Blood-and-thunder appearance
7+ Year Member
Oct 20, 2012
Up on the Hydra's back
Resident [Any Field]
In 2014, 56 DO students took the USMLE Step 2CS, with a 93% pass rate -- numbers which are roughly consistent with the past several years as well. Being among such a niche group, I thought I'd give my experience as a DO student taking the Step 2CS. I'm expecting much of my audience will be discovering this thread through the search function years in the future, so I'll try and write with that in mind. Even if I may no longer be an active user when you're reading this, feel free to shoot me a PM for further questions and I'll try and reply.

A bit about myself: Did poorly on mock patient encounters in MS1, then did average thereafter. Good to excellent MS3 evals. 260+ USMLE Step 1 and 2CK. Average charisma around patients. Native English speaker.

My preparation:
I took the Step 2CS in summer 2015, and it was the first of the four Step 2 tests I took (the others being Step 2CK and both COMLEX). My school's scheduled preparation was actually scheduled after when I took this test, so I didn't have the benefit of having it going into it. I read the 20-page USMLE official bulletin on the exam twice (once the night before), and watched the informational video that they show on test day. I bought FA for Step 2CS (5th ed) and spent a couple hours 7 days out reading the introductory stuff and everything except for the rapid review cases and full cases. This was by far the most helpful to me, because it familiarized me with the scoring, process, and structure of the exam. Most importantly, it gave me the subtle insight necessary to inject my history and physical with little pearls that would score points. The cases were therefore of lesser benefit, in my opinion. I begrudgingly did 6 cases the day before my exam, and that was the entirety of my preparation (~10-15 hours). I stopped so soon because once I got familiar with the timing and practicing doing a patient encounter the way this exam wants you to, there was no added benefit to doing more cases. After all, what was I going to learn in <50 cases that I didn’t learn in almost a year of seeing patients?

Despite the overall tone of this post, I want to caution against this approach. Prepare as long as you think you need. The exam has unique twists and some very different components (e.g. wrapping up with and counseling with the patient is huge) that need to be studied for. But I wanted to give my anecdote for the person who can’t bear the thought of slugging through a ton of cases when they already would have felt ready to go if rumors about this test didn’t scare them.

My experience:
I was fortunate enough to have a testing center nearby where my family lives, so I spent the night with them and drove a couple hours to the testing center. I went out of the way to be social, as I anticipated the 10-minute and 30-minute breaks would otherwise be stressful, slow, and awkward without socialization. This really made the day better.

Standing at the door waiting for the 1st encounter of the day to start was the hardest my heart had beat for a long time. I closed my eyes, and made myself pretend I was just seeing a real patient. That worked very well. I made a couple minor omissions in history/physical information gathering in the first two cases that I ran through in my head while waiting for the time to finish up writing my notes. I fixed these mistakes in the next 10 cases. On every case, I took the following history and almost never anything beyond:
(Mother, Father, siblings)
Social history: (smoking, alcohol, sexual activity, STIs, illicit drug use. If female: pregnancies, LMP, and menopause)

I consistently finished very early, and was the first out on 2-3 cases. I seemed to spend about 5-7 minutes on the history, 2-3 minutes on the physical, and 1-2 minutes wrapping up. I finished before the warning on several cases. While practicing, time was very much an issue, but that was because I practiced with non-medical family/friends who had delays in answering and didn’t know their script. I assure you, things are very efficient in the test-day patient interview. Because of the speedy encounters, I had plenty of time to write my notes, which probably took me 8 minutes on average.

I felt that I had excelled in 3-4 cases, screwed up a part of 2-3 cases, and performed normally on the rest. I had minor omissions and imperfections on every case. I was a bit unnerved by both how simple and how repetitive my physical exams were. I did heart + lungs for every patient (which was literally just me auscultating in 2-3 spots for heart, then 4 spots for lungs…no other maneuvers), then maybe 1-2 systems after that. There were only 4 other systems I did physical exams for. These extra exams were cursory as well; for example, my abdominal exam was 4-quadrant bowel sounds, quick palpation all over, and a couple of tests/signs if indicated (even then, I forgot to do some of these tests/signs on an in-your-face obvious case where they would be indicated). I was concerned that I took their official recommendation to be focused/quick a little too far.

I was fortunate enough to only have one awkward moment where I mentally panicked recalling something I forgot from the previous case and had to have the patient repeat everything he just said. Other than that, all interactions were fluid, natural, and full of juicy little morsels of patient empathy and patient-centered/team-based practice. I sanitized my hands before starting every physical, always introduced myself properly (FYI I chose to do so as a doctor, not med student), helped them move, used respectful draping, and put the foot stand out when having them lie down.

In summary, I treated patients exactly like I would if they were real patients in a clinic, plus some small things like draping, asking permission once or twice, and being mindful of auscultating on direct skin. I didn't do any of that "I'm SO sorry this is happening to you...let's work together to get you better! :D" or "I'm going to look at your eyes now...I'm going to look at your chest now...I'm going to take my stethoscope off my neck now..." silly stuff that people obsess about. I just acted like a normal person. If they told me a family member died prematurely, I would pause my interview, say I was sorry to hear it, and ask if that was difficult for them. If they were angry/agitated, I paused the interview and and addressed it. Walking out of the exam, I felt very good. I would never have given this exam a second thought if SDN didn’t instill fear in me.

I didn't absolutely kill the test, but I passed by what I guess is probably a healthy margin. SEP was the highest score possible (my proudest accomplishment in my medical career thus far), while ICE and CIS touched the "borderline" band by a star or two.

General comments about the test:
-One-dimensional cases: There is only one complaint, and it is probably textbook in presentation. There are probably 1-2 interesting differentials based on what you elicit from the patient's history.

-Bread-and-butter cases: They’re not lying when they say they try and pick common patient encounters. I’ll tell you what won’t happen on the Step 2CS – you won’t get someone with the complaint of “itchy lung” or “bleeding toenail” or some BS that is either really weird or rare. You won’t have to contort your differential to fit what the patient is saying. The way it worked for me was that 2-5 things come to mind instantly before entering just off the CC, then by asking 1-2 key questions accordingly for each DDx, you confirm a diagnosis with relative solidarity.

-No-nonsense responses: Patients answer efficiently and quickly, without wasting your time. If you ask a general question about illnesses in their family, they’ll rattle off every important point about their family -- no bit-by-bit withholding for not explicitly asking a bit of information.

-“Tricks” are typical: The “difficult” questions that most standardized patients ask are things we’ve all heard before on rotations. “How does this medication work?”, “What should I expect with this treatment/disease?”, etc.

Comparison to COMLEX Step 2PE:
They are very similar tests, as to be expected. The time constraints are more limiting on the COMLEX, but only mildly so; my performance and timing was not affected. The cases are even more stereotypical/textbook. The patients throw you off less with their attitudes and questions. The differentials are more narrow, and the diagnosis is more obvious. In summary, the medicine is easier.

However, the inclusion of OMM can be a little nerve-wracking, and was definitely my weakest part. I basically just crammed Savarese the night before and then did the same thing as I did on the USMLE. I would recommend being a little more careful with the OMM than I was (give it a full day or maybe more) especially if it's a weak subject of yours, like it is for me. Patients make it rather clear when OMM is indicated, so you don't have to stress about when to do OMM, at least.

Be mindful in the differences of what they're looking for in COMLEX vs. USMLE by reading the NBOME bulletins and instructional content. There is nowhere near the same emphasis on "wrapping up" on the COMLEX as there is on the USMLE. Note writing is completely different. Being aware of these changes by reading the official instructions/recommendations is perhaps the most important part of your preparation.

I didn't buy a COMLEX-specific book, and just relied on my studying from FA Step 2CS roughly 1.5 months prior. I didn't even review FA Step 2CS before my test; my pre-COMLEX Step 2PE studying was simply the aforementioned Savarese cramming. All in all, my comments and suggestions for the USMLE Step 2CS translate well to the COMLEX Step 2PE.

Best of luck, everyone!

Disclaimer: None of the information or examples in this post are taken directly from the content within my exam.
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Blood-and-thunder appearance
7+ Year Member
Oct 20, 2012
Up on the Hydra's back
Resident [Any Field]
What is the utility of taking the CS exam as an osteopathic student? Or did you take it more for the experience?
There's not a whole lot of utility. Anecdotally, I've heard that some residency program directors for allopathic programs "appreciated" a DO applicant who took the CS -- whatever that means.

As a separate but closely related issue, taking USMLE Step 1 and both parts of Step 2 is the only way to take USMLE Step 3, which some say may help when applying for allopathic fellowships after allopathic residency. Some also say that taking the full USMLE series may help when attempting to practice overseas, in some way that is unclear to me.

I personally took the USMLE Step 2CS for the following reasons:
-Unpredictability of the future in the face of the residency merger
-Not wanting to have to think about the confusing situations that occur when you cherry pick USMLE exams as a DO student
-The minor benefits mentioned above
-Minor benefits that I may not know about or understand

Only consider taking it if you're applying for allopathic residency, of course. And further, you probably shouldn't bother if you're not planning on doing an allopathic fellowship.

Further reading:
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