USMLE What Does It Take to Fail CS?

[tco]

I realize these threads pop up every now and then, but I'm honestly curious. I just completed my exam yesterday, and realized as soon as I exited one particular room that I had made a huge mistake and forgot an entire section of the patient history (PMH including allergies, surgeries, and medications). I haven't done something like that since second year, and I don't know what I would have done to prepare differently to avoid it. I'm just accepting that I messed up and am trying to move on and plan appropriately.

Don't get me wrong, I also committed the usual mistakes that everyone realizes later - forgot to ask "this," did a shoddy neuro exam on "that" patient, etc. Did a poor job justifying my diagnoses with pertinent positives and negatives from the physical exam. However, I feel like forgetting an entire subsection of the history should be an automatic failure. If so, does anyone know how quickly is it possible for me to reschedule the exam? I need a passing grade to graduate this spring.

Part of me feels like I'm being the typical "OMG, this is so terrible," but when I objectively think about it, what I messed up on is a huge deal. Imagine your PCP not asking part of the basic history.

---

Members don't see this ad.

 

[Stellar Clouds]

You are probably over-reacting. People forget things all the time on this exam and the vast majority don't fail. I'd wait for your score before you shell out another thousand+ dollars.

 

[Kaputt]

Dude, you probably passed. No one is expected to be perfect in this exam.

 

[flyingleaf]

AMG here from top 10 US med school who has passed all OSCE's so far. I took exam in ATL on 10/9 and began panicking on my way to the airport because all I could think about was my mistakes. Reading these threads was a mixed bag, but I found it helpful when people talked about what mistakes they made and what result they got. Here are my confessions:



*I assumed a patient was homeless and asked if he lived in a shelter (I was led to believe this from HPI which led to this embarrassment during social hx); he responded "why would i live in a shelter?" After that he answered my questions, but it was not a friendly interaction.

*Didn't recheck BP in patient with terrible HTN; didn't do full cards exam; didn't counsel on HTN or lifestyle changes

*Had no idea what one lady had. She actually started smiling because my questions were so unfocused and not close to anything. On PE, I said I though I had palpated something that I thought was pertinent, but she ended up telling me it was nothing and to ignore it but I still didn't and it factored into my differential because I couldn't come up with anything else. Instead of ordering stress test, troponins, etc, I said do coronary arteriogram… (…it was last case)

*Ran out of time during closure and patient not pleased with my take on her last minute question

*Patient said I was pressing too hard during exam and then was a little pissed at me for rest of encounter

*Didn't order pelvic exam or ultrasound for patient with vaginal bleed (just got betahcg)

*Only did CAGE and ETOH counseling for one patient who was in withdrawal; others talked about drinking socially or 1-2 drinks/night and I just moved on. (very briefly counseled on smoking and safe sex though)

*Sooo many questions I wish I would have asked for all of the patients

*Overall, I think I "nailed" 4 of the cases, f*ed 2 up completely, and did in between on the rest



Overall, opened w 1 open ended q and rest were close ended. I had to jump around on the hx when I remembered I had forgotten to ask some thing and often interrupted PE to ask a question. Everyone got a basic lung/heart/abdomen exam. I did not tie up gowns after exam, but did other draping well. Didn't do full neuro exam for diabetic neuropathy and headache patients. Did crappy MSK for back pain patients. Did and reported super crappy MSE on depressed patient.



On notes, I worked my way backwards from the bottom and seemed to run out of time trying to put everything I knew in the hx. I didn't have time to put in PE for one note that needed it. Never put in vitals except for a guy with severe HTN. Never specifically asked about or put ROS in the notes (only had whatever was already included in HPI). I came up with 3 good ddx for only 3 patients, 2 good ddx for 3-4 patients, 1ddx for one patient, and BS/filler for the rest. I didn't know what different +/- physical exam findings to put for supporting diagnoses, so I just ended up pasting same crap in those boxes. I always ordered any test I could think of (got a lot of TSH's).



End result: Passed (one x in borderline with remaining x's to the right for ICE; CIS and SEP had all x's to the right)

 

[WaryWildcat]

I'm an AMG and also went into panic mode after taking my CS. I got my score back today; passed, asterisk in English proficiency, high performance in ICE, middling performance in CIS. I'm a neurotic dude, and everyone I talked to thought I was crazy, but as you'll see below, that exam was pretty much a catastrophe for me, so I don't think my neuroses were unwarranted. As part of my freakout mode, I wrote down that I could remember having made the following errors (in roughly increasing order of my perceived severity of the error):

*Did not pull out the footrest for 2 patients
*For most patients, I auscultated the heart over the gown, and for all patients, I auscultated the mitral pole over the gown and awkwardly slid my stethoscope under the gown.
*For virtually all patients, I washed my hands, and immediately afterwards touched the cotton swab container to open it and get a cotton swab for the neuro exam, and then touched the patient
*Did not do any counseling on two of my patients due to running out of time
*Frequently used medical terminology when I did get to counseling on the other patients
*For about half the patients, I changed my management plan while giving them counseling, making me look like a buffoon.
*Virtually always did my ROS in"rapidfire" format (ie, "any nausea/vomiting/diarrhea?" instead of asking about all the symptoms individually)
*Almost never asked permission to perform any examination maneuvers
*For one patient, did not document route of administration or amount of dose (ie, put "Lisinopril 40" instead of "lisinopril 40 mg daily")
*For many patients, did not document medications, or for some really dumb reason documented medications in the medical history section under the disease they were used for (ie, HTN: 10 year history, controlled on lisinopril 40 mg PO daily)

Bottom line: I did basically everything that FA tells you not to do (which, seeing as how I only read FA while in freakout mode after having taken the exam, is understandable), and I still passed, apparently quite comfortably. I'm posting my story here to reassure you that, while there are no guarantees, if you're worried about having passed the exam immediately afterwards, you probably did fine and should find something else to worry about

Also, for reference: Residency programs do not see the bars, just as they couldn't see the bars on your Step 1 and Step 2 CK reports.

 

[RosenthalFiber]

See and the sad thing is I did all of those things + wrote thorough notes and still failed ICE.

In fact my ICE bar was all the way to the left. Seems impossible...I've never had trouble with these encounters before

 

[mercaptovizadeh]

Thank God I passed, I was terrified I had failed. Praise the Lord, He is God!

 

[jcr123]

Took the test in Nov, waiting results. I remember writing in one of my PNs that I did a cardio exam even though, after thinking about it after the exam was over, I had forgotten to do one with a patient. I was just on autopilot when writing the note during that time. How much of a problem can that be?

 

[hoopie]

You aren't going to fail if you mess up something on one patient. I see that all thr time on these kinds of forums, but just think about it logically. PMH is just one small part of the grade on one patient. Your overall grade is an average of all the encounters. Maybe if you didn't do it on any patients that might be a problem.

I went through the typical months of worrying but I passed comfortably. I thought I did horrible. We aren't a good judge of ourselves on these things, and it's clear you can make a ton of mistakes throughout the exam and still pass without a problem. When I'm seeing people say they failed despite doing absolutely everything possible, either there's some error in the grading or they simply aren't realize some kind of major mistake they're making.

My advice to anyone who hasn't taken it yet is to just avoid these kinds of forums after you take the test. My immediate reaction after taking the test was that I wasn't perfect, but I did just fine. That was accurate. Unfortunately I was stupid and kept reading about it on the internet and freaked myself out. Frankly, a lot of what is said about this test is wrong. For instance, you don't need to do heart and lung exams on every patient. I only did the most basic and relevant exams on my patients, in fact in one case I practically did no exam. You need to do your basic FAR COLDER type questions, basic relevant ROS, and very basic PE. Come up with a reasonable differential, doesn't have to be perfect, you can even completely miss the obvious diagnosis. CIS-wise, I was polite, washed my hands, and asked if they had any questions a bunch of times. Barely did any counselling, wasn't overly empathetic, didn't ask how their problem affects them, etc.

I don't think it's good advice when someone says not to worry because you'll pass as long as you speak English. Take it seriously, but know that you just need to be halfway competent and you should pass with no issue.

 

[Raryn]

*One patient was a blah blah blah
*This easily takes the cake: One of my patients blah blah blah

If I were you, I'd remove these points. Or at least take out the details. Those are real CS cases (I had one of them on my exam a year ago) and it's against both NBME and SDN rules to post them.

 

[jcr123]

You aren't going to fail if you mess up something on one patient. I see that all thr time on these kinds of forums, but just think about it logically. PMH is just one small part of the grade on one patient. Your overall grade is an average of all the encounters. Maybe if you didn't do it on any patients that might be a problem.

I went through the typical months of worrying but I passed comfortably. I thought I did horrible. We aren't a good judge of ourselves on these things, and it's clear you can make a ton of mistakes throughout the exam and still pass without a problem. When I'm seeing people say they failed despite doing absolutely everything possible, either there's some error in the grading or they simply aren't realize some kind of major mistake they're making.

My advice to anyone who hasn't taken it yet is to just avoid these kinds of forums after you take the test. My immediate reaction after taking the test was that I wasn't perfect, but I did just fine. That was accurate. Unfortunately I was stupid and kept reading about it on the internet and freaked myself out. Frankly, a lot of what is said about this test is wrong. For instance, you don't need to do heart and lung exams on every patient. I only did the most basic and relevant exams on my patients, in fact in one case I practically did no exam. You need to do your basic FAR COLDER type questions, basic relevant ROS, and very basic PE. Come up with a reasonable differential, doesn't have to be perfect, you can even completely miss the obvious diagnosis. CIS-wise, I was polite, washed my hands, and asked if they had any questions a bunch of times. Barely did any counselling, wasn't overly empathetic, didn't ask how their problem affects them, etc.

I don't think it's good advice when someone says not to worry because you'll pass as long as you speak English. Take it seriously, but know that you just need to be halfway competent and you should pass with no issue.

Thanks ... Advice well taken. I have just read on some of these forums that documenting something you did not do can be considered a "fatal mistake" and that freaked me out a little. On the other hand, I can't see how such a small mistake would be a major problem.

 

[tco]

Heh. People are talking about dosages... I didn't ask about a single medication dosage the entire day. Oops.

Sent from my SCH-I535 using Tapatalk

 

[hoopie]

Thanks ... Advice well taken. I have just read on some of these forums that documenting something you did not do can be considered a "fatal mistake" and that freaked me out a little. On the other hand, I can't see how such a small mistake would be a major problem.

My impression is that if you falsely document things repeatedly, you'll get busted. One time, they definitely won't fail you. I'm pretty sure I accidently documented a physical exam finding or two that I didn't do but I was fine.

See, that kind of thing is what bothers me. People put these ideas out there of things you have to do, or else, or that if you make just one mistake you could fail the whole thing. It all just leads to people unnecessarily worrying. I mean, sure maybe if you attacked a patient you would fail. If you forget to wash your hands once, heck probably if you forget the entire day it still wouldn't be an automatic fail.

 

[hoopie]

Heh. People are talking about dosages... I didn't ask about a single medication dosage the entire day. Oops.

Sent from my SCH-I535 using Tapatalk

Don't need to oops. I never asked dosages. That's one of those things where you only have 15 minutes to cover everything and it would be a waste of time to go into that kind of detail about their meds. Especially since this test isn't about coming up with treatment plans.

 

[Mwalk7]

So my friends who also took it November 2nd got their score back two days ago and I havent. Starting to freak out!

 

[tco]

Thought I would update about this. I just got my score back a minute ago. Passed in all sections. The only thing that was exceptional was the English proficiency section (thank goodness ). The other two are between borderline and higher, closer to borderline. I wanted to update you guys because it proves that you can totally duff a couple of stations and still pass.

 

[HelpPleaseMD]

Thought I would update about this. I just got my score back a minute ago. Passed in all sections. The only thing that was exceptional was the English proficiency section (thank goodness ). The other two are between borderline and higher, closer to borderline. I wanted to update you guys because it proves that you can totally duff a couple of stations and still pass.

yea this test wears on you.... i found out i just passed and its like a weight has been lifted off my shoulders. this test shouldnt exist

literally felt tremors rite before i opened my score report. now my yr is done.

 

[darkpassenger17]

passed! what a relief. I had some serious doubts and worried the whole 2.5 months.

There is definitely something going on though because before todays results came out there were already 4 people in my class who failed and the majority didnt get their scores until today.

Good Luck everybody and hopefully everyone gets good news!

 

[HelpPleaseMD]

passed! what a relief. I had some serious doubts and worried the whole 2.5 months.

There is definitely something going on though because before todays results came out there were already 4 people in my class who failed and the majority didnt get their scores until today.

Good Luck everybody and hopefully everyone gets good news!

time to celebrate

 

[POW16]

Passed ! I'm ecstatic.

Sent from my SAMSUNG-SGH-I537 using Tapatalk

 

[doopdidoop]

yea this test wears on you.... i found out i just passed and its like a weight has been lifted off my shoulders. this test shouldnt exist

literally felt tremors rite before i opened my score report. now my yr is done.

Found out I passed too. What a relief! I second the tremors thing...and that this test shouldn't exist!! Good luck to everyone else!

 

[predmed123]

Just got my score. Passed as well and really grateful for that. I basically just followed the interview template from First Aid and it looks like that worked out. I honestly don't think I did a particularly good job with coming up with differentials and it wouldn't surprise me if I missed the Top 1 or 2 differentials on most of the cases. But I think my H+P notes were solid along with tests and imaging to order (spend enough time in a hospital and if nothing else, the common tests ordered for a chief complaint just stick in your mind). I did read First Aid cover to cover once in the 2 weeks before my exam. Didn't do much else to practice beyond reading the Step 2 CS website for the recent note format change that First Aid didn't cover. Our school did a mock mini-CS exam at the end of 3rd year which probably helped a lot in determining timing and such.

I still feel the biggest thing with this test is really the pacing and essentially getting through everything. I think First Aid does a great job giving that template of how to organize your patient encounter and I think once you get that down, you're golden.

 

[talkingcheese]

Just wanted to say that I passed yesterday, but was freaking out for the last 2 months. I spent ~10hrs casually reading FA (barely did the minicases) but only spent <10min in each room, thought none of the cases were straight forward, only spent 60secs on physical exam and had really short h&ps. Those factors plus knowing 2 people personally who failed this year = freak out. Had slightly above borderline on ice and ces, excellent english tho haha. I still hate this test.

 

[heli0x]

Just wanted to say that I passed yesterday, but was freaking out for the last 2 months. I spent ~10hrs casually reading FA (barely did the minicases) but only spent <10min in each room, thought none of the cases were straight forward, only spent 60secs on physical exam and had really short h&ps. Those factors plus knowing 2 people personally who failed this year = freak out. Had slightly above borderline on ice and ces, excellent english tho haha. I still hate this test.

How much do you know about/willing to share the 2 people who you knew failed? like what specifically they did wrong or omitted. There's alot of replies from people who have passed, but not very information on what it actually takes to fail.

 

[talkingcheese]

How much do you know about/willing to share the 2 people who you knew failed? like what specifically they did wrong or omitted. There's alot of replies from people who have passed, but not very information on what it actually takes to fail.

Both said they didn't take the test seriously, and spent much less time that I did on first aid. One said they were too focused on one diagnosis/didn't explore all possibilities with the patient, and went too quickly (why I was freaking out).

 

[HelpPleaseMD]

this test just sucks. most people leave not knowing if they did enough to pass ... and I think all of us here can find fault as to why we had failed if we did.

 

[turtledog]

I swear I had failed CS when I left the test center. Didn't counsel at least 3 patients (ran out of time, could only muster out "Do you have any questions for me?")

Totally assumed one patient had a medical condition when he didn't, then I had to apologize for assuming that he had it.

Started counseling about condom use, got too awkward, stuttered all over place, and just gave up when patient stared back at me angrily.

Didn't do any neuro exam. Only did heart and lung exam for 5 out of 9 patients. Didn't check cervical nodes or ears.

Only put 2 diagnosis, no negative pertinents, only a couple positives for each diagnosis at best. Sometimes didn't have time to put any justification.

CS is like the ultimate hazing test. There's not a single person who comes out feeling that great. There's always something you forgot, and you remember it the second you sit down in front of the computer station. Worst part is then you have to wait 2-3 months. And your school might not even let you be eligible for the match if you failed and don't have enough time to reschedule.

Got my CS score last week. Passed comfortably. I studied 2 days with FA. 250s+ Step 1 and CK.

 

[thehomelessguy]

I had a very similar experience with turtledog. I also did a VERY focused physical exam; so no need to worry that you have to do every little thing for every patient. In fact I was always the first one out of the patient's room and generally had so much time that I'd have 5 minutes or so to twiddle my thumbs after writing my patient note.

I did screw up one station pretty badly (didn't catch a "social issues" fact until near the end) but tried to recover with the time left. Also one tip. When you wash your hands ask the patient if they have any questions before you start your physical exam and either answer them or briefly tell them what you are thinking/will be doing soon. It seemed like my standardized patients really wanted me to pass and would use that time to lead me back to their "checklist" if I had forgotten something during the interview. Otherwise you waste a minute or so and it's a little awkward ignoring the patient while washing up (with real patients I normally gel/don't have such issues).

Anyways I passed. I actually only studied one day, 250+ again with Step 1 and CK.

 

[exudate]

At what site did you guys take your exam?

 

[RosenthalFiber]

Passed today after failing first time. My match will be unaffected

 

[HelpPleaseMD]

good to hear mate

 

[SVtachy]

I realize these threads pop up every now and then, but I'm honestly curious. I just completed my exam yesterday, and realized as soon as I exited one particular room that I had made a huge mistake and forgot an entire section of the patient history (PMH including allergies, surgeries, and medications). I haven't done something like that since second year, and I don't know what I would have done to prepare differently to avoid it. I'm just accepting that I messed up and am trying to move on and plan appropriately.

Don't get me wrong, I also committed the usual mistakes that everyone realizes later - forgot to ask "this," did a shoddy neuro exam on "that" patient, etc. Did a poor job justifying my diagnoses with pertinent positives and negatives from the physical exam. However, I feel like forgetting an entire subsection of the history should be an automatic failure. If so, does anyone know how quickly is it possible for me to reschedule the exam? I need a passing grade to graduate this spring.

Part of me feels like I'm being the typical "OMG, this is so terrible," but when I objectively think about it, what I messed up on is a huge deal. Imagine your PCP not asking part of the basic history.

Is it necessary to put negative findings on physical findings to support a DDx? I took my exam a few days ago and didn't seem to find much on physical so I mainly supported my DDx based on history findings. I'm starting to worry about that?
Thanks

 

[MrGrrrMonster]

Is it necessary to put negative findings on physical findings to support a DDx? I took my exam a few days ago and didn't seem to find much on physical so I mainly supported my DDx based on history findings. I'm starting to worry about that?
Thanks

Don't worry, I didn't put any negative physical findings in support of the differential and was in the very high section for the ICE section. Most of the cases are very vague and as such you won't have many positive physical findings for that matter either.

 

[SVtachy]

I was wondering that because most of them, I left blank because there were no physical findings either. :/

 

[Redoxify]

.

 

[NoBS4real]

Hey y'all.. thanks for your thoughts.
Just another case of freaking out here. Initially knew I wasn't perfect but thought I was at least halfway decent so hopefully it will be ok.. Definitely plenty of screw-ups - the ones worrying me most being the differentials and supporting info but I guess thats normal.. We'll see.. for the sake of sanity and everything coming up in the next few months I'm banking on "you really have to not know what you are doing" to fail.

 

[Melatonin87]

It honestly takes a lot to fail this exam, when I took my exam in Philadelphia I thought for sure that I failed because I had so many mistakes. I honestly felt like a ***** after finishing. There were 3 cases in which i ran out of time and had to tell the SP something like, "Oh they are paging me in the ER, I'll be right back with you results" or something like that. I only put 3 DDx on maybe 5 cases total the rest were 2 DDx. I wrote horrible notes. I think as long as you follow basic mneumonic protocol and ask all of th ROS questions and stay relevant to the CC you should be ok. Honestly if I just passed it with high marks in every category, i realized that this exam is impossible to fail for people who speak fluent English and have a functioning frontal cortex.!!!