Step 2 CS freakout

[deleted297751]

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Hey all,

I'm afraid I made some mistakes on my CS that may have affected my ICE and CIS score.

1) Didn't include a pregnancy test in a case that would usually always warrant it because patient claimed she had no sexual history (investigated this a lot)... wrote in history and made ddx reflect that point.
2) Didn't counsel on smoking/alcohol in 2 cases
3) Didn't write key history finding in case that required it for diagnosis.
4) Forgot to do a Neuro exam on a case that warranted it
5) Gave a possible bad diagnosis instead of a more full differential with easier things to handle first
6) Didn't get to answer 2 challenge questions due to time running out.

Otherwise, I believe things went fine with me having 2-3 reasonable ddx per case with the most likely (straightforward) first in every case except 1, and 2 cases with 1 ddx because the history and physical were so pointed (though my history will reveal I thought of other obvious ones, just didn't write them in the ddx because they weren't likely after certain historical points).

Any feedback on whether my worrying is appropriate or in vain would be helpful!

 

[GreatDay]

Hi,
I took my test few days ago and I feel like I did the same mistakes or even more 🙁 All because I was so anxious all the time.

 

[deleted297751]

It's a hard wait "GreatDay". My score hopefully results in the next 9 days, so regardless of the outcome, I'll write more about my experience.

Overall, I can say trolling these forums has only lead me to feel worse. Occasionally, I'll read about someone who did seemingly few mistakes and failed, and then another person who did a ton of mistakes and then passed.

Then, I realize that people only remember the things that they think they are being graded on, but since none of us know the grading rubric or how the holistic scoring is done by the graders, it's all just kind of random. Something that brought me some solace was just reading the Step 2 CS manual and really thinking if I did what they said they were looking for. Not based on forums, not based on review books. When I do that, I usually feel better.

For example, so many on these threads have said that you need 3 ddx for most cases, but on my test, 2/3rds of the cases had an obvious diagnosis, and then occasionally one additional I would consider if I was surprised by the primary not being right, so I put those down. Some cases seemed to have only 1 really ddx. Only 2 cases really seemed designed to have a lot more.

I don't think all the cases have the same "point" either. A case with a very obvious presentation may have more CIS component checkmarks, or a case with an adolescent may be checking your ability to do a proper HEADSS assessment moreso than just establishing the diagnosis, or a case that is intentionally vague may have been designed that way so that the data interpretation part can be more robust.

I think if you took a relatively complete history, did a couple of ROS q's in relation to the ddx for the problem you walked in for, did a reasonable attempt at a physical exam, wrote a note that kinda sounded like a Step 2 CK question stem in the sense that it would really point to one diagnosis primarily (by listing enough SPECIFIC features to rule in one disease, and enough pertinent negatives to rule out some others), and then wrote diagnoses that you really think are a part of the possible presentation with some supporting evidence, and not "Kaplanizing" the test by trying to fill in as many boxes as possible thinking that points are only added for putting more (as opposed to subtracted for being irrelevant), it should go fine.

This is all just speculation, and I have NOT yet gotten my results back. I was mostly afraid of this test because of a borderline OSCE performance I had a week after taking a year off, and I didn't take that as seriously as I should have. But I'm thinking if I put myself in the shoes of my medical school faculty and look at my performance and can say I didn't take this too lightly and performed on this test like I want to be a capable doctor, I'll be fine. I suspect the same for you

PM me if you wanna chat more.

 

[GreatDay]

It's a hard wait "GreatDay". My score hopefully results in the next 9 days, so regardless of the outcome, I'll write more about my experience.

Overall, I can say trolling these forums has only lead me to feel worse. Occasionally, I'll read about someone who did seemingly few mistakes and failed, and then another person who did a ton of mistakes and then passed.

Then, I realize that people only remember the things that they think they are being graded on, but since none of us know the grading rubric or how the holistic scoring is done by the graders, it's all just kind of random. Something that brought me some solace was just reading the Step 2 CS manual and really thinking if I did what they said they were looking for. Not based on forums, not based on review books. When I do that, I usually feel better.

For example, so many on these threads have said that you need 3 ddx for most cases, but on my test, 2/3rds of the cases had an obvious diagnosis, and then occasionally one additional I would consider if I was surprised by the primary not being right, so I put those down. Some cases seemed to have only 1 really ddx. Only 2 cases really seemed designed to have a lot more.

I don't think all the cases have the same "point" either. A case with a very obvious presentation may have more CIS component checkmarks, or a case with an adolescent may be checking your ability to do a proper HEADSS assessment moreso than just establishing the diagnosis, or a case that is intentionally vague may have been designed that way so that the data interpretation part can be more robust.

I think if you took a relatively complete history, did a couple of ROS q's in relation to the ddx for the problem you walked in for, did a reasonable attempt at a physical exam, wrote a note that kinda sounded like a Step 2 CK question stem in the sense that it would really point to one diagnosis primarily (by listing enough SPECIFIC features to rule in one disease, and enough pertinent negatives to rule out some others), and then wrote diagnoses that you really think are a part of the possible presentation with some supporting evidence, and not "Kaplanizing" the test by trying to fill in as many boxes as possible thinking that points are only added for putting more (as opposed to subtracted for being irrelevant), it should go fine.

This is all just speculation, and I have NOT yet gotten my results back. I was mostly afraid of this test because of a borderline OSCE performance I had a week after taking a year off, and I didn't take that as seriously as I should have. But I'm thinking if I put myself in the shoes of my medical school faculty and look at my performance and can say I didn't take this too lightly and performed on this test like I want to be a capable doctor, I'll be fine. I suspect the same for you

PM me if you wanna chat more.

 

[GreatDay]

Thank you so much for your helpful comment. My journey has just begun and I should find a way to ignore these useless flashbacks now.
On exam, I did pretty well on 6/12. But the rest I made some stupid mistakes here and there, and now I can see how stressed I was! I forgot to consult in 3 cases, had no clue what phy.ex should be done in 1-2 cases and just did a random and not so relevant GA, HEAD and NECK exam and tremor!, since I thought it could be related to thyroid. And although I was able to make a really good rapport with 5 of SPs, I "NOW" remember I should have show empathy or support in the rest of them.
For me it was about the time management in stressful situations. I even had a case who seemed annoyed by me asking ROS questions that were not so relevant, and some other stupid mistakes such as not including details in diagnostic test, for example I wrote CXR with out any description of 'PA, Lat' and etc. And, Its still coming!
I know that I have to practice more and more to familiarize myself with the US healthcare system and I am willing to do so. But I dont want to harm my application because of simply being super-anxious during the exam, an unfortunate attitude which seems fixable to me.
It was so nice of you to answer and elaborate on this.
I truly hope you get a great score and please let me know.
Best wishes for both your residency and life.

 

[Phloston]

I don't think all the cases have the same "point" either. A case with a very obvious presentation may have more CIS component checkmarks, or a case with an adolescent may be checking your ability to do a proper HEADSS assessment moreso than just establishing the diagnosis, or a case that is intentionally vague may have been designed that way so that the data interpretation part can be more robust.

I think this would be the equivalent of saying that easier vs harder questions on Step 1/2CK receive fewer or more points. But in reality all questions are worth the same amount. I haven't taken the 2CS yet, but I've read that out of the 12 encounters, only 10 are graded. And they're all likely worth the same amount in all components. They probably do that in order to "objectify" the subjectivity.

Don't get me wrong though, I'm really not looking forward to 2CS. Especially as an international student. And I'm fairly awkward in contrived encounters. I figure the American schools prep their students for this thing. Meanwhile I'm hoping FA 2CS +/- UWorld should be enough.

 

[Seedling]

I'm just going to freak out in here, since I don't want to make my own thread.

How bad is it if I didn't ask PMH/PSH, Birth hx, SH, FH for one patient because apparently I didn't feel like doing it that one time? I did it for EVERY patient except my last one. No idea why. 🙁

 

[choc_mint]

I'm just going to freak out in here, since I don't want to make my own thread.

How bad is it if I didn't ask PMH/PSH, Birth hx, SH, FH for one patient because apparently I didn't feel like doing it that one time? I did it for EVERY patient except my last one. No idea why. 🙁

I did exact same mistake, missed the whole PMH, Sxhx, FH, SH in one case. Also done some other mistakes described by OP. FWIW, I passed with high performance on ICE. So I think as long as your other cases went well, it should not cause you to fail.

 

[1tbspofpatience]

anyone know if almost all scores will be released tmrw for those who took CS between Nov and Dec or does score reporting vary by site or when you took the exam?

 

[deleted297751]

Good luck to everyone who finds out tomorrow. My fingers (and stomach) are crossed for all of us

 

[deleted297751]

Good luck to everyone who finds out tomorrow. My fingers (and stomach) are crossed for all of us

 

[PapezCirDead]

Hi
I have the same question
I took the test during the first week of December, and I don't know ,,, Should I expect the results to show up tomorrow???

I am freaking out , Started to remember all the mistakes I did....

If you hear anything please let us know

some good result are refreshing sometimes,,, Also sharing the anxiety with others make it not less but more acceptable may be?!!!


thanks

 

[1tbspofpatience]

i got an email a little while ago so if that's the case then I guess you get it today

 

[deleted297751]

Got results back and I passed. Wanted to make sure to follow up on this thread as I hated it when people would write their mistakes and not give the ending.

Looking at my report--attached at the end-- I maxed out on CIS (I wrote below why I think this was, if this will help any of our foreign medical grad friends), and as expected was at the upper edge of borderline for ICE. I will write my mistakes for ICE below more generally so that people can see how far down the rabbit hole you can go and still pass relatively safely, and what I did for CIS in every encounter that likely led to such high performance.

For ICE:
For every encounter, I would write down my LIQORAAA the PAMHUGSFOSS then a small ddx for the initial complaint by age. After going in and asking open-ended questions, I would then ask 2-3 questions for each of the other ddx, then goes through the PAMHUGSFOSS. These are the reasons I believe I lost quite a few points
1) Didn't write as many pertinent negatives into the notes as I should have based on the primary ddx
2) Had some cases where the ddx was missing another somewhat obvious choice that should have been considered
3) Had lapses in what was recorded in the note from what was done in the exam. If you look online, part of the reason CS was switched to take away checklists is that many students were missing points in documentation while just asking a ton of questions without thought. I believe the new test format penalizes for this if adequate information isn't in the notes.
3) Didn't do as full of a physical exam as I should have (complete Neuro, esepcially sensory and reflexes, some MSK maneuvers, almost never did full respiratory (fremetis and egophany when the case was clearly resp), never did full CV (checking for PMI on a female patient as I didn't think it was worth it to lose points from being potentially awkward).
4) In the ddx section, I forgot I could add rows so I never had more than 3 history points for some diagnoses, although I made some of each point really long
5) Editorialized in the workup (I would order things and say in parenthesis afterward only if A,B,and C on follow-up). Probably not what the test was looking for.

I felt like i made a ton of mistakes on each case (I won't share them here due to USMLE rules), but it seems like I was still okay. I think if you weren't surprised by too many of the encounters and had a strategy before you entered the room, you'll be fine. It's the cases where the chief complaint wasn't something I prepped for that caused my ICE to have some ability to suffer.

For CIS:
1) I entered every room and said patient's name immediately, shook hands, then asked if I could sit.
2) Immediately after the chief complaint, I said I'm sorry to hear that and showed sadness on my face
3) After questioning, I always explicitly asked "What is the biggest concern of your illness right now, and how can I help you best"
4) After this, I always explicitly asked "If you could put your finger on what was going on, what would you guess it is."

Doing the two above almost always brought out the challenge question and made the rest of the encounter in terms of information literacy and where to focus much much easier.

5) Did a more full social history on each patient, and during the social history explained why I thought the chief complaint might be affecting some part of their life (either some activity, work, ability to diet etc.)
6) Didn't counsel every patient, but did ask them their willingness to change. If they said no, I let it go instead of trying to convince. Some were receptive and then did counseling for them. Don't think it's necessary to do it in every patient, or even that it's warranted (as we learn in med school).
7) Asked about patient's job more while washing hands before exam
8) After exam summarized findings
9) Gave patient 1 or 2 ideas of what may be going on, and asked if they thought that could be what it was
10) Gave and idea of 1 or 2 things we could do to determine (even if it was just a future visit), and asked if they had any questions on that
11) Asked if they had any questions again
12) Told them I'm sorry they are going through this, but how I was concerned for their health and as a "team" we would figure out how to help them best
13) Tried to incorporate some aspect of the encounter as an ending joke (either about a book we both read or some aspect of their job, or kids, or etc.)
13) Left the encounter

Every patient was pretty much smiling by the time I left the room, which I think should be the goal of CIS. Even in one case where I felt bad about how the encounter ended, I pretty much followed this rubric minus the joke at the end and more emphasis on teamwork.

Of course this all has an aspect of personal style to it, but it gets at each of the things that the USMLE says it explicitly wants on their website for the 5 domains CIS is now graded on.

Okay, I wish you all so much luck on the rest of your waiting. One thing I would say is that we all tend to overestimate small risks and give them much more juice when they feel "salient." AKA, we keep reading horror stories giving the image of failing more mental space than it deserves. I wish I had never seen any of these things online and followed other's advice. I would have probably saved myself ~ 100 hours of real worrying over the past few months

 

[GreatDay]

Congratulations 🙂

 

[anbuitachi]

wow you took it in january and got it back already?!

 

[boltzmann77]

2) Immediately after the chief complaint, I said I'm sorry to hear that and showed sadness on my face - ha ha ha
That made me chuckle.
Glad you passed!

 

[step2csscared]

Hey guys, I just took my cs a few weeks ago and really scared about how it went. Especially the ICE part, if someone could shed some light:

1) can't remember it
2) should've put the the 2nd ddx as first and vice versa but they were both good. 3rd ddx was way off, had one supporting point, don't know why I even put it
3) first 2 ddx pretty wrong. 3rd ddx was way off (had supporting points but only 1-2)
4) went well
5) went well
6) went ok
7) encounter went ok, ddx were also ok (i didn't have more than 2 supporting points for each ddx)
8) really wasn't sure what patient had, weak ddx and 1-2 points supporting them
9) went well, but forgot 1-2 important questions about chief complaint
10) went well, but forgot 1-2 important questions about chief complaint as well
11) went well
12) went well


Aside from that I would usually finish with 1-2 minutes to spare after closure, counseling and the basics (washing hands, proper draping, knocking, physical exam etc). I'm mostly worried about the ICE but then again who knows about the other sections, I just feel I messed up a bunch of diagnosis that I should've gotten.

Thanks for any advice

 

[pierre1201]

Hi,
I have weird case and need some advice on that - On my very first pt note during which i was completely freaked out and was typing fast so as not to forget anything, I accidentally wrote 'LMP' abbrev without writing how many weeks ago it happened since i couldnt remember it and simply moved on with typing. Than i realized that i did not asked pt straight forward q about it - just 'bout her periods in the past. Problem is - i forgot to remove this abbreviation before i ran out of time and submitted my note with that stupid mistake !!!
Can anyone tell me whether or not such a mistake will count as an attempt to falsify pt note ?????

 

[zywiec]

Hi,
I have weird case and need some advice on that - On my very first pt note during which i was completely freaked out and was typing fast so as not to forget anything, I accidentally wrote 'LMP' abbrev without writing how many weeks ago it happened since i couldnt remember it and simply moved on with typing. Than i realized that i did not asked pt straight forward q about it - just 'bout her periods in the past. Problem is - i forgot to remove this abbreviation before i ran out of time and submitted my note with that stupid mistake !!!
Can anyone tell me whether or not such a mistake will count as an attempt to falsify pt note ?????

I wouldn't worry about typo's during the exam. They are inevitable, and furthermore if they want to have a "zero mistakes otherwise you are lying by default" policy, then they would explicitly state that, and give us an extra 10 minutes. I did the same thing - I flipped it onto autopilot and wrote out the standard note we all see on rounds and definitely missed a few edits that could be viewed as falsified findings. You'll be ok!

 

[shannon13]

Congratulations 🙂

hi, did you pass?

 

[Saminto]

Hi! I've been reading these threads because I, too, am completely freaking out after taking CS. I felt bad about how it had gone right after, but now that it has been a few days, I am remembering more and more things that went terribly wrong. I know from reading a bunch of threads about this that many people feel like this and they usually pass, but since I can't stop thinking about these things, I wanted to ask what you think about a couple mistakes, and if anyone has passed with a similar story. I'm not so worried about CIS, but very worried about ICE.

1. For one case, I listed a totally ridiculous diagnosis first. It was a total brain fart moment--wrong anatomical structure. In my frenzied mind I didn't even register this until I submitted my note. The second 2 diagnoses were also bad...there are much more likely things it could be, now that I think about it. In 2 other cases, my first diagnosis was far from likely. In one, it was basically a spelling mistake, but one which turned it into a completely wrong answer.
2. There were MANY more questions I should have specifically asked, like pertinent positives and negatives. I can think of at least 2-3 VERY important and relevant things I should have asked and didn't for about every case.
3. I kept running out of space in my HPI area, so only documented drugs, alcohol, smoking when it was actually relevant to the complaint. Does anyone know if they score ICE purely from the note? Or will I get credit for asking about these things from the SP?
4. I never shook hands. It didn't even occur to me...it's not something I normally do when I walk into a patient's room, and at my school's practice version of CS, the SP running it said there is no need to shake hands, and she prefers it when students don't.

I know no one can tell me whether this will turn out ok or not. But I am really worried about the ridiculous diagnoses I put in my notes. So if anyone can comment on doing something similar and how it turned out, I would really appreciate it! I don't even understand how I could have done that. It's crazy what happens to you because of nerves and stress on the day of this exam. Anyway, best of luck to all who are waiting on scores, etc!

 

[zywiec]

Saminto, I did some of the same thing with the ridiculous ddx, but if you can support it, I think it will hold out to be OK in the end. I ran out of space as well so instead of writing "HPI:.." I just deleted it and did "Patient is a 37 yo f c/o.." blah blah blah, had to fit the + sign for positive bowel sounds somehow!

 

[Saminto]

Thanks, Zywiec, appreciate the reply. I did support my ridiculous diagnosis at least...I'm just hoping that bombing 1-2 cases like that won't be enough to fail. Everything else was either fine or so-so...I know I missed some really important questions, but there's only one other case that I think I might have failed the ICE component on. The patient was being really difficult...he kept saying that he didn't understand my questions and asking me to repeat stuff, so that cost a lot of time. But if they set it up like that, hopefully they understand that you can't fit in all the pertinent +/- questions! In real life, you'd just have to take a couple extra minutes. I hate how artificial this test is. The whole time, I was so nervous and feel like that really cost me some focus/rational thinking. This wait is going to be really hard...

 

[Pipa2016]

Hey Saminto, I too just realized (almost three weeks after taking my exam) that I didn't shake ANY of the SPs hands and I'm completely freaking out about it
I'm studying for CK now but debating whether I should start studying for the CS again 🙁

 

[Phloston]

Hey Saminto, I too just realized (almost three weeks after taking my exam) that I didn't shake ANY of the SPs hands and I'm completely freaking out about it
I'm studying for CK now but debating whether I should start studying for the CS again 🙁

Definitely don't start studying for CS again. The handshake will come out of the CIS points. And if you do fail CIS you could argue that you're Shomer Negiah.

 

[Abinash]

Hey Saminto, I too just realized (almost three weeks after taking my exam) that I didn't shake ANY of the SPs hands and I'm completely freaking out about it
I'm studying for CK now but debating whether I should start studying for the CS again 🙁

I can totally relate to you. I just didnt shake hands with my patients and Im freaking at it now. And could you tell me about your results. Anyone please let me know if hand shakes are scored in Cs exams.