Step 2 CS, Fear, and You

[sacrament]

So I found out that I passed today, 6.5 weeks after I took the exam. Here's the thing about Step 2 CS. You go into it knowing that you have a 97% chance of passing, yet you constantly hear anecdotes (some personal, some second-hand) about good students who, to their utter shock, fail the goddamn thing. At my school, 5 people in the class ahead of me failed it and at least a couple were totally solid--people you'd never expect to fail a clinical skills exam. So you go into it knowing that you have a 97% chance of passing, yet as the days and weeks roll on, that starts to feel more like 50%, and then more like 10%, and then finally you're totally convinced that you must have failed, and that your upcoming interviews at top-tier programs are all for naught once you get that big fat FAIL in the mail. At least, that was my experience.

Step 2 CS is a pile of sh1t. I'm still furious about the m-f-ing thing even after I passed it. And it's only going to get worse for the classes to come... think about it. The major stumbling block right now is that nobody knows how the f-ing thing is graded. Sure, there are some educated guesses and some of it is common sense, and yet there is still some mystery surrounding it since, after all, people are still failing. However, as time goes on, the mass of anecdotal evidence is going to uncover the grading scheme... people who failed will compare notes and figure out what all those f-ing checkboxes are. Word will spread, and an algorithm will be devised that ensures a perfect score. But the NBME can't have that! If everybody passes it, doesn't that sort of invalidate the whole purpose of having a "weeding out" exam like this? If nobody gets weeded out? So what will they do? They'll ratchet it down in order to generate more failing scores. The cut-off for passing will get higher and higher. The cases will get trickier. Instead of being a worthless, expensive pile of sh1t test, it'll become a worthless, expensive, unfair and picky pile of sh1t test. This m-f-er has to be stopped. When our generation comes into positions of authority in the medical world, we must remember what a nightmare this f-er is and shout it down. Step 2 CS must die.

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[chicamedica]

So I found out that I passed today, 6.5 weeks after I took the exam. Here's the thing about Step 2 CS. You go into it knowing that you have a 97% chance of passing, yet you constantly hear anecdotes (some personal, some second-hand) about good students who, to their utter shock, fail the goddamn thing. At my school, 5 people in the class ahead of me failed it and at least a couple were totally solid--people you'd never expect to fail a clinical skills exam. So you go into it knowing that you have a 97% chance of passing, yet as the days and weeks roll on, that starts to feel more like 50%, and then more like 10%, and then finally you're totally convinced that you must have failed, and that your upcoming interviews at top-tier programs are all for naught once you get that big fat FAIL in the mail. At least, that was my experience.

Step 2 CS is a pile of sh1t. I'm still furious about the m-f-ing thing even after I passed it. And it's only going to get worse for the classes to come... think about it. The major stumbling block right now is that nobody knows how the f-ing thing is graded. Sure, there are some educated guesses and some of it is common sense, and yet there is still some mystery surrounding it since, after all, people are still failing. However, as time goes on, the mass of anecdotal evidence is going to uncover the grading scheme... people who failed will compare notes and figure out what all those f-ing checkboxes are. Word will spread, and an algorithm will be devised that ensures a perfect score. But the NBME can't have that! If everybody passes it, doesn't that sort of invalidate the whole purpose of having a "weeding out" exam like this? If nobody gets weeded out? So what will they do? They'll ratchet it down in order to generate more failing scores. The cut-off for passing will get higher and higher. The cases will get trickier. Instead of being a worthless, expensive pile of sh1t test, it'll become a worthless, expensive, unfair and picky pile of sh1t test. This m-f-er has to be stopped. When our generation comes into positions of authority in the medical world, we must remember what a nightmare this f-er is and shout it down. Step 2 CS must die.

Totally agree. I have yet to take it, and i'm really annoyed by the whole thing (ever since it was first introduced). My school has a much more thorough exam, that we take for free (or is at least included in our tuition). The only reason I see for this step 2 CS is for the NBME to make a profit. That's it. It used to be only for ECFMG students. It should stay that way. That's the point of step 2 CS anyway--to weed out the poor english speakers. Anyone from a US medical school is going to have decent clinical skills, and at least get tested by an OSCE by their own schools, so this is NOT about improving clinical skills education, imo. I am currently in debt because of it, and I have yet to pay for a hotel to stay at the night before the test.

 

[cyanocobalamin]

We have routine csa exams throughout medschool, the worrisome thing is that I believe no one has ever failed cs from my school, so it would be embarassing to fail it. Opening the envelope, I assumed it would be a 'P' and it was.

Supposedly the exam is supposed to catch the lowest common denominator with regard to clinical skills proficiency (ie there is a large margin for even marginal candidates), so you can be pretty deficient in the area of cs, and still pass.

 

[sacrament]

We have routine csa exams throughout medschool, the worrisome thing is that I believe no one has ever failed cs from my school, so it would be embarassing to fail it. Opening the envelope, I assumed it would be a 'P' and it was.

Supposedly the exam is supposed to catch the lowest common denominator with regard to clinical skills proficiency (ie there is a large margin for even marginal candidates), so you can be pretty deficient in the area of cs, and still pass.

Supposedly, yes, except some of the people failing are not marginal candidates. My guess is that most of the people who fail did not take the exam seriously, and rolled in there with an attitude. I rolled in with an attitute too, but I think I hid it well.

 

[neilc]

i took it last week, and am currently going through some of those emotions...i can remember forgetting a lot of stupid things (ie no fundoscopic on any pt with h/o htn, completely blew my history on a 46y/o w/amenorhea, etc....) and i am completely convinced that i blew it and will be booted from the match (IMG's get that if they don't pass by rank order day) and have wasted all this damn money on the test, applications and interviews.

anybody have some zantac for me?

 

[cyanocobalamin]

Supposedly, yes, except some of the people failing are not marginal candidates. My guess is that most of the people who fail did not take the exam seriously, and rolled in there with an attitude. I rolled in with an attitute too, but I think I hid it well.

They may not be marginal candidates overall, but they are marginal candidates with regard to clinical skills, or at least as measured by the CSA of step 2. Otherwise they should have passed.

I did not study for the exam because I felt school had prepared me well enough for it.

 

[ear-ache]

Our Dean of Students informed us that it is not uncommon for good students, from good programs, to fail step 2 cs. He stated that this problem was recently echoed at a recent national conference consisting of Deans of Students from programs across the country. Medical Schools are frustrated because neither the student (or the school) gets any feedback as to what the student's deficiencies are. Additionally these failed students have done well with standardized patients tests and on their ward evaluations. Random....

PS - I'm anxiously awaiting my Step 2cs score from 9/16.

 

[Smurfette]

i took it last week, and am currently going through some of those emotions...i can remember forgetting a lot of stupid things (ie no fundoscopic on any pt with h/o htn, completely blew my history on a 46y/o w/amenorhea, etc....) and i am completely convinced that i blew it and will be booted from the match (IMG's get that if they don't pass by rank order day) and have wasted all this damn money on the test, applications and interviews.

anybody have some zantac for me?

I did no fundoscopic exams on anyone, and I passed. Frankly, you can forget a whole host of physical exam components and still pass. This test is about communication skills and speaking english. Everyone has completely different DDx's for all the patients, and (almost) everyone still passes....even if you miss an obvious thing on the differential. Depending what questions you ask, you may get a quite different history from a patient than someone else. And you know what? It doesn't matter. Really. It's not worth worrying about....what's done is done, just wait for the piece of paper that says "pass" to come.

 

[neilc]

I did no fundoscopic exams on anyone, and I passed. Frankly, you can forget a whole host of physical exam components and still pass. This test is about communication skills and speaking english. Everyone has completely different DDx's for all the patients, and (almost) everyone still passes....even if you miss an obvious thing on the differential. Depending what questions you ask, you may get a quite different history from a patient than someone else. And you know what? It doesn't matter. Really. It's not worth worrying about....what's done is done, just wait for the piece of paper that says "pass" to come.

yeah, i can't really worry now. i gotta do my interviews and get a match. if i fail, i fail, nothing to be done. so, screw it, i am gonna go get drunk. whee!

thanks for the words of encouragement, though. it is nice to hear stories like this. i talked to my classmates that have taken it and passed, and they had a lot of stories about things they forgot to do....still, cross your fingers for me!

 

[sacrament]

The problem is that because absolutely no feedback is given to those of us who pass, and because most people do pass, it's natural to assume that the test is ridiculously easy and that only people with truly horrendous clinical skills will fail it. So it's very easy for somebody who passed the test, and who doesn't know of anybody who failed it, to say "Don't worry! Just show up and don't spit in the patient's mouth and you'll pass!" Those of us who are acutely aware of people who were shocked to fail are less comforted by this advice. At my school we have a serious of relatively rigorous clinical exams, three during the first year, three during the second year, and two long and involved ones during the third year. People fail these, they are tough. Much tougher, in my opinion, than the light-weight CS. But of the small number of people at my school who failed Step 2 CS, none of them failed our school's own exams. Despite the odds being drastically in your favor, this is worrisome because it almost seems that that's all it comes down to: odds. There doesn't seem to be much you can do to ensure you'll be in that passing crowd. That is, if you're worried about failing you can't just study more and feel better. You just pay a thousand bucks and roll the dice.

Another notion I've had: apparently there are schools where absolutely nobody fails, schools where a sizable number fail, and only a few schools like mine where just a handful fail. Why is this? I find it difficult to believe that there are accredited medical schools in the United States which are preparing students so poorly that they're doomed to fail goofball tests like the CS. I have to wonder if it is because of idiosyncratic regional differences in the perception of good "clinical skills." One example. From many sources there is a strong recommendation that you constantly chatter during the physical exam, asking permission to perform each maneuver and giving feedback on each as you go. To me, this is bizarre. I've never seen a clinician do this, I've never done this (except during the test) and I've never experienced it as a patient. This is an east coast thing? I have no idea. But I almost have to wonder if there are a number of checkboxes for behaviors that are foreign to the experience of medical students from particular regions. Because nobody should fail this, not even only 3%.

 

[bigfrank]

I didn't pour that much energy (either way) into the exam. Just view it as another hurdle and don't let it stress you out.

Congrats on passing.

 

[sacrament]

I didn't pour that much energy (either way) into the exam. Just view it as another hurdle and don't let it stress you out.

Awhile back, you said this:

First off, don't let people deter you from studying with idiotic comments like, "all you need to do is pass your third year and you're golden." This is a fallacy. While you probably would pass even if you didn't study at all, is this a risk you're willing to take?

I know it seems I'm obsessing over this, especially since it's over for me. But this is my point: people who have put it behind them suddenly find the exam to be a total non-issue. Well taking the exam is an issue, if only because it's expensive, and I don't think any of us should forget that. If the only people who cry out against this test are medical students, who the hell is going to listen? I'm taking a "remember the Alamo" stance on this. But I know that people with pet issues get irritating, so I suppose for now I'll get off my Step 2 CS soapbox and get back to concentrating on cable television.

 

[EctopicFetus]

I know someone who strongly opposed the implementation of this exam. Word was that the NBME poured in millions to show the vaildity of this test. Of course they couldnt as this test is extremely subjective with what supposedly was very poor interrater reliability (which is a little surprising to me). Then they pushed this thing through without the student rep(s) on the committee being present. It seems like they are just trying to get their money back. Whatever, I have had to do so many ******ed things to get to this point. I sort of agree with frank.. This is just another stupid ass hurdle that I will have to overcome. I mean the stupidity of the medical education is just ongoing. Thank god the majority of my clinical rotations have been incredibly education even if the grading of them was/is questionable (getting an A in a class I had no business getting an A in and then getting Bs where I truly should have earned an A). Onward and upward people! Graduation is only months away! Good luck!

 

[TommyGunn04]

I have yet to take it...My school has a much more thorough exam, that we take for free (or is at least included in our tuition). The only reason I see for this step 2 CS is for the NBME to make a profit. That's it. It used to be only for ECFMG students. It should stay that way. That's the point of step 2 CS anyway--to weed out the poor english speakers. Anyone from a US medical school is going to have decent clinical skills, and at least get tested by an OSCE by their own schools, so this is NOT about improving clinical skills education, imo. I am currently in debt because of it, and I have yet to pay for a hotel to stay at the night before the test.

I'd like to play devil's advocate here for a bit, because I see some valid reasons for a CS-type exam. I don't mean to pick on you chicamedica, but your arguments are ones that are commonly voiced against CS, so I'd like to briefly examine their relevance and validity, and suggest that perhaps they don't hold a much water as many of us presume.

1. You suggest that your school's clinical skills exam is superior. If you haven't yet taken step 2 CS, how do you know that your school's exam is "more thorough." Also, on what basis is this "thoroughness" measured? Given that no one seems to know with certainty exactly what CS is measuring, how can we make such comparisons in a meaningful/useful/valid way? Furthermore, given that a growing empirical literature suggests that physicians are actually rather poor communicators, one might think a CS-type exam a worthwhile endeavor.

2. You allege that the exam is a moneymaking scheme, but is there any data to suggest that it is actually a profitable endeavor for the NBME? There very well may be, but I haven't seen it myself, and would like to see such evidence. Having taken the exam, I can see how it would be a rather costly endeavor requiring a substantial infrastructure to operate. It seems more like a headache than anything for the NBME.

3. You assert that the point of CS is to "weed out poor English speakers" (or that it used to be when it was an IMG-only test). Since the exam evaluation has 3 main components, only one of which is spoken English proficiency, I would think the NBME also views it as having at least two other main points. (this is based on the 3 categories listed on my score report) Clearly there are other purposes of this exam.

4. You suggest that the cost is prohibitive. While I too was upset at the extra financial burden imposed by this exam, the cost itself is hardly a legitimate argument against requiring it, especially given the enormity of debt amassed by most medical students. In the grand scheme of things, an extra $1,500 isn't much when the average debt even among public medical school students is, if I recall correctly, >$80,000. Indeed, 4th year students probably spend that much on just a couple of interviews given travel costs these days. Furthermore, if CS is indeed a valuable exercise in ensuring adequate training of future physicians, the $975 cost doesn't hold much weight as an argument against it. Rather, whether or not it should be required should depend on its utility in medical education, not on its cost.

Like I said, I'm just playing devil's advocate here. I'm still not sure what to think of the exam myself, but I can definitely see some value in it, given the countless poor interactions I've already witnessed between patients and their physicians. Please don't take offense; my only intention here is for this post to generate some meaningful discussion rather than the usual complaining and speculation about CS.

 

[neilc]

i am fully in support of a CS type exam, and have been for a while. i look at it like i do step 1 and CK...i mean, our schools teach us basic and clinical science and give us exams in these topics, yet the NBME still insists that we verify our competence in these subjects through a standardized, national exam. they certainly can and should do the same with clinical skills.

however, after taking the test, i see lots of problems. the main one being that nobody knows exactly what the CS is looking for. step 1 and step 2 CK have some pretty clear topic lists that can be tested. you know if you master those topics, you will pass. as sacrament mentioned above, at least you can generate some comfort level via studying more on weak subjects. the CS offers no such guidelines, and nobody knows what the heck we are being tested on, outside of the rather vague classifications of spoken english, communication skills and data gathering.

so, tommygun, while i can go along with your devils advocate position, i don't think that any of the four points you made are the reasons the CS is crap. simply, the NBME should have done a far better job then this. give us a test, charge us a ridiculous amount, whatever. but, at least let us know what we need to do, how we will be evaluated and take the subjectivity out of the exam.

 

[CANES2006]

Took Step 2 CS on Saturday, and thought it was complete crap and just a money making scheme as well.

 

[dominofx]

i personally agree that US students should have to take the CS exam though i am a foreign student..i took it 4 weeks ago and im stull awaiting my result..i had a hard bastard..4 freaking neuro cases..drove me insane..but i figured that all the mistakes i made, have to be common..i mean come on..how much physical exam can you do in 5 minutes..especially if its a CNS case and they have other symptoms such as abdominal..the only thing that scares me is the written part..i have a friend who is an american med student and he failed the written part!!! makes no sense and till this day he has no clue why..he was fine on PE and communication which is apparently the majority...thing is..you HAVE to pass all parts..in order to pass..so if you pass english prof., communication, and PE..you can still fail the written part..which is the only dumb thing im afraid of because i barely looked at it..man..my advise to those who havent taken it..if you have no idea..look to your left at the abbreviations list and try to apply whatever is necessary..good luck

 

[TommyGunn04]

Took Step 2 CS on Saturday, and thought it was complete crap and just a money making scheme as well.

This type of statement solidifies my point. Sure, many of us make similar claims, but is there really any evidence supporting these assertions? One could also say that step 1 is a complete load of crap, that it's all about making money for the NBME, and that board scores don't correlate with one's doctoring skills or prowess as a physician. But on what basis would such an assertion be made? We're certainly not the experts, as we're the ones being evaluated. Regardless of how students feel about the test, it may actually have some value. That's what we should really be arguing about, not our emotional reactions to it.

I just don't see the value of calling this test "complete crap" and a "money making scheme," aside from the fact that it makes us feel good after shelling out over $1,000 to take it. It's a nice way to blow off some steam, but doing so is the intellectual equivalent of calling little Bobby a "doo-doo head" on the playground.

 

[TommyGunn04]

so, tommygun, while i can go along with your devils advocate position, i don't think that any of the four points you made are the reasons the CS is crap. simply, the NBME should have done a far better job then this. give us a test, charge us a ridiculous amount, whatever. but, at least let us know what we need to do, how we will be evaluated and take the subjectivity out of the exam.

I agree that there needs to be heightened awareness as to what CS is actually testing, WHY the NBME feels it's necessary to test it, and how the test is actually graded. As far as them charging a "ridiculous amount," we really can't know how "ridiculous" it is until we know how much it actually costs them to rent/build the centers, pay the actors, pay the physician graders (who surely don't come cheap!), etc. It's clear that the money argument doesn't hold water, logically.

But I venture that much of students' anger about this exam is due to the newness of the exam, and due to the fact that the loudly voiced concerns of groups like AMSA were seemingly ignored by the NBME. Simply put, CS is something new that wasn't required of our predecessors, and this upsets many of us. Why should we have to take this new test, especially when we don't understand its purpose or its methods? Well, here's the NBME's reason, straight from their website (http://www.usmle.org/bulletin/2006/overview.htm):

"A clinical skills examination was part of the original design of USMLE. The NBME was charged with including a test of clinical skills using standardized patients when such an examination was shown to be valid, reliable, and practical. NBME research and the work of other organizations administering clinical skills examinations demonstrate that clinical skills examinations measure skill sets different from those measured by traditional multiple-choice questions. Mastery of clinical and communication skills, as well as cognitive skills, by individuals seeking medical licensure is important to the protection of the public. "

It also says, "Step 2 assesses whether you can apply medical knowledge, skills, and understanding of clinical science essential for the provision of patient care under supervision and includes emphasis on health promotion and disease prevention. Step 2 ensures that due attention is devoted to principles of clinical sciences and basic patient-centered skills that provide the foundation for the safe and competent practice of medicine."

This sounds pretty clear to me. I'm not saying that the current implementation is perfect, but such things are rarely without problems. What do people think of these reasons?

 

[CANES2006]

This type of statement solidifies my point. Sure, many of us make similar claims, but is there really any evidence supporting these assertions? One could also say that step 1 is a complete load of crap, that it's all about making money for the NBME, and that board scores don't correlate with one's doctoring skills or prowess as a physician. But on what basis would such an assertion be made? We're certainly not the experts, as we're the ones being evaluated. Regardless of how students feel about the test, it may actually have some value. That's what we should really be arguing about, not our emotional reactions to it.

I just don't see the value of calling this test "complete crap" and a "money making scheme," aside from the fact that it makes us feel good after shelling out over $1,000 to take it. It's a nice way to blow off some steam, but doing so is the intellectual equivalent of calling little Bobby a "doo-doo head" on the playground.

Dude, are you for real? Your condescending attitude is too much. Maybe if you remove your lips from the USMLE Step 2CS inventors' a$$ for two seconds you might be able to grasp the reality that everyone else on this board and the medical profession as a whole sees so clearly: USMLE Step 2CS is just a money making scheme!

 

[neilc]

Dude, are you for real? Your condescending attitude is too much. Maybe if you remove your lips from the USMLE Step 2CS inventors' a$$ for two seconds you might be able to grasp the reality that everyone else on this board and the medical profession as a whole sees so clearly: USMLE Step 2CS is just a money making scheme!

uhhh...i don't think it is a money making scheme. and, i have yet to hear the "rest of the medical profession" state anything like that.

the test is ridiculously expensive (my definition of ridiculous is ANYTHING that approaches $1000, tommygun. it is an absolute measure ) but, i think that most of the medical profession thinks that such a test is appropriate. the problem seems to lie in how the test is administered and evaluated. that is where the vast majority of the complaints i hear seem to originate. of couse we complain about the cost. it is a lot of money. but, so are the other steps, and nobody claims those are money making schemes, right? and, i think a computer based test has a much lower cost basis than an exam that requires so many people to be trained and present for the entire exam. really, i think the computer based tests have less justification for the cost.....maybe those are the money making schemes!

tommygun, those definitions are fine. but, that is a really, really subjective set of evaluation criteria. compare that to the step 1 and step 2 CK. they provide a very detailed list of the exact topics that are potentially tested. i think a far more fair method would be to have a series of rooms, and inside have a medical professional to evaluate us. have a dummy to examine, a series of heart sounds to listen to, a patient to evaluate, a finding to elicit, write a note, whatever. then, grade us on that and move us on. instead we have some patient trying to remember everything we do, we wonder how much leeway they have in interpreting our physical findings and the questions we ask. we don't know what is considered important or essential. in short, it is simply too subjective and undefined.

my biggest worries are that a patient will not mark the check box for a history question if i did not use some exact key phrase they are looking for. or that they will have forgoten that i actually did this exam, or mentioned they should quit smoking. there just seems to be too much leeway for the patient to screw us by simply forgetting something. and what recourse do we have for that? what verification process is there?

the NBME can design a better, more fair exam.

 

[TommyGunn04]

Dude, are you for real? Your condescending attitude is too much. Maybe if you remove your lips from the USMLE Step 2CS inventors' a$$ for two seconds you might be able to grasp the reality that everyone else on this board and the medical profession as a whole sees so clearly: USMLE Step 2CS is just a money making scheme!

Let's not get personal here. Like I said, I'm just trying to play devil's advocate. Until you can show me some data proving that CS is a "money making scheme" I'll continue to argue, rightfully and logically, that these are simply empty assertions.

 

[TommyGunn04]

tommygun, those definitions are fine. but, that is a really, really subjective set of evaluation criteria. compare that to the step 1 and step 2 CK. they provide a very detailed list of the exact topics that are potentially tested. i think a far more fair method would be to have a series of rooms, and inside have a medical professional to evaluate us. have a dummy to examine, a series of heart sounds to listen to, a patient to evaluate, a finding to elicit, write a note, whatever. then, grade us on that and move us on. instead we have some patient trying to remember everything we do, we wonder how much leeway they have in interpreting our physical findings and the questions we ask. we don't know what is considered important or essential. in short, it is simply too subjective and undefined.

my biggest worries are that a patient will not mark the check box for a history question if i did not use some exact key phrase they are looking for. or that they will have forgoten that i actually did this exam, or mentioned they should quit smoking. there just seems to be too much leeway for the patient to screw us by simply forgetting something. and what recourse do we have for that? what verification process is there?

the NBME can design a better, more fair exam.

I wholeheartedly agree! Now we're getting somewhere! These are some fantastic arguments, and to my knowledge the NBME hasn't adequately addressed or even responded to these concerns, despite the efforts of AMSA and other groups. In any case, it's nice to hear such thoughtful, logical arguments about CS, instead of the usual thoughtless complaining and name-calling that gets us nowhere.

Does anyone have any information about the outcome of student activism that occurred against CS? (I know the ultimate outcome of course, but I'm wondering if there are any documents from the NBME containing data or their reasoning for setting up the exam in this particular fashion)

I really wish the NBME would create a forum for students to voice concerns like this. Like I said, yours are very valid concerns, and I think the test could be significantly improved through student feedback. But my impression is that they've been unwilling to have the conversation It's very unfortunate.

 

[TommyGunn04]

tommygun, those definitions are fine. but, that is a really, really subjective set of evaluation criteria. compare that to the step 1 and step 2 CK. they provide a very detailed list of the exact topics that are potentially tested...

I think you're right about this, but I also think the subjectiveness of the subject matter itself somewhat necessitates this vagueness. Or perhaps I just can't think of a better way to evaluate certain aspects of patient-doctor interactions. The skill of communication is the one that comes to mind. Communication is a difficult skill to assess, and although one can create a list of important components that generally make for good communication, it ultimately comes down to a patient's "feeling" about their interaction with the physician. In this sense, it may be better that there's some vagueness built into the interaction. Just as one has difficulty defining "art," it's tough to pin down a definition of "good communication." With regards to physical exam findings things can certainly be more objective, and your point about this is well taken, but when it comes to the communication category I'm not sure how to best measure this. I'm just thinking out loud about this...

 

[neilc]

perhaps for the communication component, you could have a doorway scenario that states 'communicate to this patient that they have pancreatic cancer, and offer counseling'....you go in and you talk to the patient about the cancer, the prognosis, the therapeutic possibilities, offer support and answer questions. and, this could either be observed by or the patient could be a medical profesional. in the exam description/requirements it could state that you need to know how to communicate bad news effectively, accurately and compasionately.

i can see your point about the subjective nature of evaluating the communication skills, but i am not sure it needs to be that way. make us take an english test for that portion. give us some concrete job that we need to do, and have a qualified person evaluate that skill. i just think that cramming all of these skills into a 15 minute visit and 10 minute note session, and having it evaluated by standardized patients is a fair or accurate way to assess this.

the other problem i have with evaluating these soft skills...where is the line for competence? at what point do these skills need to be present to say somebody is minimally qualified to practice medicine? i can get behind a minimum skill level for basic physical exam techniques, for a decent history extraction, and for a solid grasp of the language. but, i really have a hard time with somebody potentially saying "well, you covered the details well, but you just didn't seem empathetic enough to me", and then getting a fail on a licensing exam from that. it is just too soft a criteria for the potential consequence of failing.

 

[sacrament]

but, i really have a hard time with somebody potentially saying "well, you covered the details well, but you just didn't seem empathetic enough to me", and then getting a fail on a licensing exam from that. it is just too soft a criteria for the potential consequence of failing.

The biggest problem here is that they aren't even judging how empathetic a person you are, they're judging how good an actor you are. The most sensitive and caring soul in the world might still have a difficult time mustering up much empathy for a standardized patient.

 

[neilc]

The biggest problem here is that they aren't even judging how empathetic a person you are, they're judging how good an actor you are. The most sensitive and caring soul in the world might still have a difficult time mustering up much empathy for a standardized patient.

excellent point.

 

[dominofx]

number one..i dont think US students should take this exam..even though i am a foreign student..i think i mistyped before..number 2..i think communication SHOULD be the most important part of this exam..empathy etc..please dont tear me up on this..just an opinion..i thinkwe proved our medical knowledge on the other two exams..i think foreigners MUST take this to PROVE to teh US medical community that they can handle a health care system outside of their own..as far as american students..i think its dumb..because every medical program has a test just like it..unlike foreign schools..i mean you should see some of th residents where i did rotations in chicago..they were HORRIBLE to the patients..they need to learn some manners..hopefully this will help them..empathy is very important in medicine..medicine should remain a humbling profession free from over egos..i took the exam and had a killer..never heard of the cases..it was the new one i think..but still..it is a necessary evil..the price about makes sense to me too..there is a lot of expense..i dont think there is a CEO in the ecfmg buying a boat with our money..haha..take care

 

[tx oms]

If everybody passes it, doesn't that sort of invalidate the whole purpose of having a "weeding out" exam like this? If nobody gets weeded out? So what will they do? They'll ratchet it down in order to generate more failing scores. The cut-off for passing will get higher and higher. The cases will get trickier. Instead of being a worthless, expensive pile of sh1t test, it'll become a worthless, expensive, unfair and picky pile of sh1t test. This m-f-er has to be stopped. When our generation comes into positions of authority in the medical world, we must remember what a nightmare this f-er is and shout it down. Step 2 CS must die.

You're right. The test is about nothing more than making money. I finished dental school and I'm in medical school/oral surgery residency now. CS exams have been part of the dental world for about 70 years. The dental examiners say the same things as far as the reason for having the exams. Weed out exams should not exist. Weeding people out is the responsibility of medical and dental SCHOOLS, not the USMLE. The schools should have to show that they are able to weed out weaker students--if not the school should be discredited. The real point of CS exams is to make money. My dental exam cost well over $1000.

Based on the dental model, the USMLE won't increase it's failing rate. Most people pass the dental CS exams and have for a long time. As long as the testing agencies get their money they'll let people pass.

 

[Hurricane]

I think that the US medical schools should be responsible for making sure their graduates have clinical and communication skills. Many schools already have their own clinical skills exam with standardized patients. I think that passing an exam like this should be sufficient, and should be a requirement of all US medical students. If the NBME isn't going to accept a test given by an accredited medical school, then what's the point of accrediting medical schools in the first place?

I'm an MD/PhD student in my final year, so I started medical school well before the CS exam was instituted. (Yeah, I'm old.) I remember all the arguing in the years leading up to the exam. Officials from our school were opposed to it, and argued pretty much what I stated above. But the NMBE was adamant about administering a clinical skills test, and building their own facilities to do it.

Then it was argued that since so many schools already had built (or were planning to build) their own testing facilities, it would be easier on the students if the NBME would accredit these schools as official testing sites, instead of making students travel to one of five cities. The NBME rejected that idea too, and said that smaller schools complained that this would put them at a disadvantage if they didn't have their own testing facilites. Nobody knew where that was coming from. I mean, we're far from the largest or most expensive school in the US, and we had a testing facility. Even if there was a smaller school out in rural Ohio somewhere without their own testing facility, it's still easier for their students to drive to Cincinnati than have to fly to LA or Atlanta* because of the NBME's byzantine scheduling system. And the disadvantage argument is bogus too. Not having a testing facility at your school in which to practice puts you at a disadvantage whether you're taking step 2 at a neighboring med school or at one of the NBME's testing sites, so the point is moot. Officials in our dean's office have said that it seemed like the NBME had already decided how they were going to do step 2, that they were determined to build their own facilities, and had no interest in discussion or compromise.

That attitude pisses me off and makes me resentful of having to pay for and take this stupid test, regardless of whether it's a moneymaking scheme or if they are actually making a profit. And as others have pointed out, it does not seem to be working well. But even if everyone suddenly determines this was a failed experiment and should be discontinued, it's not going to happen until the NBME recoups their investment. Because money definitely is a factor, even if it's not THE factor.

* A friend recently took the test in Chicago, and was standing next to a guy from Atlanta, who couldn't get a spot in his own friggin' city, because of the NBME's opening and closing of spots. That is ridiculous.

 

[neilc]

I think that the US medical schools should be responsible for making sure their graduates have clinical and communication skills. Many schools already have their own clinical skills exam with standardized patients. I think that passing an exam like this should be sufficient, and should be a requirement of all US medical students. If the NBME isn't going to accept a test given by an accredited medical school, then what's the point of accrediting medical schools in the first place?

I'm an MD/PhD student in my final year, so I started medical school well before the CS exam was instituted. (Yeah, I'm old.) I remember all the arguing in the years leading up to the exam. Officials from our school were opposed to it, and argued pretty much what I stated above. But the NMBE was adamant about administering a clinical skills test, and building their own facilities to do it.

Then it was argued that since so many schools already had built (or were planning to build) their own testing facilities, it would be easier on the students if the NBME would accredit these schools as official testing sites, instead of making students travel to one of five cities. The NBME rejected that idea too, and said that smaller schools complained that this would put them at a disadvantage if they didn't have their own testing facilites. Nobody knew where that was coming from. I mean, we're far from the largest or most expensive school in the US, and we had a testing facility. Even if there was a smaller school out in rural Ohio somewhere without their own testing facility, it's still easier for their students to drive to Cincinnati than have to fly to LA or Atlanta* because of the NBME's byzantine scheduling system. And the disadvantage argument is bogus too. Not having a testing facility at your school in which to practice puts you at a disadvantage whether you're taking step 2 at a neighboring med school or at one of the NBME's testing sites, so the point is moot. Officials in our dean's office have said that it seemed like the NBME had already decided how they were going to do step 2, that they were determined to build their own facilities, and had no interest in discussion or compromise.

That attitude pisses me off and makes me resentful of having to pay for and take this stupid test, regardless of whether it's a moneymaking scheme or if they are actually making a profit. And as others have pointed out, it does not seem to be working well. But even if everyone suddenly determines this was a failed experiment and should be discontinued, it's not going to happen until the NBME recoups their investment. Because money definitely is a factor, even if it's not THE factor.

* A friend recently took the test in Chicago, and was standing next to a guy from Atlanta, who couldn't get a spot in his own friggin' city, because of the NBME's opening and closing of spots. That is ridiculous.

the argument you make for not having the CS seems pretty weak to me. school all have great facilities and programs for teaching and evaluating basic science knowledge, right? yet we still have to take step 1....i think the valid argument for the exam is to make sure all schools are meeting a national standard for all of the skill sets a doctor is required to possess.

that being said, step 2 CS could be improved. it would have been nice to have testing centers at each school, but i can see how that may be viewed as less neutral, and taken the test away from NBME, who really should be administering it. but, bottom line is that the current test is worse than no test.

test us if that is what is required. but, make it a fair test, let us know what we need to do to pass it, provide feedback and make it more convenient. in short, make it more like step 1 and CK.

 

[tx oms]

the argument you make for not having the CS seems pretty weak to me. school all have great facilities and programs for teaching and evaluating basic science knowledge, right? yet we still have to take step 1....i think the valid argument for the exam is to make sure all schools are meeting a national standard for all of the skill sets a doctor is required to possess.

I wouldn't mind if all national board exams were abolished and schools were left to weed out ******s; however, it would be difficult to assess the schools' ability to do so without a national exam. Written tests are more objective and less costly to the student. Testing a fundamental knowledge level against a national standard seems fair.

If the CS exam is so wonderful and helpful for assessing students, can't we then conclude that anyone who graduated before the CS exam may not be a good doctor b/c they've never undergone formal CS testing?

 

[Orange Julius]

My biggest problem with is is the freaking thousand dollars I had to shell out for it. The rest I can tolerate. Just more meaningless medschool garbage. I'm used to it at this stage.

 

[cyanocobalamin]

The problem is that because absolutely no feedback is given to those of us who pass, and because most people do pass, it's natural to assume that the test is ridiculously easy and that only people with truly horrendous clinical skills will fail it. So it's very easy for somebody who passed the test, and who doesn't know of anybody who failed it, to say "Don't worry! Just show up and don't spit in the patient's mouth and you'll pass!" Those of us who are acutely aware of people who were shocked to fail are less comforted by this advice. At my school we have a serious of relatively rigorous clinical exams, three during the first year, three during the second year, and two long and involved ones during the third year. People fail these, they are tough. Much tougher, in my opinion, than the light-weight CS. But of the small number of people at my school who failed Step 2 CS, none of them failed our school's own exams. Despite the odds being drastically in your favor, this is worrisome because it almost seems that that's all it comes down to: odds. There doesn't seem to be much you can do to ensure you'll be in that passing crowd. That is, if you're worried about failing you can't just study more and feel better. You just pay a thousand bucks and roll the dice.

Another notion I've had: apparently there are schools where absolutely nobody fails, schools where a sizable number fail, and only a few schools like mine where just a handful fail. Why is this? I find it difficult to believe that there are accredited medical schools in the United States which are preparing students so poorly that they're doomed to fail goofball tests like the CS. I have to wonder if it is because of idiosyncratic regional differences in the perception of good "clinical skills." One example. From many sources there is a strong recommendation that you constantly chatter during the physical exam, asking permission to perform each maneuver and giving feedback on each as you go. To me, this is bizarre. I've never seen a clinician do this, I've never done this (except during the test) and I've never experienced it as a patient. This is an east coast thing? I have no idea. But I almost have to wonder if there are a number of checkboxes for behaviors that are foreign to the experience of medical students from particular regions. Because nobody should fail this, not even only 3%.

We're actually taught to do this. It's part of what's called 'facilitative behavior' and we're graded on it for csa. It lets the patient know what's going on and keeps them engaged and seen as a big plus. You could tell the patient "OK, I'm going to first feel for your heart and then listen to your heart...Is it ok if I listen to your belly now?, etc." Obviously it's not perpetual chatter, but just a little here and there to keep the pt engaged. Nothing idiosyncratic about it, obviously don't do it in every clinical setting but a definite must for csa and helps some patients feel at ease. Same with reiterating the hpi, sh, fh, pmh, etc. after each section. That's 'documentation' which you get points for. Don't patients ever ask you how their lungs sound afterwards if you don't tell them? These are all very transparent well known grading criteria for clinical exams, and I simply assume that step 2 cs is similar in nature with regards to grading with what are widely accepted practices.

 

[sacrament]

We're actually taught to do this.

Well, this definitely supports my theory re: regional differences in clinical behavior.

You could tell the patient "OK, I'm going to first feel for your heart and then listen to your heart...Is it ok if I listen to your belly now?, etc." Obviously it's not perpetual chatter, but just a little here and there to keep the pt engaged.

It's funny... I've had four or five classmates, after finding out that I've taken the CS, ask me "Did you really do that crazy chattering and feedback during the physical exam like they say to in First Aid? Didn't it feel weird? I don't know if I'm going to do it." I always tell them to just go ahead and do it, no matter how bizarre it seems, because apparently the graders are expecting it.

These are all very transparent well known grading criteria for clinical exams, and I simply assume that step 2 cs is similar in nature with regards to grading with what are widely accepted practices.

I assure you that these are not universally practiced behaviors.

 

[cyanocobalamin]

Well, this definitely supports my theory re: regional differences in clinical behavior.

I assure you that these are not universally practiced behaviors.

Not universally practiced, but widely known about. There are a variety of rating scales, but they cover similar stuff. It's not like this stuff is secret dude, it's all out there. Here's one article for example.

If some medical schools can have a near 100% pass rate (like our 100% pass rate last year), it must mean that the exam can be prepared for. It is not a crapshoot.

Communicating with your patient during the exam is not a regional thing. I would think all patients from Alabama to Spokane would like to be talked to during the exam instead of sitting through dead awkward silence.

http://www.stfm.org/fmhub/fm2005/March/Julie184.pdf

 

[sacrament]

Communicating with your patient during the exam is not a regional thing. I would think all patients from Alabama to Spokane would like to be talked to during the exam instead of sitting through dead awkward silence.

The article you link talks about information sharing and clear communication, which is certainly important and definitely a required skill. I'm not saying we don't talk to the patient during the exam, and I'm not saying we refuse to share any findings, but we definitely don't have this protocol where we ask permission to perform each individual component and then immediately give feedback. Now mind you, I'm not saying this a bad idea, just that it seems very foreign to me. Again, I've never had a doctor do this with me, and I've never seen a doctor do this with any other patient. When I did it during the exam, it felt very staged and rote.

"May I please listen to your lungs? Good, your lungs sound clear. May I please listen to your heart? Your heart sounds normal. May I please press on your belly? Okay, everything feels fine there. May I please..." It feels like you're going through a script. It's awkward to me; I have no intention of actually doing this in real life. (Again, not that I think it's a bad practice. I just can't flow with it. I'll continue asking permission one time before beginning the exam, chatting like normal during the exam, and sharing findings one time at the end of the exam, like I always have and which seems to work fine for both me and the patient.)

 

[Sivastraba]

Ok I am going to give you my unpleaseant experience with this new test. I just finished Medical School. I was one of the first students in my Medical School to have taken this test the last year. I had never payed for a prep course for either Step I or Step 2CK and Passed them in my first attempt. I decided to pay for a FALCONS REVIEW COURSE (DONT Take THIS S^#^#) to study for this test, since it was a new test for all of the US grads. It was even a bigger hurdle for those US grads whose second language is English. I payed closed to 1500 + lodging for a week in a hotel for this prep. I went to the test (After paying another gram + lodging) very confident (I think that may have been the reason). Anyway, there was a delay in getting the results back and by the time I did (I Failed it) it was too late to retake it for the match. So I lost my chance of Matching the last year. Guess what? I have just taken it the 2nd time this year in the beginning of October, BUT NOW THE FC#(*&#*&(*&# NBME is DOING A READJUSTMENT IN THE POOL OF APPLICANTS so they expect a dely in giving back results to students taking this test during October and November (>12 weeks). I can't take this BS anymore. I am thinking of seriously suing the NBME for this kind of "Administrative" crap which is only destroying the life of people who want to get a job so that they can get on with more important things in life. I am really thinking of suing these NBME b*(*&^*( , if I don't get these results soon.

So there is a huge controversy in whether this is a Money making scheme. You guys want proof? Ok here is mathematical proof:


There are a 126 American Med Schools. Each Med School has a class size that can go from 100 to 250. I will be conservative and say that in average each medschool has 150 students per class. So in one particular year:

150 (students) x 1000 (per student) = $150,000 per Medical School per year

So if you have 126 Medical Schools:

126 x $150,000 = $18, 900, 000 (18 MILLS, close to 19 M per year.)

Isn't this sufficient proof?

This test is full of it. The amount of clinical exposure a Medical Student gets in the last two years is more than enogh to obtain all clinical the clinical tools needed to be competent. In addition, all school have OSCES. This test is just full of it....

 

[Hawkeye Kid]

...i think the valid argument for the exam is to make sure all schools are meeting a national standard for all of the skill sets a doctor is required to possess...

How is this a valid argument for making ME pay money for a test and jeopardizing MY chances of graduating/matching/getting licensed/etc? It seems to me that you're defending the test to insure that individual SCHOOLS are up to par. Isn't that the point of the LCME? And even if some test like CS were required to judge the SCHOOLS, then the cost and ramifications should be their responsibility. They want me to take a CS-like exam as part of the accreditation process? Fine. But to say that I have to pay for a test and suffer the consequences if I fail in order to make sure that my school is meeting some (likely arbitrary) standard makes no sense.

 

[neilc]

How is this a valid argument for making ME pay money for a test and jeopardizing MY chances of graduating/matching/getting licensed/etc? It seems to me that you're defending the test to insure that individual SCHOOLS are up to par. Isn't that the point of the LCME? And even if some test like CS were required to judge the SCHOOLS, then the cost and ramifications should be their responsibility. They want me to take a CS-like exam as part of the accreditation process? Fine. But to say that I have to pay for a test and suffer the consequences if I fail in order to make sure that my school is meeting some (likely arbitrary) standard makes no sense.

i guess i worded my statement incorrectly. the point i was making was that the schools teach us clinical skills, but that alone does not mean that a med student is adept at it. so, the exam is in place to verify that the individual student is competent at this skill set.


my point is that the CS is in place to verify that we as students have this skill set and the knowledge to perform clinically. i do not think the current CS does an especially good job of it, but i do see why a test of this nature should be in place.

CS is basically the same thing as step 1, but for clinical science. nobody has a problem with the justification for step 1, as far as i can see. yet, the same arguments can be made against step 1 as i have heard for step 2. and the arguments make no sense! i mean, we all took anatomy, physiology, path, micro, exams all through med school. and they were tough! so, why do we have to take step 1?? because we have a national standard that needs to be met. and, there is a significant percentage of students that slip through med school basic science and fail step 1. so, obviously, the test is justified. why should the assumption be that the school does a good enough job teaching all students clinical skills? just because the skill set is well taught does not guarantee that all students will master it, even if they pass the classes.

so, even though your school may teach clinical skills like no other, the CS is simply in place to make sure we all meet a national standard.

unfortunately, the skill set tested is not something that can be done as objectively as step 1. and, it is also a shame that we are in the development period of this exam, so we are suffering through the first imperfect test and the development of this test.

as said before, this exam could be done better, and i hope it can be done cheaper. but, i still feel that it is testing a skill set that should be examined in all med students, and on a national level.

 

[Hawkeye Kid]

i guess i worded my statement incorrectly. the point i was making was that the schools teach us clinical skills, but that alone does not mean that a med student is adept at it. so, the exam is in place to verify that the individual student is competent at this skill set.
QUOTE]

I hoped that was the case, since I agree with most of your posts, or at least find them well-defended and insightful. You are hereby pardoned for your error.

 

[souljah1]

neilc,

most US medical schools have their own clinical exams that test history taking and physical exam skills, the ability to come up with an assessment and plan, and the more subtle findings such as how the standardized patient felt during the interaction, ethics, communication, etc.

at my school we have clinical performance examinations and observed structured clinical examations. all include standardized patients, all evaluate students' ability to be competent with the above objectives, etc. the graduating class last year generally felt that our clinical exams were much harder and that the step 2cs test was a joke. out of 150'ish students who took the CS exam last year, 2 failed. when around 1.5% of your class fails, is there really a need to ensure competency given that the overwhelming number of students graduating from our school do just fine? In other words, 98-99% of our class pays a thousand dollars plus the cost of travel, lodging, etc to take a test that is easier than the FREE tests that we receive at school.

the bottom line is that the overwhelming majority of us medical grads do fine (i've heard that the pass rate is around 96% here), however foreign medical graduates pass on a much lower level (80's).

I personally think that if your US medical school has its own means of evaluating clinical skills then you should not have to take this test. However, if your school doesn't have these things, or if you are a foreign medical graduate, you should have to take the exam.

 

[tigershark]

"May I please listen to your lungs? Good, your lungs sound clear. May I please listen to your heart? Your heart sounds normal. May I please press on your belly? Okay, everything feels fine there. May I please..." It feels like you're going through a script. It's awkward to me; I have no intention of actually doing this in real life. (Again, not that I think it's a bad practice. I just can't flow with it. I'll continue asking permission one time before beginning the exam, chatting like normal during the exam, and sharing findings one time at the end of the exam, like I always have and which seems to work fine for both me and the patient.)

Maybe you dont understand the fundamental concept? It's not so much as asking for persmission to do stuff as it is keeping the patient informed as to what is going on.

Continuosly asking "May I ..." over and over is indeed awkward. But informing patients of what you are doing seems like common courtesy to me. What part of the country are you from? If you had no medical knowledge at all, wouldnt it put you more at ease if the doctor told you what he was about to do before he opens your gown and starts touching you?

 

[sacrament]

Maybe you dont understand the fundamental concept? It's not so much as asking for persmission to do stuff as it is keeping the patient informed as to what is going on.

Continuosly asking "May I ..." over and over is indeed awkward. But informing patients of what you are doing seems like common courtesy to me. What part of the country are you from? If you had no medical knowledge at all, wouldnt it put you more at ease if the doctor told you what he was about to do before he opens your gown and starts touching you?

I usually state one time, upfront, that I'll be doing a physical exam and "is that okay?" Even somebody with no medical knowledge at all probably understands that when I put a stethoscope on their chest and ask them to breathe deeply, that I'm listening to their lungs. At certain points I usually do toss in an offhand "let's listen to your heart" as I roll through things... but no way do I stand there with my hands clasped while I introduce and close each physical exam component, waiting for patient approval of abdomen percussion and pausing to see if they've grasped the fundmental concept of "I just pushed on your belly." This goes way beyond "keeping a patient informed" and is PC-ness gone amok, not to mention it's weird. If my doctor ever painfully lurched through such an exam I would thank her for her time and then never return.
(I won't even get into the weirdness that, in the CS, every single patient is in a gown, regardless of why they are there and regardless of any expection that they will or won't need a stem-to-stern physical exam or pap smear. I personally have never put on a patient gown, and in the 7 or 8 outpatient clinics that I've spent time in, none of them had an "everybody in gowns" policy. Talk about making a patient feel uncomfortable... nevermind asking for permission to poke their belly and then doing it and then saying "I just poked your belly", how about not making everybody wear a flimsy assless gown.)

 

[neilc]

neilc,

most US medical schools have their own clinical exams that test history taking and physical exam skills, the ability to come up with an assessment and plan, and the more subtle findings such as how the standardized patient felt during the interaction, ethics, communication, etc.

at my school we have clinical performance examinations and observed structured clinical examations. all include standardized patients, all evaluate students' ability to be competent with the above objectives, etc. the graduating class last year generally felt that our clinical exams were much harder and that the step 2cs test was a joke. out of 150'ish students who took the CS exam last year, 2 failed. when around 1.5% of your class fails, is there really a need to ensure competency given that the overwhelming number of students graduating from our school do just fine? In other words, 98-99% of our class pays a thousand dollars plus the cost of travel, lodging, etc to take a test that is easier than the FREE tests that we receive at school.

the bottom line is that the overwhelming majority of us medical grads do fine (i've heard that the pass rate is around 96% here), however foreign medical graduates pass on a much lower level (80's).

I personally think that if your US medical school has its own means of evaluating clinical skills then you should not have to take this test. However, if your school doesn't have these things, or if you are a foreign medical graduate, you should have to take the exam.

i understand that most schools have great clinical skills instruction. but, most schools also have great basic science instruction as well. what is your schools pass rate on step 1? most US schools are comfortabley in the 90's on this exam as well.

i agree that the test should be cheaper, and should be more objective. additionally, i feel that students should have a strong idea going into the exam as to what is required. but, i don't buy this "our school teaches us clinical skills, so we don't have to pass a standardized exam" argument. your school teaches you everything, but you still have to pass step 1 and step 2 ck. step 2 cs is a pretty logical next step as well. i just wish they would do it better!

btw, i think if you correct for english language skills, IMG's and US grads would have very similar pass rates.

 

[neilc]

I hoped that was the case, since I agree with most of your posts, or at least find them well-defended and insightful. You are hereby pardoned for your error.

thanks for the compliment and the pardon!