USMLE Took CS twice. Willing to help anyone.

[Uhl88]

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[Phloston]

Hi Dvleeman,

Thanks for being so kind as to help others on this forum.

1) Do you have any big tips regarding empathy / communication skills?

2) Is there anything you did (or didn't do) the second time that made a difference relative to the first?

Thank you for taking the time to address these questions. But I understand if you're busy.

Phloston

 

[ShenMeYiSi]

I took CS recently and my prep was solely based on FA cases and the kaplan core cases book. They're both solid resources for content and practicing with a partner. I felt like the cases on the real test were pretty similar to the basic and standard ones in the books. I took a mock test with a company early in my prep and was completely blindsided by the kinds of cases and challenges that were presented, but after a few weeks of timed practice and utilizing the feedback I got from the SPs on my mock test, I sort of felt like there was not much else I could do but be nice and be myself on test day. I guess that's the best advice? Write a good note as well, of course. Practice writing it within 8-10 minutes even if you are a fast typer, you have to be prepared for things like not being used to typing on an older fashioned keyboard and things like that.
My test experience was weird - It's really hard to gauge how you might have done or what kind of an impression you might have made on an SP, whether they liked you or not, and it even left me second guessing myself as to whether or not I had completed all my tasks in the room.
With regards to the empathy stuff - I feel like the best way to go about it is to be as organic as you can be, if you were talking to a friend or someone you cared about, and they tell you something that's bothering them, genuinely express your interest and facilitate them to expand on that if you feel like it would help you understand them/their condition better, or simply express your sympathy/extend a helping hand and offer to help them work through it. That's it. You don't need to be over the top about things like that, you really just have to focus on gaining their trust since that will make them more likely to tell you things that may be important in a patient encounter. Make them feel important, and that the time they have with you is time that you are 100% dedicated and listening to them.
I felt like the SPs were willing to volunteer information and they were personable for the most part. I was usually able to get 2 diagnoses and workups done without hesitation, but for some cases, a 3rd dx was kind of hard to find, which I think is okay. Naturally, I worry that things might have gone too smoothly and I'm overestimating my performance, but then again maybe that's really just the essence of the exam? Here's hoping. Won't find out til mid-July anyway. Good luck to all of you!

 

[Phloston]

I took CS recently and my prep was solely based on FA cases and the kaplan core cases book. They're both solid resources for content and practicing with a partner. I felt like the cases on the real test were pretty similar to the basic and standard ones in the books. I took a mock test with a company early in my prep and was completely blindsided by the kinds of cases and challenges that were presented, but after a few weeks of timed practice and utilizing the feedback I got from the SPs on my mock test, I sort of felt like there was not much else I could do but be nice and be myself on test day. I guess that's the best advice? Write a good note as well, of course. Practice writing it within 8-10 minutes even if you are a fast typer, you have to be prepared for things like not being used to typing on an older fashioned keyboard and things like that.
My test experience was weird - It's really hard to gauge how you might have done or what kind of an impression you might have made on an SP, whether they liked you or not, and it even left me second guessing myself as to whether or not I had completed all my tasks in the room.
With regards to the empathy stuff - I feel like the best way to go about it is to be as organic as you can be, if you were talking to a friend or someone you cared about, and they tell you something that's bothering them, genuinely express your interest and facilitate them to expand on that if you feel like it would help you understand them/their condition better, or simply express your sympathy/extend a helping hand and offer to help them work through it. That's it. You don't need to be over the top about things like that, you really just have to focus on gaining their trust since that will make them more likely to tell you things that may be important in a patient encounter. Make them feel important, and that the time they have with you is time that you are 100% dedicated and listening to them.
I felt like the SPs were willing to volunteer information and they were personable for the most part. I was usually able to get 2 diagnoses and workups done without hesitation, but for some cases, a 3rd dx was kind of hard to find, which I think is okay. Naturally, I worry that things might have gone too smoothly and I'm overestimating my performance, but then again maybe that's really just the essence of the exam? Here's hoping. Won't find out til mid-July anyway. Good luck to all of you!

Were there any things you forgot to do / write up of arguable importance for any of the encounters?

I'm going through the FA cases now, and I find that for every case it seems as though there's always something I might forget to ask or write up. I know it's been said this exam is more about efficiency and less about perfection, but I'm curious as to your thoughts because you seem pretty confident about things.

 

[ShenMeYiSi]

Were there any things you forgot to do / write up of arguable importance for any of the encounters?

I'm going through the FA cases now, and I find that for every case it seems as though there's always something I might forget to ask or write up. I know it's been said this exam is more about efficiency and less about perfection, but I'm curious as to your thoughts because you seem pretty confident about things.

That's a good question since I felt like my entire day was too smooth and it left me feeling like I made some serious blunders because I was under the impression I'd have to struggle a lot more. I was able to finish my encounters with 2-3 minutes to spare, and sometimes nearly 5 minutes because some of the SPs hammer home their script quickly and you get the answers to your most important questions without digging too much. I was able to do a full review of systems for everyone and usually nothing pops up that they haven't already told you. They'll ask challenging questions, and you either know how to answer them by reading the FA sample ones, or using your best judgement and common sense to answer them, which shouldn't be that hard. In my case, they were generally happy with my answers, I felt.
Where I felt like I should have paid more attention, or practiced in much more detail, were focused physicals for joints and neuro cases. I practiced a lot of full heart and lung exams and ended up missing a few pieces here and there with those on test day. Since I had time to spare, I should have utilized those minutes to do a more thorough exam in areas of interest and I feel like in the interest of time, and in the back of my head knowing I was only going to find normal things, I glazed over those and now wish I hadn't. Again - efficiency over perfection, definitely, but for the sake of completeness, if I had to do it again, I'd practice more physicals.
Documentation wise, I felt comfortable with most of it. The DDx and workup are worth the most points, so since you are reading FA, practice the mini cases by covering up the ddx and workup and guessing them because I found that helpful. The HPI should tell a story that lines up with your ddx in chronological order and I'm not sure I was able to do that since I had no time to edit and double check, but generally if you tell the story in a logical manner, you should be fine.

 

[Phloston]

That's a good question since I felt like my entire day was too smooth and it left me feeling like I made some serious blunders because I was under the impression I'd have to struggle a lot more. I was able to finish my encounters with 2-3 minutes to spare, and sometimes nearly 5 minutes because some of the SPs hammer home their script quickly and you get the answers to your most important questions without digging too much. I was able to do a full review of systems for everyone and usually nothing pops up that they haven't already told you. They'll ask challenging questions, and you either know how to answer them by reading the FA sample ones, or using your best judgement and common sense to answer them, which shouldn't be that hard. In my case, they were generally happy with my answers, I felt.
Where I felt like I should have paid more attention, or practiced in much more detail, were focused physicals for joints and neuro cases. I practiced a lot of full heart and lung exams and ended up missing a few pieces here and there with those on test day. Since I had time to spare, I should have utilized those minutes to do a more thorough exam in areas of interest and I feel like in the interest of time, and in the back of my head knowing I was only going to find normal things, I glazed over those and now wish I hadn't. Again - efficiency over perfection, definitely, but for the sake of completeness, if I had to do it again, I'd practice more physicals.
Documentation wise, I felt comfortable with most of it. The DDx and workup are worth the most points, so since you are reading FA, practice the mini cases by covering up the ddx and workup and guessing them because I found that helpful. The HPI should tell a story that lines up with your ddx in chronological order and I'm not sure I was able to do that since I had no time to edit and double check, but generally if you tell the story in a logical manner, you should be fine.

How do you know the DDx and workup are worth the most points; is there a printed grading scheme somewhere?

Thanks again for your time in addressing my questions.

 

[ShenMeYiSi]

How do you know the DDx and workup are worth the most points; is there a printed grading scheme somewhere?

Thanks again for your time in addressing my questions.

Sure!
I took a mock test/short course with a company, and for an hour or so on the first day, we were given a session about the basic breakdown of what the test is like, how it's graded and what's expected of you, and that's when they said now that the CS exam has changed (I guess that's recent, like within the past year or so), there is a greater focus on the content of the note and proper documentation, so that's how I have that information. I never searched for a rubric or grading scale of any kind, but I doubt there is a published one anywhere.

 

[Phloston]

Sorry for the late reply. I took this test twice, and hopefully not a third time. Per my dean and the OSCE professor, I should be more than fine, but than again, this test is barely an objective assessment. Therefore, I living like an anxious wreck right now but.. who knows. Anyways, I know that when I was taking the test first time, I was too focused on getting all the question - attempting to not just get all the history but also getting extraneous answers to irrelevant findings. Certainly, this unfocused approach to history probably hurt my ICE as it was lying near the borderline and failure. I also forgot to take out the leg extension for all my abdominal exam, which also added to the poor ICE. Forgot to do any thyroid exam, didn't do very much any MSK PE maneuvers, didn't do an appropriate CV exam by auscultating side to side but rather completed one side after another. My notes were complete and sometimes beyond the character limit, but I feel like my notes also suffered because it was not focused. I had too many superfluous details that weren't related to the diagnosis or the CC. Also, I tried to fill all three diagnosis for all the cases, which probably hurt since they weren't well supported with hx findings. I also had too many unnecessary diagnostic workup, much more than required for the initial assessment (e.g., having both MRI and xray for some bone injury). I believe these all added to the poor ICE performance since the USMLE specifically notes what they look for in the PN. I don't think my ddx were too off, since I felt that most of the HPI were very straight forward in most cases. Regardless, all these contributed to the poor performance, and my ICE was literally a bar from failing. Also, I took the test in Philadelphia.. don't know this this contributed to anything but the floating myth is that it has the highest fail rate.. Anyhow, the component I failed was the CIS, and this is really because I had no idea what they were looking for. I should have studied the Kaplan book on this, but I completely neglected the components of the CIS but instead thought "just be nice and I should be fine." I just threw some "I am sorry to hear that, that must be rough" and really didn't do anything else. I think my mannerism was also kinda rude, since I was too focused on obtaining the history and I know my focused face doesn't look too happy. My closure was also very vague and wasn't prepared, I ended up fumbling through words and using medical jargon. I always summarized and paraphrased, but forgot to wash hand for one case and didn't maintain eye contact but was too focused on the blue sheet. I didn't nod, didn't use much gestures, didn't warm the stethoscope, didn't use any open ended questions except for the first question, didn't answer the challenging questions very well since I didn't read FA on this part. Funny thing is when I was reading the test center, I thought the test was ridiculously easy and therefore there was no way I would fail the darn thing. Well few months later, I was quite shocked to find both my ICE and CIS to be very low, with CIS failing and ICE barely passing.

Second time around, I changed a lot of things. I practiced with five friends who passed the test with flying colors, worked with my OSCE professor who is a guru when it comes to this exam. She had helped multiple classmates successfully remediate (for some reason this year we had quite a large number of students fail... this may be due to the increased passing threshold for CIS and ICE) During practice, I focused on both the ICE and CIS. I made sure to auscultate properly, symmetrically from right to left. I made sure to be focused with the PE. No wasting time doing unnecessary exams. Same thing with the history. Only relevant history, no ridiculous ROS unrelated to CC. With regards to CIS, I made sure to practice writing while maintaining eye contact. I used shorthand which substantially reduced the time spent on looking at the paper. Matter of fact I barely looked at the paper while talking to the patient. I made sure to let the patient explain the history by using multiple open ended questions. My voice was more empathetic, I had better bedside mannerism, and the language was kind and genuine. During preparation, I scored perfectly on the communication part from the SPs who were grading me. And after 4 weeks of thorough preparation, I took the test again, this time in Atlanta. Except for one angry SP, all the SPs were receptive and kind. Nevertheless, I made several mistakes during the test, such as forgetting to use the sanitizer for one case due to getting off my rhythm, forgetting MMSE and neuro exam when they may have been warranted, flustered and rushed through one case, put 3 ddx for like 4, 1 for 2 cases, and rest 2 ddx, felt like i forgot ton of hx questions for several cases, missed PE maneuvers for some cases, forgot some diagnostic tests such as rectal and pelvic exam for one case, didn't ask some social history questions like exercise, diet, lifestyle, living condition, safety although I didn't have any abuse case, forgot to counsel some smoking pts or pts using marajuana, didn't use enough medical terminology in the PN (wrote vomiting instead of emesis), probably missed documenting few PE that I did and I wrote some ROS hx that I wasn't sure if I asked, since my note were kinda messy (again, didn't look at the paper to maintain eye contact)... and overall I worried about the quality of my PN.

On the bright side, I know there were several things I improved from the previous test, which includes:

- kept everything very focused. both the history and the physical exam, although I did end up asking chest pain, sore throat, heart palpitation, SOB for most of the pt since I always did cardiopulm auscultation

- was generally empathetic, whenever doing the abdominal exam, I always asked the pt if he/she felt comfortable lying on the exam table, pulled out the extension, and when helped the pt sit back up, ask the pt the pt is comfortable lying on the table.

- draped the pt appropriately, exposing only the the minimum skin, untied and tied the gown back appropriately and folded the gown to expose the back and the chest for ascultation

- washed hands for all cases except 1, always knocked and introduced/ smiled/ shaked hands/ always asked 3-4 open ended questions and maintained eye contact while pt talked, used transitional statements when switching from HPI to ROS to rest of the hx such as "well Mr/Mrs, I want to now ask you few questions about your general health, would that be okay?", also told the pt "Mr/Mrs so and so, I wanted to let you know that everything we talk is going to remain confidential, but i wanted to ask you few questions about your sexual practices" before asking about sexual hx

- counseled pt when I could, asked CAGE for all drinkers (may have been unnecessary) but I said it in the way of "so, Mrs/Mr so and so, here are few questions we ask all pt who drink.. do you mind if I ask those questions?"

- smiled when leaving the room if the pt encounter was good, always left saying "Thank you for letting me serve you today, I hope you feel better soon"

- did LIQRAAA ODFP for all pain pts

- asked for more details every time I finished closed ended-questions, summarized after finishing history, always told the pt what physical exam I was going to do

- I told the pt what I was doing while I was doing the physical exam, auscultated heart and lungs for all patient including the PMI for female pt by asking the pt to lift her left breast

- palpated thyroid when appropriate, did abdominal exam (inspection, auscultation, palpation, percussion) when appropriate with additional manuevers,

- did additional MSK maneuvers along with ROM, sensation, pulses, strength, DTRs for 2 MSK cases I think

- always finished closure with what I thought the concerning ddx were for the CC, the diagnostic tests I was going to order, and left the room with about a min (average) to spare

- always finished pmhx, pshx, shx, fhx, meds, allergies along with the HPI

- answered challenging questions appropriately

- explained all things in layman terms even after using the medical terms

- pretty certain i got main diagnosis and few ddx for 10/12 but not certain for the other 2..

Anyways, there were definite improvements and changes from my first attempt, my question is with the incredible subjectivity of the test, will any of these improvements help me pass the second time.. Anyways, sorry for the long read. I will make a separate post on list of things that definitely helps the CIS and ICE score. These recommendations are collected from multiple friends who passed the darn test with above average performance.. Anyways, I hope this is a bit helpful..

Thanks a lot for this detailed write-up. That's really helpful and nice of you to give feedback like that.

What I'm confused about is the DDx and investigations. In FA, it sometimes lists like 9 or 10 DDx and investigations for each case, and sometimes they're horrendously off. On the real deal, are we literally supposed to put just 2 or 3 for each? Because if that's the case, it makes no sense whatsoever that FA goes so overboard for each case.

And for your PNs, did you always follow a common structure (e.g., HEENT, neck, chest, etc.) regardless of the case, or were there times you just focused on what seemed most important?

Thanks again. I'm appreciative of any time you are willing to put forth to answer these questions.

 

[ShenMeYiSi]

Thanks a lot for this detailed write-up. That's really helpful and nice of you to give feedback like that.

What I'm confused about is the DDx and investigations. In FA, it sometimes lists like 9 or 10 DDx and investigations for each case, and sometimes they're horrendously off. On the real deal, are we literally supposed to put just 2 or 3 for each? Because if that's the case, it makes no sense whatsoever that FA goes so overboard for each case.

And for your PNs, did you always follow a common structure (e.g., HEENT, neck, chest, etc.) regardless of the case, or were there times you just focused on what seemed most important?

Thanks again. I'm appreciative of any time you are willing to put forth to answer these questions.

After having studied for a few months and talking to several people who took the exam before and around the same time as I did, what I gathered was that FA has a tendency to overdo it when it comes to listing the DDx, especially in the mini cases section. What I learned though was the reason why they sometimes take you for a ride like that, is that when you read the doorway information and see a chief complaint, your mind basically should auto-populate about 5-7 potential DDx before you even see the pt so that you can direct your questioning to gather the appropriate data. Some people don't like this method because it feels like pigeon-holing you into digging for a dx that YOU want to find, rather than letting the pt tell you the story. I, however, like this method because it prevents me from being disorganized in my approach to asking questions in a timed setting and I feel like I get the information I need that way. For the purposes of writing the note on test day, there are 3 blanks available to fill your top 3 DDx, but I've heard conflicting reports as to the benefits and pitfalls of actually filling out the 3rd DDx if you feel like it's a stretch. Some people say it's better to leave it blank if you find that you have to take a guess that might seem farfetched. I have no idea. I left the 3rd one blank for some of my cases and for some I legitimately had a 3rd possibility that I was able to support by history and ordering appropriate workup.

For the PEx, I generally follow the head to toe structure like you mentioned, but there are times, and you'll know this when you do the cases, where you have to focus on an extremity for example, or full neuro exam, or something else. I've also heard conflicting reports about this - some people say that every pt deserves a cardio/pulm exam because a cursory one doesn't take that much time, and some people say that if you are just evaluating a joint or extremity, then your heart/lung exam may be redundant. Again, I have no idea. I preferred to err on the side of completeness and ended up doing heart/lungs for everyone on my test.

Hope that helps.