USMLE I failed CS.

[deleted699098]

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I failed the ICE component.

I'm a US IMG, so the SEP & CIS components weren't a problem (I attached my score report for reference).

My problem is, I don't know what exactly to work on to pass next time!

My CK score was 227 (1st attempt). I took the Kaplan 5-days course in Chicago a month before my test, and I did the Kaplan book and FA.
My attendings for all my clinical rotations (I'm shadowing/visiting physician at a local hospital) all expected me to breeze through the test, based on my bedside manner and my clinical knowledge.

Nothing too crazy happened during the test. I took it in Atlanta, the 3PM session.
I do remember having some trouble coming up with a DDx for a case or two. I didn't finish the physical for another case (the 5-minute alert caught me off guard!).
Otherwise, nothing was in any way unusual or disturbing.

So I'm not quite sure what I messed up bad enough to merit failing the ICE component.
Suggestions?
And assuming my clinical knowledge needs to be polished (it's been 8 months now since I last studied for CK!), what's the best approach? I'm scheduled to take the test Jan 12th.

 

[Bully Ball]

I failed the ICE component.

I'm a US IMG, so the SEP & CIS components weren't a problem (they're actually off the charts on my score report).

My problem is, I don't know what to fix to pass next time!

My CK score was 227 (1st attempt). I took the Kaplan 5-days course, I did the Kaplan book and FA. My attendings for all my clinical rotations (shadowing/visiting physician at a local hospital) all expected me to breeze through the test, based on my bedside manner and my clinical knowledge.

Nothing too crazy happened during the test. I do remember having some trouble coming up with a DDx for a case or two Otherwise, nothing was in any way unusual or disturbing.

So I don't even know what I did wrong.
Suggestions? And please ask

The CIS basically tests your interpersonal skills, so your bedside manner is fine

The SEP basically tests your english, so that should be fine

You failed the ICE component which tests your ability to document a note, create an ordered list of differentials and be able to justify those differentials with support from the H&P.

I'm sorry you failed, but from my perspective, ,what I bolded is what I think you need to fix in order to pass next time. I try to be a glass half-full person so I'll say that if there's one silver lining I can see, it's that you failed the ICE component. I think it would be harder to change my personality or improve my english than study and practice for what I think is the most objective portion of the exam.

 

[deleted699098]

The CIS basically tests your interpersonal skills, so your bedside manner is fine

The SEP basically tests your english, so that should be fine

You failed the ICE component which tests your ability to document a note, create an ordered list of differentials and be able to justify those differentials with support from the H&P.

I'm sorry you failed, but from my perspective, ,what I bolded is what I think you need to fix in order to pass next time. I try to be a glass half-full person so I'll say that if there's one silver lining I can see, it's that you failed the ICE component. I think it would be harder to change my personality or improve my english than study and practice for what I think is the most objective portion of the exam.

Do you have any specific suggestions for me? I'm definitely going through FA and the Kaplan CS notes again, but that didn't really help much the first time.
Thanks a lot, btw!

 

[The Alienist]

The ICE is basically your PN, PE and how relevant was your questioning (checklists). I really don't think it is about getting the exact diagnosis, but how you approach a specific complaint. For example, if you have a patient with diarrhea, you should be able to ask relevant questions and make significant PEs, such as "could you please describe the feces, do have any belly pain? have you noticed any recent change in you weight? etc". So, I'd focus on how to approach each complaint. Additionally, make sure your notes are organized and logical. I made tons of serious mistakes (not silly stuff, like forgetting to wash hands in one case) and still passed without even touching the borderline. Also, consider taking one of those courses, if you think it would be helpful.

 

[takeuponeidea]

I failed the ICE component.

I'm a US IMG, so the SEP & CIS components weren't a problem (they're actually off the charts on my score report).

My problem is, I don't know what to fix to pass next time!

My CK score was 227 (1st attempt). I took the Kaplan 5-days course, I did the Kaplan book and FA. My attendings for all my clinical rotations (shadowing/visiting physician at a local hospital) all expected me to breeze through the test, based on my bedside manner and my clinical knowledge.

Nothing too crazy happened during the test. I do remember having some trouble coming up with a DDx for a case or two. Otherwise, nothing was in any way unusual or disturbing.

So I don't even know what I did wrong.
Suggestions?

sorry to know that...can you upload the score just to have a look at your ICE.

As per my knowledge, we should conclude our diagnosis logically with the help of decent HPI PN section apart from supporting history and PE under diagnosis...better luck next time...FA CS is good but workup and PE is extensive...Kaplan core cases is good....combined both together and practice with study partner and ask him to grade your PN....try to score max on PE with focused exam

 

[deleted699098]

The ICE is basically your PN, PE and how relevant was your questioning (checklists). I really don't think it is about getting the exact diagnosis, but how you approach a specific complaint. For example, if you have a patient with diarrhea, you should be able to ask relevant questions and make significant PEs, such as "could you please describe the feces, do have any belly pain? have you noticed any recent change in you weight? etc". So, I'd focus on how to approach each complaint. Additionally, make sure your notes are organized and logical. I made tons of serious mistakes (not silly stuff, like forgetting to wash hands in one case) and still passed without even touching the borderline. Also, consider taking one of those courses, if you think it would be helpful.

Looking back, I realize I tended to go all over the place with my questions, then miss a lot on my PE.
I took the Kaplan course. It was quite helpful, with the mnemonics and how to write the PE and what not. But not much help with the PE (I've always sucked at PE for exams

sorry to know that...can you upload the score just to have a look at your ICE.

As per my knowledge, we should conclude our diagnosis logically with the help of decent HPI PN section apart from supporting history and PE under diagnosis...better luck next time...FA CS is good but workup and PE is extensive...Kaplan core cases is good....combined both together and practice with study partner and ask him to grade your PN....try to score max on PE with focused exam

I just attached my score report to my original post.
I sure do hope I have better luck next time, it's exasperating,
Thanks a lot!

 

[takeuponeidea]

Looking back, I realize I tended to go all over the place with my questions, then miss a lot on my PE.
I took the Kaplan course. It was quite helpful, with the mnemonics and how to write the PE and what not. But not much help with the PE (I've always sucked at PE for exams



I just attached my score report to my original post.
I sure do hope I have better luck next time, it's exasperating,
Thanks a lot!

Your CIS and SEP is great and really bad luck for ICE. I know as a medical student/graduate, we all know basic clinical qs and PE but sometimes things may not work well...As per my knowledge these things are useful....Explore CC and get some info on ROS and do focused PE and finally organize PN with just 2 DD's (most of the cases) if you feel short of time....support DD with Hx,PE and order workup only for DD's

you can share your CIS skills and tips as your cis is high....

How can send you PM...I will send you ICE tips

 

[deleted699098]

Your CIS and SEP is great and really bad luck for ICE. I know as a medical student/graduate, we all know basic clinical qs and PE but sometimes things may not work well...As per my knowledge these things are useful....Explore CC and get some info on ROS and do focused PE and finally organize PN with just 2 DD's (most of the cases) if you feel short of time....support DD with Hx,PE and order workup only for DD's

you can share your CIS skills and tips as your cis is high....

How can send you PM...I will send you ICE tips

I'd love to share anything that can be of benefit to anybody tackling the test. I'm fairly new to SDN so bear with me!

 

[hopingforthebest123]

Where did you take the test at if you don't mind me asking?

 

[deleted699098]

Where did you take the test at if you don't mind me asking?

I don't mind at all - I took it in Atlanta, May 26th.

 

[operaman]

Sorry this happened man, but with a little prep you should have no trouble passing it the next time. In the end you'll need:

1) Set mnemonics for all parts of the interview. Such a low bar on the score report means you gave up a lot of easy points on basic HPI points. Pick a mnemonic and just do it every time. Ditto for the PMH (incl OBGYN if female), FH, SH, ROS. You need the mnemonic so you can rattle them off fast. Time is critical in this exam as you well know, so you don't want to run out of time for your exam and for the counseling/closure/affecting your life stuff that got you a nice high CIS score. There are not really many style points for this test; just get through your checklist while maintaining decent rapport.

2) Have a basic physical exam you do EVERY time unless obviously not indicated. There really aren't many times when you shouldn't do a basic heart/lungs/abdomen exam. These are pretty easy to do in succession in 1 minute. Remember, you don't really have to find anything, just execute the moves. I do all posterior lung fields while pt sitting on edge of bed; then lay them back and do anterior lungs, heart, and abdomen while supine. If remotely indicated, you could easily add a brief neuro exam with an additional 30-45 seconds.

3) Memorize common DDx ahead of time. When I took my exam, I pretty much had my ddx for most of the cases before I knocked on the door. Sure, some will evolve during the interview into something else, but I would sketch a brief ddx in the 10 seconds before you walk in the door. After you rattle of your mnemonics, think through how your ddx has evolved and ask additional questions as needed.

4) Practice with the patient note form. I liked starting at the bottom with my ddx and supporting points. Some people get too bogged down with the HPI; remember there are no style points, so don't let a beautifully crafted HPI prevent you from getting some points in the dx/plan.

 

[deleted699098]

Sorry this happened man, but with a little prep you should have no trouble passing it the next time. In the end you'll need:

1) Set mnemonics for all parts of the interview. Such a low bar on the score report means you gave up a lot of easy points on basic HPI points. Pick a mnemonic and just do it every time. Ditto for the PMH (incl OBGYN if female), FH, SH, ROS. You need the mnemonic so you can rattle them off fast. Time is critical in this exam as you well know, so you don't want to run out of time for your exam and for the counseling/closure/affecting your life stuff that got you a nice high CIS score. There are not really many style points for this test; just get through your checklist while maintaining decent rapport.

2) Have a basic physical exam you do EVERY time unless obviously not indicated. There really aren't many times when you shouldn't do a basic heart/lungs/abdomen exam. These are pretty easy to do in succession in 1 minute. Remember, you don't really have to find anything, just execute the moves. I do all posterior lung fields while pt sitting on edge of bed; then lay them back and do anterior lungs, heart, and abdomen while supine. If remotely indicated, you could easily add a brief neuro exam with an additional 30-45 seconds.

3) Memorize common DDx ahead of time. When I took my exam, I pretty much had my ddx for most of the cases before I knocked on the door. Sure, some will evolve during the interview into something else, but I would sketch a brief ddx in the 10 seconds before you walk in the door. After you rattle of your mnemonics, think through how your ddx has evolved and ask additional questions as needed.

4) Practice with the patient note form. I liked starting at the bottom with my ddx and supporting points. Some people get too bogged down with the HPI; remember there are no style points, so don't let a beautifully crafted HPI prevent you from getting some points in the dx/plan.

Operaman, you have no idea how invaluable your comments are! Thank you so much! Points 2, 3, & 4 are almost as if you were with me during my exam and pointed out my mistakes. Thanks a lot!!!

 

[Phloston]

I failed the ICE component.

I'm a US IMG, so the SEP & CIS components weren't a problem (they're actually off the charts on my score report).

My problem is, I don't know what to fix to pass next time!

My CK score was 227 (1st attempt). I took the Kaplan 5-days course, I did the Kaplan book and FA. My attendings for all my clinical rotations (shadowing/visiting physician at a local hospital) all expected me to breeze through the test, based on my bedside manner and my clinical knowledge.

Nothing too crazy happened during the test. I do remember having some trouble coming up with a DDx for a case or two. Otherwise, nothing was in any way unusual or disturbing.

So I don't even know what I did wrong.
Suggestions?

P.S. I attached my score report for reference

I followed FA's style to a T and barely passed the ICE. My take is that FA overemphasizes the broad systems based approach when in reality a lot of that stuff doesn't contribute significant points (if any at all) to the score. I believe had I strictly been hyper-presenting complaint focused and not so concerned about listening to heart/lung sounds and doing hands/glands check on every pt, as well as having not spent so much time documenting that stuff in my notes, I would have scored higher. Because to be completely honest, my clinical skills are strong, and the biggest reason people struggle with ICE is due to the mere ambiguity of exactly what the usmle is looking for. My advice is to do a broad history as normal but the P/E and note should be hyper-focused and detailed regarding the presenting complaint. I know people who didn't do well on the MCQ usmles who've done well on ICE. That tells you this has nothing to do with what you know or how competent you are, and instead just how well you follow the usmle's nebulous structure.

 

[deleted699098]

I followed FA's style to a T and barely passed the ICE. My take is that FA overemphasizes the broad systems based approach when in reality a lot of that stuff doesn't contribute significant points (if any at all) to the score. I believe had I strictly been hyper-presenting complaint focused and not so concerned about listening to heart/lung sounds and doing hands/glands check on every pt, as well as having not spent so much time documenting that stuff in my notes, I would have scored higher. Because to be completely honest, my clinical skills are strong, and the biggest reason people struggle with ICE is due to the mere ambiguity of exactly what the usmle is looking for. My advice is to do a broad history as normal but the P/E and note should be hyper-focused and detailed regarding the presenting complaint. I know people who didn't do well on the MCQ usmles who've done well on ICE. That tells you this has nothing to do with what you know or how competent you are, and instead just how well you follow the usmle's nebulous structure.

Yeah I totally agree with that! It has nothing to do with actual knowledge, it's all about how you perform it the way they want it.

 

[indomethacin_]

I got a higher performance on ICE.
Most of the diagnosis I made, I backed up with at least 4-8 supporting findings, especially including pertinent negatives even if it seemed silly to add them.

This was advice I had received from an upper classman.
I don't know if this is what helped me score high on the ICE, but every bit of effort counts in my book.

Random example from my bluesheet notes when I was studying:
DDx #1 Deep Venous Thrombosis
History findings
- History of 15 hour plane flight
- Swelling of right calf
- No history of fever
- No history of trauma
- Gained 20 pounds in last year
- Smokes 1 PPD for 20 years
- Works as a long truck driver

Physical Exam findings
- Left calf tender to palpation
- Redness of right calf
- Homan's sign +
Just my 2 cents, best of luck.

 

[deleted699098]

I got a higher performance on ICE.
Most of the diagnosis I made, I backed up with at least 4-8 supporting findings, especially including pertinent negatives even if it seemed silly to add them.

This was advice I had received from an upper classman.
I don't know if this is what helped me score high on the ICE, but every bit of effort counts in my book.

Random example from my bluesheet notes when I was studying:
DDx #1 Deep Venous Thrombosis
History findings
- History of 15 hour plane flight
- Swelling of right calf
- No history of fever
- No history of trauma
- Gained 20 pounds in last year
- Smokes 1 PPD for 20 years
- Works as a long truck driver

Physical Exam findings
- Left calf tender to palpation
- Redness of right calf
- Homan's sign +
Just my 2 cents, best of luck.

Thanks! I definitely overlooked negative findings because, as you said, I considered them "silly."

 

[Dactino]

I scored towards higher side on the ICE. I did focused history and physical exam in most of the patients and was usually out of the room 2 mins early. Quickly rattled off the history mnemonic, summarized and asked if they would like to add more. Then proceeded to PE. most of the patients i started the PE by looking at their pupils and mouth. Just a quick look. I also did heart and posterior lung exam in all patients. That hardly takes a minute or even much less. For 2-3 cases where i felt neuro exam was warranted i quickly did a few tests for CN 5,7 and 12. I had already looked at the pupils and the mouth in the beginning. I wrote in the notes CN grossly intact for these pts. It hardly takes 30s if you do it quick. The SPs are very cooperative. I also did knee reflexes and biceps reflex for these patients. Similarly for thyroid complaints i checked for thyroid from the back and checked biceps and knee reflexes. I think you get points for doing things and it doesnt really matter if you are doing them perfectly. In the patient note i always mentioned pertinent negatives.

 

[deleted699098]

I scored towards higher side on the ICE. I did focused history and physical exam in most of the patients and was usually out of the room 2 mins early. Quickly rattled off the history mnemonic, summarized and asked if they would like to add more. Then proceeded to PE. most of the patients i started the PE by looking at their pupils and mouth. Just a quick look. I also did heart and posterior lung exam in all patients. That hardly takes a minute or even much less. For 2-3 cases where i felt neuro exam was warranted i quickly did a few tests for CN 5,7 and 12. I had already looked at the pupils and the mouth in the beginning. I wrote in the notes CN grossly intact for these pts. It hardly takes 30s if you do it quick. The SPs are very cooperative. I also did knee reflexes and biceps reflex for these patients. Similarly for thyroid complaints i checked for thyroid from the back and checked biceps and knee reflexes. I think you get points for doing things and it doesnt really matter if you are doing them perfectly. In the patient note i always mentioned pertinent negatives.

Thank you! I'm starting to get a feel for what I missed on my exam. Invaluable feedback here!

 

[juventusman31]

Thanks! I definitely overlooked negative findings because, as you said, I considered them "silly."

Thanks for being so candid!
My question to you is: how many supporting findings did you have on average for each of your diagnoses?

 

[deleted699098]

Thanks for being so candid!
My question to you is: how many supporting findings did you have on average for each of your diagnoses?

If I remember right, I think I had an averge of 4-5 supporting findings (history AND physical), although some were kinda "far-fetched" in my opinion.

 

[jjjma]

I understand your frustration FryyM. I took my CS 2 weeks ago and I am still awaiting my results; this was my second go around so hopefully I am ok. I made allot of corrections and also ran into many pits. I counsel every patient but one because of time; I had a uncooperative patient who I believe was suffering from anxiety disorder do to palpitations who was pissed that I didn't formally list heart attack as top diagnosis she really put me off allot. Lastly I had a patient who suffered from diarrhea but responded negative to pain/fever/chills/travel/pallor/joint pain/oral ulcers/multiple sexual partners/blood in stool/recent party causing food posion/changes in stool color/recent sick contacts he only reported 3 week history of watery diarrhea that was not associated with anything and denies any aggreviating factors ie food/bread/wheat products I was completely lost for this guy. I put DD Lactose intolerance, Celiac disease, and gastro however I didnt or stool parasite/ova and IGA stool antibodies. I put stool culture, stool leukocytes, CBC, Na/K; I was just lost and it was last case. However my presentation was

Mr.X is XX y/o male who presents with 3wk history of diarrhea. Patient unsure of any triggers or causes of diarrhea. Symptoms are daily and happens 5-6x each day. Patient reports watery stool; 2 day history of cramping however resolved; denies any prior episdose and denies progression. Patient denies aggreviated factors and reports Imdium and Pepto Bismuth to be uneffective. Patient denies any associate pain/fevers/chills/hematochazia/abd pain/heartburn/joint soreness/pallor of skin/sick contacts/recent travel/oral ulcers/recent parties. In addition patient unsure if food is a primary factor for diarrhea

ROS: negative unless otherwise stated above
PMH: denies
ALL: denies
Meds: Imdium and Bismuth
FHx: denies
SurHx: denies
SocHx: denies alcohol/tobacco/drugs; patient married and sexual active with wife
OccHx: work history

General: cooperative, normal judgement, NAD
Vitals: stable and afebrile
HEENT: forgot to inspect mucos membranse; normcephalic
CV: RRR. S1S2, negative murmurs/rales/gallops
Resp: CTAB, nonlabored, negative chest wall tenderness
GI: normal bowel sounds, nondistended/nontender; negative hepatosplenomegaly;
Skin: warm, dry intact; negative pallor


DD:
1) Lactose intolerance:
- watery stool for 3wks; 5-6 episodes each day; reports food "runs through him"
- reported water stool not releived by imdium; denies travel/fevers/fevers/heartburn, blood in stool; or abd pain
- unsure if food is possible cause

2) Celiac Disease
- reported water stool not releived by imdium; denies travel/fevers/fevers
- unsure if food is possible cause

3) Projectile Diarrhea: I should have put gastro I was rushing here
- water stool; history of cramping that has resolved

Orders: CBC,Na/K, stool culture/ stool antigens/leukocytes; rectal exam

Informed patient of my thougts for his diarrhea and the 3 possible causes above;
I told patient during exam that I was unsure of his possible causes, however I am going to get blood work; check stool for bacterial and start fluids; I also informed him that when the results of the test are confirmed that I will personally return and provide him with the details in addition make any corrects at that time.

I feel I did bad for this case

 

[deleted699098]

I understand your frustration FryyM. I took my CS 2 weeks ago and I am still awaiting my results; this was my second go around so hopefully I am ok. I made allot of corrections and also ran into many pits. I counsel every patient but one because of time; I had a uncooperative patient who I believe was suffering from anxiety disorder do to palpitations who was pissed that I didn't formally list heart attack as top diagnosis she really put me off allot. Lastly I had a patient who suffered from diarrhea but responded negative to pain/fever/chills/travel/pallor/joint pain/oral ulcers/multiple sexual partners/blood in stool/recent party causing food posion/changes in stool color/recent sick contacts he only reported 3 week history of watery diarrhea that was not associated with anything and denies any aggreviating factors ie food/bread/wheat products I was completely lost for this guy. I put DD Lactose intolerance, Celiac disease, and gastro however I didnt or stool parasite/ova and IGA stool antibodies. I put stool culture, stool leukocytes, CBC, Na/K; I was just lost and it was last case. However my presentation was

Mr.X is XX y/o male who presents with 3wk history of diarrhea. Patient unsure of any triggers or causes of diarrhea. Symptoms are daily and happens 5-6x each day. Patient reports watery stool; 2 day history of cramping however resolved; denies any prior episdose and denies progression. Patient denies aggreviated factors and reports Imdium and Pepto Bismuth to be uneffective. Patient denies any associate pain/fevers/chills/hematochazia/abd pain/heartburn/joint soreness/pallor of skin/sick contacts/recent travel/oral ulcers/recent parties. In addition patient unsure if food is a primary factor for diarrhea

ROS: negative unless otherwise stated above
PMH: denies
ALL: denies
Meds: Imdium and Bismuth
FHx: denies
SurHx: denies
SocHx: denies alcohol/tobacco/drugs; patient married and sexual active with wife
OccHx: work history

General: cooperative, normal judgement, NAD
Vitals: stable and afebrile
HEENT: forgot to inspect mucos membranse; normcephalic
CV: RRR. S1S2, negative murmurs/rales/gallops
Resp: CTAB, nonlabored, negative chest wall tenderness
GI: normal bowel sounds, nondistended/nontender; negative hepatosplenomegaly;
Skin: warm, dry intact; negative pallor


DD:
1) Lactose intolerance:
- watery stool for 3wks; 5-6 episodes each day; reports food "runs through him"
- reported water stool not releived by imdium; denies travel/fevers/fevers/heartburn, blood in stool; or abd pain
- unsure if food is possible cause

2) Celiac Disease
- reported water stool not releived by imdium; denies travel/fevers/fevers
- unsure if food is possible cause

3) Projectile Diarrhea: I should have put gastro I was rushing here
- water stool; history of cramping that has resolved

Orders: CBC,Na/K, stool culture/ stool antigens/leukocytes; rectal exam

Informed patient of my thougts for his diarrhea and the 3 possible causes above;
I told patient during exam that I was unsure of his possible causes, however I am going to get blood work; check stool for bacterial and start fluids; I also informed him that when the results of the test are confirmed that I will personally return and provide him with the details in addition make any corrects at that time.

I feel I did bad for this case

Thanks for taking the time time to write this detailed explanation!

 

[J ROD]

Yeah, I left some stuff out. Got some stuff down. It went fast as hell. Just hoped I passed. Will see when the results come out. Have no clue what and how they grade so why worry until it is time I say.

GL!

 

[deleted699098]

Yeah, I left some stuff out. Got some stuff down. It went fast as hell. Just hoped I passed. Will see when the results come out. Have no clue what and how they grade so why worry until it is time I say.

GL!

Yeah that's the icky part - you can't really tell what and how they grade it!