Step II please help me with this decision!

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ohyeahbaby

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10+ Year Member
I'm a USMD student who is a very weak applicant. I was fortunate enough to get 20+ FM interviews. I failed Step 1 and barely passed it the 2nd time around. I got a decent CK score, and that may have been why I got those interviews.

About a week ago we had our final OSCE (structured in a way that resembles the actual CS exam very closely). My score was in the 3rd percentile compared to my classmates. I never gave two craps about ICM or any of the OSCEs in the last few years of medical school. In fact, I've never really studied for anything ICM related except this weekend because I'm scheduled to take CS in 3 days.

Even though I hauled a$$ this weekend, I'm obviously at a very high risk for failing CS. I'm also a VERY weak applicant who was advised to go to literally every single interview I got. I feel that a failed CS would kill my application. I know it's not required for ranking at any of the programs I'm interviewing at. My school's deadline for taking it is still about 2 months from now. The day I'm scheduled to take CS is the last day of my eligibility period, so I'd have to pay the whole fee again.

If you were in my shoes, would you reschedule CS and just take it a month or so from now when you're positive that you're ready? or would you just take it now? Are there even dates available? (the site won't let me see dates past my eligibility period). Money isn't an issue because my school will increase my financial aid budget for the year to cover that huge expense of reapplying to take CS.

any thoughts you may have in regards to my situation would be VERY much appreciated...
 
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when i checked 2 weeks ago dates were still open feburary onwards. It sounds like you made the decision for yourself. If your not ready, there is no point taking it.

as a side note. I took the test on the 26th. i thought first aid was enough, but that is me saying this w/o knowing my score
 
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Yes, but the OP can't take the exam in Feb as he/she needs if for being ranked (at least in most programs, though failing it now would be worse that not having a score). Someone else needs to chime in about whether no CS would be okay or not for ranking, as I'm not sure how many programs would still rank someone without CS.

What areas are you weakest at? What feedback about your weaknesses did you get from your school? Can you dedicate the next 3 days to reading First Aid for the CS? Can you practice the clinical scenarios in the book with a practice patient? It's a huge gamble here.

Although I did not take CS, I took and passed the DO equivalent of the CS exam, and the First Aid book really helped me with my differential diagnoses.
 
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rkaz said:
Yes, but the OP can't take the exam in Feb as he/she needs if for being ranked (at least in most programs, though failing it now would be worse that not having a score). Someone else needs to chime in about whether no CS would be okay or not for ranking, as I'm not sure how many programs would still rank someone without CS.

What areas are you weakest at? What feedback about your weaknesses did you get from your school? Can you dedicate the next 3 days to reading First Aid for the CS? Can you practice the clinical scenarios in the book with a practice patient? It's a huge gamble here.

Although I did not take CS, I took and passed the DO equivalent of the CS exam, and the First Aid book really helped me with my differential diagnoses.
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well he specifically stated that none of his programs required step 2 cs before the match list. None of the IM programs i interviewed at required CS either.
 
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Oh sorry.... I completely missed that line. Reading posts over my small phone screen in my downtime isn't conducive to the best reading ability. Apologies.
 
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Take it at your scheduled date, but practice, practice, practice with a friend and first aid. The reason I say take it now is so that worse case you do fail, you have a month to retake. If you fail right before the deadline to take CS, won't your school yank you from rotations?
 
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thank you rkaz and helpplease for your responses. Yes, none of my programs require CS for ranking.

Merick, you make a HUGE point. Yes, they yank us from our rotations. You're right, I need to take this now, and see what happens. I'm almost through first aid and will for sure have gone through it at least once by Friday morning.

Again, thanks so much everyone for your thoughts. I really appreciate the input. I still wasn't sure if I was going to take it or not on Friday until I read your replies.
 
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You have less than 2 days left, and so much on the line with all of your interviews lined up. So live and breathe CS for the next 1.5 day without distraction. Make it a definite goal to get through the entire First Aid book. If you feel like slacking off, just remind yourself of how you'd feel with either outcome 8 Weeks or so from now.

And don't forget the easy points by smiling and being friendly with your patients, and draping appropriately.

Best wishes!
 
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ohyeahbaby said:
thank you rkaz and helpplease for your responses. Yes, none of my programs require CS for ranking.

Merick, you make a HUGE point. Yes, they yank us from our rotations. You're right, I need to take this now, and see what happens. I'm almost through first aid and will for sure have gone through it at least once by Friday morning.

Again, thanks so much everyone for your thoughts. I really appreciate the input. I still wasn't sure if I was going to take it or not on Friday until I read your replies.
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You can do this! Whenever I feel like I can't do something I think "dumber people have made it through, so I will too!" 🙂 Treat the people on CS like real patients, have a system, drape properly, listen on skin, if you don't do something/forget something document truthfully and wash your hands. Looking forward to hearing that you passed 8 weeks from now.
 
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MerickManual said:
You can do this! Whenever I feel like I can't do something I think "dumber people have made it through, so I will too!" 🙂 Treat the people on CS like real patients, have a system, drape properly, listen on skin, if you don't do something/forget something document truthfully and wash your hands. Looking forward to hearing that you passed 8 weeks from now.
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thank you so much for the words of encouragement. they gave me today off my rotation to study for CS, so I am going for it. If you have any last minute tips or advice or mnemonics or a simple system that you used which you wouldn't mind sharing, I am open to anything. I have very bad ADD and tend to get along perfectly with patients, but forget to ask the right questions.

Again, thanks so much for the encouragement, and I will for sure let you know how tomorrow goes.
 
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ohyeahbaby said:
thank you so much for the words of encouragement. they gave me today off my rotation to study for CS, so I am going for it. If you have any last minute tips or advice or mnemonics or a simple system that you used which you wouldn't mind sharing, I am open to anything. I have very bad ADD and tend to get along perfectly with patients, but forget to ask the right questions.

Again, thanks so much for the encouragement, and I will for sure let you know how tomorrow goes.
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hey there, just wanted to leave some last minute advice. I was super worried about failing this test, but found out I passed yesterday. My score graphs seemed pretty fair, when I consider my own mistakes. My ICE was mostly to the right, even when I screwed up multiple cases. I wouldn't stress too much about that category, particularly because you got a decent CK score. I think you'll do fine.

My CIS was borderline though, and in retrospect, I think that was fair. Here are things that I didn't do, which you should try to make sure you do tomorrow:

-My closings weren't very good. I stumbled through a lot of them, sometimes because I hadn't come up with a diagnosis and/or a set of diagnostic tests on the spot. I think you should practice this. Go through several cases in your FA book, and practice summarizing a case, presenting 2-3 possible diagnoses, and a set of diagnostic tests. Remember that you're supposed to specifically get permission from the patient when you're going to order sensitive exam maneuvers (i.e. rectal or pelvic exams). I think I forgot to do that on like 2 patients.

-Don't forget to counsel. In fact, I would recommend counseling as soon as you hear them say they are a smoker, drinker, drug user, or unsafe sexer. I forgot to counsel on 3-4 patients probably because I planned to leave it to the closing. But by the end, I was thinking too hard of the diagnosis and the panel of tests I needed to order, that I simply forgot to counsel entirely. It worked much better when I started counseling on the spot.

-I didn't make small talk with the patients. I was a nice guy, shook hands, smiled, made empathetic statements, etc. But I didn't really pretend like the actors were real patients. Who knows if this matters, but it seems that other test takers have had good results with striking up brief conversation while hand-washing or whatever.

-Don't forget the foot-rest. I forgot for the first 2-3 patients.

As for the ICE, like I said, I don't think that should be a huge concern because you can screw up several cases pretty badly (as I did), and still pass comfortably. I would practice typing up some notes on the step 2 CS site. The interface is exactly the same, and you'll get a sense of how you're going to want to format your note. I think a good note can help out quite a bit, even when your exams and/or differentials are lacking.

That's about it I think. Let me know if you have any questions. Wish you all the best tomorrow.
 
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Worried232 said:
hey there, just wanted to leave some last minute advice. I was super worried about failing this test, but found out I passed yesterday. My score graphs seemed pretty fair, when I consider my own mistakes. My ICE was mostly to the right, even when I screwed up multiple cases. I wouldn't stress too much about that category, particularly because you got a decent CK score. I think you'll do fine.

My CIS was borderline though, and in retrospect, I think that was fair. Here are things that I didn't do, which you should try to make sure you do tomorrow:

-My closings weren't very good. I stumbled through a lot of them, sometimes because I hadn't come up with a diagnosis and/or a set of diagnostic tests on the spot. I think you should practice this. Go through several cases in your FA book, and practice summarizing a case, presenting 2-3 possible diagnoses, and a set of diagnostic tests. Remember that you're supposed to specifically get permission from the patient when you're going to order sensitive exam maneuvers (i.e. rectal or pelvic exams). I think I forgot to do that on like 2 patients.

-Don't forget to counsel. In fact, I would recommend counseling as soon as you hear them say they are a smoker, drinker, drug user, or unsafe sexer. I forgot to counsel on 3-4 patients probably because I planned to leave it to the closing. But by the end, I was thinking too hard of the diagnosis and the panel of tests I needed to order, that I simply forgot to counsel entirely. It worked much better when I started counseling on the spot.

-I didn't make small talk with the patients. I was a nice guy, shook hands, smiled, made empathetic statements, etc. But I didn't really pretend like the actors were real patients. Who knows if this matters, but it seems that other test takers have had good results with striking up brief conversation while hand-washing or whatever.

-Don't forget the foot-rest. I forgot for the first 2-3 patients.

As for the ICE, like I said, I don't think that should be a huge concern because you can screw up several cases pretty badly (as I did), and still pass comfortably. I would practice typing up some notes on the step 2 CS site. The interface is exactly the same, and you'll get a sense of how you're going to want to format your note. I think a good note can help out quite a bit, even when your exams and/or differentials are lacking.

That's about it I think. Let me know if you have any questions. Wish you all the best tomorrow.
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thank you so much for the detailed advice. It definitely makes me feel better. If you don't mind, I just had a few questions:

1- When I write down my differentials, I tend to end up writing the same exact history findings and physical exam findings for all 3 diagnoses (for most cases). Did you find yourself doing the same thing by any chance?

2- I did well on CK, but here's my problem: I totally suck when it comes to physical exams. As in, I don't know when to do each physical exam, particularly with musculoskeletal. I remember during our school's OSCE, this 40 yr old dude presented with joint pain after playing basketball. I didn't know whether to do the ant/post drawer test, check his reflexes, ask him to walk around the room to see his gait, etc... I was going to youtube a few videos and use my school's website to find some videos of physical exams today. So I guess my question is this: if you really suck when it comes to doing physical exams and deciding when to do them, are there specific ones you would want to focus on before the test?

3- Are there certain physical exams that I can just go ahead and do in every single patient encounter? I know we listen to heart/lungs no matter what. Anything else we do no matter what when it comes to physical exams?

4- When you say you screwed up a few cases badly, how bad are we talking about? I only ask this because people come here to this website and complain about the most ******ed "screw ups", and I was just wondering if I can compare my potential screw ups to yours.

Again, I REALLY appreciate you taking the time to write down your thoughts.
 
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ohyeahbaby said:
thank you so much for the detailed advice. It definitely makes me feel better. If you don't mind, I just had a few questions:

1- When I write down my differentials, I tend to end up writing the same exact history findings and physical exam findings for all 3 diagnoses (for most cases). Did you find yourself doing the same thing by any chance?
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Yeah, that happens. I definitely used a lot of repeats when justifying my differentials. That being said, don't be afraid to get creative with the history and physical exam findings you list. For example, if a young person comes in with chest pain, you can justify pericarditis with things like "young age" and "absence of family history of premature coronary artery disease".

2- I did well on CK, but here's my problem: I totally suck when it comes to physical exams. As in, I don't know when to do each physical exam, particularly with musculoskeletal. I remember during our school's OSCE, this 40 yr old dude presented with joint pain after playing basketball. I didn't know whether to do the ant/post drawer test, check his reflexes, ask him to walk around the room to see his gait, etc... I was going to youtube a few videos and use my school's website to find some videos of physical exams today. So I guess my question is this: if you really suck when it comes to doing physical exams and deciding when to do them, are there specific ones you would want to focus on before the test?
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I'm not great at physical exams either, to be honest. But apparently mine were good enough. I did spend time watching youtube vids of particular maneuvers though, so I think that's a good idea. I would plan out right now what exams you're going to do for knee pain, ankle pain, shoulder pain, arm pain, and back pain. Remember for joint pain you're going to test reflexes, range of motion, sensation, strength, plus any special exams. The drawer tests, for example, are useful for knee pain, but I had a patient with knee pain and I didn't do any special exam maneuvers (which was stupid), and it turned out to not be a big deal. Remember to inspect the joints above and below the joint of interest too. Also if a person complains of right extremity pain, remember to compare range of motion, reflexes, palpation, strength, sensation on the left side too (I forgot to do this on one patient).

3- Are there certain physical exams that I can just go ahead and do in every single patient encounter? I know we listen to heart/lungs no matter what. Anything else we do no matter what when it comes to physical exams?
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I'm not sure about this. It seems like other test takers are reporting that they did fine without listening to heart/lungs on every patient. I personally listened to heart/lungs for each patient, even when it felt ridiculous, because I didn't know what else to do. If you have more important things to do (like a comprehensive neuro exam), I wouldn't worry about it, but I can't speak from personal experience on this.

4- When you say you screwed up a few cases badly, how bad are we talking about? I only ask this because people come here to this website and complain about the most ******ed "screw ups", and I was just wondering if I can compare my potential screw ups to yours.

Again, I REALLY appreciate you taking the time to write down your thoughts.
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I don't really remember everything I did wrong at this point, but I did do plenty of things wrong, believe me. I flat out did not know the diagnosis on at least 2 cases, and my differentials were very sparsely supported as a result. On an additional 2-3 cases, I was unsure of my diagnosis, and when I went to write my differential I realized I had forgotten to ask a bunch of important questions. I usually had 3 diagnoses listed, but on several cases I could only come up with 2. I ran out of time in the middle of a neuro exam (in a case where a neuro exam was super important). As I mentioned above, I forgot to do certain special exam maneuvers. There were a lot of other things, I just can't think of them right now, so don't worry too much about it. Overall, I was less concerned about failing ICE than I was about CIS, because the actors won't really let you know if they are happy or disappointed with you.

I think people worry too much about ICE if they don't get the right diagnosis or whatever, but that's not really that big of a deal. There's so many other ways to get points (such as doing the physical and including relevant elements in your note) that even if your diagnoses are off, you will still be okay. If anything, I would be thinking about how you are going to lock down points in CIS (with particular emphasis on good closures and counseling, as well as all the other easy things you already know to do like shaking hands, washing hands, draping, footrest, asking to untie gown, tying gown back up for the patient, smiling, asking if patient has any questions, expressing empathy, etc.).
 
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Worried232 said:
Yeah, that happens. I definitely used a lot of repeats when justifying my differentials. That being said, don't be afraid to get creative with the history and physical exam findings you list. For example, if a young person comes in with chest pain, you can justify pericarditis with things like "young age" and "absence of family history of premature coronary artery disease".



I'm not great at physical exams either, to be honest. But apparently mine were good enough. I did spend time watching youtube vids of particular maneuvers though, so I think that's a good idea. I would plan out right now what exams you're going to do for knee pain, ankle pain, shoulder pain, arm pain, and back pain. Remember for joint pain you're going to test reflexes, range of motion, sensation, strength, plus any special exams. The drawer tests, for example, are useful for knee pain, but I had a patient with knee pain and I didn't do any special exam maneuvers (which was stupid), and it turned out to not be a big deal. Remember to inspect the joints above and below the joint of interest too. Also if a person complains of right extremity pain, remember to compare range of motion, reflexes, palpation, strength, sensation on the left side too (I forgot to do this on one patient).



I'm not sure about this. It seems like other test takers are reporting that they did fine without listening to heart/lungs on every patient. I personally listened to heart/lungs for each patient, even when it felt ridiculous, because I didn't know what else to do. If you have more important things to do (like a comprehensive neuro exam), I wouldn't worry about it, but I can't speak from personal experience on this.



I don't really remember everything I did wrong at this point, but I did do plenty of things wrong, believe me. I flat out did not know the diagnosis on at least 2 cases, and my differentials were very sparsely supported as a result. On an additional 2-3 cases, I was unsure of my diagnosis, and when I went to write my differential I realized I had forgotten to ask a bunch of important questions. I usually had 3 diagnoses listed, but on several cases I could only come up with 2. I ran out of time in the middle of a neuro exam (in a case where a neuro exam was super important). As I mentioned above, I forgot to do certain special exam maneuvers. There were a lot of other things, I just can't think of them right now, so don't worry too much about it. Overall, I was less concerned about failing ICE than I was about CIS, because the actors won't really let you know if they are happy or disappointed with you.

I think people worry too much about ICE if they don't get the right diagnosis or whatever, but that's not really that big of a deal. There's so many other ways to get points (such as doing the physical and including relevant elements in your note) that even if your diagnoses are off, you will still be okay. If anything, I would be thinking about how you are going to lock down points in CIS (with particular emphasis on good closures and counseling, as well as all the other easy things you already know to do like shaking hands, washing hands, draping, footrest, asking to untie gown, tying gown back up for the patient, smiling, asking if patient has any questions, expressing empathy, etc.).
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thanks again for all your advice. Extremely helpful. Will definitely let you know how this thing goes tomorrow! 🙂
 
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Worried232 said:
I would be thinking about how you are going to lock down points in CIS (with particular emphasis on good closures and counseling, as well as all the other easy things you already know to do like shaking hands, washing hands, draping, footrest, asking to untie gown, tying gown back up for the patient, smiling, asking if patient has any questions, expressing empathy, etc.).
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that's literally the only thing I did that day

i thought it went pretty horrible. In fact, I thought it went so horrible that if by some act of God I actually do pass this dog and pony show, there is something VERY wrong with the system. Timing was the biggest issue here. I had a patient with lower back pain, wrote the perfect note, asked the perfect questions, came up with the perfect ddx's, and while I was writing the physical exam findings, I realized I didn't even look at his back!!!

Then came the dude clutching his head in agony. I called it a migraine without even asking him which side of his head hurts or if it was both sides. Yup, no neuro exam. Though I got a good famhx, with a lot of his family having been dxed w/ migraines.

Abdominal pain pt: same deal. perfect questions, perfect everything. Then as I'm writing my physical exam findings, I realized I didn't even touch the dam abdomen.

I was too busy getting famhx, soc hx, etc... asking/counseling on prevention (e.g. colonoscopy, pap smears, etc), asking if they have any other questions, washing my hands, etc...the physical exams did s.hit for me. I did heart and lungs for everyone.

I think I was surprised by two things: how ridiculously easy the cases were, and how ******ed I was.

I'm expecting to redo this thing. The only thing I will be practicing on is timing. It's not rocket science. You can usually make the dx in the first 30 seconds. It's the rest of this thing that wasted my time, like answering their ******ed questions, or keeping them on track and asking them politely to shut the f.uck up so I can get through my list of qu's, etc...

i introduced myself as a 4th year medical student in each encounter. So if they hold that against you, I for sure failed.

the only good part of that day was at the end in the elevator listening to everyone b.itch about how bad their day went. So I started to think that I couldn't have been the only one. But then again, their complaints were the same old ******ed a.ss SDN complaints.
 
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I don't think you necessarily failed if you messed up some physical exams. There seems to be a lot of misunderstanding of how the grading works on this. Even if you bomb the PE portion, you should still be able to pass if you did well on the other aspects of ICE. PE is just one part of that. Now granted, it may be difficult to support some of your differentials without the right physical exams being done. But it sounds like you did a pretty thorough job on the rest of the ICE stuff which should be able to make up for missing some PE.

Furthermore, you listed three examples of where you forget to do important PE maneuvers. Are those just three examples of where that happened or are those the only times? If you flubbed the physicals on three patients, that's definitely not an automatic fail. That's only 3/12 patients, and for all you know some of those could be experimental patients anyway.

One thing I'll add is I noticed you said you did heart/lungs on everyone. This is kind of a general thing but it really irks me to see that when you also mention that you forgot to do the relevant exams. I really wish the idea that you MUST do heart/lung exams on everyone would go away. I mean, for all I know I may have missed points for not doing it, my ICE score was far from perfect. But I did pass and I only did heart/lungs when it was relevant to my differential. Your issue shows why it's a bad idea to put so much focus on doing those exams on everyone - you waste time that you could have used doing more relevant exams. If a patient has abdominal pain or a headache, is it likely that you'd be using heart/lung findings to support your differentials at all? Probably not, but you certainly could use abdomen and neuro exams in those cases. You may or may not miss some points for not doing CV/Resp exams, but you absolutely will lose points for not doing a neuro exam on a headache patient. And those points will be lost in both the PE section as well as the differential section. So it's obvious to see where your money is at, if you have to choose.

When I was taking the test, I focused on doing the relevant exams and then I planned to also do heart/lungs if I felt like I had the time to do those, which I never felt I did, so I didn't do them. And I did fine.

Not trying to pick on you or anything but for everyone preparing to take this test - focus on what's relevant!!! If you have time to be thorough great but when you're in the heat of the moment the time tends to tick away pretty fast, better to focus your efforts on the things that make a difference in your note rather than spending precious time forcing these really long mnemonics and things like that into every patient encounter.
 
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MerickManual said:
For some reason this thread popped into my mind today while wasting time on SDN. Any news on how you did?
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thanks for asking! 🙂

unfortunately, i'm still shi tting my pants here... according to their website, the scores will start coming out on wednesday. I've been a nervous wreck. I haven't been able to focus on anything else.

And it kills me knowing that if I did fail, the score will come out before the programs submit their final ranks.

will for sure keep you posted though 🙂
 
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I know the feel man. My results come out wednesday too. I think i did fine, but the more time that has elapsed the more worried i get. I didnt feel this way for any of my steps. sigh.
 
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HelpPleaseMD said:
I know the feel man. My results come out wednesday too. I think i did fine, but the more time that has elapsed the more worried i get. I didnt feel this way for any of my steps. sigh.
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i feel you dude... i have never had a test mess with my head the way this s.hit has. There isn't actually a single test I've ever taken in my life that has bothered me so much.
 
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Good luck to us all tomorrow. My permit link is gone, but I honestly dont know what that even means. im gonna neurotically check my email tomorrow near 11 am eastern O_O
 
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holy s.hit! I passed!!!! (and actually did really well)

goes to show you how f.ucked up the system is.

After this experience, I've lost faith in the system. As happy as I am to have passed, I didn't deserve to pass. This exam has hands down been the shadiest experience I've ever had. Zero transparency, crazy fees, and downright degrading to our evidence-based medical system.

I just hope that I never have to be part of something as sketchy as this. I honestly feel dirty just for being part of it. The FSMB and the NBME should be ashamed of themselves for degrading our profession like this.
 
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ohyeahbaby said:
holy s.hit! I passed!!!! (and actually did really well)

goes to show you how f.ucked up the system is.

After this experience, I've lost faith in the system. As happy as I am to have passed, I didn't deserve to pass. This exam has hands down been the shadiest experience I've ever had. Zero transparency, crazy fees, and downright degrading to our evidence-based medical system.

I just hope that I never have to be part of something as sketchy as this. I honestly feel dirty just for being part of it. The FSMB and the NBME should be ashamed of themselves for degrading our profession like this.
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be happy ! and you did deserve to pass. we are often our hardest critics.
 
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i've been looking at this thread as i saw it discussed mnemonics. i'll be taking my CS in late March and haven't been using the mnemonics b/c they were tripping me up as i am practicing and keep looking down at paper. is it necessary to even use them the day of test? i would think the peds one would come in handy, but the adult hpi and ros ones i just cant get into using as i practice the cases from FA and kaplan.
 
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