Hey everyone,
Back in July I learned that I had failed the ICE section of my CS exam. I was bewildered. I had always done well during my school's OSCE examinations and received an average grade in those courses ("B" or roughly 85%).
I was depressed. Seriously. Receiving a fail on a big exam like this can really mess with your confidence level. In addition, the exam results offer ZERO constructive feedback for your attempt. They take your $1200 - $1500 plus travel expenses and tell you "Sorry, some guys in a room somewhere decided you weren't good enough". I requested a score recheck and it took me 6 weeks to receive a poorly written stock response letter basically telling me I shouldn't have requested it. I was disgusted. I seriously full-heartedly believe that the exam is unfair in it's current state and it feels almost criminal to someone who is told they haven't passed.
Anyway, that's not what this post is about. After a few hours wallowing in self-pity and cursing the examiners I picked up the pieces and immediately set into motion the actions needed to schedule a retake. Obtaining another date was extremely difficult. People rarely cancel and you have to be sitting at your computer when it happens. (Protip: Get friends and family to check openings for you).
Searching the internet for advice on what I could have possibly done wrong proved fruitless. There is a real lack of quality posts about people's experiences. A few people did reach out to me via DM and I am thankful for their support.
My goal today is to provide some QUALITY suggestions to people who are having trouble passing the ICE component of this exam.
The ICE component is scored in two ways. The first is a checklist that the SP fills out regarding the physical exam techniques that you performed. The second is by a physician who reviews your patient note.
First a PSA: this is NOT MERELY AN ENGLISH LANGUAGE EXAM. Slap anyone in the face who tells you "Do you speak English? Then you'll pass." This exam tests time management. It tests history taking. It tests critical thinking. It tests knowledge of exam maneuvers. It tests memory. It tests your ability to write a detailed patient note. It tests your ability to come up with a differential and support it. It tests your knowledge of diagnostic tests.
Regarding the physical exam:
Remember the patient is just ticking off a checklist. You don't lose any points for examining something that didn't need to be examined. You just lose time. So don't overthink it. Pick the system (HEENT, Pulmonary, Cardio, Abdomen, MSK, Neurological) that you feel is most relevant to the patient's complaint and do a thorough examination of that system. Always follow the procedure of Inspection, Palpation, Percussion, Auscultation (IPPA) (unless its the abdomen, then its IAPP). Don't skip Percussion! It is likely a box on the SP's checklist. While you are doing the main examination, consider whether or not you want to do a second system. For example, if the patient has pneumonia and mentions a sore throat, you may want to do a pulmonary exam followed by an HEENT exam. If you are running out of time, just do the most relevant parts of that system (i.e. look in their mouth, check for lymphadenopathy).
Practice, Practice, Practice the detailed examinations for each system. Make a list of special exam maneuvers (i.e. Rovsing's sign, Psoas sign, Tinnel's sign etc.) and know them by heart.
ALWAYS REMEMBER TO:
- Wash your hands and/or wear gloves prior to doing the physical exam
- Drape the patient properly. Drape female's chest if you need to expose their chest (they wear bras)
- Pull out the little platform at the end of the bed if you ask the patient to lay down
- Examine the patient from the right side of the bed
- Keep your eyes open (some patients can have make-up on that look like a bruise or something else)
- Tell the patient before you are going to do something (ex. untie their gown, palpate the abdomen)
- Always re-tie the patient's gown
- Listen on bare skin (never auscultate through the patient's gown)
Always err on the side of caution. For example, if you get a phone case and its a dad wondering if they should bring their son in for a stuffy nose with zero other symptoms. Your answer should be "I think it would be best to bring him in, I can't give an accurate diagnosis without a physical examination."
Regarding the patient note:
Ten minutes is NOT A LOT OF TIME to write a history, physical, differential, supporting history and physical for each differential, and a list of diagnostic tests. You need to practice with the time limit to get used to it.
Through various sources I have heard that the differential and supporting history and physical is the most important section. Followed by diagnostic tests, followed by history, followed by physical. So you should try to do them in this order.
THE HISTORY
This section is the ONLY way the examiners know you took a good history. The patient doesn't have a checklist for your history. A physician will basically compare your history to a pre-typed history that was given to the SP... which sucks, because if the SP makes a mistake, it gets translated to your PN... and then you lose points for it. Practice history taking and have someone review your note to make sure you are able to remember everything.
Be sure to do a detailed ROS, PMHx, PSHx, Meds, Allergies, Family Hx, Social Hx, Sexual Hx, OBGYN.
PHYSICAL EXAM
Do this section last. It is the least important. The SPs are healthy, so unless they faked a physical exam finding, you will be basically writing out a standard report of a normal system. So practice those. It should be muscle memory.
Example: Abdomen: Soft, non-tender, non-distended. No visible masses or surgical scars. Bowel sounds normal. No hepatosplenomegaly noted.
There is a warning message at 2 minutes remaining. This is when you should switch to writing the physical exam section. Copy/Paste the vitals or if they were normal write "Vitals WNL". Then start typing out the results of the main system you examined. Then the second system. Include any special tests you did - positive or negative. If you have extra time, make sure you got down everything NOTABLE about the patient. If you have, type out Cardio and Resp results if you managed to quickly listen to the patients heart and lungs. If you finish that, maybe start typing a general description of the patient. Use as much flowery medical terminology in this section as you can. Avoid lay language.
DIFFERENTIALS
These matter. If you consistently get your top differential wrong despite doing well in every other way, I think you would still fail the ICE section. Regardless of how "vague" you feel the cases are, you should have a top choice, and it should be well supported. Shoot for 6-8 supporting history findings. Remember that basic stuff can be included too. For example, if someone comes in with right knee pain after a car accident... "right knee pain" and "history of trauma" would both be credible things to put in your supporting history section. D0n't forget to throw family history and smoking in there if its relevant to the diagnosis.
For supporting physical, its okay if your patient didn't have any positive physical findings. You can leave that section blank. But often times the patients will have some sort of finding if you do your exam properly. For someone with appendicitis for example, be sure to put Rovsing's sign positive, Rebound tenderness positive, Psoas test positive, if you've done those tests and they were positive. NEVER EVER EVER write anything like "non-contributory" anywhere on your note.
Regarding the remainder of your diagnoses... Only put them if you feel you can support them. For the rare case, its okay to have just one differential. For most cases, you would have at least two. For some, you would be able to think of three. The second and third don't need to be as well supported. Put some of the stuff you put for the first one, then add any differentiating factors. You don't need 6-8 supporting history for these. 3-4 would be fine. These don't have to be the same differentials the examinees chose, as long as you supported them and they are reasonable.
How do you get good at forming differentials? Buy First Aid for CS. Do ALL the practice cases and mini-cases. Twice.
DIAGNOSTIC TESTS
Start with the most relevant test for ruling in / ruling out your top differential, and add on from there. I pretty much always put CBC and Electrolytes. First Aid for CS is a good way to familiarize yourself with all of the diagnostic tests you will likely consider ordering during the exam. You may have heard of these tests before during your third year, but you need them in your brain, ready to spit out within less than a minute. So read and practice.
Don't forget that some examinations are diagnostic tests (e.g. pelvic exam, breast exam) on this exam.
Don't forget that they don't like some terms. For example CMP and LFT are big no-nos. Don't use these and give them an excuse to fail you.
I hope this is helpful.
Back in July I learned that I had failed the ICE section of my CS exam. I was bewildered. I had always done well during my school's OSCE examinations and received an average grade in those courses ("B" or roughly 85%).
I was depressed. Seriously. Receiving a fail on a big exam like this can really mess with your confidence level. In addition, the exam results offer ZERO constructive feedback for your attempt. They take your $1200 - $1500 plus travel expenses and tell you "Sorry, some guys in a room somewhere decided you weren't good enough". I requested a score recheck and it took me 6 weeks to receive a poorly written stock response letter basically telling me I shouldn't have requested it. I was disgusted. I seriously full-heartedly believe that the exam is unfair in it's current state and it feels almost criminal to someone who is told they haven't passed.
Anyway, that's not what this post is about. After a few hours wallowing in self-pity and cursing the examiners I picked up the pieces and immediately set into motion the actions needed to schedule a retake. Obtaining another date was extremely difficult. People rarely cancel and you have to be sitting at your computer when it happens. (Protip: Get friends and family to check openings for you).
Searching the internet for advice on what I could have possibly done wrong proved fruitless. There is a real lack of quality posts about people's experiences. A few people did reach out to me via DM and I am thankful for their support.
My goal today is to provide some QUALITY suggestions to people who are having trouble passing the ICE component of this exam.
The ICE component is scored in two ways. The first is a checklist that the SP fills out regarding the physical exam techniques that you performed. The second is by a physician who reviews your patient note.
First a PSA: this is NOT MERELY AN ENGLISH LANGUAGE EXAM. Slap anyone in the face who tells you "Do you speak English? Then you'll pass." This exam tests time management. It tests history taking. It tests critical thinking. It tests knowledge of exam maneuvers. It tests memory. It tests your ability to write a detailed patient note. It tests your ability to come up with a differential and support it. It tests your knowledge of diagnostic tests.
Regarding the physical exam:
Remember the patient is just ticking off a checklist. You don't lose any points for examining something that didn't need to be examined. You just lose time. So don't overthink it. Pick the system (HEENT, Pulmonary, Cardio, Abdomen, MSK, Neurological) that you feel is most relevant to the patient's complaint and do a thorough examination of that system. Always follow the procedure of Inspection, Palpation, Percussion, Auscultation (IPPA) (unless its the abdomen, then its IAPP). Don't skip Percussion! It is likely a box on the SP's checklist. While you are doing the main examination, consider whether or not you want to do a second system. For example, if the patient has pneumonia and mentions a sore throat, you may want to do a pulmonary exam followed by an HEENT exam. If you are running out of time, just do the most relevant parts of that system (i.e. look in their mouth, check for lymphadenopathy).
Practice, Practice, Practice the detailed examinations for each system. Make a list of special exam maneuvers (i.e. Rovsing's sign, Psoas sign, Tinnel's sign etc.) and know them by heart.
ALWAYS REMEMBER TO:
- Wash your hands and/or wear gloves prior to doing the physical exam
- Drape the patient properly. Drape female's chest if you need to expose their chest (they wear bras)
- Pull out the little platform at the end of the bed if you ask the patient to lay down
- Examine the patient from the right side of the bed
- Keep your eyes open (some patients can have make-up on that look like a bruise or something else)
- Tell the patient before you are going to do something (ex. untie their gown, palpate the abdomen)
- Always re-tie the patient's gown
- Listen on bare skin (never auscultate through the patient's gown)
Always err on the side of caution. For example, if you get a phone case and its a dad wondering if they should bring their son in for a stuffy nose with zero other symptoms. Your answer should be "I think it would be best to bring him in, I can't give an accurate diagnosis without a physical examination."
Regarding the patient note:
Ten minutes is NOT A LOT OF TIME to write a history, physical, differential, supporting history and physical for each differential, and a list of diagnostic tests. You need to practice with the time limit to get used to it.
Through various sources I have heard that the differential and supporting history and physical is the most important section. Followed by diagnostic tests, followed by history, followed by physical. So you should try to do them in this order.
THE HISTORY
This section is the ONLY way the examiners know you took a good history. The patient doesn't have a checklist for your history. A physician will basically compare your history to a pre-typed history that was given to the SP... which sucks, because if the SP makes a mistake, it gets translated to your PN... and then you lose points for it. Practice history taking and have someone review your note to make sure you are able to remember everything.
Be sure to do a detailed ROS, PMHx, PSHx, Meds, Allergies, Family Hx, Social Hx, Sexual Hx, OBGYN.
PHYSICAL EXAM
Do this section last. It is the least important. The SPs are healthy, so unless they faked a physical exam finding, you will be basically writing out a standard report of a normal system. So practice those. It should be muscle memory.
Example: Abdomen: Soft, non-tender, non-distended. No visible masses or surgical scars. Bowel sounds normal. No hepatosplenomegaly noted.
There is a warning message at 2 minutes remaining. This is when you should switch to writing the physical exam section. Copy/Paste the vitals or if they were normal write "Vitals WNL". Then start typing out the results of the main system you examined. Then the second system. Include any special tests you did - positive or negative. If you have extra time, make sure you got down everything NOTABLE about the patient. If you have, type out Cardio and Resp results if you managed to quickly listen to the patients heart and lungs. If you finish that, maybe start typing a general description of the patient. Use as much flowery medical terminology in this section as you can. Avoid lay language.
DIFFERENTIALS
These matter. If you consistently get your top differential wrong despite doing well in every other way, I think you would still fail the ICE section. Regardless of how "vague" you feel the cases are, you should have a top choice, and it should be well supported. Shoot for 6-8 supporting history findings. Remember that basic stuff can be included too. For example, if someone comes in with right knee pain after a car accident... "right knee pain" and "history of trauma" would both be credible things to put in your supporting history section. D0n't forget to throw family history and smoking in there if its relevant to the diagnosis.
For supporting physical, its okay if your patient didn't have any positive physical findings. You can leave that section blank. But often times the patients will have some sort of finding if you do your exam properly. For someone with appendicitis for example, be sure to put Rovsing's sign positive, Rebound tenderness positive, Psoas test positive, if you've done those tests and they were positive. NEVER EVER EVER write anything like "non-contributory" anywhere on your note.
Regarding the remainder of your diagnoses... Only put them if you feel you can support them. For the rare case, its okay to have just one differential. For most cases, you would have at least two. For some, you would be able to think of three. The second and third don't need to be as well supported. Put some of the stuff you put for the first one, then add any differentiating factors. You don't need 6-8 supporting history for these. 3-4 would be fine. These don't have to be the same differentials the examinees chose, as long as you supported them and they are reasonable.
How do you get good at forming differentials? Buy First Aid for CS. Do ALL the practice cases and mini-cases. Twice.
DIAGNOSTIC TESTS
Start with the most relevant test for ruling in / ruling out your top differential, and add on from there. I pretty much always put CBC and Electrolytes. First Aid for CS is a good way to familiarize yourself with all of the diagnostic tests you will likely consider ordering during the exam. You may have heard of these tests before during your third year, but you need them in your brain, ready to spit out within less than a minute. So read and practice.
Don't forget that some examinations are diagnostic tests (e.g. pelvic exam, breast exam) on this exam.
Don't forget that they don't like some terms. For example CMP and LFT are big no-nos. Don't use these and give them an excuse to fail you.
I hope this is helpful.
