Step 2

[Medstudentquest]

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So I looked at the NBME site and I saw some of the answers to questions I had. I have not been able to find anything talking about an exact score distribution though.

For example, do we get a certain number of points for the HPI, a certain # of points for the Ddx and for the work up out of a total # of points? Anyone know this info?

 

[John Deere Gree]

Seriously read the instructions...I'd hate to see you fail this thing.

 

[Medstudentquest]

Seriously read the instructions...I'd hate to see you fail this thing.

I read the instructions and the components of the test and passing all components, etc. There is no distinct scoring (as far as # of points) for each part of the patient note anywhere.

 

[John Deere Gree]

I read the instructions and the components of the test and passing all components, etc. There is no distinct scoring (as far as # of points) for each part of the patient note anywhere.

Because there isn't any distinct scoring that the NBME lets test takers know about. Speak in English, Ask lots of questions, a type a note like you would during med school and you'll pass.

 

[Antoni B]

Frankly, I'm glad that the NBME doesn't post scoring rubrics. If they did, I bet a whole lot more US medical students would fail, because we'd be so focused on getting all our points that we'd freak out--which is what it seems like you're doing, OP. Just chill out, pretend the SP is actually a real patient in the clinic, and do what you've been trained to do. There's a reason that 97% of us pass on the first attempt. It just isn't that hard.

 

[howelljolly]

Nobody knows exactly how the exam is scored.

The SP fills out a checklist of things that you did/didnt do, and whether or not you did them correctly.

A physician reads and scores your note based on some unknown criteria.

If you read FA for the CS you get an idea of that they are probably looking for.

Examine the correct body part, examine it correctly. Take the history as you normally would. Write the note the way you normally would. Instead of SOAP its more to-the-point.... S-O-DDx-investigations.

Wash your hands, speak English, be excessively polite, tell the patient what you think, ask if they have questions (they usually will).

You'll do fine.

 

[Medstudentquest]

Nobody knows exactly how the exam is scored.

The SP fills out a checklist of things that you did/didnt do, and whether or not you did them correctly.

A physician reads and scores your note based on some unknown criteria.

If you read FA for the CS you get an idea of that they are probably looking for.

Examine the correct body part, examine it correctly. Take the history as you normally would. Write the note the way you normally would. Instead of SOAP its more to-the-point.... S-O-DDx-investigations.

Wash your hands, speak English, be excessively polite, tell the patient what you think, ask if they have questions (they usually will).

You'll do fine.

I'm just concerned because some of the ddx they have and the workup is just plain wacky! Some of the stuff I've seen on First aid just makes no sense and they even say, this is unlikely. I am freaking out because what if I can't figure out what the patient has? Also I'm worried because 15 mins. to do everything is not alot and it's hard to do things like a mini mental and a neuro exam in 7 minutes or something. Also if I can't figure out the ddx by the time that the "counseling" is done, what am I going to say? Or what if I give them the wrong diagnosis?

Ok, I guess I'll go back to finishing up studying before my exam. I hope it goes well!!!!

 

[Elfy]

Ok, I guess I'll go back to finishing up studying before my exam.

Weren't you supposed to take it today or something?

Yes, some of the random stuff in FA doesn't make sense, especially in those not-so-crammable mini-cases. But most of it does (at least for the Step 2 CS book, which is very dense and is supposed to refresh your theoretical knowledge base, not just help you brush up on your interpersonal skills). There are other prep books with practice cases, as you probably know since you mentioned you had the Kaplan material as well. If you find yourself stuck, just switch to another book. The rest of your post deals with administrative aspects of this test that none of us on SDN are able to fix.

 

[Medstudentquest]

Weren't you supposed to take it today or something?

Yes, some of the random stuff in FA doesn't make sense, especially in those not-so-crammable mini-cases. But most of it does (at least for the Step 2 CS book, which is very dense and is supposed to refresh your theoretical knowledge base, not just help you brush up on your interpersonal skills). There are other prep books with practice cases, as you probably know since you mentioned you had the Kaplan material as well. If you find yourself stuck, just switch to another book. The rest of your post deals with administrative aspects of this test that none of us on SDN are able to fix.

Oh-do you think FA for Step 2CS is no good? That's what I've been using! I take it this week. Its' too late to change anything as far as study materials. I read through the Kaplan booklet once and it was pretty useless. I will be finishing the mini cases tomorrow. Oh well I'll do the best I can.

 

[Elfy]

I don't think FA for Step 2 CS is no good. It certainly flows smoother and is more readable than the old FA for Step 1 (not talking about the two newest FA books, basic science and organ systems for Step 1, those rock). FA for Step 2 CS does have some glitches, though, as you noticed. Most US seniors like yourself use FA only and do well.

What Kaplan booklet are you referring to? There are 2 Kaplan books with 35 practice cases each: Step 2 Clinical Skills and Step 2 CS Complex Cases. There's no single good book for this test.

 

[howelljolly]

FA does have some unlikely DDx, by their own admission. I think that they might be "common wrong answers", and readers would benefit in knowing why they are low on the differential.

Remember, you dont have to be perfect, and you dont need 5 DDx per case to pass... you can come up with fewer than that.

And yeah, the neuro exam will chew up your time. I know people that have had 3 neuro cases. Yikes.

My question is, how much of the physical exam do you do? You are supposed to do a focused physical related to the case. I just dont get how you can get away with that. For a cardiac case, how do you not examine the skin, mucous membranes, extremeties...?

 

[abbaroodle]

HJ: for a cardiac case, I would definitely include listening to the neck (even though in real life it is a totally unreliable PE finding!), looking for edema/pulses, quickly listening to lungs in some cases (CHF). For an arhthmia if I am thinking about hyperthyroid I would check reflexes for example but probably not the rest of the neuro exam. Again, whatever I would do in real life. I would start where the money is and if you have time go to more remote parts of the PE.

MSQ: Keep it simple. First Aid CS is fine. As stated, no one knows how many pts you get for anything or what you really need to do and it ultimately doesnt matter - just do the best you can. Dont over think it!

(I did fill out my DDx and w/u 1st since I didnt want to run out of time on them and I also thought of others while I was typing. But I dont know how the score is done.)

There are some weird DDx in FA. (ED comes to mind as one of them.) Dont sweat it. Just use it to remind yourself of what you know and dont focus on what you dont. I wouldnt use this as a good time to learn random zebras! All my cases were common things and cc's I saw in med school. I guess a pt with diarrhea could have some weird amoeba that I have never heard of, but I think asking about travel/camping and sick family members and including O&P on w/u and "parasitic diarrhea" on DDx is probably sufficient.

I dont know what percentage of things you need to do right to pass, but that threshold seems to be pretty reasonable given that 97% of people pass. A lot of cases you wont know the diagnosis when you leave. Just throw out a few things. You can probably be pretty vague in your counceling. Dont worry if you miss something. Just list it on your DDx in your note and move on.

 

[Medstudentquest]

HJ: for a cardiac case, I would definitely include listening to the neck (even though in real life it is a totally unreliable PE finding!), looking for edema/pulses, quickly listening to lungs in some cases (CHF). For an arhthmia if I am thinking about hyperthyroid I would check reflexes for example but probably not the rest of the neuro exam. Again, whatever I would do in real life. I would start where the money is and if you have time go to more remote parts of the PE.

MSQ: Keep it simple. First Aid CS is fine. As stated, no one knows how many pts you get for anything or what you really need to do and it ultimately doesnt matter - just do the best you can. Dont over think it!

(I did fill out my DDx and w/u 1st since I didnt want to run out of time on them and I also thought of others while I was typing. But I dont know how the score is done.)

There are some weird DDx in FA. (ED comes to mind as one of them.) Dont sweat it. Just use it to remind yourself of what you know and dont focus on what you dont. I wouldnt use this as a good time to learn random zebras! All my cases were common things and cc's I saw in med school. I guess a pt with diarrhea could have some weird amoeba that I have never heard of, but I think asking about travel/camping and sick family members and including O&P on w/u and "parasitic diarrhea" on DDx is probably sufficient.

I dont know what percentage of things you need to do right to pass, but that threshold seems to be pretty reasonable given that 97% of people pass. A lot of cases you wont know the diagnosis when you leave. Just throw out a few things. You can probably be pretty vague in your counceling. Dont worry if you miss something. Just list it on your DDx in your note and move on.

Thanks for your suggestions. I am freaking out though. I studied a long time today and not sure if it's the fatigue or my normal test anxiety but in the evening I decided to switch my test date. Ugh. I have looked at the cases and the *mini cases* in FA several times, but for whatever reason, I was completely blanking today and between the far out ddx and the worry, I figured it would be best to switch. I don't know if i should keep studying or just take it. I have it scheduled for next Monday. I am wondering whether I should review things once more and just take it then because otherwise I'll just keep pushing it forward.

 

[howelljolly]

Thanks for your suggestions. I am freaking out though. I studied a long time today and not sure if it's the fatigue or my normal test anxiety but in the evening I decided to switch my test date. Ugh. I have looked at the cases and the *mini cases* in FA several times, but for whatever reason, I was completely blanking today and between the far out ddx and the worry, I figured it would be best to switch. I don't know if i should keep studying or just take it. I have it scheduled for next Monday. I am wondering whether I should review things once more and just take it then because otherwise I'll just keep pushing it forward.

just take it

this is just a matter of practicing. and you've practiced on the wards. you won't gain much more by reading the cases over and over again.

remember to be specific in your orders, and to "order" pelvic and rectal exam if its warranted.

wash your hands

speak english

say please and thank you

and JUST TAKE IT

 

[Medstudentquest]

just take it

this is just a matter of practicing. and you've practiced on the wards. you won't gain much more by reading the cases over and over again.

remember to be specific in your orders, and to "order" pelvic and rectal exam if its warranted.

wash your hands

speak english

say please and thank you

and JUST TAKE IT

I should. But it's kind of difficult to get psyched for a test like this especially because since I had the whole issue with the rank list issue and couldn't get a spot, it's sort of pointless, especially since I haven't been able to find anything after the match. Not really much of a difference if I have to wait until next year to get a spot. 🙁

 

[Antoni B]

MSQ,
You really have to get a grip on yourself. You've gone from "I freaked out" to "it's kind of difficult to get psyched for a test..." already. Take some deep breaths and think rationally about this exam.

97% of AMG's pass. 97%. That probably includes you, even if you don't memorize the First Aid for 2CS differential lists for every possible condition. You do not need to be even close to perfect; in fact, I'd say that the biggest problem I had with the exam is that I tried to do everything and nearly ran out of time. And despite running behind on almost every case and mildly freaking out about it, I still passed.

So, I hate to be mean, but quit belly-aching and, as Howell-Jolly said, just take it.

 

[Medstudentquest]

MSQ,
You really have to get a grip on yourself. You've gone from "I freaked out" to "it's kind of difficult to get psyched for a test..." already. Take some deep breaths and think rationally about this exam.

97% of AMG's pass. 97%. That probably includes you, even if you don't memorize the First Aid for 2CS differential lists for every possible condition. You do not need to be even close to perfect; in fact, I'd say that the biggest problem I had with the exam is that I tried to do everything and nearly ran out of time. And despite running behind on almost every case and mildly freaking out about it, I still passed.

So, I hate to be mean, but quit belly-aching and, as Howell-Jolly said, just take it.

Antoni, the thing is that I tend to be the exception to everything! I mean I realize that 97% of AMG's pass, but then again well over 90% of AMG's match, and because of the screw up, I didn't. So I would really hate to be part of the 3% who don't pass CS.

 

[Antoni B]

Antoni, the thing is that I tend to be the exception to everything! I mean I realize that 97% of AMG's pass, but then again well over 90% of AMG's match, and because of the screw up, I didn't. So I would really hate to be part of the 3% who don't pass CS.

I'm sure it seems like that, and I also worried about being part of that 3%. But, you've got to step back and think clearly about it. Did you do well in your clinical clerkships? The OSCEs you had during that time? I'm sure you did. CS is not much different than exams you've probably already had. If anything, it was easier than my medical school's standardized patient-based exams.

So you made a terrible mistake in putting together your Match. I remember reading about that, and I feel terrible for you. I don't know how many times I double-checked my own match list to make sure something similar didn't happen to me. But one thing going wrong has no bearing on anything else unless you let it. The only way you will end up in that unfortunate 3% is if you freak out, lock up, try to do a 45 minute complete H&P in a 15 minute visit, and get lost in a herd of zebras when all they're really testing is common stuff. I know it's tough to believe, but CS is there to make sure you're a competent clinician--not a genius-level one.

No more rescheduling; no more beating yourself up over things that you can't change. Walk in that testing center confident that what you learned in medical school translates into good clinical practice. You've already, based on your previous posts, studied/prepared more than 97% of other American medical students for this exam. Why would they pass and you not?

 

[Medstudentquest]

I'm sure it seems like that, and I also worried about being part of that 3%. But, you've got to step back and think clearly about it. Did you do well in your clinical clerkships? The OSCEs you had during that time? I'm sure you did. CS is not much different than exams you've probably already had. If anything, it was easier than my medical school's standardized patient-based exams.

So you made a terrible mistake in putting together your Match. I remember reading about that, and I feel terrible for you. I don't know how many times I double-checked my own match list to make sure something similar didn't happen to me. But one thing going wrong has no bearing on anything else unless you let it. The only way you will end up in that unfortunate 3% is if you freak out, lock up, try to do a 45 minute complete H&P in a 15 minute visit, and get lost in a herd of zebras when all they're really testing is common stuff. I know it's tough to believe, but CS is there to make sure you're a competent clinician--not a genius-level one.

No more rescheduling; no more beating yourself up over things that you can't change. Walk in that testing center confident that what you learned in medical school translates into good clinical practice. You've already, based on your previous posts, studied/prepared more than 97% of other American medical students for this exam. Why would they pass and you not?

You definitely have a rational view point. Im just pretty scared and it would be really really bad if I failed this thing. Yes I've done well in clerkships and from what I know I've done well in OSCE's. I was thinking of doing a very thorough PE for the SP's since I didn't want to lose any points, especially since CS FA says to do a very thorough PE for some cases. But I'm not sure you could do a full PE in 3-5 mins.

Should I read everything through once more at this point? I feel like the info is not sticking.

I do have, even normally for tests, a high degree of test anxiety. Obviously in med school it's not like you have much of a choice of when the test is-but the fact that I can keep changing the date, especially since I don't have a position at this time, makes this different.

 

[Antoni B]

MSQ,

I know it's hard to look at this from a detached perspective. I also have a ton of test anxiety--I hardly slept the night before the CS exam. But when I walked into that testing center, I looked around at the other 23 people taking the exam and realized that they were all in the same boat I was. And despite utter sleep deprivation and being unable to think straight, I still passed.

I always feel like the info isn't sticking, even though all the evidence points to the contrary. It's natural to feel that way--I bet you do before a lot of exams. But once the initial rush of adrenaline settles down, it will come to you. If it makes you feel better to look back through First Aid right before the exam, it wouldn't be a bad thing. But imagine how much better you'd do if, somehow, you managed not to be a nervous wreck?

As for doing a comprehensive, detailed PE on some cases, there simply isn't enough time. But there is enough time to do a focused, detailed exam of specific systems. Just think about what you would do if it were a busy clinic day and you knew you had to get through patients every 15 minutes. Use common sense.

 

[peppy]

Also remember that you do not have to do everything perfect to pass. A lot of people pass even when they made some mistakes during the test.
Just try your best and if it doesn't work out then you will likely pass on the retake. That would not be the end of the world - a lot of people have done that.
Good luck!!!!

 

[Medstudentquest]

Also remember that you do not have to do everything perfect to pass. A lot of people pass even when they made some mistakes during the test.
Just try your best and if it doesn't work out then you will likely pass on the retake. That would not be the end of the world - a lot of people have done that.
Good luck!!!!

Well it's taken, so I guess it is what it is! It's just hard to know what they wanted for certain cases, and I'm concerned about whether I did all the PE parts they wanted. I may have missed some I think. I'd love to know how the scoring works and which encounters don't count! I guess it will be a long time to wait until scores come back. I just hope I passed!!

By the way, did you see that a psych spot opened up?

 

[funshine]

Quick question about CS: Do we really elicit the gag reflex in patients when checking for CN 9/10 function? I am unsure b/c at my school, we're not supposed to really gag them, just go through the motions.

Also, we could give them a drink of water and technically that would test CN 9 and 10 too...

 

[peppy]

By the way, did you see that a psych spot opened up?

I sent you a PM about this. Thanks for the heads up.

Do we really elicit the gag reflex in patients when checking for CN 9/10 function?

I think a good rule of thumb is: Don't do anything that could be uncomfortable for the standardized patient.

 

[Law2Doc]

...
I think a good rule of thumb is: Don't do anything that could be uncomfortable for the standardized patient.

I wish you'd said that before I did that needle thoracostomy. 🙂