I think I failed Step 2 CS

[JP2740]

I almost feel like failure is random... I know three people who have failed CS. All of them decently smart, personable, and very fluent in english. I am sure they didn't mess up anything more than I did yet they failed?

Yup I was reading a lot of forums after my exam fearing that I failed. Honestly who knows because none of us are in the room (fishy right?), but when I compare my mistakes to many people who failed idk what I did that they did not do. I feel like compared to some failures I could have easily failed. However, when I got my score report, I was not near borderline in ANY section. How could that possibly be??? There's some interesting stats out there about the people who fail and retake almost near 100% pass on their second try (I've seen this quoted somewhere on the interwebz but never verified it myself). It would seem unlikely that the pass rate amongst failures should be so high the second time.

Worst of all, I think Johns Hopkins or some hospital came out with some article bashing the test, and some people (also on the interwebz) think that they might've started increasing the failure rate in response to that to justify this scam. I didn't really spend much time verifying any of this so take what I say with the grain of salt but the exam baffles me in general.

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[tiedyeddog]

Yup I was reading a lot of forums after my exam fearing that I failed. Honestly who knows because none of us are in the room (fishy right?), but when I compare my mistakes to many people who failed idk what I did that they did not do. I feel like compared to some failures I could have easily failed. However, when I got my score report, I was not near borderline in ANY section. How could that possibly be??? There's some interesting stats out there about the people who fail and retake almost near 100% pass on their second try (I've seen this quoted somewhere on the interwebz but never verified it myself). It would seem unlikely that the pass rate amongst failures should be so high the second time.

Worst of all, I think Johns Hopkins or some hospital came out with some article bashing the test, and some people (also on the interwebz) think that they might've started increasing the failure rate in response to that to justify this scam. I didn't really spend much time verifying any of this so take what I say with the grain of salt but the exam baffles me in general.

Someone I know personally has two failed attempts. Didn't study for the first. I have no idea what happened for the second but he had to pull out from the match because of the second.

 

[tiedyeddog]

One that has been proven is that there is a big contrast bias - that is if a student or couple of students prior to your encounter perform "nicer" or more "professional" than you do, then naturally even if your performance is "average" you will be compared to them and the SP's judgement will be naturally biased. Perhaps this is the reason why PA has the presumed high failure rate, since there are excellent allopathic schools around the area with very few IMGs normally taking the test in PA center. I can only hope I passed this time.. Honestly, due to insane amounts of fear, I have been practicing with 7-8 IMG partners (also as a part of my intellectualization coping mechanism), also wrote a 30 page study guide with 30+ CC, physical exam, ddx, and diagnostic workup from memory, and been preparing for another date. I really hope/wish that nobody has to go through what I am going through.

http://www.ncbi.nlm.nih.gov/pubmed/?term=bias usmle step 2 cs

My testing center had a very large amount of IMGs the day I took it. I don't know if all testing centers do this, but the entire day I followed a Pakistani IMG. When I spoke to him during lunch he could barely string together comprehensible sentences and he told me that was his third time taking it.

I am 100% positive I did better than I otherwise would have just by following that guy. There is no way it didn't bias the SP's, he had to be a reference frame for the SPs even if it was a subconscious one.

 

[Promethean]

Wow. Thanks for the file.

I helped someone prepare for this test, a US grad who was attempting to enter the match after some time away from medicine. We ran through scenarios with me coaching her based on the prep books she had bought. I was glad for the insight into what I may have to face in just a few years (though who knows how it will have changed by then.)

She was also terrified that she had failed the test. Some of the cases were too easy. She kept thinking that maybe they were trying to trick her, because the diagnosis was just a little too obvious. And did she remember to counsel each person on diet, exercise, and lifestyle? Etc.

Of course she passed.

I think that the test is mostly an elaborate mock up so that it seems somehow legit when they screen out IMGs with accents deemed too strong. The few US grads who fail it are sacrifices to that effort. There may be a tiny percentage of people who really are grossly incompetent or incapable of polite interaction with other humans... but how many people like that could possibly make it to the point of being eligible to take that exam?

 

[operaman]

CS was the only exam I've ever taken where I walked out genuinely not knowing whether or not I passed. Even thought we all feel beat down a bit after step 1, I definitely knew I had passed. Not so with CS. Definitely had some nerves opening the score report!

The whole thing is a black box and I don't think we have any real sense of what it takes to pass or fail it. Perhaps some form of legal action will ultimately force their hand and get everyone a peek behind the curtain or at least the chance to appeal a failing score where someone reviews and rescores your encounters. If that ever happens, it will be a long time off.

In the meantime, best advice would be:

1) Prepare for this test. It is no longer a test of your English proficiency.

2) Take it early. Slots fill months in advance and scoring takes a long time; take it early so you have time to re-take it if you fail. If you take it in Jan/Feb and fail, you may not be able to retake and get it rescored in time for graduation. I feel like August would be the best time: early so you could theoretically retake it 2x if the worst happened; just late enough that the failure wouldn't be scored in time to show up on your initial ERAS submission.

3) Practice with another human being. This is clearly a "click the checkbox" style of grading, but you have a lot of boxes to potentially check in a very short time frame. Part of the battle is getting fast enough. These are not normal clinical encounters and you will be expected to do/ask things you may not ever do in real life, so your normal routine that you have practiced over M1-M3 will probably need some adjustment to be sure you hit all the boxes.

4) Beware CIS. If you read the published literature on CS, you'll see that AMGs are more likely to fail CIS. There was also a study a number of years back that showed your school's final OSCE-like test correlates well with CS scores in every category....except CIS. Another paper suggested that time spent on closure had a more significant impact on CIS scores than total time spent in the encounter. To me, this says you earn a ton of your CIS points in the closure, so running out of time will obviously hurt you.

5) There are no style points. Acting empathetic will not get you points. Saying something empathetic will. Ditto for any other factor you might ordinarily communicate non-verbally.

6) According the NBME's papers, a number of factors beyond your control can/will impact your score. This includes the quality of other students, sequence of stations, how strict the SP is, and even the type of encounter itself.

In reviewing the literature, I think the non-obvious failures probably arise out of a perfect storm of misses. It's not just missing the laundry list of things people say they didn't do but still somehow pass. You'll notice that people enumerate all their errors but that they cover the whole gamut of scored elements. People don't usually fail unexpectedly in >1 area; it tends to be one that gets them.

 

[tiedyeddog]

CS was the only exam I've ever taken where I walked out genuinely not knowing whether or not I passed. Even thought we all feel beat down a bit after step 1, I definitely knew I had passed. Not so with CS. Definitely had some nerves opening the score report!

The whole thing is a black box and I don't think we have any real sense of what it takes to pass or fail it. Perhaps some form of legal action will ultimately force their hand and get everyone a peek behind the curtain or at least the chance to appeal a failing score where someone reviews and rescores your encounters. If that ever happens, it will be a long time off.

In the meantime, best advice would be:

1) Prepare for this test. It is no longer a test of your English proficiency.

2) Take it early. Slots fill months in advance and scoring takes a long time; take it early so you have time to re-take it if you fail. If you take it in Jan/Feb and fail, you may not be able to retake and get it rescored in time for graduation. I feel like August would be the best time: early so you could theoretically retake it 2x if the worst happened; just late enough that the failure wouldn't be scored in time to show up on your initial ERAS submission.

3) Practice with another human being. This is clearly a "click the checkbox" style of grading, but you have a lot of boxes to potentially check in a very short time frame. Part of the battle is getting fast enough. These are not normal clinical encounters and you will be expected to do/ask things you may not ever do in real life, so your normal routine that you have practiced over M1-M3 will probably need some adjustment to be sure you hit all the boxes.

4) Beware CIS. If you read the published literature on CS, you'll see that AMGs are more likely to fail CIS. There was also a study a number of years back that showed your school's final OSCE-like test correlates well with CS scores in every category....except CIS. Another paper suggested that time spent on closure had a more significant impact on CIS scores than total time spent in the encounter. To me, this says you earn a ton of your CIS points in the closure, so running out of time will obviously hurt you.

5) There are no style points. Acting empathetic will not get you points. Saying something empathetic will. Ditto for any other factor you might ordinarily communicate non-verbally.

6) According the NBME's papers, a number of factors beyond your control can/will impact your score. This includes the quality of other students, sequence of stations, how strict the SP is, and even the type of encounter itself.

In reviewing the literature, I think the non-obvious failures probably arise out of a perfect storm of misses. It's not just missing the laundry list of things people say they didn't do but still somehow pass. You'll notice that people enumerate all their errors but that they cover the whole gamut of scored elements. People don't usually fail unexpectedly in >1 area; it tends to be one that gets them.

This is all EXCELLENT advice, this should be stickied in the step 2 subforum.

I echo that you HAVE to at least read one cases style book. I did Kaplan cases and 90% of the cases I saw were exactly like the cases and went exactly that way.

One other thing to add is if a patient has some kind of prop on: Wrist brace, bruise make-up, make-up trying to emulate jaundice or if they are acting depressed, withdrawn, or bring up a topic out of the blue (my mom died, etc) then ASK about it and ask about it early! There will 100% of the time be a reason for this, either they are being abused, its a physical exam finding, or they are depressed and you need to say something empathetic.

 

[operaman]

Here's a hypothetical WTF failure scenario for this exam:

AMG, 245+ on step 1 and CK, AOA, H/HP on all clerkships, no history of OSCE failures

1) Decides not to study for CS, or studies minimally by skimming FA cases and decides he's "got this"
2) Struggles with time and is unable to close on 3 encounters
3) Has to rush closure on 4 others
3.5) His "good" closures are simply ddx, plan, questions? -- no additional ? about values/culture/preferences regarding plan; no additional counseling
4) Forgets to ask about all the social/lifestyle/allergies/how dx is affecting their life/what they think it might be/substances/mood/sex/etc. that he doesn't usually ask about in normal clinical encounters
4.5) Misses the not-so-subtle DV/NAT/IVDU/etc. case and all its associated counseling/empathizing
5) In his focus to get the correct ddx, uses fewer open ended questions.
6) Fails to counsel on smoking cessation after every mention of tobacco use
7) Uses some occasional jargon without realizing it
8) acts empathetic, but rarely SAYS something empathetic
9) Rushes his physical exam a bit and is maybe slightly less attentive to patient comfort and modest than normal
10) Is testing with a group of well-prepared high-achieving students
11) Has more stringent SPs
12) Has his unscored encounters near the end of his day when CIS scores are highest

This guy would probably still pass, but I hope you can see how all of these misses are in the same area (CIS) and maybe be enough to push someone just under the passing range. I think this examinee, assuming he passed the other sections, would come away feeling like he did well and performed on par with his usual OSCE performance back at his med school.

TL;DR -- Practice for this test. Everyone else in your class has to take it too; practice with someone.

 

[Kaustikos]

Mine too actually, they just pushed up the last day to take it by a month and a half because a couple people had to withdraw from the match because they couldn't take it in time before matriculation to residency. I think it is absolutely insane an exam we have to travel to, get a hotel for, then pay 2.5 k for takes more than two months to grade. Especially when you consider the crap results they give you. I have no idea how to interpret how I did other than I passed. The whole thing is a scam.

Yeah,
My school has an OSCE which is a simulated version of CS. Took just long to grade because they look at each recording and correlate it to patient evaluation. So, if you only have eight sites, I can see why it takes so long. But then why not hire satellite staff to do the videos. Or volunteer staff to be patients. I wouldn't mind being a patient to help expedite things.
But the 2.5k is an insult. But we need to get used to it apparently.

Thats nice that some schools mandate a deadline to take it. My school does not, and as such I didn't take mine until January of this year and was definitely somewhat concerned about whether or not my grade would be back in time for rank lists. I know many programs do not care too much one way or the other, but I think its best to have it in early.

I didn't take it till January. I had it earlier but got an interview invite so I had to reschedule. Didn't worry me much since I was comfortable with the test. I honestly want to do a sticky about this even though I'm sure it's there.

CS was the only exam I've ever taken where I walked out genuinely not knowing whether or not I passed. Even thought we all feel beat down a bit after step 1, I definitely knew I had passed. Not so with CS. Definitely had some nerves opening the score report!

The whole thing is a black box and I don't think we have any real sense of what it takes to pass or fail it. Perhaps some form of legal action will ultimately force their hand and get everyone a peek behind the curtain or at least the chance to appeal a failing score where someone reviews and rescores your encounters. If that ever happens, it will be a long time off.

I dunno. I disagree about it only because I feel we aren't told what we need to focus on. I think it's less grading but more "how should we prepare" or "what is the criteria divided into?"

1) Prepare for this test. It is no longer a test of your English proficiency.

2) Take it early. Slots fill months in advance and scoring takes a long time; take it early so you have time to re-take it if you fail. If you take it in Jan/Feb and fail, you may not be able to retake and get it rescored in time for graduation. I feel like August would be the best time: early so you could theoretically retake it 2x if the worst happened; just late enough that the failure wouldn't be scored in time to show up on your initial ERAS submission.

3) Practice with another human being. This is clearly a "click the checkbox" style of grading, but you have a lot of boxes to potentially check in a very short time frame. Part of the battle is getting fast enough. These are not normal clinical encounters and you will be expected to do/ask things you may not ever do in real life, so your normal routine that you have practiced over M1-M3 will probably need some adjustment to be sure you hit all the boxes.

4) Beware CIS. If you read the published literature on CS, you'll see that AMGs are more likely to fail CIS. There was also a study a number of years back that showed your school's final OSCE-like test correlates well with CS scores in every category....except CIS. Another paper suggested that time spent on closure had a more significant impact on CIS scores than total time spent in the encounter. To me, this says you earn a ton of your CIS points in the closure, so running out of time will obviously hurt you.

5) There are no style points. Acting empathetic will not get you points. Saying something empathetic will. Ditto for any other factor you might ordinarily communicate non-verbally.

6) According the NBME's papers, a number of factors beyond your control can/will impact your score. This includes the quality of other students, sequence of stations, how strict the SP is, and even the type of encounter itself.

In reviewing the literature, I think the non-obvious failures probably arise out of a perfect storm of misses. It's not just missing the laundry list of things people say they didn't do but still somehow pass. You'll notice that people enumerate all their errors but that they cover the whole gamut of scored elements. People don't usually fail unexpectedly in >1 area; it tends to be one that gets them.

1 - agreed. That was a reason for failing. People whom took the test were like "just know how to speak english" or "no one cares in residency programs" which, imo, perpetuated this.

2 - yeah, the problem is schools don't tell them this. I wasn't told about scheduling until spring of third year. Had I known, I would've scheduled late spring/early summer. If I had to reschedule, it wouldn't matter.
Schools need to literally send an email before third year begins and say "hey, step 2 cs, keep that in your budget"

3 - I will add: if you're the patient, act like one. Be dumb, vague, etc. It helps the interviewer learn how to ask questions properly and also helps you see how your questions you ask can be misinterpreted or not understood. Also, make it fun. I volunteered to be a patient for my underclassmen and at first they thought I was being a dick but at the end I told them why I was like that. Plus my social history was hilariously distracting.
So I'd only add that if you have upper classmen, ask if they can help.
4 - Yeah, definitely. I made that a priority. If I wasn't concluding at 1 minute, I would do so in the best attempt.

5 - Yeah, correct me if I'm wrong but saying "I'm sorry about x, y or z. Can I ask you some questions so I can better help resolve this issue? "
Or "I know this is distressing for you, but blah blah blah"
Just let them know you do give a **** and that's why you're asking questions.
6 - yup

 

[operaman]

I failed the CIS portion of the test first time. What I don't understand is my ICE was literally a bar from failing. I thought my PN notes were well-organized (at least similar to the FA notes), my physical exam were certainly lacking but definitely not to the point of being close to the failure. I know my ddx were pretty much right on target, except few cases. I did order excessive tests, but honestly I know friends who did the same thing and passed with high colors (these are colleagues I worked with and gauged their performance with mine. At least during practice they were not significantly different). I really think what happened was my focused face which apparently looks upset dissatisfied few SPs who had the pleasure of talking with other students who interacted with supreme empathy and therefore made my face/interaction look like the dark side. I think SPs can easily write you off, purposely miss a few checkmarks here and there, or give you additional points, since there is no real way of checking them. I am trying to be comical here, but in reality, this test has really consumed my life with significant distress. What's ironic is I am decent with patients in real life, had few patients who wanted me to be their PCP. But of course, this was when I was interacting with them without the added stress of being evaluated, truly being myself.

The ICE portion of the exam is at least a little more objective and easier to address, and it's the part we get the most prep for through our OSCEs. Ask all the right questions, do the indicated exam maneuvers, and write a decent note -- basta cosi. From what you are saying about your note, you probably lost your points on the hx and exam part of the encounter and your notes were ok.

Again, for future test takers, this is not quite like your normal encounter and you are expected to cover a lot of ground very quickly. A lot of people find success with mnemonics for the basic pmh/sh/fh/ros questions you ask every time. You may also be doing too few physical exam maneuvers, or not doing them correctly (listening through clothes, etc.). Check and make sure you aren't using any non-standard exam maneuvers; ie. in real life I never percuss the liver edge, but instead use the scratch trick because it's faster and more accurate for me -- SPs might wonder wtf I was doing and not give appropriate credit. I also do a slightly non-standard neuro exam that I picked up from an old attending I really liked, but got dinged on an OSCE once for it.

The literature definitely supports the idea that SPs are not completely objective and subtle things may hurt you. I also wonder if the increase in average preparation among students is gradually pushing the bar higher; if you go after the well prepared guy who basically rattles off the checklist with time to spare, and you're hemming and hawing and struggling, you may get dinged even if you still eventually check all the boxes.

 

[GadRads]

Bias in such subjective test is inherent. Now, I have personally spoken to the NBME representative on this issue. I asked her about the use of the video recordings. She basically said the videos are used for one sole purpose, to assure that SPs acted and responded correctly. Now there is no way and neither does NBME care to check if the SP tallied the PE and CIS components correctly (they got rid of history checklist in 2013). Essentially, you are left with a contrast bias, selection bias, inherent bias thay comes with human grading, and critical mistakes (checking the wrong box) that could lead to a unfortunate failure. Literally SP may think that you didnt act kind enough compared to the prior examinee and not give credit for certain CIS components. Now there are 12 encounters to limit the bias, but if you are performing without knowing the components, you may fail. I had a colleague (AOA, top 10 of class) who scored way left in CIS on his first attempt. On second attempt, all he did different was barely write on the blue sheet, make more eye contact and he scored on the way right. Other difference was the test center. He took it in Atl first time around, then took it in LA. He basically said he didnt know what to make out of the test except its really a numbers game. Certain percentage gotta fail, and the rumor has it that about 4 fail everyday per SP center.

This is also consistent with the fact CIS is the most common reason why US students fail. It appears the more you kiss the SP's ass, the better your grade. Similarly, the "nicest" doctors get sued much less than "mean" docs. I have a resident friend who is charming and super friendly naturally, and her CS bars were off the charts. Her Step scores were way below average, however.

 

[Uhl88]

So there is also the test center bias that comes with the culture and traditions of the area. Not to mention the bad acting.. Having taken the test twice i remember there were consistently 2+ SPs who gave me the wrong response initially (which i caught since it was completely contrary to the working diagnosis) and I had to prompt the patient again only to get the right response... I actually had one patient who told me she was hurting on the wrong side when clearly the fake bruise was on the other.. I quickly corrected her by asking again.. But seriously.. And I also had a SP with extremely poor acting skills, like smirking during the encounter, yawning during the encounter, literally telling me his story as if reading straight off the script without any fluctuation in his voice.. While i am sitting there making all sorts of empathy sympathy sad solemn hopeful kind soothing melodramatic expressions and gestures. I do want to give credit to the other 3 SPs who were excellent with their acts.. I remember genuinely feeling sorry for this one lady to the point of softly crying inside.

 

[ACSurgeon]

So there is also the test center bias that comes with the culture and traditions of the area. Not to mention the bad acting.. Having taken the test twice i remember there were consistently 2+ SPs who gave me the wrong response initially (which i caught since it was completely contrary to the working diagnosis) and I had to prompt the patient again only to get the right response... I actually had one patient who told me she was hurting on the wrong side when clearly the fake bruise was on the other.. I quickly corrected her by asking again.. But seriously.. And I also had a SP with extremely poor acting skills, like smirking during the encounter, yawning during the encounter, literally telling me his story as if reading straight off the script without any fluctuation in his voice.. While i am sitting there making all sorts of empathy sympathy sad solemn hopeful kind soothing melodramatic expressions and gestures. I do want to give credit to the other 3 SPs who were excellent with their acts.. I remember genuinely feeling sorry for this one lady to the point of softly crying inside.

Yawning can be a sign of something - depression, sleep deprivation, other psychosocial issues

 

[operaman]

Bias in such subjective test is inherent. Now, I have personally spoken to the NBME representative on this issue. I asked her about the use of the video recordings. She basically said the videos are used for one sole purpose, to assure that SPs acted and responded correctly. Now there is no way and neither does NBME care to check if the SP tallied the PE and CIS components correctly (they got rid of history checklist in 2013). Essentially, you are left with a contrast bias, selection bias, inherent bias thay comes with human grading, and critical mistakes (checking the wrong box) that could lead to a unfortunate failure. Literally SP may think that you didnt act kind enough compared to the prior examinee and not give credit for certain CIS components. Now there are 12 encounters to limit the bias, but if you are performing without knowing the components, you may fail. I had a colleague (AOA, top 10 of class) who scored way left in CIS on his first attempt. On second attempt, all he did different was barely write on the blue sheet, make more eye contact and he scored on the way right. Other difference was the test center. He took it in Atl first time around, then took it in LA. He basically said he didnt know what to make out of the test except its really a numbers game. Certain percentage gotta fail, and the rumor has it that about 4 fail everyday per SP center.

The bias thing is definitely an issue and one the NBME has published about in the past. I don't think bias alone is enough to fail someone, but I think it's yet another factor in the perfect storm that can lead to a CIS failure.

There's a great article from 2007 in Academic Medicine where the NBME elaborated a little bit on their scoring system for CIS. I'd post excerpts but not sure if that runs afoul of fair use, so the title is: "Assessing the Communication and Interpersonal Skills of Graduates of International Medical Schools as Part of the United States Medical Licensing Exam (USMLE) Step 2 Clinical Skills (CS) Exam" and you can easily PubMed it yourself. The Methods section has a nice discussion about how the CIS section is scored and what sort of things they're looking for. Based on the article, it's pretty easy to reverse engineer their scoring algorithm.

 

[Uhl88]

Yeah I found the article, also found a pdf of the list that they have for the CIS rubric. There were two components called the advanced exploring emotions, where you were to ask the patient about what the patient thought the illness was and how it was affecting their lives. Unfortunately I found this after I took my second test, so I took the exam by performing everything as I was instructed by my OSCE director. I just maintained eye contact, used more open-ended questions, let the patient talk, made sure to nod appropriately, use empathetic gestures, express sympathy, explore emotions if needed. I had ~2 patients where I attempted to explore their emotions, but it was fairly unsuccessful, since both were not willing to open up to me. Who knows maybe I should have prompted them few more times until they finally talked. Honestly, this test is more of a game than anything. Also, I don't know how people perform high on both components. I think you really have to compensate one component to do well on the other with the limited time. For instance, if you end up exploring the patient's emotions and counseling the patient, then you kinda have to abridge your PE and history taking. If you are too thorough on the history, you may run out of time and not finish the closure. I suppose if you focus too much on one component over the other, there's a good potential to fail on the particular component...

 

[Kaustikos]

Sure except it was right after lunch and he was trying his best to conceal it by shutting his mouth as much as he can.

You do know you have every right to break scene and ask, right? Like when I did an eye exam and this women had anisocoria. I asked and she admitted she just recently had an eye exam and it wasn't pertinent. Because I would've left and immediately called neuro and neurosurgery

 

[Kaustikos]

Yeah I found the article, also found a pdf of the list that they have for the CIS rubric. There were two components called the advanced exploring emotions, where you were to ask the patient about what the patient thought the illness was and how it was affecting their lives. Unfortunately I found this after I took my second test, so I took the exam by performing everything as I was instructed by my OSCE director. I just maintained eye contact, used more open-ended questions, let the patient talk, made sure to nod appropriately, use empathetic gestures, express sympathy, explore emotions if needed. I had ~2 patients where I attempted to explore their emotions, but it was fairly unsuccessful, since both were not willing to open up to me. Who knows maybe I should have prompted them few more times until they finally talked. Honestly, this test is more of a game than anything. Also, I don't know how people perform high on both components. I think you really have to compensate one component to do well on the other with the limited time. For instance, if you end up exploring the patient's emotions and counseling the patient, then you kinda have to abridge your PE and history taking. If you are too thorough on the history, you may run out of time and not finish the closure. I suppose if you focus too much on one component over the other, there's a good potential to fail on the particular component...

Jesus
Don't explore their emotions. You're basically screwing yourself over and falling for the bait. I'm not saying it to be some dingus but you literally have no time to explore that.

 

[FIREitUP]

oh man this thread has me freaking about about step 2 cs. took it during my year off so if I fail the residency programs will know before I submit my application. Definitely had a couple encounters that were weird and seemed experimental, fumbled through some of their challenge questions, had some awkward interactions (one patient asked me to pass her bottle of water and I thought it was some sort of odd trick and I asked if I could give it to her after the exam and she gave me a weird look).

 

[alpinism]

oh man this thread has me freaking about about step 2 cs. took it during my year off so if I fail the residency programs will know before I submit my application. Definitely had a couple encounters that were weird and seemed experimental, fumbled through some of their challenge questions, had some awkward interactions (one patient asked me to pass her bottle of water and I thought it was some sort of odd trick and I asked if I could give it to her after the exam and she gave me a weird look).

Don't.

Step 2 CS has an >95% first time pass rate.

This is typical SDN neuroticism. Do some review/studying the week prior (FA/Kaplan cases) and you'll be fine.

It's a weird exam. I really think that if you make sentences with subjects and marginally conjugated verbs, make eye contact and put on your empathy face at some point during the HPI, you will pass. Not exactly sure who it's supposed to filter out to be honest. Failures seem completely random, and rare, exceedingly rare for AMG's. Whatever. Congrats, regardless.

Agreed.

 

[Uhl88]

Don't.

Step 2 CS has an >95% first time pass rate.

This is typical SDN neuroticism. Do some review/studying the week prior (FA/Kaplan cases) and you'll be fine.



Agreed.

Except now they have incorporated piloting CIS subcomponents to increase the failure rate to estimated 8-9 percent. Just in our school and the schools around, the failure rates have essentially doubled. I don't know how true this is, but I heard of a med school in the west having 20 kids /114 fail the test. Now, the part of the blame could be attributed to the poor preparation and inadequate OSCE experiences in the curriculum, but the bar has certainly been lifted without warning, and no-one has yet figured out just how much AMGs have failed this year. I guess NBME wanted to show us that this is no longer a english proficiency exam that people once made out to be, you really gotta know how to play by their rules.

 

[Uhl88]

Also, food for thought, in our school, 6/7 who failed were male and majority of us failed due to CIS. I think gender bias is clearly evident. I wonder if this is because few of us portray a monotonic, nonchalant picture than the female students or what we esteemed to be "confidence" is perceived as arrogant.. I am not sure. I did end up speaking on a higher tone, tried to be warming/soothing on the second attempt, pretty much opposite to the first.

 

[sazerac]

Don't.

Step 2 CS has an >95% first time pass rate.

This is typical SDN neuroticism. Do some review/studying the week prior (FA/Kaplan cases) and you'll be fine.



Agreed.

Like everything else in medicine, the prior classes had it easy. Their admission requirements were lower, their tuition was lower, their Step requirements for decent specialties were lower, and their failure rate on CS (if they even HAD a Step 2 CS - it's a pretty recent exam) was lower.

When people started pointing out that the ill-conceived Step 2 CS test was just an expensive and unnecessary test of English proficiency that Americans overwhelmingly passed, they could have shut the program down (except for IMG / FMG).

Instead they justified their existence by failing far more American medical students than ever before. "See, Step 2 CS is necessary - we are weeding out those unfit to be a doctor! Give me more money because I perform this necessary service!"


I can only wonder what BS will have to be overcome by the class of 202x and beyond. Medicine is like one of those cartoon bridges that crumbles behind you as you run across it.

 

[seminoma]

THANK YOU for updating this thread with your outcome. The worst possible thing to read on this thread is a highly relatable post of someone fearing they failed, with either a cliffhanger (usually) or worse, a confirmed failure.

I take mine in 7 days. Ugh.

Man this year has flown by. Seems like just a few days ago I was following your step 1 studying progress.

 

[Apoplexy__]

Man this year has flown by. Seems like just a few days ago I was following your step 1 studying progress.

Seriously. Best of luck on your Step 1, man. PM me if you need anything.

 

[Kaustikos]

t
lol. I just used my judgement that my SP was probably having postprandial coma after lunch. I am sure if it was part of the script he would have been more enthusiastic about expressing his yawns. It looked more like he was trying his best to conceal it. He did do a good job telling me to call him doctor instead of Mr.

Exactly my point. I really couldn't for the angry patient since I had really no time and I ended up flustering a bit and rushing through the closure. It was a poor choice to explore his emotions, I prompted him like 2-3 times and he still wasn't desiring to reveal it to me. I don't get this test. It feels more like a simulation game than anything else. It's almost like you are given a choice of few expressions you could say, and when you say the right thing, you prompt the SP to give the correct response, thereby giving you more points.

Angry patients only require you to say "I can understand your frustration, but would you mind if I blah blah blah to help you out? Answering these questions and this exam will allow me to better help alleviate this issue"
That's usually what they want from these simulations. Otherwise, you can calmly state how their acting, though understandable, isn't going to allow me to help you.

oh man this thread has me freaking about about step 2 cs. took it during my year off so if I fail the residency programs will know before I submit my application. Definitely had a couple encounters that were weird and seemed experimental, fumbled through some of their challenge questions, had some awkward interactions (one patient asked me to pass her bottle of water and I thought it was some sort of odd trick and I asked if I could give it to her after the exam and she gave me a weird look).

It's NOT that difficult. People are just worried because of how they feel walking out of the exam. I was furious/little worried about my performance but it's all because they want to assess how you handle these patients without screwing up the interview. If you act like a human being (and remember that this is acting), it makes things easier. Attempted physical exams aren't scrutinized remotely that bad. It's about how you interview them and, honestly, close the encounter properly. That means simply concluding everything and telling them what you plan on doing next. You can even go as far as saying "Okay, let me confer with my colleagues and figure out the best course of action." Of course, don't say that unless you don't know what's up at all. Because you NEVER say you don't know. Never. Also, don't say bye. Say "I'll be back. Let the staff know if you need anything else in the meanwhile"

 

[operaman]

It's not difficult for the 92% of AMGs who pass, and many of those who fail probably do so for obvious reasons. I think the crux of the discussion here is aimed at those who fail but for less obvious reasons. Knowing what's covered on the rubric for CIS can help future examinees prepare and lessen the chance that they'll be in that small minority of people impacted by this exam. Really strong students are being hit -- our derm PD was reviewing apps while I was on that elective and he asked us WTF was going on with CS and why so many applicants had failed it.

I really think the perfect storm is why these people are failing, so taking precautions to ensure you maximize your points on each station is probably a good idea. You may do flawlessly on ICE, but leave out enough touchy-feely stuff and look too nervous and you may be risking a CIS failure. While people say the failures are completely random, we all know that isn't really true. All they did was move the bar for passing a little bit higher in each category, thus making a perfect storm of errors more likely to cause failure.

While you can read stories here of people who really screwed the pooch and still passed, you'll notice that the errors they remember appear to run the gamut of categories so they probably don't lose enough points in any one to cause a failure. I think this leads to the half-true assumption that you can make a ton of mistakes of be just fine.

 

[FIREitUP]

ugh, this waiting is terrible. all i can remember is how un-empathetic i was and how in my notes i often didn't put things that i had asked the patient that weren't relevant to the hpi since i didn't have room (like meds, allergies, sh). this exam is really ridiculous.

 

[FIREitUP]

ugh, this waiting is terrible. all i can remember is how un-empathetic i was and how in my notes i often didn't put things that i had asked the patient that weren't relevant to the hpi since i didn't have room (like meds, allergies, sh). this exam is really ridiculous.

Score comes in 20 minutes. Trying not to freak out!!!

 

[Tired]

...

 

[Kaustikos]

I thought CS was just a legal way to screen out all the IMGs who don't speak English well?

Not when AMGs (not the car) are failing it more often now.

 

[FIREitUP]

Not when AMGs (not the car) are failing it more often now.

lol hope i passed

 

[tiedyeddog]

lol hope i passed

I'm sure you did fine, relax. Have a beer for me tonight to celebrate.

 

[FIREitUP]

I'm sure you did fine, relax. Have a beer for me tonight to celebrate.

PASSED!!! Was borderline in ICE and CIS (that was so close)!!

 

[tiedyeddog]

PASSED!!! Was borderline in ICE and CIS (that was so close)!!

Strong work

 

[operaman]

I thought CS was just a legal way to screen out all the IMGs who don't speak English well?

It truly was that ~10 years ago. It began as an IMG-only test, then AMGs had to take it too but it was a joke. Then after some backlash about the cost basically just being a tax on AMGs since 99% passed, they revised the scoring to increase the failure rate which now sits around 8% of AMGs if I remember correctly.

EDIT: just looked it up: 2013-2014, 1st time US MD pass rate was 95%. That's also the rate for Step 1 and 2 ck. So pass rates are high, but CS failures are just as common as Step 1 failures.

 

[Tired]

...

 

[Wordead]

Our entire class passed CS on the first try....and there are more than a few people that I wouldnt let care for a hamster much less a human. I don't really understand how there are so many failures. I had literally no idea what the diagnosis was for 1/3 of the cases, didn't close on a few encounters, and every patient note I wrote was the same thing. Still passed comfortably on every section and maxed out CIS. I dont consider myself particularly empathetic or great at acting, either, so I'm just befuddled by a 10% failure rate at some schools.

 

[tiedyeddog]

Our entire class passed CS on the first try....and there are more than a few people that I wouldnt let care for a hamster much less a human. I don't really understand how there are so many failures. I had literally no idea what the diagnosis was for 1/3 of the cases, didn't close on a few encounters, and every patient note I wrote was the same thing. Still passed comfortably on every section and maxed out CIS. I dont consider myself particularly empathetic or great at acting, either, so I'm just befuddled by a 10% failure rate at some schools.

Maybe you're rediculously good looking? Did you break out blue steel at the end of every encounter?

I really don't know the answer...

 

[Wordead]

Maybe you're rediculously good looking? Did you break out blue steel at the end of every encounter?

I really don't know the answer...

Well, naturally, but that doesn't explain the rest of the mere mortals in my class.

 

[FIREitUP]

honestly Step 2 CS is probably the biggest bull**** test on the planet. The NBME is out of control requiring AMG's to travel to 5 designated sites (really couldn't get a couple extra sites?) and drop $1300 to pretend failed actors have diseases.

 

[toodaloo]

Hey folks, took CS and am pretty nervous. I just now realized that I auscultated all my patients hearts OVER the gown (usually first thing I do on exam). Didn't even cross my mind during the exam. During lung exam I did it on skin, abdominal exam was on skin, and if they had a CV problem I dropped the gown to palpate the chest. Have no idea why auscultating the heart on skin didn't click with me. Really dumb move, I know. Along with other minor stuff, how bad is this? Now of anyone who failed because of this?

 

[Promethean]

Panic less. If that was your biggest issue, you will be fine.

Sent from my SM-N910P using Tapatalk

 

[almostmd88]

Ok, this test is driving me insane..so much that a google search lead me to this thread.

I took CS about 3 weeks ago. When I walked out of the test, I was very confident I passed. It SEEMED like a breeze. All the cases were super straight forward. I finished about a minute or 2 early on each one, closed on every case, and came up with very relevant differentials and diagnostic tests. The patients all seemed content with me as well. But, as the weeks went by, I started remembering all the mistakes I made and pretty much convinced myself that I failed. I'm studying for CK now and every time I read a vignette I think back to the relevant case I had on CS...its that bad.

I'll admit, I over prepared for this test, but only to prevent a disaster. Everything I read said to do a FOCUSED history and physical, so thats what I did. My main concern is, on top of everything else I forgot due to nerves (like random associated symptom questions), I did a very focused physical exam. For instance, if I was interviewing a patent and zoned in on a cadio etiology, I would ONLY do a full cardio exam. I didn't look at the mouth, feel lymph nodes, or do anything extra. I did this on every patient. Its freaking me out because I feel like I should have done a quick general exam on everyone just to include it in my note for completeness (for example, quickly auscultating the stomach on a cardio patient, or auscultating the heart on a case of clear lung etiology). The PE section of my note was very focused and will probably look incomplete to anyone who's grading it.

I know people are going to read this and think "theres another neurotic med student", but I seriously think that approaching the test in this manner is grounds to fail. I just wish I spent the extra 60 seconds and done a general exam on everyone. I don't know what to do to get my mind off this crap. Did I really mess up here?

 

[Cytarabine]

Took it like a month ago. Not sure when we get scores? Honestly, I felt good about it, would be surprised if I failed. Was pleasantly surprised by actor quality but we don't have standardized patients at my school so pretty minimal exposure to that. I think the most important thing is to have a system for every patient that allows you to check off as many boxes as you can efficiently. Just have to pass, not kill it, so focus on never missing stuff that is likely a check box for every pt. Can write more if I get my score back and actually did well, but my system was honestly based on what I read on a couple good sdn posts. FA wasn't tremendously helpful, but I think it's still worthwhile

Also, food for thought, in our school, 6/7 who failed were male and majority of us failed due to CIS. I think gender bias is clearly evident. I wonder if this is because few of us portray a monotonic, nonchalant picture than the female students or what we esteemed to be "confidence" is perceived as arrogant.. I am not sure. I did end up speaking on a higher tone, tried to be warming/soothing on the second attempt, pretty much opposite to the first.

In medical communication literature, female physicians are pretty reliably shown to be statistically significantly more likely to do things like respond to patient emotions, ask open ended questions, probe psychosocial issues, etc. It's prob just a translation of what happens in practice

 

[pk1989]

After several days of thinking about my errors I finally came up with a list that, for now, seems to be all i can remember i screwed up on: 1. Ran out of time to write the tests i'd order for 1 patient 2. Put CT and Xray of head when i meant spine 3. accidentally wrote an incorrect abbreviation for a differential (cant specify due to USMLE rules) 4. forgot to do a few key physical exam maneuvers i.e. heaves, thrills, pmi, when required 5. didnt ask anyone about quality of life being affected/in what way its affected them i.e. didnt ask if affects sleep or work, etc, never said im sorry about their chief complaint, i would just kinda throw in random apologies and sorries when it fit throughout the case or say things like we'll definitely try to help you now, thats the goal, we'll definitely try to get this fixed for u asap, i'll keep u in the loop, ill tell you the results as they come, etc etc etc and i also didnt ask what they thought it could be or how do u think this can be managed etf... wtf thats so counterintuitive....yea lemme baby them in layman terms then ask hey how do u think this treatment etc shud be?? Fogured a closure with what i thimk it is and the relative tests and asking if further questions/concerns will suffice 6. had 1 awkward moment with a patient that was unexpected during a left lateral decubitus pt said well this is awkward but i apologized right away for it 7. Didn't document things like scars or tattoes but mentioned it to the patient 8. was running out of space multiple times on the HPI so if say a person didnt smoke, drink, etc... i deleted those things from HPI so i can fit something more pertinent, so basically seems like i asked an entire social history but will not get credit for doing so because ran out of space to fit in other things and the things i did ask will not be known now even thought they were done 9. multiple differentials seemed off to me, some i could not think of more than 1 because felt so obvious, other times (possibly 2-4) was completely boggled by what to even put down as first one, and other times something i should have put on the list, i didn't and didnt realize it after, just kinda hoping the ones i kept still can fit the HPI, etc. 10. never put pertinent negatives into the differentials 11. several patients during the encounter (maybe 2) i forgot to ask a key question that would have lead to a certain better test being ordered aka the patient gave clues to something i, in my ever lasting nervousness and anxiety did not pick up on as hey buddy u may wanna ask about this or inquire about that. 12. I never summarized the HPI/physical findings, i just did the closure and told them what I think it can be/why i think its that/what tests id order/why id order them, not sure if doing a closure but not a summary will kill 13. Provided counseling for whoever i thought needed it for things like alcohol... but in case like alcohol i forgot to say the CAGE results... again something i did that won't be in note 14. didn't put in vital signs for every patient... probably had em all for only half and some of them i just put in w/e i thought was actually pertinent 15. Few times wrote "non-medical" terminology 16. scared **** out of patient by saying cancer.... but obviously wiggled around it saying its not for sure we have to run tests, etc etc 17. when i did my abdominal exam... instead of pulling from the bottom... i figured if the patient is already ungowned for the cardiac/resp exam, may as well help them lay down and just pull gown down a little more and do abdomen 18. didnt ask every female about their obgyn history, menopause etc, only if it was needed (or so i thought) 19. lot of my physical exams seemed kinda weakish, i did the typical heart/lungs... +s1/s2 no murmurs rubs gallops regular rate rhythm clear to ausc bilaterally (never wrote no wheezes rales or rhonchi tho whoops) 20. Forgot cn 11 on one patient and 8 on an other 21. Forgot to ask birth hx and development in peds case 22. Forgot to ask about medication compliance for a pt that obviously needed that question asked ...but that was a case i screwed up completely head to toe... 23. Phys exams were very basic usually i.e. rre s1s2 no mrg and clear to ausc bilaterally for heart/lungs 24. Feel like maybe half my dx were wrong...25. Forgot to ask 1 or 2 patients who looked in pain if i can help or make more comfy Im definitely gonna remember other things... but as it stands... it seems like i failed ICE or CIS or both

 

[Crayola227]

After several days of thinking about my errors I finally came up with a list that, for now, seems to be all i can remember i screwed up on: 1. Ran out of time to write the tests i'd order for 1 patient 2. Put CT and Xray of head when i meant spine 3. accidentally wrote an incorrect abbreviation for a differential (cant specify due to USMLE rules) 4. forgot to do a few key physical exam maneuvers i.e. heaves, thrills, pmi, when required 5. didnt ask anyone about quality of life being affected/in what way its affected them i.e. didnt ask if affects sleep or work, etc, never said im sorry about their chief complaint, i would just kinda throw in random apologies and sorries when it fit throughout the case or say things like we'll definitely try to help you now, thats the goal, we'll definitely try to get this fixed for u asap, i'll keep u in the loop, ill tell you the results as they come, etc etc etc and i also didnt ask what they thought it could be or how do u think this can be managed etf... wtf thats so counterintuitive....yea lemme baby them in layman terms then ask hey how do u think this treatment etc shud be?? Fogured a closure with what i thimk it is and the relative tests and asking if further questions/concerns will suffice 6. had 1 awkward moment with a patient that was unexpected during a left lateral decubitus pt said well this is awkward but i apologized right away for it 7. Didn't document things like scars or tattoes but mentioned it to the patient 8. was running out of space multiple times on the HPI so if say a person didnt smoke, drink, etc... i deleted those things from HPI so i can fit something more pertinent, so basically seems like i asked an entire social history but will not get credit for doing so because ran out of space to fit in other things and the things i did ask will not be known now even thought they were done 9. multiple differentials seemed off to me, some i could not think of more than 1 because felt so obvious, other times (possibly 2-4) was completely boggled by what to even put down as first one, and other times something i should have put on the list, i didn't and didnt realize it after, just kinda hoping the ones i kept still can fit the HPI, etc. 10. never put pertinent negatives into the differentials 11. several patients during the encounter (maybe 2) i forgot to ask a key question that would have lead to a certain better test being ordered aka the patient gave clues to something i, in my ever lasting nervousness and anxiety did not pick up on as hey buddy u may wanna ask about this or inquire about that. 12. I never summarized the HPI/physical findings, i just did the closure and told them what I think it can be/why i think its that/what tests id order/why id order them, not sure if doing a closure but not a summary will kill 13. Provided counseling for whoever i thought needed it for things like alcohol... but in case like alcohol i forgot to say the CAGE results... again something i did that won't be in note 14. didn't put in vital signs for every patient... probably had em all for only half and some of them i just put in w/e i thought was actually pertinent 15. Few times wrote "non-medical" terminology 16. scared **** out of patient by saying cancer.... but obviously wiggled around it saying its not for sure we have to run tests, etc etc 17. when i did my abdominal exam... instead of pulling from the bottom... i figured if the patient is already ungowned for the cardiac/resp exam, may as well help them lay down and just pull gown down a little more and do abdomen 18. didnt ask every female about their obgyn history, menopause etc, only if it was needed (or so i thought) 19. lot of my physical exams seemed kinda weakish, i did the typical heart/lungs... +s1/s2 no murmurs rubs gallops regular rate rhythm clear to ausc bilaterally (never wrote no wheezes rales or rhonchi tho whoops) 20. Forgot cn 11 on one patient and 8 on an other 21. Forgot to ask birth hx and development in peds case 22. Forgot to ask about medication compliance for a pt that obviously needed that question asked ...but that was a case i screwed up completely head to toe... 23. Phys exams were very basic usually i.e. rre s1s2 no mrg and clear to ausc bilaterally for heart/lungs 24. Feel like maybe half my dx were wrong...25. Forgot to ask 1 or 2 patients who looked in pain if i can help or make more comfy Im definitely gonna remember other things... but as it stands... it seems like i failed ICE or CIS or both

Part of CS was documentation. This is horrible coming from me the Ramble Queen, but you need to at least put in some spaces between your paragraphs if ever wanted someone to read this block of text. If you just wanted to get off your chest onto the internet never to be read, cool.

 

[pk1989]

Sorry it came out weird when i posted it!

After several days of thinking about my errors I finally came up with a list that, for now, seems to be all i can remember i screwed up on:
1. Ran out of time to write the tests i'd order for 1 patient
2. Put CT and Xray of head when i meant spine
3. accidentally wrote an incorrect abbreviation for a differential (cant specify due to USMLE rules)
4. forgot to do a few key physical exam maneuvers i.e. heaves, thrills, pmi, when required
5. didnt ask anyone about quality of life being affected/in what way its affected them i.e. didnt ask if affects sleep or work, etc, never said im sorry about their chief complaint, i would just kinda throw in random apologies and sorries when it fit throughout the case or say things like we'll definitely try to help you now, thats the goal, we'll definitely try to get this fixed for u asap, i'll keep u in the loop, ill tell you the results as they come, etc etc etc and i also didnt ask what they thought it could be or how do u think this can be managed etf... wtf thats so counterintuitive....yea lemme baby them in layman terms then ask hey how do u think this treatment etc shud be?? Fogured a closure with what i thimk it is and the relative tests and asking if further questions/concerns will suffice
6. had 1 awkward moment with a patient that was unexpected during a left lateral decubitus pt said well this is awkward but i apologized right away for it
7. Didn't document things like scars or tattoes but mentioned it to the patient
8. was running out of space multiple times on the HPI so if say a person didnt smoke, drink, etc... i deleted those things from HPI so i can fit something more pertinent, so basically seems like i asked an entire social history but will not get credit for doing so because ran out of space to fit in other things and the things i did ask will not be known now even thought they were done
9. multiple differentials seemed off to me, some i could not think of more than 1 because felt so obvious, other times (possibly 2-4) was completely boggled by what to even put down as first one, and other times something i should have put on the list, i didn't and didnt realize it after, just kinda hoping the ones i kept still can fit the HPI, etc.
10. never put pertinent negatives into the differentials
11. several patients during the encounter (maybe 2) i forgot to ask a key question that would have lead to a certain better test being ordered aka the patient gave clues to something i, in my ever lasting nervousness and anxiety did not pick up on as hey buddy u may wanna ask about this or inquire about that.
12. I never summarized the HPI/physical findings, i just did the closure and told them what I think it can be/why i think its that/what tests id order/why id order them, not sure if doing a closure but not a summary will kill
13. Provided counseling for whoever i thought needed it for things like alcohol... but in case like alcohol i forgot to say the CAGE results... again something i did that won't be in note
14. didn't put in vital signs for every patient... probably had em all for only half and some of them i just put in w/e i thought was actually pertinent
15. Few times wrote "non-medical" terminology
16. scared **** out of patient by saying cancer.... but obviously wiggled around it saying its not for sure we have to run tests, etc etc
17. when i did my abdominal exam... instead of pulling from the bottom... i figured if the patient is already ungowned for the cardiac/resp exam, may as well help them lay down and just pull gown down a little more and do abdomen
18. didnt ask every female about their obgyn history, menopause etc, only if it was needed (or so i thought)
19. lot of my physical exams seemed kinda weakish, i did the typical heart/lungs... +s1/s2 no murmurs rubs gallops regular rate rhythm clear to ausc bilaterally (never wrote no wheezes rales or rhonchi tho whoops)
20. Forgot cn 11 on one patient and 8 on an other
21. Forgot to ask birth hx and development in peds case
22. Forgot to ask about medication compliance for a pt that obviously needed that question asked ...but that was a case i screwed up completely head to toe...
23. Phys exams were very basic usually i.e. rre s1s2 no mrg and clear to ausc bilaterally for heart/lungs
24. Feel like maybe half my dx were wrong...
25. Forgot to ask 1 or 2 patients who looked in pain if i can help or make more comfy

Im definitely gonna remember other things... but as it stands... it seems like i failed ICE or CIS or both
Part

 

[pk1989]

Sorry! Came out odd i reposted it thanks!

Part of CS was documentation. This is horrible coming from me the Ramble Queen, but you need to at least put in some spaces between your paragraphs if ever wanted someone to read this block of text. If you just wanted to get off your chest onto the internet never to be read, cool.

 

[Hr1900]

Sorry it came out weird when i posted it!

After several days of thinking about my errors I finally came up with a list that, for now, seems to be all i can remember i screwed up on:
1. Ran out of time to write the tests i'd order for 1 patient
2. Put CT and Xray of head when i meant spine
3. accidentally wrote an incorrect abbreviation for a differential (cant specify due to USMLE rules)
4. forgot to do a few key physical exam maneuvers i.e. heaves, thrills, pmi, when required
5. didnt ask anyone about quality of life being affected/in what way its affected them i.e. didnt ask if affects sleep or work, etc, never said im sorry about their chief complaint, i would just kinda throw in random apologies and sorries when it fit throughout the case or say things like we'll definitely try to help you now, thats the goal, we'll definitely try to get this fixed for u asap, i'll keep u in the loop, ill tell you the results as they come, etc etc etc and i also didnt ask what they thought it could be or how do u think this can be managed etf... wtf thats so counterintuitive....yea lemme baby them in layman terms then ask hey how do u think this treatment etc shud be?? Fogured a closure with what i thimk it is and the relative tests and asking if further questions/concerns will suffice
6. had 1 awkward moment with a patient that was unexpected during a left lateral decubitus pt said well this is awkward but i apologized right away for it
7. Didn't document things like scars or tattoes but mentioned it to the patient
8. was running out of space multiple times on the HPI so if say a person didnt smoke, drink, etc... i deleted those things from HPI so i can fit something more pertinent, so basically seems like i asked an entire social history but will not get credit for doing so because ran out of space to fit in other things and the things i did ask will not be known now even thought they were done
9. multiple differentials seemed off to me, some i could not think of more than 1 because felt so obvious, other times (possibly 2-4) was completely boggled by what to even put down as first one, and other times something i should have put on the list, i didn't and didnt realize it after, just kinda hoping the ones i kept still can fit the HPI, etc.
10. never put pertinent negatives into the differentials
11. several patients during the encounter (maybe 2) i forgot to ask a key question that would have lead to a certain better test being ordered aka the patient gave clues to something i, in my ever lasting nervousness and anxiety did not pick up on as hey buddy u may wanna ask about this or inquire about that.
12. I never summarized the HPI/physical findings, i just did the closure and told them what I think it can be/why i think its that/what tests id order/why id order them, not sure if doing a closure but not a summary will kill
13. Provided counseling for whoever i thought needed it for things like alcohol... but in case like alcohol i forgot to say the CAGE results... again something i did that won't be in note
14. didn't put in vital signs for every patient... probably had em all for only half and some of them i just put in w/e i thought was actually pertinent
15. Few times wrote "non-medical" terminology
16. scared **** out of patient by saying cancer.... but obviously wiggled around it saying its not for sure we have to run tests, etc etc
17. when i did my abdominal exam... instead of pulling from the bottom... i figured if the patient is already ungowned for the cardiac/resp exam, may as well help them lay down and just pull gown down a little more and do abdomen
18. didnt ask every female about their obgyn history, menopause etc, only if it was needed (or so i thought)
19. lot of my physical exams seemed kinda weakish, i did the typical heart/lungs... +s1/s2 no murmurs rubs gallops regular rate rhythm clear to ausc bilaterally (never wrote no wheezes rales or rhonchi tho whoops)
20. Forgot cn 11 on one patient and 8 on an other
21. Forgot to ask birth hx and development in peds case
22. Forgot to ask about medication compliance for a pt that obviously needed that question asked ...but that was a case i screwed up completely head to toe...
23. Phys exams were very basic usually i.e. rre s1s2 no mrg and clear to ausc bilaterally for heart/lungs
24. Feel like maybe half my dx were wrong...
25. Forgot to ask 1 or 2 patients who looked in pain if i can help or make more comfy

After several days of thinking about my errors I finally came up with a list that, for now, seems to be all i can remember i screwed up on: 1. Ran out of time to write the tests i'd order for 1 patient 2. Put CT and Xray of head when i meant spine 3. accidentally wrote an incorrect abbreviation for a differential (cant specify due to USMLE rules) 4. forgot to do a few key physical exam maneuvers i.e. heaves, thrills, pmi, when required 5. didnt ask anyone about quality of life being affected/in what way its affected them i.e. didnt ask if affects sleep or work, etc, never said im sorry about their chief complaint, i would just kinda throw in random apologies and sorries when it fit throughout the case or say things like we'll definitely try to help you now, thats the goal, we'll definitely try to get this fixed for u asap, i'll keep u in the loop, ill tell you the results as they come, etc etc etc and i also didnt ask what they thought it could be or how do u think this can be managed etf... wtf thats so counterintuitive....yea lemme baby them in layman terms then ask hey how do u think this treatment etc shud be?? Fogured a closure with what i thimk it is and the relative tests and asking if further questions/concerns will suffice 6. had 1 awkward moment with a patient that was unexpected during a left lateral decubitus pt said well this is awkward but i apologized right away for it 7. Didn't document things like scars or tattoes but mentioned it to the patient 8. was running out of space multiple times on the HPI so if say a person didnt smoke, drink, etc... i deleted those things from HPI so i can fit something more pertinent, so basically seems like i asked an entire social history but will not get credit for doing so because ran out of space to fit in other things and the things i did ask will not be known now even thought they were done 9. multiple differentials seemed off to me, some i could not think of more than 1 because felt so obvious, other times (possibly 2-4) was completely boggled by what to even put down as first one, and other times something i should have put on the list, i didn't and didnt realize it after, just kinda hoping the ones i kept still can fit the HPI, etc. 10. never put pertinent negatives into the differentials 11. several patients during the encounter (maybe 2) i forgot to ask a key question that would have lead to a certain better test being ordered aka the patient gave clues to something i, in my ever lasting nervousness and anxiety did not pick up on as hey buddy u may wanna ask about this or inquire about that. 12. I never summarized the HPI/physical findings, i just did the closure and told them what I think it can be/why i think its that/what tests id order/why id order them, not sure if doing a closure but not a summary will kill 13. Provided counseling for whoever i thought needed it for things like alcohol... but in case like alcohol i forgot to say the CAGE results... again something i did that won't be in note 14. didn't put in vital signs for every patient... probably had em all for only half and some of them i just put in w/e i thought was actually pertinent 15. Few times wrote "non-medical" terminology 16. scared **** out of patient by saying cancer.... but obviously wiggled around it saying its not for sure we have to run tests, etc etc 17. when i did my abdominal exam... instead of pulling from the bottom... i figured if the patient is already ungowned for the cardiac/resp exam, may as well help them lay down and just pull gown down a little more and do abdomen 18. didnt ask every female about their obgyn history, menopause etc, only if it was needed (or so i thought) 19. lot of my physical exams seemed kinda weakish, i did the typical heart/lungs... +s1/s2 no murmurs rubs gallops regular rate rhythm clear to ausc bilaterally (never wrote no wheezes rales or rhonchi tho whoops) 20. Forgot cn 11 on one patient and 8 on an other 21. Forgot to ask birth hx and development in peds case 22. Forgot to ask about medication compliance for a pt that obviously needed that question asked ...but that was a case i screwed up completely head to toe... 23. Phys exams were very basic usually i.e. rre s1s2 no mrg and clear to ausc bilaterally for heart/lungs 24. Feel like maybe half my dx were wrong...25. Forgot to ask 1 or 2 patients who looked in pain if i can help or make more comfy Im definitely gonna remember other things... but as it stands... it seems like i failed ICE or CIS or both

Did you pass then , i did the test 2 days ago and i am.freaking out

 

[pk1989]

Yep yep passed

 

[Prince090]

Yep yep passed

Thank you for telling us two years later.