Failed Step 2 CS

[GATO]

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[NPR]

I think a checklist is helpful but you have to keep it short. You have to keep it general. You have to be flexible enough to use it to start off the conversation but be ready to branch off based on what the patient is telling you.

You create something as long and crazy as the one you did and you'll spend more time trying to recall it then actually conversing with the patient.

In a way, I think an exam like this is useful because it really weeds out those who cannot communicate with patients without the use of a checklist.

Let's be honest, if you can't do that after 4 years of med school, maybe being a physician just isn't in your future? (There are those that will argue CS should be reserved for just FMGs then but it wouldn't surprise me if more than a few AMGs were similarly inept)

 

[GATO]

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[pocketknife52]

man i hope u pass the next time around......it really is too bad.......it is a stupid ass test......no question about it.......

 

[GATO]

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[pocketknife52]

you know writing them down outside the room im sure is fine, but the thing is you dont have to worry about writing in the room, i think i wrote down every answer to every question i asked....of course in short hand, etc....... i always looked them in the eye when i asked them a question......but i looked down while writing usually.... while they answer the question say...."okay" in this concerned voice/tone......hard to explain this.....but the bottom line is this.......if you write down a mnemonic outside the room and go in and only ask those questions you may miss some......i dunno i just didnt use them......but they cant hurt.....it just doesnt seem necessary......

 

[GATO]

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[GATO]

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[size_tens]

Since you seem to be having trouble with time, I have 1 suggestion that should help a little: wear gloves every time instead of washing/drying your hands. I did this for every encounter and passed.

 

[GATO]

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[dgruntledmizzou]

Sigh.

I don't think you're going to get it.

This isn't a protocol-driven exam. Enter, have a conversation, be a decent human being. It's really not that hard.

 

[GATO]

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[dgruntledmizzou]

I think the key for the exam is to treat SPs like real patients with empathy

Exactly, and it's very difficult if you approach it with a systematic protocol.

 

[GATO]

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[GATO]

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[Femtochemistry]

wow this thread is becoming GATO's personal blog

 

[GATO]

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[winner123]

wait, let me get this straight...these are the sentences you should avoid?? If that's true, then I am fubar...I said about 1/2 of these

Femto,I never said that using only these sentences will make one pass this exam.
These are some of the sentences which can enhance your communication.

Passing this exam depends not only on what sentences u use but also on how effectively u use them.
Femto,u said that u used half of these sentences in your exam. Would it be wrong to say that had u not used those sentences you would have done much worse on your exam than what u probably have done.

This exam does not test how good a commentator/fluent speaker you are.
It tests your interaction with a human being.
It tests how slow,loud,simple,confident,compassionate,respectful and kind u are.
In my humble opinion u still r not getting what this exam is about.
You still seem to believe that it is about checklists,and fluency.

By the way,GATO u r doing a good job.
I believe you will pass it next time.

 

[winner123]

Here are some physical exams I found in a book so that I can save my time. I hope they are helpful.

• Joint exam: Inspection; Palpation; ROM; MRS; Distal pulse. Sensory exam: Back & Hip & Knee & Ankle/Foot - just above patella (L4), lateral lower leg (L5), lateral foot (S1); Shoulder & Elbow & Hand - 5th finger pad (ulnar nerve), 3rd finger pads (median nerve), dorsum of hand at web space between thumb and second fingers (radial nerve).
• Brief torso exam is indicated when back pain, rash, depression, mental status change, fatigue, extremity problem. “I’d like to take a look at your back. May I untie your gown? Please lower your gown.” “Now I’ll listen to your lungs. Please breathe in and out through your mouth.” Listen at 4 places on the back. “Now I’ll listen to your heart.” Listen to 4 places. Don’t forget to retie the gown. “Now I’d like to look at your belly. Let me fix the bed to make it comfortable. Can you please lie back? Please raise your gown.” “Now I’ll listen to your belly.” One place for 3 seconds. “I need to press on your belly now.” Palpate 4 quadrants.
• Brief neurological exam is indicated when headache, mental status change, dementia, or head trauma. If the patient is not oriented to person, place, and time, do the rest of the mental status exam. Cranial nerves: Do the 5th nerve last. Say, “Clench your teeth,” and then check the 5th sensory with cotton balls (all three branches). Sensory exam: Check just the tip of the third finger and the top of the foot where the great toe and second toe meet (only use cotton balls). Check both sides at once. Motor strength: “Squeeze my fingers; pull me in; kick out, kick out.” Test the upper extremities at the same time but test leg strength one leg at a time. Deep tendon reflexes: Check brachial and patella only. Cerebellar: Gait.

GATO.

GATO, my advice to u is : Always do a brief and a relevant exam.
Never do a full physical exam.

 

[winner123]

As I told, I took a mock exam in Kaplan. I have a question about evaluation of Spoken English (SEP) by SPs. 8 SPs said 100%. 2 SPs said 50%. 1 SP said 0%. I can understand that 2 SPs said 50%. I am unable to understand why 1 SP said 0%. Am I mute and deaf? Is the SP just harrasing me?

GATO.

GATO, the result of your spoken english in kaplan mock exam must have been 100%.If it is not so,then there is a problem somewhere.
This is not to discourage u ,but to help you make up your deficiencies.
May be you were too fast,verbose,or too low in your speech.
I hope it helps.
Best Regards.

 

[winner123]

I tried the way in the mock exam of Kaplan to see what the result was.
The result was not bad. The SPs appreciated? or evaluated well. But sometimes I did not have any questions to ask. I was blank. The mnemonics of my protocol is for just in case when I run out of things to ask.

GATO.

My advice : no mnemonics are needed.
only practice is needed.
Remove all inhibitions from yourself,just let the conversation start.
If you were blank during the exam then I bet my head that u certainly lack enough timed practice of all the case scenarios.

 

[hj0517]

I just clicked on this post out of curiosity because it seems very active. Just out of interest - Gato, why so many mnemonics? And what year of school are you in? I'm just asking because I'm in my penultimate year in the UK and our rotations are all about Hx Physical DDx and Labs. What I'm getting at is that people don't tend to use mnemonics for stuff thats logical - only one way to pass CS exams of any nature and thats practice. Good luck dude!

 

[GATO]

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[GATO]

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[agranulocytosis]

Good lord. That's a lot to type.

 

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[fungusflu]

Hey Gato:

I hope my reply gets to you in time. I really feel bad for you so if you want to, we can practice on Skype. There's nothing more important than timed practice (even when your English is not so good). I just study from First Aids CS (practiced each questions at least 3 times) and also questions from USMLEWorld but my exam questions were mostly covered in FA. Let me know. My e-mail is [email protected].

 

[GATO]

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[GATO]

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[Taurus]

My eastern Indian roommate is watching football games with his friends. They really like them, discussing about the playoff.

Sitting in bar, shooting the breeze with people, getting shot down by all the hot women. That's your best way to prepare for this test.

 

[GATO]

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[GATO]

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[ROBINHO]

Hi Gato,
I have read your posts extensively. I am an International Med student. I havent written my exams yet but there is something not right about the way u are going it. I think so many mnemonics and u just have to relax and practice a lot.
I will write my exams in Atlanta on Friday(wish me luck). I havent had the chance to practice very well, but I think I will make it in God's name.
If I clear my hurdle, maybe I can help u. Especially the part about practising your english and u can use me as my patient.
[email protected]
my skype is maxieafari

I can only get back to you next week.
I cant promise a lot....but at least I can give u some mins of my time, at least once a week and we are going to win this thing together. SO dont worry at all. Trust me.

 

[winner123]

I added this bold sentence in my note.

• Fever: “Have you been running a fever? Do you sweat a lot during the night?”
• Fatigue: “Do you feel tired?”
• Appetite: “How is your appetite?”
• Weight changes: “Has your weight changed any? How much? Over what period of time? Was it intentional?”

Ask height and weight for pre-employment physicals, pediatric cases, and other cases in which patients will want help with managing their diabetes, hypertension, or obesity.

“What does your blood pressure normally run?” “Have you ever been immobilized?” “How often do you test your blood sugar? How high have your sugars been?” Don’t forget to ask about rash and fever in joint-pain cases.
Thyroid function 5 (BS HiTS) (“Have you noticed any change in your bowel habits? Constipation? Diarrhea? ; Has your skin been very dry/very moist lately? ; Have you been losing your hair? ; Do you find yourself having trouble adjusting to cold or hot temperature recently? ; Do you have trouble sleeping?”)

GATO,

Mnemonics are not needed at all.These mnemonics will ultimately be of no use to you and will on the contrary frustrate you.
Gato,you need to concentrate on the patient in the test not on your mnemonics.You can not go into the exam with such a huge burden of mnemonics on your mind .You have to feel free while you are in the exam.
I have told you earlier as well that about 60% of what we do in the patient encounters is all but the same.So ,you need to do only 10-15% different in every encounter.
The way to practice goes like this that you have to use only your common sense to dissect each chief complaint.Once you disect the chief complaint then ask about some asociated symptoms based on the differential diagnosis in your mind.
For example,Let us take fever.
Dissection of this chief complaint will be like:

1. When did it start?
2. How high is your fever?
3. Do you have fever now?
4. Do you constantly have fever or does it come and go?

Now , questions about associated symptoms will be like:

1.Do you have any shaking of your body while you have fever?
2.Do you get any night sweats?
3.Do you have any cough?


Then you can add some more common questions on the ROS(Review of Smptoms).

Look, you need to ask these questions in simple,and slow english.

I must warn and tell you that your method of prepararion is not practicable at all.It will just simply add to your misery in the exam.

Just use common sense.
I can tell you with certainty that USMLE Step2cs is an exam which even a nonmedical person can pass after a little bit of practice.
I know many Standardised patients with whom I worked and found that they were much better than medical graduates in asking about symptoms ,doing physical exam ,etc.
So,use common sense in asking questions about chief complaint and ask about asociated symptoms based on the differential diagnoses you remember for each chief complaint.
This is very important because when you are not overburdened or stressed in your exam only then can you concentrate on communication skills like eye contact,empathy,respect,reassurance,etc. in your exam.

P.S. I do not want you another harm,I want you to pass.

 

[sade]

Hi Gato,
I would like to give you some advice on CS. I have skimmed through your posts and the impression I get is you are being rigid in your studies by sticking to mneumonics. I would like you to recall how you did medical rotations in your 4th year of medical school. Remember the ease you could ask qns and catch hints from patients and ask follow up questions accordingly. The way you could gain a patients trust so that they could tell you their problems. That is the approach you need to have to cs. You have to be relaxed and communicate more with the patient using body language. Smile, eye contact, handshake, a pat on the back, a laugh ...etc . I am also an IMG but had the advantage of studying at a university using PBL system so Im used to these exams only difference was I was doing it in a different language. I had 10days to prepare for the exam in english.

What I have observed from the exam is the communication skills( especially non verbal) and asking relevant qns to the patients complaint is more important. Addressing the patients qns or "behaviour"( difficult patient/angry/ crying) is also a skill you need to work on as thats how they try to break you. You will not be able to ask all qns from ROS so be specific in relation to the complaint coz that can be a clue to rule out/in a diagnosis . Counselling on bad health practises is a big plus and making sure you can close your case. The five minutes for physical examination is usually not enough. So you have to focus on important systems. E.g patient with HT - check eyes, lungs, heart(dont forget the carotids and renal for bruit) and extremities.

Regarding time, I would advice you to practise always with a clock. And mentally use the 5minute bell ring as a warning to finish up your case. If you are planning to wash your hands, you can save time by washing them while you are taking the last part of the social history. But tell the patient that you would like to wash your hands and MAINTAIN eye contact and ask the few qns remaining. DOnot write anything after this, drape your patient and do the examination.

In short CS is a game of acting, you are acting to be the best dr on earth with the best bedside manners, you ask relevant qns, make your patient comfortable and feel safe. Once you have gained the patients trust you examine your patient, counsel them and plan to see again, smile say goodbye. Then you have to write a readable, concise patient note.

For the patient note writing down the diagnosis, examination findings and tests before the HPI helped me to write quicker and finish on time.

Mneumonics can be handy to remember things but as you did not create it yourself you have the risk of going blank. So, if you like using mneumonic create your own or modify others and OWN THEM. At the door after quickly reading the note at the door I would quickly think of differentials so those guided me on what to qn the SP.
I used this mneumonic (S/L)IQORAAA PAMH(ITS)RFOS(SADWADOEST) and if there is h/o of ALCOHOL abuse/overuse ask CAGE qns.

H(ITS)-Hospitalization, Illness, Trauma, Surgery
SADWADOEST-Smoking,Alcohol,Drugs,Weight changes, Appetite,Diet,Occupation,Exercise,Stress,Travel.
^^^The only one I used but because I knew it I usually concentrated on the usefullness in the social hx.

I know cases will come in any order in the exam but when I was preparing for the exam I studied cases by systems and made notes. CVS, pulmonary, musculoskeletal.... with mneumonics, counselling qns etc. So even if the cases could be twisted I could think of a system and come up with differentials and tests to do. And I used to time myself writing the PN notes with acceptable abbreviations. and drew the stickman for DTR.
If you see anything from Tattoos to onychomycosis you must document it on your PN as it shows you are observant(also needed for medicolegal issues in the real world) and may help with your diagnosis e.g pt mayhave hepatitis for the former and diabetes for the later. (I always mentioned it aloud to the patient and if its something to discuss we do so while Im examining.)

This is what I can think of as of now. I used FA and UW(noted cases which werent on Fa or differences and stuck to one book + my notes), I had bought the Kaplan book ,cs blueprints, too but were useless. I like reading from different sources had also a copy of cs checklist which I could carry with me in the beginning. I found myself a phone buddy and we used to take turns doing the cases and correct each otheresp. the timing. After we finished our sessions I used to time myself and write the PN's of the patients I interviewed.

If you have any qns, pm me.
wish you all the best.