believe cs is not that much about medical knowledge. We have step 1 and step2ck for that. So maybe it is best to think of more complicated diagnosis after the 3,4 simple ones are ruled out. Just list the 2 most common ddx and 1 or 2 that you might miss (depression in patient with fatigue) or those that are important to rule out (ACS in middle-aged man with dyspepsia)

Lets take fatigue. I would write: Thyroid, Anemia, Depression,Cancer before going in.Now there are a dozen other ddx for fatigue but this way I knew I want to definitely look for clues for these 4. If the patient was a young woman, having anemia in my list reminded me to ask about her menstrual history in more detail. With an older patient it reminded me to ask for GIB, weight loss,.... And of course there are systems that you ask about in every patient (Like respiratory and cardio) so I would't put it up there. Some people use mnemonics and it works for them but they are not for me!

Best of luck

I passed, buddy! Thank God! I appreciate you having spoken to me during that difficult time. Wanted to share the good news!

 

[johnbakkar]

This is an old

 

[johnbakkar]

I failed step 2 CS in July this year, I was horrific. On retake, I spent too much time trying to get all the questions right that I almost out of time for several cases. Forgot closing on at least 2 cases. The worst part of all is forgetting very obvious ddx in 3-4 cases. Did not list things in most likely ddx. Did not provide very solid supporting evidence. I forgot the entire workup for 4 cases. I am scared that I may failed again this time is about DDX which I alaways thought that I was very confortable with. STEP 2 CS is horrible, why do they have to make it such a rush. why dont they give us 30 minutes at the end to review our note. What a scam. I may have to retake it a third time. I am AMG, my medical career is almost over thank to this stupid test.

 

[ortnakas]

Hi everyone,
My physical exam section was fairly standard and contained all the relevant information. For example, if I did an abdominal exam, and didn’t find anything I might write something like:

"Abdomen non-tender, non-distended. No scars, visible masses or pulsations. Normal bowel sounds. No hepatomegaly or splenomegaly. No guarding or rigidity."

I am sure that this could be a little more detailed, and again, its just an example of what I would put without any positive findings, but I do not think its anywhere near worthy of a failing grade.

I didn't read the whole thread, so I apologize if someone already said this-- but based on this sentence, maybe they thought you documented things you didn't actually test for? Unless you actually palpated for hepatosplenomegaly on every abdominal exam. Or say if you documented "CN II-XII intact" without actually doing a full neuro exam, etc. I took the COMLEX PE, not the USMLE CS, but I remember being warned multiple times that this is a reason people fail our version.

 

[pintu4]

I passed, buddy! Thank God! I appreciate you having spoken to me during that difficult time. Wanted to share the good news!

So, what you did differently this time?

 

[LUNA25hawaii]

Thought I'd chime in here. Haven't been to this board in quite some time (recently started residency) but saw some news about the CS and decided to check back out of curiosity.

Your story is similar to mine. I failed the ICE portion, but I think I had about 5 stars in the borderline area.

I also don't understand how I failed. My only thought that seemed valid in that regard was that I put some unlikely "rule-out" type of diagnoses on my first attempt. Later I read that you lose points for unlikely differentials. I figured if the CC is chest pain, any good doc would have MI in his differential. However, although you would consider that at least temporarily, it doesn't need to go on the CS differential I guess if it doesn't fit with the entire patient history. Other than that I really can't think of many mistakes. Forgot the work up section of one case, but I've seen several stories of people not even finishing on multiple encounters that still end up passing.

I passed on my second attempt well into the "higher performance" section with very little change. I used mnemonics for the hpi and ROS. That was about the only difference. Still collected similar data. Just did it by logical history taking before with no real system. Also of note, I had ZERO work with standardized patients between attempts. So it was all practice with note writing and the adjustments to what I included in the differential that apparently allowed me to jump from a fail to "higher performance" asterisks. Not trying to say I didn't commit mistakes that warranted a fail; however, I do have a hard time believing that.

So yeah, I paid the $1300 twice. (Must've gone up if it's now $1600...ridiculous) Also spent 4 days total with travel and probably another $300 on hotels across both attempts. It's awful. And in the end I felt (and still feel) cheated out of my money.

The good news is nobody at residency programs seemed to care too much. Most interviewers (almost all) were too old to have taken the exam. One asked me what it was. She had no idea how it worked. When I explained the differential diagnosis scoring, she seemed to think it was a bit odd as well.

Good luck on your second attempt. That passing score feels amazing. Opening the link probably caused dangerous palpitations though.

thank you so much, I also have failed cs last time, it was hard for me to believe what happened, I and my boyfriend practiced together and he passed, we did the exam same day, with same patients, our diagnosis and work up plan for each patient were same,( I fail ICE) I had better performance than him for other two. I was behind him in typing speed, while we were practicing. when I think about, later on, i feel i didn't write enough information in history and examination but eager to fill DDs and work up. I am terrified to do it again, it is really inspirational to read your post. thank you so much sharing this.