Yet another CS freakout thread :(

[cabergoline2]

I finished my cs before a couple of days. And I am going through the ritual of nightmare and panic attacks. I think I might flunk..Or if I pass it ll be borderline.

My mistakes list.

1) In 2 patients I ran out of time at the end of counseling. ie I was not able to give them an opportunity to ask questions.
2) I answered a challenging question badly.And the reason is that it was not phrased as a question. It was only after I came out of the room that I realized that he meant to ask something. And his statement was meant for me to earn brownie points on empathy.
3) did not dim the lights for a fundus exam
4) in one patient I lifted the stethoscope before the end of expiration on 2 occasions. I put it back at the same spot again. And absent mindedly put in on the ipsilateral intercostal right above that one instead of alternative listening on left and right lung. I corrected myself here though by doing the entire thing again.
5) forgot to document stuff in hpi/pe that I had actually elicited in the patient. In one occasion I wrote something in the Note that I did not do.
6) forgot to counsel one patient on weed. he was abusing 2 substances. I only counseled him on 1 that was directly related to his HPI.
7) Used British spellings in the patient note on 2 occasions. (Oesophagus vs Esophagus)
8) HPI was ultra abbreviated .
9) I wrote down the ddx and supporting findings before HPI . Consequently may have missed writing stuff in hpi that i might have wrote down in the ddx box.
10) forgot to ask how the condition affected his life. but that is bizzarre. also forgot to ask the patients perspective on the diagnosis. mainly because i did not have the time..it would be bizzare if they expected that.
11) Small talked on only 3 cases. There was no clear cut segue for small talk in other cases. Besides I was nervous while sanitizing my hands.

What I did do -

1) Introduced myself and established me role.
2) Sanitize my hands with alcohol. explain the patient that it is an alcohol based sanitiser and asked him if he was allergic to alcohol.
3) Ask open ended questions for HPI followed by specific relevant questions. THe usual PAM HUGS
4) Ask every patient about his occupation.
5) Closed every patient. Closure included summary.1-2 diagnosis and 1-2 investigations.i gave patient opportunity to ask questions.Was cut short of 2 cases due to time.
6) used appropriate transitional statements.
7) spoke clearly and was easy to understand
8 gave 3 ddx for most cases..atleast 2 of them were very well supported through history. however except 3-4 cases I had very little PE findings.
9) was empathetic ..however I happen to be a stoic and expressionless person in real life. my neutral expression is like a Vladimir Putin stare.
9) assisted patients during PE. Pulled out the foot rest. Did not palpated painful spots more than once.


overall I feel that the test is a massive waste of time and money.

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[cabergoline2]

add to the above : there was a Neuro/Psych patient that was super slow. He took like 2 minutes to ans wer mmse questions.. I examined the cranial nerves at the same time of doing the mmse..while examining his eyes he winced and expressed discomfort . But it was a non verbal expression. It was only after I came out of the room that I realized that I pissed him off .

 

[cabergoline2]

also did not percuss and do tvf in anterior chest of a respi case as it was a young female with pendulous breasts...

 

[Ismet]

You probably did fine. I don't think any of the mistakes were killers. Most people do better than they think. The HPI abbreviations - did you use only the abbreviations in the accepted list?

add to the above : there was a Neuro/Psych patient that was super slow. He took like 2 minutes to ans wer mmse questions.. I examined the cranial nerves at the same time of doing the mmse..while examining his eyes he winced and expressed discomfort . But it was a non verbal expression. It was only after I came out of the room that I realized that I pissed him off .

The slowness and the pain with eye examination was probably part of the diagnosis.

 

[cabergoline2]

You probably did fine. I don't think any of the mistakes were killers. Most people do better than they think. The HPI abbreviations - did you use only the abbreviations in the accepted list?



The slowness and the pain with eye examination was probably part of the diagnosis.

slowness was...pain was not...i have a sinking feeling that the hand sanitizer might have something to do with the pain.i was reasonably sure my hands were dry...but i inadvertently touched his upper sclera..and i did not re tie his and a few others gown...but my draping in general was excellent...kaplan tells me that re-tying gowns is inconsequential and would not likely cost anything as they have a likert scale type rating ...so draping would be on a scale of 1-5 etc...but that also introduces an element of subjectivity ... I am not sure about the level of reproducibility and psychometric validity...but even then i did not do well...

i did some research...they have published a lot of articles in the journal "academic medicine."

it seems that on an average US seniors score 60% in physical exams...(range 51-71)... data from 2005-2008 indicate an CIS score of 72%...they likely have a likert like scale...i l post screen shots of the article if i get time...

 

[Nabin]

I have my exam in two weeks. Do you really think your mistakes are that bad or are you having a laugh? I am asking this in all seriousness because right now I am not worried about missing the things that you said you've done. Maybe you want a perfect performance, but trust me I have read a lot lot worse experiences with people passing with high performance. Tell me you are serious. Anyways, good luck! I'm sure you will do very well.

 

[cabergoline2]

I have my exam in two weeks. Do you really think your mistakes are that bad or are you having a laugh? I am asking this in all seriousness because right now I am not worried about missing the things that you said you've done. Maybe you want a perfect performance, but trust me I have read a lot lot worse experiences with people passing with high performance. Tell me you are serious. Anyways, good luck! I'm sure you will do very well.

I am dead serious..I am unable to think straight now.. Thing is that the element of subjectivity in the exam is immense. A lot could depend upon the SPs present at a particular time. Whatever NBME/ECFMG says ,it is impossible to completely standardize this test..I know an ivy league AMG with great step1/ck scores flunk CIS...And she was not an outcast ...but among the most charming and empathetic persons I know..and she has great reviews... at the same time some people with crappy performance passed...

i assure you that I am not having a laugh at anyone's expense...i am genuinely scared ...

what freaks me out the most is running out of time in 2 cases...though luckily i had almost completed my closure then...

from what I have heard , running out of time in multiple cases is the most common cause for failure in CIS section...Because the closure +summary+giving opportunity to patient to ask questions has much much more weight than rest of the encounter combined..

the girl i mentioned above ran out of time in 4-5 encounters..

 

[Nabin]

Yeah I understand. Its normal to have this anxiety after the exam. Maybe I will freak out after I give mine. From what I have heard AMGs have to do something really really bad to fail this test, something like swear at them? haha.
And you're correct about the closure + summary... thing. That is very important. Everyone that has given the exam advises me to even skip some portions of PE if you think you'd run out of time in closure. I think you should be good if you've just not managed to give the SPs opportunity to ask any question two times. I've read worse experiences here. Hence, I found your issues really trivial. You should relax. All the best!

 

[endoffouryears]

“Or if I pass it’ll be borderline.”

Pass is a pass. Who cares if it’s borderline… The SPs are borderline standardized anyhow, and no matter what anyone says the most important thing is whether you pass it on the first attempt or not. That is what the residency programs really care about with regard to CS.

“1) In 2 patients I ran out of time at the end of counseling. ie I was not able to give them an opportunity to ask questions. “

If you still summarized with a bit of efficiency, and discussed the plan with them, then this is probably not a big deal. Asking if they have questions is important, but not as important as summarizing and clarifying the plan. The SPs know on some level that this test is BS. The only doctor’s who spend ten minutes in the room with their patients are the ones who don’t care about their patients. The test is set up to force you to display efficiency, not to be perfect in every way.

“2) I answered a challenging question badly. And the reason is that it was not phrased as a question. It was only after I came out of the room that I realized that he meant to ask something. And his statement was meant for me to earn brownie points on empathy.”

There are no “brownie points” for empathy. ;-) There is only one check box for empathy and one point to be obtained. There are lots of ways to earn that empathy point from the SPs perspective. I used a canned phrase over and over with every patient and what mattered is how I delivered it. They gave me a chief complaint, I said, “I’m sorry to hear this has been happening. Can you tell me little more about it?” Empathy and open ended questioning, check. Two points there. We all express and accept emotions like empathy in different ways. Your gestures might imply you are being empathetic, but if the SP doesn’t pick up on that then you just missed you point for empathy. So you only need one expression of empathy to get the point for empathy. Just because you missed that particular opportunity you referred to, doesn’t mean you missed the point for empathy on that SP.

“3) did not dim the lights for a fundus exam”

Don’t need it anyway. Been taught it both ways for the test. The fact that you did it at all is going to gain you some points that others didn’t get. It’s going to be negative anyhow, so this component of the PE is mostly scored on how well you did it. Not shutting the lights off doesn’t keep you from doing it well, so you won’t lose points for that.

“4) in one patient I lifted the stethoscope before the end of expiration on 2 occasions. I put it back at the same spot again. And absent mindedly put in on the ipsilateral intercostal right above that one instead of alternative listening on left and right lung. I corrected myself here though by doing the entire thing again.”

Will be fine. Redoing it was likely not necessary in this scenario but you basically guaranteed you got the points by redoing it.

“5) forgot to document stuff in hpi/pe that I had actually elicited in the patient. In one occasion I wrote something in the Note that I did not do.”

Discrepancies between that you did and what you wrote happen often. It’s not a big deal unless there are too many and the computer flags them. Otherwise it’s all part of the lack of standardization in the test. Not putting things in the note that you did in the PE only results in you missing the opportunity to support your diagnosis with more relevant evidence, but that does not mean you failed to do this in the first place. Kaplan taught us to put 8-10 pieces of supportive evidence in the first dx, 6-8 in the second dx, then 4-6 in the third diagnosis (if you have one, and you don’t always need one.) If you did this, and you supported the ddx with RELEVANT content, then you should be fine regardless of leaving things out.

“6) forgot to counsel one patient on weed. he was abusing 2 substances. I only counseled him on 1 that was directly related to his HPI.”

Also not a big deal. Counseling for all illicit substances is important but the fact that you counseled on the thing that was most relevant to the top dx is beneficial. You only get one point for counseling the patient. Doing it twice doesn’t get you two points.

“7) Used British spellings in the patient note on 2 occasions. (Oesophagus vs Esophagus)”

Spelling only matters under a few scenarios.
a) Your spelling is consistently widely bad. Otherwise as long as you aren’t botching every other word and what you write can be comprehended easily, you’re fine.
b) The written content of the actual diagnosis itself is actually by a computer initially. If you diagnosis is misspelled, or otherwise written in a way that is not recognized by the computer, then you may not get points for having a written diagnosis at all. Something tells me they are smart enough to consider the similarity between Oesophagus vs Esophagus, but I may be giving them too much credit. ;-)

“8) HPI was ultra abbreviated .”

All of them? Depending on how abbreviated they were, it could hurt you a lot. Kaplan taught us that you cannot get points for things you write to support the DDx if you do not include those things in the HPI above, and their people actually graded the exams in the past, so they are being dead serious. In my opinion, many people pass ICE or fail ICE on this principal alone. They think they can leave pertinent positive and negative findings out of the HPI and put them in the support for the ddx alone, instead of writing them in both areas. Most people who pass do not know this either. They are simply doing it because they are used to writing a full HPI with pertinent negatives and positives included. If they are fast enough a typist, which many people are, then rewriting those components into the support for each ddx is not difficult. If they are smart they practice organizing the HPI content so it is easy to cut and paste into the support for the ddx. So how short were your? Was it all of them you abbreviated or just a few?

“9) I wrote down the ddx and supporting findings before HPI . Consequently may have missed writing stuff in hpi that i might have wrote down in the ddx box.”

See above comments.

“10) forgot to ask how the condition affected his life. but that is bizzarre. also forgot to ask the patients perspective on the diagnosis. mainly because i did not have the time..it would be bizzare if they expected that.”

I do not understand your use of the term “bizzare” here. Why is this “bizarre”? Asking the patient’s perspective on the dx is helpful because it gives you something to follow up on, and ask further questions about, which provides other possible evidence to support your ddx. In the long run its just one question out of many that can get you points, so if you did other things thoroughly then I would not worry.

“11) Small talked on only 3 cases. There was no clear cut segue for small talk in other cases. Besides I was nervous while sanitizing my hands.”

There is no real room for “small talk”. The “small talk” you are referring to is exploring their life and unconvering how their condition is effecting them. What I mean is, the fact that the patient’s daughter just got a divorce could easily be considered small talk, but it is meaningless to you on the test if they do not have anxiety over it, or some sense of depression over it that allows you to use that information to support your diagnosis. This is part of the importance for establishing rapport for the patient interaction. It’s not because the test really cares much about you establishing rapport. You only get one point in CIS for establishing rapport and it doesn’t take much to get it started, but establishing rapport is what can lead you to the most sensitive evidence you need for the HPI and supporting evidence for ICE. THAT can gain you numerous points in ICE. Most students often do not realize this, so they don’t take this concept very seriously.

“What I did do -
1) Introduced myself and established me role.”

Good

“2) Sanitize my hands with alcohol. explain the patient that it is an alcohol based sanitiser and asked him if he was allergic to alcohol.”

Overkill. Just sanitizing is anough.

“3) Ask open ended questions for HPI followed by specific relevant questions. THe usual PAM HUGS”

Good

“4) Ask every patient about his occupation.”

Good. Did you use it to support your diagnoses though? Like I explained above, knowing their occupation is meaningless to you on the test if it doesn’t act as support for a diagnosis. You don’t get points on CIS for asking occupation.

“5) Closed every patient. Closure included summary.1-2 diagnosis and 1-2 investigations.i gave patient opportunity to ask questions.Was cut short of 2 cases due to time.”

You only need to give the patient 1 diagnosis. More than this is just confusing and prevents them from asking their crucial follow up question. Most people fall short on time in a few cases. Not a big deal. I did. Still passed.

“6) used appropriate transitional statements.”

Bravo…

“7) spoke clearly and was easy to understand”

Nice…

“8) gave 3 ddx for most cases..atleast 2 of them were very well supported through history. however except 3-4 cases I had very little PE findings.”

Most cases have very little PE findings, but this is when pertinent negatives from the PE become important. They are crucial because they help you to prioritize which diagnosis is primary vs. secondary vs. tertiary. Additionally, normal vital signs can support any diagnosis, so hopefully you cut and pasted them into the supportive evidence for each diagnosis. If they were abnormal then you need to be more selective of when you use the abnormal component in the PE support.

“9) was empathetic ..however I happen to be a stoic and expressionless person in real life. my neutral expression is like a Vladimir Putin stare.”

Funny but may hurt you when it comes to building rapport and expressing empathy. I guarantee you though, that you will not be the first Frankenstein student to pass this exam, so don’t worry about it.

“9) assisted patients during PE. Pulled out the foot rest. Did not palpated painful spots more than once.”

Good.

“overall I feel that the test is a massive waste of time and money.”

You are absolutely correct about this. No other way to say it. This test proves only one thing, that the student can ACT like a doctor.

 

[cabergoline2]

passed...
high performance * in sep..
ice was midway between the shaded region and high performance...
cis had 2 star dipping in the shaded borderline region...

happy that i won't have to think of this crap again...