impending step 2 CS failure

[epsilonprodigy]

---

Members don't see this ad.

I just took CS, and failed. This isn't one of those "OMG, I'm not sure I was empathetic enough" post. I. FAILED. It's a mathematical certainty. Despite getting great reviews about my real clinical skills, I've always been terrible at OSCE's and usually pass by the skin of my teeth. I get really caught up in the "hidden agendas" and all the crap you're supposed to do that no one would ever actually do in real life. I don't anticipate getting much reassurance once I outline my mistakes, but for those who are curious:
1. Took a solid history and got into some "counseling" early on by virtue of the challenge question. "Dr., I'm afraid I have X.." leading me to discuss some DDX possibilities. I then resumed the hx, did a physical exam in which I forgot optho, and had NO time for actual closing. Effectively blurted, OK we're going to test you for X, Y and Z. Any questions?"
2. Psych one- this was okay-ish, I think.
3. DISASTER. Totally straightforward DDX, but SP was pretending to be in severe pain and angry. I did the whole smarmy "I'm soooo sorry, pain meds, how can I make you comfortable, etc." I think my history-taking was solid. I knew you'd get dinged if you repeated painful maneuvers, so my exam of the pertinent system was crappy because I'd already verified that *duh* it hurt severely- no need to make the guy do a bunch of maneuvers that wouldn't change my ddx. When the guy yelped, I said "we will continue this part of the exam after we get you soem pain meds." Durrrrh, I forgot that I was starring in improv theater and not in the actual ER for a minute. Also forgot to auscultate when it was definitely relevant. Worst part- I was tinkering with my note so much that I ran out of time and put ZERO physical exam (although I did back up my ddx with physical exam findings, I didn't fill out the PE box itself.) The third of my ddx was less well-substantiated than another item that I should have put instead.
4. Meh- think I'm ok w/ the first DDX item but should have put something different for the second.
5. Respiratory issue- forgot to percuss, do tactile fremitus and ask about smoking. Easy ddx
6. Respiratory again- forgot tactile fremitus again.
7. Forgot to do optho exam which was warranted based on PMH (but not necessarily the CC itself); did another relevant exam maneuver but forgot to document it.
8. Think this was OK.
9. Forgot to ask about smoking, though not directly relevant to anything. Probably jacked up an MSK maneuver. Did not support my main DDX with as many items as I should have, as I wasn't perfectly familiar with the condition (got the DX itself right, though.)
10. SP was super-pissy, not sure if I "addressed her concerns" satisfactorily. Also pretty sure I jacked up at least 1-2 MSK PE maneuvers, although DDX was self-explanatory without them.
11. Urinary complaint- didn't ask about sexual function.
12. Used iffy wording on my main dx; not sure if this will count as "proper medical terminology."

General issues:
-asked about substance use other than what I mentioned, but didn't CAGE anyone (they all had like 1 beer/mo., so super awkward to do CAGE, but obviously not an excuse here.)
-not sure I summarized appropriately
-didn't list vitals in my note except once when fever was important- hard to say if this was important or not.
-not entirely confident that I backup up my DDX with enough detail in many cases

Long story short- I choked. By the end, I felt like I was at least getting the hang of it, and could pass if I were to take another one immediately after- it was the lack of realistic practice that got me. I would love to hear others' opinions on this situation, specifically about what to do next. At this point, I'm planning on continuing to study and practice timed notes, with the intention of signing up for a retake ASAP. I'm not sure if you can just go ahead and sign up for another date before your score is even back, but if you can, I will. Unfortunately, my #1 program, which is also my home institution, requires passing CS in order to rank applicants, and my #2 requires passing on the first attempt. I hear there is some wiggle room with these policies, however, and would love to hear from anyone who can comment further on this.

 

[DryHopped]

Took it recently, pretty sure I failed too. Most of my encounters I had 2 DDX, with not much supporting info. Only had time for PE specifically relevant to CC, didn't do the whole CV, Lungs, Abdominal exam on every pt that everyone seems to swear by on this site. So many patients with cancer specific symptoms who freaked out on me when I closed talking about cancer and I had no clue what to say... but seriously I had no other reasonable DDX than cancer and life threatening diseases on many encounters, it was ridiculous. So much for the whole "most of the encounters you will see will be similar to what you will see in a clinic or ED statement in the USMLE step 2 CS content guide.... Probably not going to match because of this test.

 

[grt398]

I think a lot of people worry they failed when leaving the test center; I'm pretty concerned right now b/c I had a few encounters where I completely forgot to do parts of the PE, or forgot to summarize, or forgot to counsel etc. Plus my pts had limited physical exam findings supporting most of my ddx but there's just no way to tell until you get your score. It's a particularly annoying part of this test unlike Step 1/2CK where I felt I knew I'd pass, I just didn't know where my score would end up. I think all we can do is wait till Feb unfortunately.

 

[Moko]

In all likelihood, all three of you will pass. Many people leave the test thinking they failed because they forgot to do parts of the history, exam, or closure. Fortunately though, the majority of people in this situation will end up passing. Just suppress the urge to worry and wait for the score report--nothing you do now will change the outcome.

For what it's worth, I missed multiple important diagnostic considerations, forgot to collect any medical history for one patient (PMH, PSH, All, Meds, FH, SH--the works), in addition to other more minor mishaps not unlike the ones listed above, and still passed with very healthy margins. Hopefully you guys will get the same news in several weeks.

 

[Psai]

You'll be fine op. Just need to wait for the score to come out

 

[epsilonprodigy]

Thanks for the encouragement, guys. Incidentally, I thought of something else I forgot: I didn't get a numerical pain score for EVERY SINGLE SP with pain, even though I asked the rest of the pain Q's. So stupid. I do that every single day.

The NBME says you can't re-register until you get your score back. Still waiting on advice from my advisory dean. This is a real disaster considering that it will cause us to have to move. As I said, my top 2 (local) programs actually care about this crock of ****, but most others on my rank list don't. My husband is now pressuring me to suicide match for local programs, seeing as now I'll almost certainly be overlooked by the locals. This would effectively mean NOT matching and either scrambling (not likely to be local either!) or taking a year off and reapplying. Since that would make me even more of an underdog, I am unlikely to do it no matter what he says. (From the get-go, we agreed that I'd rank based on geography with far-away programs as backups, but now that this has happened, he's gun-shy.) When I started out, I had no idea that a few meaningless hours could cause my entire career and family life to go down the tubes.

 

[22031 Alum]

Thanks for the encouragement, guys. Incidentally, I thought of something else I forgot: I didn't get a numerical pain score for EVERY SINGLE SP with pain, even though I asked the rest of the pain Q's. So stupid. I do that every single day.

The NBME says you can't re-register until you get your score back. Still waiting on advice from my advisory dean. This is a real disaster considering that it will cause us to have to move. As I said, my top 2 (local) programs actually care about this crock of ****, but most others on my rank list don't. My husband is now pressuring me to suicide match for local programs, seeing as now I'll almost certainly be overlooked by the locals. This would effectively mean NOT matching and either scrambling (not likely to be local either!) or taking a year off and reapplying. Since that would make me even more if an underdog, I am unlikely to do it no matter what he says. When I started out, I had no idea that a few meaningless hours could cause my entire career and family life to go down the tubes.

In all likelihood, you passed and all this is like a cow's opinion. But whatever happens, suicide ranking is probably the worst thing you could do.

Not that his opinion/advice is informed in the slightest, but what exactly is your husband's logic for thinking you should suicide rank the programs you think will overlook you?

 

[epsilonprodigy]

His thought is that I could scramble, and maybe a spot would turn up locally in prelim or another specialty. I'm applying to gen surg but decided long ago that if I ended up scrambling, I'd take gen Surg or OB since I loved it and seriously considered applying to it. My husband was open to the possibility of moving when it was a remote "backup plan." I didn't think it would come to fruition either, since I'm otherwise a strong applicant.

I've tried to explain that by suicide matching/scrambling/reapplying, I'd relinquish even more control over where I land. We'll see if he comes around. I'm also curious if programs will be willing to take this less seriously than they normally would, because (get this!) I was a nurse before med school. I know how to deal with REAL patients. I also know enough not to counsel a patient in acute distress about ETOH as they try to die in front of me. And apparently, that's where the problem lies

 

[22031 Alum]

That's a terrible reason to suicide rank. Granted, I think most reasons to suicide rank are terrible, but an attempt to control where you end up is probably the worst. With each successive step in this process, you lose more control over where you end up. Your best shot at controlling anything is in the original match, which gives you the most chances to end up in a place of your choosing that wanted you. In the SOAP, disregarding the fact that you'd be going to a program sight unseen, there are no guarantees there'd even be any openings in the place you want to be. And then, if you don't get a place in the SOAP, you've become a previously-unmatched reapplicant which limits your options even more than scrambling.

Since you mentioned OB, I will tell you that last year was the first year ever that there were zero spots available in the scramble. I know there are always Surgery Prelim spots to be had, but I'm not sure how many of those try to fill in the scramble if they don't match someone, vs. just staying unfilled. A Gen Surg person could explain that better.

All that said, I still think you probably passed.

 

[epsilonprodigy]

I'm obviously so glad to hear that anyone thinks I might've passed, given the seriousness of the mistakes I listed. I'm just curious then...if that mess doesn't equal failure, what on earth does?

 

[Moko]

I'm obviously so glad to hear that anyone thinks I might've passed, given the seriousness of the mistakes I listed. I'm just curious then...if that mess doesn't equal failure, what on earth does?

My thought is that in order to fail any portion of the CS exam, there needs to be consistent shortcomings across some aspect of the encounter.

For the ICE portion: e.g. Consistently failing to inquire more about their presenting symptoms, not asking a relevant ROS, or forgetting parts of the medical or social history. Perhaps the history was performed very inefficiently such that there wasn't enough time to ask other relevant questions (unbeknownst to the examinee). Similarly, confusing documentation with poorly formed DDx and workup across multiple patient encounters would result in many lost points.
For the CIS portion: e.g. There are people who may unknowingly be dismissive of patients' complaints and concerns. Perhaps they are unintentionally interrupting patients or cutting them off prematurely. Did they forget to introduce themselves consistently or were rushing through the encounter? Or maybe their explanations come off as cold and uncaring, giving the impression that their empathy was rehearsed and 'not real' (i.e. it's not just what you say, but also how you say it). Were they seen as condescending and lecturing when counselling or delivering the closure?

At the end of the day, it's hard for someone to know whether they were consistently "missing" something on the test. If someone were to fail, I think it's more likely because of something they weren't aware of vs. the nitpicky details that people (myself included ) tend to obsess over after the test.

No way to know whether you failed until you see the score report. Hopefully it'll bear good news. Good luck

 

[Psai]

You really need to work on that neuroticism. You haven't even gotten your score report back. Just sit tight for a few months, there's really nothing you can do about it at this point. And suicide matching is incredibly stupid.

 

[CodeNineyNine]

Every single one of my classmates that I talked to listed multiple tests they forgot to do, counseling they didn't perform, diagnoses they missed, etc. One of my good friends dropped her stethoscope and cursed out loud, and in her ensuing panic forgot to wash her hands. She passed, as did all of my classmates. Don't worry until you get your score report.

 

[downthedrain]

Definitely in the same boat as the other people in this thread. Missed the main dx in two cases, and in one case, forgot to pull the leg rest out until the patient mentioned his legs were uncomfortable (I apologized profusely and went on with the exam, but was a bit frazzled after). Also blanked on what to ask a patient who had memory issues (got a mini mental in at the last minute and threw in some thyroid questions towards the end, but literally blanked). Not much any of us can do until scores come out, but it's good to hear from people who also had mishaps and then passed. It makes the impending wait just a tiny bit less terrifying. Just wondering, are the CS exams scaled against the mean as well or is it purely based on passing a threshold?

 

[Vascularanastomosis]

Few more days..this wait is killing me 🙁

 

[endoffouryears]

Do not give up the ghost! I know how easy it is to let your emotions grab a hold of you. This test is VERY subjectively graded and you may not have lost nearly as many points as you think.


Before I give you some comments, I need to say that I am waiting on the result of CS myself. Although I prepared extensively, taking a Kaplan course, working directly with SPs, using both First Aid and Kaplan practice cases fully, almost twice through on First Aid, etc. I learned a lot about how this test works, mostly from Kaplan. I’d like to share some of that with you.


Most of the comments I give you below is what the physicians and SPs at Kaplan taught us, and these people are steeped in the professional execution of this exam. It was an invaluable course for me.


“…and usually pass by the skin of my teeth”


If this is true, what steps did you take to make sure you did not perform similarly on the actual exam? Did you do anything additional to prepare, aside from using First Aid and practicing with friends? Many physicians and SPs who work with/have worked with the actual exam do not put any faith in FA as a singular resource. I have heard more than one of them say, “Students pass in spite of FA, not because of FA.”


“I then resumed the hx, did a physical exam in which I forgot optho, and had NO time for actual closing. Effectively blurted, OK we're going to test you for X, Y and Z. Any questions?"


No time for actual closing is an issue because, remember, this test is not just about doing things, it’s about how well you do them. However, the SP may actually give you some credit on the checklist for parts of the summary and closing if he felt good rapport with you, felt like you addressed their needs well, etc. etc. It can be graded very subjectively. Also remember, that is just one case out of 12. If you did a decent job closing for others this case may have no real impact at all on your CIS average.


“Psych one- this was okay-ish…”


Did you do any kind of MMSE? SIGECAPS? Did you include in your note any information about affect, mood, liability etc.? Many students do not realize that while there is usually no opportunity for PE in psych cases, visually confirmed components of the patient’s behavior counts for PE, and can get you points that others miss. If you did any of those in the HPI and added some to the PE, you might have gotten yourself extra points to make up for those you could have lost in other cases.


“…I said "we will continue this part of the exam after we get you some pain meds." Durrrrh, I forgot that I was starring in improv theater and not in the actual ER for a minute.”


Yes, you are not supposed to repeat painful maneuvers or you might lose points for empathy, or properly performing the PE maneuver. Kaplan taught us, for this reason, to leave potentially painful maneuvers until the very end of the PE, and in a sense, you seem to have done this. You really may not be as screwed in this case as you think. The SP may perceive of what you did as a “well performed” component of the PE, and give you full points for having left a painful maneuver for later. The concept of, “Did the student perform the PE component well?”, can be very subjective…


“Also forgot to auscultate when it was definitely relevant.”


It is almost always relevant, and easy points. There are perhaps three types of cases that do not require auscultation, so we were taught to do a three point cardiac auscultation in every case, and four point respiratory auscultation at the posterior in every case. Easy points. But keep in mind, it’s just one component of the case, and if you supported you DDx well enough the points you may lose here might be irrelevant when you add them all up.

“…although I did back up my ddx with physical exam findings, I didn't fill out the PE box itself.”


Unfortunately, according to Kaplan, you cannot get points for things supporting the DDx that you do not put in the HPI or PE boxes. You will lose some points here. Remember, regardless of what people say online, there is no such thing as failing 1 or 2 cases in CS and then immediately failing the test. You either meet the needs for their algorithm with your overall points, or you do not. So you may not have gotten any points for the PE components you used to support your DDx, but you may have unknowingly compensated for that with other components in your note.


“Meh- think I'm ok w/ the first DDX item but should have put something different for the second.”


We students often get caught up trying to “get the right dx” on each case of this test. The reality is, the test is about what the patient COULD have, not what they DO have. None of the cases are designed to present one clear Dx as the predominant one. This is the reason why supporting your DDx is so important. There are a variety of diagnoses for each patient that the physician will recognize as appropriate, but if you can’t support them properly then the Dx you put is irrelevant.


“Respiratory issue- forgot to percuss, do tactile fremitus and ask about smoking. Easy ddx”


Again, a subjective issue. The SP may give you the points for having performed the respiratory exam well, or they may not. The physician grading your note may give you full credit for respiratory or they may not. It is very subjective. Also, (like a broken record here) those are just a few points out of an entire abundance of points available to you.


“Respiratory again- forgot tactile fremitus again.”


Same as above.


“Forgot to ask about smoking, though not directly relevant to anything.”


Again, might lose a point, but not going to cripple your average. Something to remember; your comment about “not directly relevant” is inaccurate. It is directly relevant to the points you get for the social history component of the HPI. However, the physician grading this may not even notice it if you wrote a clear, strong and coherent HPI around it.


“…got the DX itself right, though.”


As I mentioned above, there really is no such thing as a correct diagnosis on this test. What matter is whether the diagnosis is reasonable, and that you support the diagnosis well.


“Urinary complaint- didn't ask about sexual function.”


Depending on the complaint you could easily make an argument for or against this being part of a “relevant” ROS for this patient. For that reason you may not have lost any points here at all.


“Used iffy wording on my main dx; not sure if this will count as "proper medical terminology."”


The main diagnosis you put is scored in two ways. A computer reads the main diagnosis and if it is in the list of “reasonable” diagnoses, and it is spelled right, you get the point. Then the physician scores it as well, although with a subjective eye. As disheartening as it is, spelling the diagnosis right is important, but spelling errors in the body text of the HPI and PE are less important. The computer scoring it has no tolerance for misspellings with regard to the diagnosis, but luckily human beings do look at them.


“…but didn't CAGE anyone.”


Kaplan taught us not to CAGE anyone unless they exceed their recommended daily allowance of alcoholic “drinks”. One a day for females, 2 a day for males. So if nobody was binging or exceeding their daily allowance, then CAGE questions would have been inappropriate. Sounds like you did fine with that.


“not sure I summarized appropriately.”


What did you do to summarize? Proper summary and closing according to Kaplan is: Mention a few components of Hx and/or PE that support the Dx. Dx given in medical terms. Explain Dx to patient in lay terms. Explain tests to be ordered in lay terms. Ask patient if they agree with plan. Ask patient if they have follow up questions. So do you feel like you did okay with respect to summary and closing?


“didn't list vitals in my note except once when fever was important- hard to say if this was important or not.”


That is an issue. Normal vitals can support nearly any diagnosis and are easy points in both the PE box and the supporting info for the DDx. They can be easily cut and paste from the second tab of the note form and put in the PE box within seconds.


“not entirely confident that I backup up my DDX with enough detail in many cases.”


Kaplan taught us to put atleast 8 pieces of supporting evidence (Hx and/or PE) for the first Dx. Four to six for the second Dx. And 2-3 for the third diagnosis. Did you meet or get close to that criteria? Remember, chief complaint is supportive Hx. Age of patient can be supportive hx. Gender, race, appearance, and anything from the past medical hx can be supportive hx in addition to the associated signs and symptoms.


“I didn't get a numerical pain score for EVERY SINGLE SP with pain…”


You will lose points for this in the HPI and potentially in the supporting evidence portion of the DDx, but again, just one component of a larger list of points you could have acquired in each case, and the average is what matters most.


“…and could pass if I were to take another one immediately after.”


Do not jump to this conclusion! If, god forbid, you need to repeat this test, you MUST address the things you know you did wrong by practicing them properly! But, you also need to get advice from people who can help you find additional things to correct that you may not be aware of. The only worse than failing CS once, is failing it twice. Do not rush back into it…


“…with the intention of signing up for a retake ASAP.”


As above. Do not rush into this test. The stories we hear from students about how easy this test is and how most people pass with minimal effort are based on half truths. How many of your fellow students are 100% truthful with you about their performance and preparations on tests? Additionally, stories of this test being easy are becoming less and less common. The test format was changed a few years ago, and was made more difficult. Not everyone is a mastermind high performing student who can pass this test with just a few days of study using FA. Some people, like me, need significant practice to feel like they are going to “perform” their part on the test correctly and efficiently. Yes, it is a performance like you said above, and nobody is teaching us to practice that performance.


Do not assume you have failed. Give yourself some credit for the things you have done right and the hard work you have done. The test is very subjective, and from what I see above, a lot of your errors fall into the realm of the subjective for both the physician grading the note, and the SP. Keep studying if you feel like you should, but don’t do it assuming that you failed, do it because you will pick up some things that will make you a better physician along the way.


If you failed, I would encourage you to take a Kaplan course. I feel like they really helped me to know what was missing in my preparations, and hopefully I will see good results on the test itself sometime soon.


Best of luck to you, both on this test, and on the Match. 🙂

 

[blueskies519]

.

 

[Light Yagami]

Really unfortunate we all have to take this exam. What was once an exam strictly for foreign grads to test English competency has morphed into this annoying beast. Of course, like all else the test administrators saw $$$ and expanded the scope. Utter waste of time. Especially for someone like me going into psych.

 

[Vascularanastomosis]

Can u guys start posting when u hear anything?

 

[DryHopped]

Took it recently, pretty sure I failed too. Most of my encounters I had 2 DDX, with not much supporting info. Only had time for PE specifically relevant to CC, didn't do the whole CV, Lungs, Abdominal exam on every pt that everyone seems to swear by on this site. So many patients with cancer specific symptoms who freaked out on me when I closed talking about cancer and I had no clue what to say... but seriously I had no other reasonable DDX than cancer and life threatening diseases on many encounters, it was ridiculous. So much for the whole "most of the encounters you will see will be similar to what you will see in a clinic or ED statement in the USMLE step 2 CS content guide.... Probably not going to match because of this test.

I ended up passing with high performance in CIS and SEP, my ICE was in the middle but nothing close to borderline. I am so glad to have this exam behind me. To all of those worried about not passing, you most likely passed if you were able to do most of what is asked in First Aid for step 2 CS in the majority of your encounters, just keep yourself busy and try not to think about it until you get your score report.

 

[grt398]

I think a lot of people worry they failed when leaving the test center; I'm pretty concerned right now b/c I had a few encounters where I completely forgot to do parts of the PE, or forgot to summarize, or forgot to counsel etc. Plus my pts had limited physical exam findings supporting most of my ddx but there's just no way to tell until you get your score. It's a particularly annoying part of this test unlike Step 1/2CK where I felt I knew I'd pass, I just didn't know where my score would end up. I think all we can do is wait till Feb unfortunately.

So as follow-up I passed fine, with ICE/CIS scores middle of the road but nothing close to borderline and * for SEP as expected. I probably overprepared a bit since I did both FA for Step 2 CS and about 1/2 of the UWorld cases over the course of a week. Most people seem fine preparing 2-3 days and if you're in the middle of the primary care rotation, maybe even with 1-2 days, and I suspect I would have been as well but I didn't want to take any chances. Agree with DryHopped above that you'll likely pass if you can do most of what's in FA.

 

[DTiop]

I had a question about the new rules: just wondering if the patient still has a checklist of what questions we've asked. Is it true that the SP only have a checklist for the physical exam portion, and that the HPI/history is reflected in the note?

 

[Ismet]

I had a question about the new rules: just wondering if the patient still has a checklist of what questions we've asked. Is it true that the SP only have a checklist for the physical exam portion, and that the HPI/history is reflected in the note?

I think it hasn't been that way for over a year. SPs don't score you on the history questions you ask, only on the PE maneuvers you do. ICE is made up of the PE score and then your note.

 

[DTiop]

Thanks so much for the answer Ismet. I guess I'm way behind.

Just wondering if anyone knows how they grade the phone interviews. If SPs only grade physicals, does the note alone contribute to the ICE score?

 

[Ismet]

Thanks so much for the answer Ismet. I guess I'm way behind.

Just wondering if anyone knows how they grade the phone interviews. If SPs only grade physicals, does the note alone contribute to the ICE score?

Yes

 

[ct303]

So @epsilonprodigy - what happened????

 

[Alaa 22]

I nearly did not have a single complete note, I ran out of time in every note and it was the PE that I decide to sacrifice, I don't write notes during the encounter itself and after 5-6 pt I satrted to get confused with Past family hx!! I was like "wait who's mother got HTN?!! this pt or the previous one!!" I panicked and was so scared, I did good with the ddx and workup , I did very bad on the PE and forgot some maneuver in almost every encounter, but I took a good hx and always made sure that I counsel them, I was so certain that I failed there was no doubt in my mind , I even started to plan when to take it the second time and from who I would borrow the money LOL, but 2 days ago I got the result and I PASSED, I thought I would share this maybe it would calm you down

 

[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 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 26. Forgot to pull rest out for one patient.
Im definitely gonna remember other things... but as it stands... it seems like i failed ICE or CIS or both

 

[foxymulder]

@epsilonprodigy currently freaking out about my CS now and would really like to know what ended up happening here!

 

[Ashantua]

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 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 26. Forgot to pull rest out for one patient.
Im definitely gonna remember other things... but as it stands... it seems like i failed ICE or CIS or both

Hey did u end up passing ?

 

[pk1989]

Hey did u end up passing ?

Yeps

 

[Ashantua]

Yeps

Wow congrats ! I’m so scared. I had only 2 solid differentials, left out a work up plan in one case and overall concerned about my counseling skills. Literally 9/12 of my cases didn’t have a challenging question at the end ? :/

 

[Hr1900]

Wow congrats ! I’m so scared. I had only 2 solid differentials, left out a work up plan in one case and overall concerned about my counseling skills. Literally 9/12 of my cases didn’t have a challenging question at the end ? :/

You think you blew up the exam and you are scared . I think you did better than me , you are worried about counseling , but i forgot to counsel 4 -5 sps about smoking , alcohol., diet ..

 

[Hr1900]

Wow congrats ! I’m so scared. I had only 2 solid differentials, left out a work up plan in one case and overall concerned about my counseling skills. Literally 9/12 of my cases didn’t have a challenging question at the end ? :/

You think you blew up the exam and you are scared? . I think you did better than me , you are worried about counseling , but i forgot to counsel 4 -5 sps about smoking , alcohol., diet .. i feel like ****

 

[tylander]

You think you blew up the exam and you are scared? . I think you did better than me , you are worried about counseling , but i forgot to counsel 4 -5 sps about smoking , alcohol., diet .. i feel like ****

How did it turn out???

 

[DrGoon]

they failed and then gave up on being a doctor after they went unmatched in FM

 

[theepadika]

Took it recently, pretty sure I failed too. Most of my encounters I had 2 DDX, with not much supporting info. Only had time for PE specifically relevant to CC, didn't do the whole CV, Lungs, Abdominal exam on every pt that everyone seems to swear by on this site. So many patients with cancer specific symptoms who freaked out on me when I closed talking about cancer and I had no clue what to say... but seriously I had no other reasonable DDX than cancer and life threatening diseases on many encounters, it was ridiculous. So much for the whole "most of the encounters you will see will be similar to what you will see in a clinic or ED statement in the USMLE step 2 CS content guide.... Probably not going to match because of this test.

hey did you end up passing?

 

[type12]

hey did you end up passing?

Given that they are a resident now, it's somewhat possible