Freaking out about Step 2 CS

[ahmedjq]

I'm taking it on Monday. I'm a US AMG and haven't had any clinical problems, and I'm freaking out about the new scoring guidelines and such with regards to increased standards in CIS and ICE.

I'm going through first aid right now, and I have no idea how I"m going to ask every single one of these questions. I always get about 70-80% correct in FA2 CS, but then I feel like if I try to shoot for asking 90% of the questions, I lose bedside manner points because I'm so wrapped up in asking the next question.

And I always forget a portion of the questions in the peds cases....

I heard the test isn't simply about shaking their hand, washing hands, and being polite to pass CIS now.

And I always forget to do something. If I remember to counsel, I forget to tell the patient (I'm practicing on my wife of course) something else, but I do end up closing.

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[ipizzy]

You don't need to ask all of those questions listed in FA for CS!

This is a pass/fail exam. You can afford to prioritize a smaller, more manageable set of tasks to complete with every patient. Don't worry about doing every little thing!

IMO, the things to prioritize and complete for every patient:

0) DDx. Before even entering the room, spend 20 seconds outside the door and jot down a quick differential diagnosis based on the one-liner. This will help you tailor your ROS questions to be RELEVANT.

1) Introductions. Knock on door. Enter the room and say the patient's name right off the bat (e.g. Hi Ms X). Introduce yourself, shake hands, make eye contact. This is probably where many of your CIS points are picked up, so practice this until it is routine.

2) HPI. Ask your typical HPI questions. Be open ended at first ("How can I help you today?"). Use whatever mnemonic you like. I used FAR COLDER (frequency, associated symptoms, radiation, character, onset, location, duration, exacerbating factors, relieving factors). This should be easy; you've done third year.

2a) ROS. Use your DDx that you jotted down to ask some pointed ROS questions. E.g. let's say you have an abdominal pain case and your DDx that you jotted down in your 20-seconds of prep time was diverticulitis, obstruction, kidney stone. Now you quickly ask about fevers, colonoscopies, changes in bowel habits, changes in urinary habits. You can be pretty open-ended like this; I literally asked people if they noticed changes in their bowel habits and usually the SP would give up whatever was on their script pretty easily. Don't worry about hitting every relevant ROS question; you don't have that much room to write in the note anyway.

3) Empathy. Pick something from the HPI and empathize with it for every patient. e.g. "I'm sorry, that sounds frustrating!" Boom, more CIS points.

4) Past History and Habits. Ask about the other stuff: PMH, Meds, Allergies, FH, SH (include tobacco/ethanol/drugs/sex if relevant). Again, easy peasy if you've done third year!

5) Counsel. If SH positive, stop here and COUNSEL before you move on. Do it right away so you won't forget.

6) Transition. Ask the patient if there is anything else they wanted to talk about before you move on to the physical exam. More CIS points for being open ended

7) If answer to 6 is no, then ask if you can proceed to your physical exam. Ask if you can do an exam.

8) Hands. Put on gloves.

9) Physical Exam. Before every exam maneuver, tell the patient what you are about to do: "If it's alright with you, I'd next like to listen to your heart." Listen to heart and lungs on everyone; add in relevant systems and maneuvers depending on the case.

10) Explain exam. Explain what you are doing and what you are finding during exam maneuvers. "I'm pressing on your belly to see if I can feel any masses. Your belly feels normal." Again, if you explain as you go along, you won't forget to do it later.

11) Summarize. After physical exam is complete, summarize for the patient what your differential diagnosis is. "Based on your symptoms and the physical exam, you most likely have X. It could also be Y and Z. In order to arrive at the right diagnosis, we'll need to do some tests."

12) Testing. Tell the patient about the tests you plan on sending. Explain every test in the most basic way possible before the patient has a chance to ask - e.g. "We need a CT of your belly, which is essentially a set of x-rays that gives very detailed pictures."

13) Questions. Ask if they have questions. Every patient will try to throw you a curveball question, FA is great for preparing for these. Just spend a day reading through those couples pages where they go through the 'difficult questions' that patients might ask you.

And then go write your note! Have a script of the order of your clinical encounter and stick to it. Make a mnemonic of the different steps if you can't remember the script of 13 things above. You can even jot down your mnemonic before you enter the room if you're feeling nervous; that way, you just refer to your cheat sheet if you get flustered.

 

[ahmedjq]

Thanks for reassuring me. I already do most of that stuff, and I have my pointed ROS ready to go. I also have a generic ROS that should cover my main differentials, meaning fevers, chills, wt changes, appetite changes, chest pains, shortness of breath, cough, changes in urination, changes in bowel habits. etc.

And if it's a fatigue issue, i'm gonna talk about sleepiness, depression, stress, caffeine, endocrine issues. Same strategy with other chief complaints.

 

[ahmedjq]

If while summarizing that you forget to ask something in the ROS, is it okay to do so while you're summarizing? Do I have to resummarize?

 

[Fontain]

The above was a great walk-through, thanks. Do any of you have more mnemonics for the different parts of the history taking, and what are your specific questions for the different ROS or different chief complaints?

I'm learning the clinical examination and history taking at the moment, so your experiences and notes are really helpful.

 

[alternatego]

awesome thread

 

[Esprit00]

The above was a great walk-through, thanks. Do any of you have more mnemonics for the different parts of the history taking, and what are your specific questions for the different ROS or different chief complaints?

I'm learning the clinical examination and history taking at the moment, so your experiences and notes are really helpful.

Use First Aid and/or Kaplan Step 2 CS Core Cases. It should be helpful.

 

[ipizzy]

If while summarizing that you forget to ask something in the ROS, is it okay to do so while you're summarizing? Do I have to resummarize?

no don't resummarize, if you forget something you can double back if you think it's important enough. it should be easy enough to weave into your summary: "i think X is most likely because of what you've told me. sometimes people with X have abc. Do you have abc? Well, that's good to know. We'll still need to do some tests to be sure."

 

[socrates89]

great post

 

[ipizzy]

The above was a great walk-through, thanks. Do any of you have more mnemonics for the different parts of the history taking, and what are your specific questions for the different ROS or different chief complaints?

I'm learning the clinical examination and history taking at the moment, so your experiences and notes are really helpful.

For ROS, some of the big questions:

General: fevers, weight changes, energy changes
HEENT: sore throat, runny nose, lumps in neck, difficulty swallowing
Neuro: changes in vision/hearing, weakness, difficulty walking, changes in sensation/numbness, headache, seizures
CV: chest pain, palpitations, fainting, leg swelling, nocturia/orthopnea
Lungs: cough, SOB, wheezing
Abdomen: pain, changes in bowel habits (diarrhea/constipation/melena/hematochezia), nausea/vomiting
GU: dysuria/frequency/urgency, hesitancy, blood in urine, sexual dysfunction
Skin: rashes/lesions
Endocrine: changes in skin quality/hair/nails, polydipsia, polyuria, etc (the biggies to ask symptoms about are diabetes, thyroid problems)
Psych: SIGECAPS (depression screen - sleep changes, decline in interest/hobbies, guilt, energy changes, concentration ability, appetite changes, psychomotor agitation or ******ation, suicidal ideation), CAGE (alcohol - cut back/annoyed/guilty/eye opener), DIGFAST (manic symptoms - distractability, irresponsibility, grandiosity, flight of ideas, activity increased, sleep decreased, talkativeness)

Obviously list is not all-inclusive. You get better at coming up with relevant ROS questions the more you take histories; don't expect to be focused at first! You'll likely ask a little bit of everything until history taking becomes more routine. Then once you get the basics down, you'll start thinking about your DDx while your in the room with the patient. You'll get to the point where your DDx guides what questions you choose to do for ROS.

 

[ahmedjq]

Finished CS.

Holy crap, tehre's no way you can do all the exams listed in first aid CS. At most you can do 3 exams, and that's according doing a standard listening of heart, lungs in two spots. So really, I had only time to do ONE specialized exam.

How huge is misdocumenting something? On a patient that said he had a medication allergy, I accidentally wrote NKDA in a rush. Am I screwed?

I was able to finish notes, but man, some of my differentials were a stretch because 9 cases were painfully obvious.

I forgot to ask about caffeine intake in one case, and realized when I left and it really could have helped my differential.

I'm pretty sure I forgot to shake hands a few times too, just the stress of the situation made me forget something stupid. But I empathized a ton out of them and did my best to respond to their concerns. A lot of them smiled at me after I said "well lets try and figure out what's causing this so we can get you feeling better!"

Edit: OMG, I think I forgot to shake hands on most of the patients. AM I gonna fail? I didn't have a bad feeling leaving any of the encounters, most patients were friendly and I even joked around with a few. Talked about Atlanta site seeing and how their work was going etc. etc.

 

[ahmedjq]

God I can't believe I forgot to shake hands a few times due to stress. I feel awful. I feel like crying.

 

[Esprit00]

Finished CS.

Holy crap, tehre's no way you can do all the exams listed in first aid CS. At most you can do 3 exams, and that's according doing a standard listening of heart, lungs in two spots. So really, I had only time to do ONE specialized exam.

How huge is misdocumenting something? On a patient that said he had a medication allergy, I accidentally wrote NKDA in a rush. Am I screwed?

I was able to finish notes, but man, some of my differentials were a stretch because 9 cases were painfully obvious.

I forgot to ask about caffeine intake in one case, and realized when I left and it really could have helped my differential.

I'm pretty sure I forgot to shake hands a few times too, just the stress of the situation made me forget something stupid. But I empathized a ton out of them and did my best to respond to their concerns. A lot of them smiled at me after I said "well lets try and figure out what's causing this so we can get you feeling better!"

Edit: OMG, I think I forgot to shake hands on most of the patients. AM I gonna fail? I didn't have a bad feeling leaving any of the encounters, most patients were friendly and I even joked around with a few. Talked about Atlanta site seeing and how their work was going etc. etc.

When I finished my CS, I had a rude awakening from a friend about draping. A lot of my patients had the drape folded on top of their knees so I figured I didn't need to do anything. I pretty much didn't manipulate with the drape on anyone except maybe two who I needed to hand the drape to. There were a few times I forgot to pull out the leg rest and one of the actors needed to ask me if there was something for her legs. I also ran out of time to close in one case and partially closed on the second. There was one patient note where my differential was initally CHF and then I quickly changed it to GERD and while most of pertinent information I put to support both diagnoses were interchangeable, my workup was all of CHF because I ran out of time to change it to GERD. I also forgot to document Murphy's sign even though I did it.

Despite all of that, thankfully I passed. Granted, I was very in the "let's find out all your symptoms and history" phase and didn't really butter up my patients beyond the occasional do you need a tissue or I'm sure that must have been hard. That's probably why my CIS score was the lowest but thankfully I passed. Everything else was high pass.

Point of this is: you're going to think you screwed up and you will periodically freak out for the next two months till you get your score. Just relax. Chances are you did better than you thought you did.

 

[ahmedjq]

When I finished my CS, I had a rude awakening from a friend about draping. A lot of my patients had the drape folded on top of their knees so I figured I didn't need to do anything. I pretty much didn't manipulate with the drape on anyone except maybe two who I needed to hand the drape to. There were a few times I forgot to pull out the leg rest and one of the actors needed to ask me if there was something for her legs. I also ran out of time to close in one case and partially closed on the second. There was one patient note where my differential was initally CHF and then I quickly changed it to GERD and while most of pertinent information I put to support both diagnoses were interchangeable, my workup was all of CHF because I ran out of time to change it to GERD. I also forgot to document Murphy's sign even though I did it.

Despite all of that, thankfully I passed. Granted, I was very in the "let's find out all your symptoms and history" phase and didn't really butter up my patients beyond the occasional do you need a tissue or I'm sure that must have been hard. That's probably why my CIS score was the lowest but thankfully I passed. Everything else was high pass.

Point of this is: you're going to think you screwed up and you will periodically freak out for the next two months till you get your score. Just relax. Chances are you did better than you thought you did.

But isn't the handshake absolutely critical?

Oh crap, I also didn't realize that I had to ask to untie the gown. In some patients, I had them ungown themselves, and in some patients, I said "I am going to untie your gown now so I can listen". I also forgot to retie some SPs gown multiple times.

 

[Esprit00]

But isn't the handshake absolutely critical?

Oh crap, I also didn't realize that I had to ask to untie the gown. In some patients, I had them ungown themselves, and in some patients, I said "I am going to untie your gown now so I can listen". I also forgot to retie some SPs gown multiple times.

The handshake is pretty important but apparently so is draping. Maybe they'll overlook your lack of a handshake for your friendliness and/or other things that will count towards your CIS score.

Just don't stress. They don't want perfection, just efficiency. Well actually, I'm not going to lie. You ARE going to stress up until the day you get your score but try not to think about it and remind yourself that you have to screw up royally to fail. And chances are, as an AMG, you're probably okay.

 

[ahmedjq]

The handshake is pretty important but apparently so is draping. Maybe they'll overlook your lack of a handshake for your friendliness and/or other things that will count towards your CIS score.

Just don't stress. They don't want perfection, just efficiency. Well actually, I'm not going to lie. You ARE going to stress up until the day you get your score but try not to think about it and remind yourself that you have to screw up royally to fail. And chances are, as an AMG, you're probably okay.

Man, I think you just made me more worried. LOL. All my patients were already draped, so I don't think I worried about it, but now I remember that some of my patients were clothed and I just listened to their heart and lungs without a drape

I mean, I know I'm just trying to reassure myself, but I am looking at old posts that say that shaking hands is not essential to building rapport (as there are people that passed without shaking , as long as you're nice, conversational and pay attention to the patients needs and treat them like a person and butter them up), and are respectful and indicate what you're doing to them, then maybe it's possible I didn't colossally screw this up.

Here's what I did do every time:

1.Addressed the pt by his name, said "Hi, I'm XXXX, a medical student. I'll be taking care of you today and doing your history and physical. Is that alright?"
2. Used transitions, and constantly explained what I was going to ask. "I'd like to ask about your general medical conditions", "I'd like to ask about sexual health, if that's okay. Everything is confidential".
3. Washed hands, during which I asked about pt's job, life, the city of atlanta. Someone recommended to me to see the georgia aquarium. I asked patients about the coca cola museum and whether it was worth going to.
4. Explained my physical exam as I was doing it.
5. Closed and counselled on alcohol, contraceptive use every time it came up. CAGED people whose alcohol abuse contributed to their medical condition
6. I empathized with the patient. "I can imagine how your sleep troubles are affecting your jobs. Hopefully we can find the cause and get you treated appropriately".
7. Answered challenge questions with "I'd like to do some testing first before I can give you this med" or "we'll give you something for pain control, as you're feeling very uncomfortable." Someone asked about antibiotics, and I explained why we shouldn't treat with antibiotics immediately, as they have side effects and we don't wanna cause more problems.

I think my main fear is that I didn't build rapport in the beginning. I may have forgotten to say nice to meet you a few times. There were two really acute cases where the first thing I said in the room as the pt was writhing in pain is "Sir are you okay? Is there anything I can do to make you more comfortable right now?"

 

[Radonkulous]

....

 

[ahmedjq]

Took the exam recently. Forgot to counsel and CAGE all my patients that needed to even though I had it in my mind. Probably wasn't the most empathetic either. Thought like I did everything else decently well. Somebody reassure me!!!

You don't need to CAGE unless their alcohol is a serious issue. >2 drinks/day in men, >1 in women. If they have a medical problem related to their alcohol use, then you have to do it.

 

[Radonkulous]

...

 

[ahmedjq]

My point was that I didn't CAGE ANYONE and didn't really counsel anyone on smoking cessation, etc.

Meh, my error is prob more ridiculous. I mean, a handshake is considered an important rapport builder. Even if all the patients appreciated my comments and were happy with all the plans I gave them, how do I know they all secretly didn't hate me or I did something offensive and came off as abrasive, even though I didn't realize or mean it?

It's best to just forget about this dumb test. If something happens, just take it again. I know, it's a pain, but it's not like we have another choice. What's the other choice? Not graduate? LOL

 

[ahmedjq]

How big of a deal is it to forget painfully obvious tests even if you had the right thinking, diagnosis?

For example, I may have forgotten to order amylase/lipase in a case of acute pancreatitis... stress makes you do weird things, ya know?

 

[ahmedjq]

Got my score today, passed. My heart goes out to those who weren't so lucky. Stupid test.

It's not as easy as it once was.

My ICE performance was spanning the borderline area, three Xs to the right, and then two Xs to the left.

CIS was comfortably towards the higher performance, and english proficiency was an asterisk.

I definitely feel that my differentials hurt me on this test, along with the lack of supporting findings, and as a result, I didn't order enough tests. Really know your differentials and tests so you can avoid being borderline.

The poor feedback that this score report gives is dumb.

CIS is about not being a robot and being able to small-talk and being a great actor

ICE is about how good you are at documenting things, doing a thorough enough ROS and a rinky dink physical exam, and being able to generate differentials and support them within a matter of 2-3 minutes, and not missing any colossally obvious ones CONSISTENTLY.

The point is being competent CONSISTENTLY. If you make 1 or 2 huge mistakes it's okay. It's about making serious mistakes consistently (my guess). I'm sure the reason I was borderline was because I didn't document a couple things correctly from my encounter (for one encounter I accidentally wrote NKDA when he really had a penicillin allergy, I think it was due to stress, I would never ever make that error again in the stress of a situation), and wasn't broad enough with the test ordering. I even forgot to order a monospot in a patient that I thought had mono or an amylase/lipase in a patient with pancreatitis. I'm sure I made sporadic errors like that.

The lack of feedback on this test is awful. The only reason I can see why the NBME doesn't give us consistent feedback from these trained physician raters is because they want to legitimize the test and fail people to show it's necessity.

Question: do residency programs see the bars on CS?

 

[mercaptovizadeh]

Got my score today, passed. My heart goes out to those who weren't so lucky. Stupid test.

It's not as easy as it once was.

My ICE performance was spanning the borderline area, three Xs to the right, and then two Xs to the left.

CIS was comfortably towards the higher performance, and english proficiency was an asterisk.

I definitely feel that my differentials hurt me on this test, along with the lack of supporting findings, and as a result, I didn't order enough tests. Really know your differentials and tests so you can avoid being borderline.

The poor feedback that this score report gives is dumb.

CIS is about not being a robot and being able to small-talk and being a great actor

ICE is about how good you are at documenting things, doing a thorough enough ROS and a rinky dink physical exam, and being able to generate differentials and support them within a matter of 2-3 minutes, and not missing any colossally obvious ones CONSISTENTLY.

The point is being competent CONSISTENTLY. If you make 1 or 2 huge mistakes it's okay. It's about making serious mistakes consistently (my guess). I'm sure the reason I was borderline was because I didn't document a couple things correctly from my encounter (for one encounter I accidentally wrote NKDA when he really had a penicillin allergy, I think it was due to stress, I would never ever make that error again in the stress of a situation), and wasn't broad enough with the test ordering. I even forgot to order a monospot in a patient that I thought had mono or an amylase/lipase in a patient with pancreatitis. I'm sure I made sporadic errors like that.

The lack of feedback on this test is awful. The only reason I can see why the NBME doesn't give us consistent feedback from these trained physician raters is because they want to legitimize the test and fail people to show it's necessity.

Question: do residency programs see the bars on CS?

Agreed, I had spillover of CIS into the borderline area (4 of 11). ICE was firmly in the "average" range and proficiency was *.

They do not see the bars. They only see that you passed (and by implication passed all three exam components).

 

[ahmedjq]

This test is an elaborate scam. Let USAMGs at LCME accredited MD programs do in-house OSCEs that force people to be competent. At least our tuition will cover it and if we screw up we get feedback so we can retake and improve. Even if we pass, we can use whatever deficiencies we have to become the best we can be.

The rationale for this exam given by the chair of the NBME is complete bunk. The fact that they're making it harder for everyone only makes them look worse.