How to do well on Step II CS

[bigfrank]

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Took the Step II CS exam a few weeks ago and found out today that I passed. I'd like to post a brief thread with some ideas that helped me out immensely. I took it "early" because I've heard that some programs will not rank you unless you have taken/passed Step II CS.

First off, don't let people deter you from studying with idiotic comments like, "all you need to do is pass your third year and you're golden." This is a fallacy. While you probably would pass even if you didn't study at all, is this a risk you're willing to take? Step II CS is an exam that is best summarized as, "of no additional benefit if you pass, but catastrophic if you fail." Therefore, why risk it?

That said, the book to buy (as others have posted) is First Aid for the Step II Clinical Skills Exam. It is a very fast read and incredibly helpful. Of note, pay attention to the first chapter that talks about the exam itself (logistics, format, etc.) and the end that has 25 cases or so that are best done with a partner. This is where a wife/boyfriend/husband/girlfriend comes in very handy. My wife was an immense help to me. She would review a case for 5 minutes, sit with the book in her lap, and answer questions in a very similar fashion as a SP (standardized patient). This was a huge help. The middle of the book has a laundry list of chief complaints --> questions to ask --> physical exam aspects --> differential diagnoses --> next steps in management. This part is absolutely worthless and I didn't even look at it.

At the end of the day, there are a few key points that are in the FA for Step II CS that I'd like to stress:

• Always smile. Be friendly. Shake hands when you enter the room and call the patient by name.
• Be very aware of the time. Many students fell short on time on test day. Practicing with a SP will be crucial here.
• Wash your hands before every physical exam. Be courteous about draping, etc.
• Be prepared for a phone conversation.
• Be prepared for talking to a mother about "Johnny" who isn't even there in the room.
• Be prepared to write short notes. I had to tailor every note, because you will have less space to write than you're accustomed to.
• Always be sure to ask the patient, "Do you have any questions? Any concerns?"
• Always summarize, at some point, the patient's history.
• Don't rattle through a laundry-list ROS. I found that my patients, when asked, "Have you had any diarrhea or constipation?" would always answer, "no constipation." Be sure to ask a concise ROS and give the patient time to answer.
• Pay attention to FA's section on "difficult patients." Keep in mind that EVERY patient has a question that you will need to answer empathetically ("Do I have cancer, doc?" "I can't pay for my pills." etc.)
• Be nice. Smile.
• Don't get stressed WHEN you run out of time on a patient, not completely finish a note, forget to examine a complete organ system, or feel like a patient was being a b!tch. All of this happened to me and I still passed.

And, finally, good luck to all. Don't be in the 4% group -- of US-MD students that fail this exam.

 

[neilc]

good advice, thanks! i have it coming up...

 

[APACHE3]

BF is right. I just passed CS. It took 8 WEEKS for results to come back. That was tough. Anyway, he's right...this exam SHOULD be easy to pass,...but to fail it really waves the red flag. FA is a great book. I also used UW, which although poorly written, has some good cases to cover. I had NO study partner. I practiced with my mirror, BUT..what I did do was schedule an EM elective one month prior to exam, so I got lucky on timing. Sub-I in an ED is about as good a practice as you get (minus the trauma) Smile, make small talk, WASH hands with SOAP (don't fake wash) they are looking. Don't write anything you don't want them to see, (they look). Just practice LIQORAAA and PAM HUGS FOSS and you've got it made. I wrote my notes because I use a lot of abbreviation. PRACTICE the note before you go, it's not as easy as you think. And in my group of 22 test takers that day (Houston), one USMG was a REPEATER, so don't take this test lightly!!! Also enjoy the food, you paid $1000 for that chicken salad sandwich!!! PS Beware..one guy kept asking all the other examinees about their patients, he was really driving me crazy, I hope they busted him. I passed the down time talking about cheap mortgages with a doc from Ireland!! Don't take any chances..GL

 

[bigfrank]

I actually did "fake wash." When you have 15 minutes (door - door), there is little time for even a minute handwashing session. I tried to keep my "handwashing" to 15 seconds. In Philly, they had the cold water turned off, so only warm water came out of the faucet, for obvious reasons. 😉

 

[APACHE3]

Just act like you hit the soap, thats all, I spent 15 seconds on wash, 5 seconds on dry, and usually did my small talk at this interval. Sometimes i got my challenging question DURING my hand wash..so that can come at any time of the encounter!! GL

 

[chak_de_phatee]

Thanks for another excellent guide BF..................looking forward to the Step2 and comprehensive clinical years writeups. Do you have the ISBN numbers yet????? 😉

 

[Aislin]

Thanks for all the advice man.

 

[Pox in a box]

How much studying do people typically do for this exam? For most it's just a requirement for graduation and you need to pass to get into a residency so don't people just delay it to focus on other exams crucial to residency like Step 2 CK?

 

[Stinger86]

I studied a few hours a day for about 2-3 weeks (I took my first month of senior year off) for the CS. Comparatively I spent 2 days studying for the CK, which I took immediately after my junior year ended.

IMO the CS was much more important than the CK because 1)it's difficult to fail the CK unless you don't even try and 2)I wasn't about to fork out another $1200+ to repeat.

Looking back, I studied for both exams way too much, especially the CS. Like other people have said, if you can speak some decent English and treat the SP like a real person, you'll be fine.... even if you suck at the H&P.

 

[Pox in a box]

I studied a few hours a day for about 2-3 weeks (I took my first month of senior year off) for the CS. Comparatively I spent 2 days studying for the CK, which I took immediately after my junior year ended.

IMO the CS was much more important than the CK because 1)it's difficult to fail the CK unless you don't even try and 2)I wasn't about to fork out another $1200+ to repeat.

Looking back, I studied for both exams way too much, especially the CS. Like other people have said, if you can speak some decent English and treat the SP like a real person, you'll be fine.... even if you suck at the H&P.

I would think the prep amount would be just the opposite. If you're a med student and have been performing well on the wards and in the clinics, shouldn't the CS be a natural transition, especially if you've already practiced with standardized patients throughout medical school? You just get a pass/fail for CS right? CK is much more objective to me and shows more realistically what your knowledge base is (especially comparing it to Step 1 or your clinical rotation evaluations). Am I wrong?

 

[Stinger86]

I would think the prep amount would be just the opposite. If you're a med student and have been performing well on the wards and in the clinics, shouldn't the CS be a natural transition, especially if you've already practiced with standardized patients throughout medical school? You just get a pass/fail for CS right? CK is much more objective to me and shows more realistically what your knowledge base is (especially comparing it to Step 1 or your clinical rotation evaluations). Am I wrong?

I guess it depends on the student and the situation. Again, I studied much more for the CS because I was worried about it (mainly the fact that we don't know exactly what is graded or how it is graded, i.e subjective) and the thought of flushing more money down the NBME's drainpipe disgusted me. Also, I did pretty well on the Step 1 (and usually do not have too much trouble with standardized tests in general) so I figured that I'd do a decent job on the CK with minimal studying. As it turns out, my CK was about 22 or so points below my Step 1, but still a reasonable score. In other words, it worked for my purposes. If one is looking to outshine a subpar Step 1 score, or wants into an incredibly competitive specialty, then that person should definitely spend a good amount of time studying for the CK. Again, depends on the student and his/her situation.

For the CS specifically, you're right that for a student performing well on the wards the CS exam ought to be an easy transition. The CS is NOT a hard exam; it just causes a lot of people to worry because it's so subjective. It sounds like you're doing well your third year, so you'll probably whip through the actual exam with no problems. And, if you've been reading all the other threads, you'll notice that you can make a TON of mistakes on the history, physical, and writeup, but as long as you can speak english clearly and treat the patient with respect (or like a good friend), you'll pass.

 

[Pox in a box]

I guess it depends on the student and the situation. Again, I studied much more for the CS because I was worried about it (mainly the fact that we don't know exactly what is graded or how it is graded, i.e subjective) and the thought of flushing more money down the NBME's drainpipe disgusted me. Also, I did pretty well on the Step 1 (and usually do not have too much trouble with standardized tests in general) so I figured that I'd do a decent job on the CK with minimal studying. As it turns out, my CK was about 22 or so points below my Step 1, but still a reasonable score. In other words, it worked for my purposes. If one is looking to outshine a subpar Step 1 score, or wants into an incredibly competitive specialty, then that person should definitely spend a good amount of time studying for the CK. Again, depends on the student and his/her situation.

For the CS specifically, you're right that for a student performing well on the wards the CS exam ought to be an easy transition. The CS is NOT a hard exam; it just causes a lot of people to worry because it's so subjective. It sounds like you're doing well your third year, so you'll probably whip through the actual exam with no problems. And, if you've been reading all the other threads, you'll notice that you can make a TON of mistakes on the history, physical, and writeup, but as long as you can speak english clearly and treat the patient with respect (or like a good friend), you'll pass.

Thanks Stinger. Best of luck to you!

 

[bigfrank]

Thanks for all the advice man.

You're very welcome.

 

[Aubrey]

I guess it depends on the student and the situation. Again, I studied much more for the CS because I was worried about it (mainly the fact that we don't know exactly what is graded or how it is graded, i.e subjective) and the thought of flushing more money down the NBME's drainpipe disgusted me. Also, I did pretty well on the Step 1 (and usually do not have too much trouble with standardized tests in general) so I figured that I'd do a decent job on the CK with minimal studying. As it turns out, my CK was about 22 or so points below my Step 1, but still a reasonable score. In other words, it worked for my purposes. If one is looking to outshine a subpar Step 1 score, or wants into an incredibly competitive specialty, then that person should definitely spend a good amount of time studying for the CK. Again, depends on the student and his/her situation.

For the CS specifically, you're right that for a student performing well on the wards the CS exam ought to be an easy transition. The CS is NOT a hard exam; it just causes a lot of people to worry because it's so subjective. It sounds like you're doing well your third year, so you'll probably whip through the actual exam with no problems. And, if you've been reading all the other threads, you'll notice that you can make a TON of mistakes on the history, physical, and writeup, but as long as you can speak english clearly and treat the patient with respect (or like a good friend), you'll pass.

I would be very interested in hearing from some AMGs who have failed the exam, and their opinions on what went wrong. It's clear that a language barrier can be a significant hurdle, but barring that..

 

[Stinger86]

I would be very interested in hearing from some AMGs who have failed the exam, and their opinions on what went wrong. It's clear that a language barrier can be a significant hurdle, but barring that..

Here's a good example of how to fail as an AMG:

Enter without knocking. Call the patient by his first name, but don't tell him who you are. Spend most of the time looking at your clipboard, especially when the patient is talking. On the rare occasion you do look at the patient, look bored. Yawn. Repeat the same hx questions over and over again. Don't wash your hands. Take the patient's gown down/off without asking permission. Maintain absolute silence during the physical exam, except to utter the occasional "wow" or "hmph!" remark. Don't explain the remarks, and simply say "shhhhhh" when he asks. Tell the patient you're about to do a rectal exam on him because everyone gets one. Say it's to check for "hematochezia" or "malignant colonic adenocarcinoma" or "surreptitious angiodysplasia". Argue with him when he resists. At the end of the encounter, tell the patient what he has and what you're going to do to him. Only use enormous vocabulary. Don't ask if that's ok with him, because you're the doctor not him. If he thinks he has some disease in particular, tell him "don't be ridiculous", and then ask him "are you the doctor?". Don't ask him if he has any worries or questions because you don't have the time to address them. Don't thank the patient for his time because he should be thanking you for yours.

That should about do it.

 

[Pox in a box]

Here's a good example of how to fail as an AMG:

Enter without knocking. Call the patient by his first name, but don't tell him who you are. Spend most of the time looking at your clipboard, especially when the patient is talking. On the rare occasion you do look at the patient, look bored. Yawn. Repeat the same hx questions over and over again. Don't wash your hands. Take the patient's gown down/off without asking permission. Maintain absolute silence during the physical exam, except to utter the occasional "wow" or "hmph!" remark. Don't explain the remarks, and simply say "shhhhhh" when he asks. Tell the patient you're about to do a rectal exam on him because everyone gets one. Say it's to check for "hematochezia" or "malignant colonic adenocarcinoma" or "surreptitious angiodysplasia". Argue with him when he resists. At the end of the encounter, tell the patient what he has and what you're going to do to him. Only use enormous vocabulary. Don't ask if that's ok with him, because you're the doctor not him. If he thinks he has some disease in particular, tell him "don't be ridiculous", and then ask him "are you the doctor?". Don't ask him if he has any worries or questions because you don't have the time to address them. Don't thank the patient for his time because he should be thanking you for yours.

That should about do it.

That's hilarious but very good points...are you suppose to call someone by their first name? I'm assuming no.

 

[Radiohead]

This may sound stupid, but I only draped my patients before I did the abdominal exam. Does anyone know if they count off/automatically fail you for that? Thanks.

 

[Stinger86]

...are you suppose to call someone by their first name? I'm assuming no.

It's always Mr., Mrs., or Ms. Even if the patient is some 18 year old high school student.

 

[Stinger86]

This may sound stupid, but I only draped my patients before I did the abdominal exam. Does anyone know if they count off/automatically fail you for that? Thanks.

I seriously doubt you can do anything horrible enough to get failed automatically, short of walking in the room and immediately dropping trou. Or referencing your First Aid during the patient encounter.

According to FA for the CS, you should go ahead and drape the patient at the very beginning of the encounter to ensure point credit. And that probably goes for all encounters. You'll definitely get full points for draping on the abdominal stations, but you should've probably draped on all of them. Think about it: you walk into the room, sit down in front of a patient wearing a knee-high gown, and your eyes are right at the level of their crotch. Draping simply preserves overall modesty and should be done with every patient. It's a small detail though and, again, you draped when it was REALLY crucial so I bet you have nothing to worry about.

 

[bigfrank]

My patients were always appropriately draped and it became an issue only when s/he had to lie down for the abd exam.

 

[Osteotome]

I failed that liberal bull#$%^ they call the CS. Which is nothing more than a bunch of old ladies that were bored of sitting around all day drinking tea and watching soaps that they decided to make up some stupid test. If I was disenchanted with the system before I am now about one step away from going to law school to get the MD/JD combo and end up on the back of phone books to sue the butt of bull%^&* artists that think this test means something.
I come from an inner city hospital where patients have about every problem in Harrisons: HTN, CHF, CHD, DM2, HIV, their feet are rotting off their body, they are pregnant, they smoke crack and drink a fifth a gin daily, have no insurance and are supposed to be on 15 meds none of which they know the name of let alone even take! But wait I'm not sure if those are acceptable abbrieviations. I failed (I think-- because they don't tell you) because I flew threw the patients because the test is so easy and someone didn't like that.
The encounters are, "I have a head ache but I didn't take my bp meds for the last month. Sorry if that only takes 5 minutes to figure out. Secondly, the standardized patients take no time because they are itching to tell you there stupid fake disease that if you ask them, "so what brings you here today?". They say, "well I lost 20 lbs in 5 minutes and my mother and my sister and my ex husband and our dog all died of pancreatic cancer and I feel like I have watermelon growing in my gut and I turned orange last week." So sorry if I decided to use the extra time a write a note and didn't do a 43 minute full physical exam on you because I will find nothing because remember, you are acting that you have this disease. And instead spent the extra time to write a note and actually spend time to come up with a plan to help you and your fake disase, instaed of sit an ponder with you what type of cloud you think you saw on they way here this morning. Because remember this is a timed exam.
Give me a break, in a medical climate where insurance companies squeeze you from one end, the lawyers squeeze you form the other and supposedly there are not enough doctors around to care for patients, that you are forced to develop speed and accuracy. Then you are punished for it. Not by a physician who knows the reality of medicine but by some lay person who says, "Oh my God ... that guy listened to the heart through the gown!" Then fails me, sucks me dry of another thousand bucks and wrecks my applications. They wonder why doctors are synical and dead. They are only adding to the problem. As if they know what makes a good doctor, there is a difference between spending 5 minutes with a patient who is there for a bp check and sitting with a dying patient and his family to help answer questions. Some how they think this test will be able to seperate those people who don't know the difference. What a joke!
Just my 3 cents, but my advice is that, yes this test is a gimy but if you waltz in with my attitute and fly through you will be branded a lepper like myself and be a thousand bucks lighter and probably locked out of competitve residency dispite having excellent scores and letters and the whole works that is this big game.

Thanks,
The obviously one of the 4% of the most heartless and worst doctors in the US by the NBME's standards. Wait probably 0.5% because I can speak English.

 

[Stinger86]

One thing my school tried to brand into our memory during practice OSCEs was that the objective of a clinical exam is to show the people in charge that you can conduct a thorough patient interview/encounter regardless of how obvious or mysterious the diagnosis. You get graded on taking a full history, doing a relevant physical exam, writing up a note that summarizes the pertinent findings, and making the standardized patient feel comfortable. In other words, you can't just walk into the patient room, see the patient with a bullet hole in his chest, and exclaim "BAM! Diagnosis gun shot wound!" and leave. You don't automatically win by correctly guessing the diagnosis; it's the work that fills up the space in between that matters. Obnoxious, yes... tedious, more often than not. But you have to jump through the hoops. Just be thankful you'll be out of medical school by the time these geniuses decide to add a "standardized" oral exam or written component to the Step 1 or Step 2 CK.

 

[bigfrank]

Osteotome,

Sorry about that. Let the rage out but double-focus your efforts to take it ASAP and pass by interview season.

 

[APACHE3]

Out of each test group, its thought 3-4 out of the 24 will fail the exam. At least one of those will be a AMG, so the numbers add up. In my group of 22, there was one repeater from South Florida. he did exactly what you did. Was in and out in 5 minutes. It would be nice to see the actual number of repeater AMG amd IMG. (I'm IMG)