I'm starting to get really scared

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Just got my CS score:

I failed again. This time it was the ICE portion (I passed the CIS and SEP). The first time it was the CIS that I failed. For the Data gathering part of the ICE this time around, it seems like I wasn't even present for the encounter. I had an asterix and 5 x's on the performance profile on the left side of the graph. This was after going through PAM HUGS FOSS and LIQORAAA and TOADESS for almost every encounter and asking additional questions (for example: if someone had diabetes, I asked them about their last HbA1C, if someone was taking meds, I asked them about any side effects etc etc).

So I'm out of the match for 2009. Not sure what I'm supposed to do or what my future in medicine is (if any). I passed Step 1 on my second attempt, Step 2 CK on my first attempt and I have 2 failures on the CS. So I already have 5 attempts and 3 failures.

Never did I imagine that it would be the CS that killed it for me.
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superoxide said:
Just got my CS score:

I failed again. This time it was the ICE portion (I passed the CIS and SEP). The first time it was the CIS that I failed. For the Data gathering part of the ICE this time around, it seems like I wasn't even present for the encounter. I had an asterix and 5 x's on the performance profile on the left side of the graph. This was after going through PAM HUGS FOSS and LIQORAAA and TOADESS for almost every encounter and asking additional questions (for example: if someone had diabetes, I asked them about their last HbA1C, if someone was taking meds, I asked them about any side effects etc etc).

So I'm out of the match for 2009. Not sure what I'm supposed to do or what my future in medicine is (if any). I passed Step 1 on my second attempt, Step 2 CK on my first attempt and I have 2 failures on the CS. So I already have 5 attempts and 3 failures.

Never did I imagine that it would be the CS that killed it for me.

Thank you everyone for all your advice and encouragement.

Moderator please close this thread. If anyone wants to get in touch with me, you can PM me.

Thanks.
Click to expand...

Hey Superoxide,

I'm sorry to hear that. I am thinking that maybe it would have been best to take Step 2 CS after the match. Have you gotten any more interviews other than the 2 you mentioned? I think that it may be a good idea to talk in person with the program directors. You've come this far and although unfortunate about the failures, I wouldn't give up. I think you can still probably match in FM.
 
Moderator: I changed me mind. Please keep this thread open. As much as I want to run away from this, I can't do that.

In response to medstudentquest: I haven't received any other interview invites.

I'm an IMG, so I wanted to take and hopefully pass the CS to be ECFMG certified. Many programs require IMG applicants to be ECFMG certified by match date.
 
superoxide said:
Just got my CS score:

I failed again. This time it was the ICE portion (I passed the CIS and SEP). The first time it was the CIS that I failed. For the Data gathering part of the ICE this time around, it seems like I wasn't even present for the encounter. I had an asterix and 5 x's on the performance profile on the left side of the graph. This was after going through PAM HUGS FOSS and LIQORAAA and TOADESS for almost every encounter and asking additional questions (for example: if someone had diabetes, I asked them about their last HbA1C, if someone was taking meds, I asked them about any side effects etc etc).

So I'm out of the match for 2009. Not sure what I'm supposed to do or what my future in medicine is (if any). I passed Step 1 on my second attempt, Step 2 CK on my first attempt and I have 2 failures on the CS. So I already have 5 attempts and 3 failures.

Never did I imagine that it would be the CS that killed it for me.
Click to expand...

It is good that they told you what you failed. Did you use a study aid for Step 2 CS? I did read first aid well before taking Step 2 CS.

Personally, I think the PAMHUGSFOSS is worse than useless. I did not use any pneumonics to figure out what to ask, because it was self-explanatory. The patient encounters are pretty much routine encounters you would see in the real world.

For a guy with suspected TB the questions I would use what I would have asked on an ER rotation, like do you have weight loss? Have you had any contact with anybody with TB? Have you had a positive TB? The patient would usually state they have had a cough for 6 months so it makes absolutely no sense at all to ask exactly when it started if he can't remember or whatever PAMHUGSFOSS is, . . . you will waste time using the pneumonic and not pass IMHO.

So, yeah you could get a patient who says that he was exposed to TB or did have a positive TB test. I think that students make the mistake of using the PAMHUGGSFOSS and think those are all the questions they need ot ask, no way at all! You do have to think when asking questions, this was the hardest part I think as you have to think on your feet and ask what needs to be asked.

I finished almost all my clinical encounters ahead of time, and was usually the first three out of the room, typed my note and had plenty of time to construct a good differential. I though maybe I wasn't thorough enough, but it doesn't make sense to use the pneumonics for each and every case at all. For half my cases I just sat there for a good couple minutes after finishing the note and submitting. I was satisifed that I asked what needed to be asked and nothing more.

I did do a family history, social history, past medical history etc . . . but from the pneumonic for my TB patients does it make sense to ask about GI habit or sleep or urinary complaints if not in the chief complaint?? I did try to do a brief ROS, but this will be limited. Similary the LIQOURAAS makes no sense for a patient with cough can you seriously ask with a straight look on your face where he coughs most??? Or the "intensity of the cough" . . .

Everybody has a way of doing H and P's and this is what I did and I passed the first time.

Remember, each case has a "trick", like maybe a patient with diarrhea which is caused by antibiotics used two weeks ago (C. Diff). . . if you don't put the whole picture together you don't get the case. This is why there is experimental cases, they want to see if say a patient can pick up maybe if a teenager with fatigue has anemia secondary to vitamin b 12 deficiency. The patient just says that they have fatigue . . .!

So, no, the PAMHUGGSFOSS will NOT work if you don't generate the questions that will help you solve the case I guess IMHO.



P-previous similar episode/past medical history/past surgical history
ALLERGY always asked
Medication always asked
Hospitalization usually always asked
Urinary habit didn't ask, unless patient had UTI sympotms
GI habit - I never asked about this, except for a GI case
Sleep - Used with a patient having problems sleeping
FH - always asked
O&G - ???
Sex - Asked this quickly each time
SH - Asked about recreational drugs, alcohol. Didn't ask about occupation unless germaine to complaint

Location - Never really asked unless patient had chest/abdominal pain
Intensity - only asked with pain
Quality - asked once with chest pain?? (can't remember)
Onset - patient's tell you when it started
Radiation - asked with pain CC, which most patient's don't have
Aggravating factors - with pain
Alleviating factors - asked them if they took meds or if anything helped
Associated symptoms - you can't ask if they have "associated symptoms" patient would be (act) confused, you have to have a differential in mind and ask them if they have say SOB with left arm pain. . .

I just did my interviews like how you normally do an H and P, like I always do cc, hpi, pmh, meds, surgical hx, social hx, family hx, ros (asked this with hpi sometimes), allergies, did the physical and told them what I thought they had. done.

If you use the pneumonics each time you could likely fail IMHO as you don't have enough time to ask the important questions which lead to the diagnosis and also other important considerations. For each case there was a clear diagnosis or at least two strong possibilities, I used the rest of the space in DDx to put in stuff it could be, but probably wasn't. Also, sometimes I would have to council the patient about testing or admission to the hospital. If you don't have the top 2-3 diagnosis in mind no way can you ask the right questions.

Also, realize that Step 2 CS has been made more difficult as the experimental phase of the test is done and they have increased what you need to do to pass.

Focus on the chief complaint, if someone has diabetes then you will get info about their meds with the medications part of the history and physical, but it might have nothing to do with the chief complaint or why they are there . . . and you can't ask "Have any side effects?" No medical jargon! If you used ALL 3 pneumonics each time then you would fail as most of the questions don't pertain to the chief complaint. I would have failed if I did this as you don't get credit for asking about HgbA1c in a patient with an ulcer . . . Don't use the pneumonics again.

I studied a great book, I can't remember the name, but they had a whole list of questions you would ask for gastric ulcer symptoms . . . much better than the pneumonics which are a quick fix if you can't ask anything else and are an easy way to try to pass. The people who administer Step 2 CS know about the pneumonics and probably don't like them as no attending or resident using them, but uses their brain to ask the right questions.
 
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DarthNeurology said:

I think also that Superoxide failed Step 2 CS will hurt as if he/she fails it again then he/she can't go through the match and will be automatically withdrawn. So, maybe this is the big problem that residency programs have with her/his application.
Click to expand...

This is why I thought PDs were passing on your application that if you failed Step 2 CS for a second time, which apparently happened, then you don't have time to take Step 2 CS again before December 31st, so you won't having a passing score by rank list time in February and will be withdrawn automatically from the match.

Most likely you will have to try to scramble for a position, which is almost impossible given how many people are trying to scramble the past couple years . . . plan on having to go through the match again next year.
 
superoxide,
So sorry that you failed the CS exam.
I don't have anything super constructive to add since I never had to take that test...it came out the year after I graduated.

I have never heard of the mnemonic you mention. It does seem like an excessive number of questions to ask every patient. Perhaps the patients have become wise to the fact that people are memorizing these mnemonics, and they are on the lookout for people who are asking questions not really relevant to the "chief complaint" at hand. If you ask too many questions such as review of systems ones, they might assume you have no idea what to ask, and no idea what is going on with the patient.

I agree with Darth...I think you should just go in there, do sort of a normal H and P, with questions focused toward whatever the chief complaint is, and let the chips fall where they may. I hope some more people who have actually taken this exam will chime in with hints/tips.

I think you should just assume this year is a no-go...you need to do something so that you definitely pass the CS the next time. Is there a review course you can take that has "live" standardized patients and a real test-like situation? Can your medical school help you out with studying for it, based on their past experiences with students who have failed?

I think you can try next year for residency. If that fails, you could go into biomedical research, sales/business, etc.
 
Sorry to hear that, Superoxide.

Keep your chin up. In a month you will be a Doctor of Medicine (you graduate in December, right). You will retake CS, you will get that ECFMG certification, and you will throw your hat in the ring next year. No questions asked.

You now have three tasks ahead of you:
1) Study for, retake, and pass CS;
2) Find employment for the next 18 months;
3) Bolster your application so that you successfully match into Family Practice next cycle.

As for #1, I agree that using First Aid for CS is the best way to go. Find a friend to practice with-- alternate the patient and practitioner roles. Study the 'mini-cases' in the front of the book to get a quick rundown of differentials for a given chief complaint. Just like clinical medicine, CS is not strictly algorithmic-- no cookie-cutter mnemonic can be applied to every patient with a variety of complaints, both acute and chronic, vague and specific.

As for #2 and #3, they are 100% linked. With loans in repayment it will be a lean year, but seek out a research position at an academic center, hopefully in a prolific lab/group, doing something with pediatric primary care. Get your name on papers and case reports, and get to know faculty well who can write you strong letters for next year. Target one or two FM programs (and I think you should focus exclusively on FM), make yourself known to the PDs longitudinally, and I think your chance of matching will increase.

All is not lost, but it is on hold for a bit.
 
I am sorry, I am trying to let this go, but I just cannot do it....If it was once, maybe. But so many times? It may keep me awake tonight if I don't post this and believe me I know how petty it is so I am sorry in advance. But in the service of correct English, I have to point out that the correct word is mnemonic. Not pneumonic. They sound similar, but do not look that way.
 
dragonfly99 said:
superoxide,

I have never heard of the mnemonic you mention. It does seem like an excessive number of questions to ask every patient. Perhaps the patients have become wise to the fact that people are memorizing these mnemonics, and they are on the lookout for people who are asking questions not really relevant to the "chief complaint" at hand. If you ask too many questions such as review of systems ones, they might assume you have no idea what to ask, and no idea what is going on with the patient.

I think you can try next year for residency. If that fails, you could go into biomedical research, sales/business, etc.
Click to expand...

Supposedly you are not punished for asking irreleveant questions during Step 2 CS. However, if you waste too much time with pointless questions then you don't have time to ask what is important. The good thing is that the standardized patients don't go "ummm . . . " but answer questions must faster than a normal patient would. Even so, I was hard pressed to finish the examination a couple times and everything I asked felt releveant.

Be aware that Step 2 CS has been made more difficult by the examination administrators, I think the change was in summer 2008?? So this may have contributed to the fail, however, if you got your results and got what apparently were very low scores on one portion then something is wrong.

If you barely passed Step 2 CK, then this would hurt you on Step 2 CS as your knowledge base may be sufficient or it may take you extra time to think of the possible differential. Residents and attendings have a thought in mind about the 5 most likely diagnosis when seeing a patient for the first time in the ED, such as for abdominal pain, and base their questions on this.

Same thing with Step 2 CS, once a patient tells you the chief complaint you should instantly think of half a dozen things automatically. Like if someone says they have "chest pain" you should be thinking beyond MI to about a dozen other possibilities as well and real specific questions like if they have a salty taste in their mouth occassionally, if the pain comes on after eating, when lying down, do they have SOB, after they exercise?? None of these questions are in those lame mnemonics.

Just asking what "exacerbates your pain" is a sure way to fail Step 2 CS as it is too medical in my opinion.

In the examination you can't just do the mnemonics (sorry about the prior spelling!) and then sit down at the computer and figure out what it was. Certainly residents can't do this as you need to be thinking while you question patients about their chief complaint. This is why a mnemonic is counter-productive as you are busy worrying about the mnemonic and then forget to think to ask the important questions.

I have seen so many people post on the Step 2 CS forum who said that they followed the "PAMHUGSFOSS" and then failed. . . Realize that there is a check-list of questions that the patient has and you only get credit for asking those questions. You won't get credit for asking about urinary tract infections in a patient with pneumoniae, on the test and in real life usually. (Although you may have time to do a full ROS in the ER, this printed on most H and P forms and is not the skill you need to learn to be a doctor).

The PAMHUGSFOSS is NOT recommended by the USMLE, but rather was someone's attempt to sell a review book for a new test. Asking all of these questions in no way will assure a pass on that portion of the examination. If you had a patient with chronic cough who has TB, and you didn't ask about exposure or past PPDs or weight loss or blood tinged sputum, then yeah you failed that part.

Asking these questions are almost useless if you aren't thinking and/or haven't done so many history and physicals that you can do it automatically. PAMHUGSFOSS doesn't work IMHO. I feel that the testing folks are making sure cases are original enough that if you just use mnemonics you will waste your time, look stupid, and fail the exam.

Step 2 CS is as much of a thinking examination as Step 2 CK IMHO . . .
 
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Hi Darth,

I used FIRST AID for both attempts. I read the whole book twice and took notes on all the cases, which I reviewed several times.

I didn't use all the mneumonics in every case. The LIQORAAA one I only used if there was any complaint of pain. So I didn't do it if someone just came in with a cough, but I did PAM HUGS FOSS on everyone, except in the pediatric cases where I left out the non applicable stuff like smoking, alcohol and sexual history, but I did ask those questions about the parents. So I would ask does anyone smoke at home? Did you smoke or drink alcohol during your pregnancy?) If I got a positive response to any of the basic questions, then I would ask follow up questions. So if they had a cough, I asked about type (dry or productive), amount, colour, odour, any blood?). Same with GI. If someone had diarrhea, I would ask if its watery? bloody? etc etc.

I did OB/Gyn history on all female patients regardless of CC.

What I'm trying to say is that I used the mnemonics as a skeleton, but then asked follow up questions if I had any positive responses. I didn't simply just use the mneumonic and end it there.

Also about associated symptoms, I gave them examples. So someone came in with chest pain, I asked them "Have you had any other symptoms, for example, radiation of pain or numbness down the left arm or lower jaw?"

About asking about side effects: I'm just looking at my First Aid CS. Case 20 on page 230 has a case of hypertension followup. Under the question list on pg 231 one of the questions is: "Medication Side effects". I think that's a very relevant question. How is that medical jargon? Also, if I remember correctly, most patients didn't state in their CC how long they've had their symptoms. I usually had to ask them "When did it start? Has it gotten better/worse since then?" (I'm not saying you're wrong, I'm just looking back at how it was on my test day)

About the HbA1C, I only asked that question if the SP had diabetes. Just like I would ask blood pressure monitoring for someone who was hypertensive.

The one thing I didn't do for both attempts is practice with a partner. I sent an email to my classmates, who have passed this test on their first attempt and they said that I should practice with someone. They will be able to see my mistakes and point them out to me. They also said that First Aid is the best prep for this test.

I am trying to figure out what I am doing *so* wrong, that I got such a low score on the data gathering part. As I said it was on the extreme low end of the scale (off the chart).

Thanks for your response and continued participation on this thread I appreciate it.


DarthNeurology said:
It is good that they told you what you failed. Did you use a study aid for Step 2 CS? I did read first aid well before taking Step 2 CS.

Personally, I think the PAMHUGSFOSS is worse than useless. I did not use any pneumonics to figure out what to ask, because it was self-explanatory. The patient encounters are pretty much routine encounters you would see in the real world.

For a guy with suspected TB the questions I would use what I would have asked on an ER rotation, like do you have weight loss? Have you had any contact with anybody with TB? Have you had a positive TB? The patient would usually state they have had a cough for 6 months so it makes absolutely no sense at all to ask exactly when it started if he can't remember or whatever PAMHUGSFOSS is, . . . you will waste time using the pneumonic and not pass IMHO.

So, yeah you could get a patient who says that he was exposed to TB or did have a positive TB test. I think that students make the mistake of using the PAMHUGGSFOSS and think those are all the questions they need ot ask, no way at all! You do have to think when asking questions, this was the hardest part I think as you have to think on your feet and ask what needs to be asked.

I finished almost all my clinical encounters ahead of time, and was usually the first three out of the room, typed my note and had plenty of time to construct a good differential. I though maybe I wasn't thorough enough, but it doesn't make sense to use the pneumonics for each and every case at all. For half my cases I just sat there for a good couple minutes after finishing the note and submitting. I was satisifed that I asked what needed to be asked and nothing more.

I did do a family history, social history, past medical history etc . . . but from the pneumonic for my TB patients does it make sense to ask about GI habit or sleep or urinary complaints if not in the chief complaint?? I did try to do a brief ROS, but this will be limited. Similary the LIQOURAAS makes no sense for a patient with cough can you seriously ask with a straight look on your face where he coughs most??? Or the "intensity of the cough" . . .

Everybody has a way of doing H and P's and this is what I did and I passed the first time.

Remember, each case has a "trick", like maybe a patient with diarrhea which is caused by antibiotics used two weeks ago (C. Diff). . . if you don't put the whole picture together you don't get the case. This is why there is experimental cases, they want to see if say a patient can pick up maybe if a teenager with fatigue has anemia secondary to vitamin b 12 deficiency. The patient just says that they have fatigue . . .!

So, no, the PAMHUGGSFOSS will NOT work if you don't generate the questions that will help you solve the case I guess IMHO.



P-previous similar episode/past medical history/past surgical history
ALLERGY always asked
Medication always asked
Hospitalization usually always asked
Urinary habit didn't ask, unless patient had UTI sympotms
GI habit - I never asked about this, except for a GI case
Sleep - Used with a patient having problems sleeping
FH - always asked
O&G - ???
Sex - Asked this quickly each time
SH - Asked about recreational drugs, alcohol. Didn't ask about occupation unless germaine to complaint

Location - Never really asked unless patient had chest/abdominal pain
Intensity - only asked with pain
Quality - asked once with chest pain?? (can't remember)
Onset - patient's tell you when it started
Radiation - asked with pain CC, which most patient's don't have
Aggravating factors - with pain
Alleviating factors - asked them if they took meds or if anything helped
Associated symptoms - you can't ask if they have "associated symptoms" patient would be (act) confused, you have to have a differential in mind and ask them if they have say SOB with left arm pain. . .

I just did my interviews like how you normally do an H and P, like I always do cc, hpi, pmh, meds, surgical hx, social hx, family hx, ros (asked this with hpi sometimes), allergies, did the physical and told them what I thought they had. done.

If you use the pneumonics each time you could likely fail IMHO as you don't have enough time to ask the important questions which lead to the diagnosis and also other important considerations. For each case there was a clear diagnosis or at least two strong possibilities, I used the rest of the space in DDx to put in stuff it could be, but probably wasn't. Also, sometimes I would have to council the patient about testing or admission to the hospital. If you don't have the top 2-3 diagnosis in mind no way can you ask the right questions.

Also, realize that Step 2 CS has been made more difficult as the experimental phase of the test is done and they have increased what you need to do to pass.

Focus on the chief complaint, if someone has diabetes then you will get info about their meds with the medications part of the history and physical, but it might have nothing to do with the chief complaint or why they are there . . . and you can't ask "Have any side effects?" No medical jargon! If you used ALL 3 pneumonics each time then you would fail as most of the questions don't pertain to the chief complaint. I would have failed if I did this as you don't get credit for asking about HgbA1c in a patient with an ulcer . . . Don't use the pneumonics again.

I studied a great book, I can't remember the name, but they had a whole list of questions you would ask for gastric ulcer symptoms . . . much better than the pneumonics which are a quick fix if you can't ask anything else and are an easy way to try to pass. The people who administer Step 2 CS know about the pneumonics and probably don't like them as no attending or resident using them, but uses their brain to ask the right questions.
Click to expand...
 
dragonfly99 said:
superoxide,
So sorry that you failed the CS exam.
I don't have anything super constructive to add since I never had to take that test...it came out the year after I graduated.

I have never heard of the mnemonic you mention. It does seem like an excessive number of questions to ask every patient. Perhaps the patients have become wise to the fact that people are memorizing these mnemonics, and they are on the lookout for people who are asking questions not really relevant to the "chief complaint" at hand. If you ask too many questions such as review of systems ones, they might assume you have no idea what to ask, and no idea what is going on with the patient.

I agree with Darth...I think you should just go in there, do sort of a normal H and P, with questions focused toward whatever the chief complaint is, and let the chips fall where they may. I hope some more people who have actually taken this exam will chime in with hints/tips.

I think you should just assume this year is a no-go...you need to do something so that you definitely pass the CS the next time. Is there a review course you can take that has "live" standardized patients and a real test-like situation? Can your medical school help you out with studying for it, based on their past experiences with students who have failed?

I think you can try next year for residency. If that fails, you could go into biomedical research, sales/business, etc.
Click to expand...

I must be doing something very wrong somewhere! I have to figure it out.

There are review courses which I can take but they are very expensive. The cheapest one at Kaplan is $1000. There's a 5 day course for $3000. There are USMLE WORLD cases for CS which is $70 for a 60 day subscription I think.

I went to an offshore medical school and they are of little help when it comes to problems like this. The students are very much on their own.

This year is definitely gone. Will have to try to match next year. But first I have to pass this test.

Thanks for your response.
 
It's really hard to keep my chin up at a time like this. I'll eventually get over it, but right now I feel like I have hit rock bottom. This is the absolute worst thing that could have happened to me. I feel stupid, humiliated and embarrassed.

I talked to my parents today and they are just confused about the whole thing. They're disappointed in me. They didn't say it, but I could tell from their voice. They were ecstatic two days ago because I finished all my rotations and I graduated from med school with the expectation that I will start earning money next summer...after all these years. But that's not going to happen now. My parents are depending on me for income. I feel like I've failed them and everyone else.

I am really doubtful that any residency will even look at my application now. I was a bad applicant before this failure, and now it's even worse. I feel like giving up, but I can't. I'm in too deep to not give it another try.

But first things first: I have to pass this test!

Thanks for replying.

BlondeDocteur said:
Sorry to hear that, Superoxide.

Keep your chin up. In a month you will be a Doctor of Medicine (you graduate in December, right). You will retake CS, you will get that ECFMG certification, and you will throw your hat in the ring next year. No questions asked.

You now have three tasks ahead of you:
1) Study for, retake, and pass CS;
2) Find employment for the next 18 months;
3) Bolster your application so that you successfully match into Family Practice next cycle.

As for #1, I agree that using First Aid for CS is the best way to go. Find a friend to practice with-- alternate the patient and practitioner roles. Study the 'mini-cases' in the front of the book to get a quick rundown of differentials for a given chief complaint. Just like clinical medicine, CS is not strictly algorithmic-- no cookie-cutter mnemonic can be applied to every patient with a variety of complaints, both acute and chronic, vague and specific.

As for #2 and #3, they are 100% linked. With loans in repayment it will be a lean year, but seek out a research position at an academic center, hopefully in a prolific lab/group, doing something with pediatric primary care. Get your name on papers and case reports, and get to know faculty well who can write you strong letters for next year. Target one or two FM programs (and I think you should focus exclusively on FM), make yourself known to the PDs longitudinally, and I think your chance of matching will increase.

All is not lost, but it is on hold for a bit.
Click to expand...
 
superoxide said:
It's really hard to keep my chin up at a time like this. I'll eventually get over it, but right now I feel like I have hit rock bottom. This is the absolute worst thing that could have happened to me. I feel stupid, humiliated and embarrassed.

I talked to my parents today and they are just confused about the whole thing. They're disappointed in me. They didn't say it, but I could tell from their voice. They were ecstatic two days ago because I finished all my rotations and I graduated from med school with the expectation that I will start earning money next summer...after all these years. But that's not going to happen now. My parents are depending on me for income. I feel like I've failed them and everyone else.

I am really doubtful that any residency will even look at my application now. I was a bad applicant before this failure, and now it's even worse. I feel like giving up, but I can't. I'm in too deep to not give it another try.

But first things first: I have to pass this test!

Thanks for replying.
Click to expand...

You appear as a very congenial person and I think that if you just master the test taking technique, you'll be a valuable addition to the medical practice since so many docs often seem to be very patronizing towards everyone and have lost their humanity. While your situation is not the best, try to look at the positives: if you don't get in anywhere this time, you will have an entire year to recharge, make some money, and best of all, make your application stronger (research+retakes) and apply to the programs that you'd actually like to attend, rather than trying to get into any program available, possibly risking an unhappy residency. Good luck to you.
 
superoxide said:
It's really hard to keep my chin up at a time like this. I'll eventually get over it, but right now I feel like I have hit rock bottom. This is the absolute worst thing that could have happened to me. I feel stupid, humiliated and embarrassed.

I talked to my parents today and they are just confused about the whole thing. They're disappointed in me. They didn't say it, but I could tell from their voice. They were ecstatic two days ago because I finished all my rotations and I graduated from med school with the expectation that I will start earning money next summer...after all these years. But that's not going to happen now. My parents are depending on me for income. I feel like I've failed them and everyone else.

I am really doubtful that any residency will even look at my application now. I was a bad applicant before this failure, and now it's even worse. I feel like giving up, but I can't. I'm in too deep to not give it another try.

But first things first: I have to pass this test!

Thanks for replying.
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Superoxide,

Although unfortunate about your failures, like others have said on here, don't give up yet. It's difficult for those who are not in the whole med school/residency application process to understand how complicated all of this is. I'm sure it's difficult for your parents to understand. Congratulations on finishing medical school and all of your requirements. That in itself is a great accomplishment. You should be proud of yourself.

I think you should take this year to recharge, study for CS and pass, maybe get a job in something medically related, and possibly doing some networking. You seem to be a congenial person like someone else said, and I think that can be to your benefit. I think especially for fields like IM or peds, you still have a shot. I also wouldn't take CS again until you are sure you can pass.

Will you still be ranking the two programs that interviewed you? Hang in there. I don't think all is lost.
 
Medstudentquest said:
Hey Superoxide,

I'm sorry to hear that. I am thinking that maybe it would have been best to take Step 2 CS after the match. ... I think you can still probably match in FM.
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Medstudentquest said:
Superoxide,

Will you still be ranking the two programs that interviewed you? Hang in there. I don't think all is lost.
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MSQ...

Just wanted to point out something you seem confused about. ALL candidates for the NRMP MUST have completed and passed alll exams needed for the ECFMG certification by the date the ROL is due.

superoxide cannot take Step 2 CS after the match if he intends to stay in the match (which he cannot unless he retakes the test within the next few days) as he will automatically be withdrawn from the match because of this failure. Therefore, he cannot rank the programs because he will not be submitting a rank list since he will be withdrawn from the match by the NRMP.

He has 3 options now:

1) retake the exam in the next few days (if even possible) so that scores are available by ROL (usually mid Feb)

2) retake the exam ASAP and miss the match, but try and get the scramble list from someone who is in the match

3) sit out the year and try again next year.

As I'm sure superoxide knows, he is butting up against some state licensing regulations which do not allow more than a certain number of attempts on the USMLEs.
 
superoxide said:
I am really doubtful that any residency will even look at my application now..
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I can't speak for the more competitive residencies, but for FM and IM its certainly not the case. Gaining interviews and offers at those programs is really more a matter of schmoozing. I am old 47 (although I probably look more like 37 and physiologically perform like 27), passed step 1 and CS the first time but failed Ck the first time, went to the caribbean, got into residency 2 years post grad but quit shortly thereafter, now going on 3 years post grad. This year applied to fewer programs than last year and got decent offers.

I had interviews here in a previous year, walked out of the interview in the middle of it. The PD from that program called all around out here and told everyone not to pick me. I mean the guy blackballed me out here - its amazing how close programs are.

but none the less I had and still have good interviews this year. I even have interviews here - its a matter of selling yourself. Blackball or not, a few emails and phone calls and selling myself with some confidence and I am in the doors right where the blackballing occured.

Leaving a program might label me a "quitter" to the shallow of thought and inexperienced in life - but showing the PD's my enduring character (ex. did not quit through undrgrad, did not quit through a prior doctorate degree, did not quit through med school , did not quit through 16 years of owning my own business, 27 years of martial arts, 3 years of teaching in a heavy gang infiltrated inner city school, 19 years of marriage etc) quickly reverses any opinion of me being a "quitter". Especially when discuss why I quit - not quitting a program is easy for a 20 something whose only ties outside the program are to mommy and daddy - my life is way more complicated than most 20 somethings can begin to appreciate. The point of me telling you this : don't let them see you through some isolated incident - show them a facet of yourself that overcomes a perceived problem. Is an SUV a easy or hard car to sell - depends on the points you present. Sell yourself the same way.

Derm or rad is probably out because its hard (impossible?) to get a PD to look past where you went to school and step 1 scores. But to say you cannot get into any residency is just out of bounds. There are FM programs that pay you to interview there. And they have residents who went to some places that even caribbean students can look askance at. You may not be a "finish residency at all costs" type of person - - but if you are willing to finish residency at all costs I am more than happy to point you to several medicine programs that would probably be glad to gobble you up.

You get ECFMG certified and yes, you can get into medicine residency. Alot of it is schmoozing and selling yourself. SUV's are what everyone wants or everyone hates depending on what people think about them. You just have to get the PD and residents to think well of you - and seriously, you can fail and even get blackballed and get those exact same people to turn around and welcome you. Just pass your test and get the ECFMG.
 
superoxide said:
. . . except in the pediatric cases where I left out the non applicable stuff like smoking, alcohol and sexual history, but I did ask those questions about the parents. So I would ask does anyone smoke at home? Did you smoke or drink alcohol during your pregnancy?) If I got a positive response to any of the basic questions, then I would ask follow up questions. So if they had a cough, I asked about type (dry or productive), amount, colour, odour, any blood?). Same with GI. If someone had diarrhea, I would ask if its watery? bloody? etc etc.

I did OB/Gyn history on all female patients regardless of CC.


Also about associated symptoms, I gave them examples. So someone came in with chest pain, I asked them "Have you had any other symptoms, for example, radiation of pain or numbness down the left arm or lower jaw?"

About asking about side effects: I'm just looking at my First Aid CS. Case 20 on page 230 has a case of hypertension followup. Under the question list on pg 231 one of the questions is: "Medication Side effects". I think that's a very relevant question. How is that medical jargon? Also, if I remember correctly, most patients didn't state in their CC how long they've had their symptoms. I usually had to ask them "When did it start? Has it gotten better/worse since then?" (I'm not saying you're wrong, I'm just looking back at how it was on my test day)

About the HbA1C, I only asked that question if the SP had diabetes. Just like I would ask blood pressure monitoring for someone who was hypertensive.

The one thing I didn't do for both attempts is practice with a partner. I sent an email to my classmates, who have passed this test on their first attempt and they said that I should practice with someone. They will be able to see my mistakes and point them out to me. They also said that First Aid is the best prep for this test.

I am trying to figure out what I am doing *so* wrong, that I got such a low score on the data gathering part. As I said it was on the extreme low end of the scale (off the chart).

Thanks for your response and continued participation on this thread I appreciate it.
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Well, I think for Step 2 CS you might have to ask if they have noticed any changes in their health since starting a medication. I am pretty sure that you don't get points for asking a patient if their medication is causing any "side effects." Farmer Bob with a 10th grade education might not know (or the actors might pretend not to know) what "side effects" are.

Many people do not know what "radiation" means, and you certainly should NOT use this on patients. You must in real life and and on the test use "does the pain travel anywhere?" Did you seriously know what radiation of pain meant before med school?

Actually this is not that releveant for Step 2 CS as the patient usually has only one chief complaint. You have to evaluate the medications and know what the side effects are and then ask the patient if their lightheadedness started when they started some hypertensive. Your quoting first aid is meaningless as it is NOT the definitive source for studying for Step 2 CS. You have to read another review book and practice cases as it didn't work for you.

But for me each case was very clear cut and there were several very clear possible diagnosis on the differential. I think because you failed Step 1 and perhaps got a marginal on Step 2 CK that possibly your knowledge base was insufficient to ask the right questions.

I do know that you can not/should not ask multiple questions in one breath, you can't say "do you have any other symptoms, radiation of pain or numbness down the left arm or jaw". That would get no credit as it is interpreted as confusing the patient. And I know for a fact that you can't use "radiation" you MUST ask "does the pain travel anywhere" both on Step 2 CS and in the real world.

I did not ask for "blood pressure measurements" in a known hypertensive as the bp is on the door, once it was very high and I re-checked it in the office. But this makes no sense if it is not releveant, likewise I am not sure if hgba1c would be releveant for an acute CC.

Obviously something went very wrong with your performance. I think it is that you failed Step 1 and Step 2 CK and have such a knowledge deficit that you need to really buckle down and re-study for Step 2 CK and Step 3 and read several review books for Step 2 CS.

Honestly, I was afraid of Step 2 CS even though I got above a 250 on Step 2 CK and read much more than First Aid Step 2 CS . . . passing the test is more than just reading FA for Step 2 CS. When I did my medicine clerkship I worked up maybe 4-5 patients each night when I was on call, i.e. wrote the history and physical and orders. If you have never done this, i.e. just had almost observership type medicine clerkship like some IMGs then yeah, you are way behind. Point being is that this should be second nature by now. I used Case Files for Step 2 CS (I think??) it had like over a hundred different clinical scenarios. You have to read this and also Step-Up to Medicine just to stay fresh.

Tell us about a case that went wrong, i.e. that you couldn't figure it out and we could help more. From your post I would say one big problem is asking too many questions in a run-on sentence and from my point of view you made at least two errors of using medical jargon in your post and therefore during the real examnation used probably a lot of them.

Also, I don't think MI patients have numbness in the jaw or left arm, i.e. I think that it is actually pain, not a stroke like numbness so that doesn't help and if the patient doesn't understand "radiation" then that question is worse than useless.
 
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superoxide said:
Moderator: I changed me mind. Please keep this thread open.
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OK, will do.

This was after going through PAM HUGS FOSS and LIQORAAA and TOADESS for almost every encounter
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Wow, I have no idea what these mnemonics stand for. If this method works for you, stick with it, but personally it'd be difficult for me to conduct a smooth history while having to thinking what the next "step" in the mnemonic is.
 
superoxide,
don't post case scenarios from your test on here - that is not allowed and you could get in trouble, which we don't want.

Darth is being harsh, but I think he likely has a point about your having some knowledge deficits, and perhaps you didn't work up as many patients during your clinical clerkship as students did at some other schools. However, I don't think I did 4-5/night as a 3rd year med student...expectations probably vary a lot by school.

I think the $70 for case scenarios sounds reasonable. Also, you might want to consider one of the Kaplan courses, even if it's expensive, like $1000. You really need to pass the exam, and I'm sure you can if you just figure things out. Usually when we had these sort of clinical skills exam when I was a student, there was usually just 1 thing wrong with the standardized patient, and if you just ask them the right stuff, they will tell you/give away what it is. For example, CHF symptoms, ACE-I cough, etc. However, you've got to be able to figure out the diagnosis. As far as figuring that out, studying Step 2 CK and Step 3 materials might be helpful. Did you feel like you couldn't figure out what the heck was wrong with the patients during the test, and couldn't figure out what to ask them, or were you surprised that you got reamed on the "information gathering" part of the exam?

I also agree with Darth that probably the standardized patients are being trained to look for certain things, like any use of medical "jargon", etc. so if you used any that would be one thing to correct. In reality, some real patients do understand stuff like "medication side effects", but it depends on their educational level. On tests like this, always assume the patient knows NOTHING medically related and isn't very smart...LOL!

I agree with practicing with another person...if you could find anyone who has already taken and passed the test, they would be the ideal person. I'll bet you that the Kaplan folks and some others might have some good insight into this test, too.

You might want to wait a few months to retake the CS exam, as you really want to pass next time. What is the latest you can take it and still be able to "scramble"?

p.s. Don't expect your parents to understand the medical training system. They are most likely clueless, just like the general public. As far as money goes, you wouldn't be able to financially support other people very well during a residency either, as residents don't make that much money. I think you should just try for a research job now, and/or a hospital job of some type.
 
Superoxide,
I really hate to see your plans derailed by the Step 2 CS test because it is IMHO a completely bogus exam. There are thousands of physicians like myself who never took Step 2 CS and no evidence that the exam has lead to any improvement in the quality of physicians. I think Step 2 CS is a money grab disguised as a measure to improve physician quality and patient safety.
The bogus studies they rammed through to justify this exam are IMHO a joke
See: http://www.academicmedicine.org/pt/...WG2RtjlQ2vlz6rkm7!976670012!181195629!8091!-1
It makes sense to assess the clinical skills of a candidate for medical licensure before granting a medical license. However to assess these skills by examining 12 actors simulating patients is IMHO ridiculous and borders on fraud.
 
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Winged Scapula said:
MSQ...

Just wanted to point out something you seem confused about. ALL candidates for the NRMP MUST have completed and passed alll exams needed for the ECFMG certification by the date the ROL is due.

superoxide cannot take Step 2 CS after the match if he intends to stay in the match (which he cannot unless he retakes the test within the next few days) as he will automatically be withdrawn from the match because of this failure. Therefore, he cannot rank the programs because he will not be submitting a rank list since he will be withdrawn from the match by the NRMP.

He has 3 options now:

1) retake the exam in the next few days (if even possible) so that scores are available by ROL (usually mid Feb)

2) retake the exam ASAP and miss the match, but try and get the scramble list from someone who is in the match

3) sit out the year and try again next year.

As I'm sure superoxide knows, he is butting up against some state licensing regulations which do not allow more than a certain number of attempts on the USMLEs.
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Hi WingedScapula,

Yes I realized that after wards that since Superoxide is a Caribbean med school grad, he would need to be ECFMG certified by the match, which would mean he'd likely would need to re-take CS shortly, which probably wouldn't be in his best interest. My mistake!
 
superoxide said:
It's really hard to keep my chin up at a time like this. I'll eventually get over it, but right now I feel like I have hit rock bottom. This is the absolute worst thing that could have happened to me. I feel stupid, humiliated and embarrassed.

I talked to my parents today and they are just confused about the whole thing. They're disappointed in me. They didn't say it, but I could tell from their voice. They were ecstatic two days ago because I finished all my rotations and I graduated from med school with the expectation that I will start earning money next summer...after all these years. But that's not going to happen now. My parents are depending on me for income. I feel like I've failed them and everyone else.

I am really doubtful that any residency will even look at my application now. I was a bad applicant before this failure, and now it's even worse. I feel like giving up, but I can't. I'm in too deep to not give it another try.

But first things first: I have to pass this test!

Thanks for replying.
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I think the best thing to do now is to try to find a job. To have a good chance at next years match you'll still need to apply to a number of programs. It may be worthwhile to think about taking the mccee, and trying your luck in the canadian match.
However with the economy tanking, and your family relying on your for $, your best bet would be to start earning $$ now.
 
Very sorry to hear that CS has been such a problem for you. I actually passed the thing, and I'm still bitter about having to spend a bunch of money and drive to Atlanta for the sole purpose of expressing my acting talents.

Here's a few tips for your next run from a guy who did just pass the test in June:

1. First Aid is key, but you're focusing on the wrong places. The actual case scenarios aren't that important. You've been to medical school. You don't need to take notes on how to determine a differential for a cough or chest pain. You DO need to look at the list of things that they check off. You would probably gain more points for knocking on the door and draping the patient than you would lose for being way off on your differential.

2. The actors are NOT doctors. There are probably some buzz questions, but these are almost always going to fall into OLDCARTS, with some relevant ROS, PMHx, PSHx, FamHx, SocHx, allergies, and meds. Anything beyond that is probably wasting your time. If you ask specifically about OB/GYN Hx to a woman with a cough, it may not seem relevant to the non-physician actor.

3. Make the encounter seem natural. I sincerely doubt that these guys remember every question you asked during the interview. If you run in with a list of pre-ordained questions and look nervous, they may take this as a negative, regardless of what you asked. On the other hand, a confident interview that touches on the obvious relative ROS and you look confident, I suspect that most of the boxes will be checked, regardless of what you actually said. I don't know what 90% of those mnemonics you mentioned mean, and it really didn't hurt.

4.Be sympathetic, break everything down, always suggest what you think it might be. Always suggest that you will need to order some more tests or check on a couple of things to make sure (Do not commit). Always tell the patient that you will do your best to comply with whatever request they come up with.

5. If someone asks you ANY question about your ability to actually get something done, the following works well: "It is my first day here at this clinic, so I'm not sure what the policy is on that. However, I will do my best to let you know as soon as I know." Since the whole scenario is made up, feel free to take it to a place that you can logically get out of a problem. DO NOT GET FLUSTERED.

Hope that helps. If you passed CK with a remotely decent score on the first attempt, you have the clinical background to pass CS.
 
miamimed is probably right.
I'll bet there is a list somewhere (USMLE web site?) of the things the patients actually grade you on. I am sure that knocking on the door, shaking hands, acting really nice and sympathetic, and acting confident will get you extra points. The standardized patients really don't know that much medicine (at least some of them) so they aren't going to be able to really grade you on your medical knowledge. You can bet they have some list of buzzwords/certain questions that they are sitting there listening to see if you asked. If you ask other stuff (even if relevant) I'm sure you're getting no points for that.

We took standardized patient exams like this in medical school, and they always had a list of things that the standardized patients were looking for, and if you did it you got a check mark, if not you didn't...
 
Thanks everyone for your posts. Things have been kinda crazy for me the last few days...me with moving back home and everything. I'll respond to your posts individually as soon as things calm down a little bit.

Thanks again.
 
Excelsius said:
You appear as a very congenial person and I think that if you just master the test taking technique, you'll be a valuable addition to the medical practice since so many docs often seem to be very patronizing towards everyone and have lost their humanity. While your situation is not the best, try to look at the positives: if you don't get in anywhere this time, you will have an entire year to recharge, make some money, and best of all, make your application stronger (research+retakes) and apply to the programs that you'd actually like to attend, rather than trying to get into any program available, possibly risking an unhappy residency. Good luck to you.
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Thanks. I'm going to retake this test sometime next spring/summer and apply next year. I'm also looking for a job. My search so far has been futile.:(
 
Thanks. I won't be ranking the two programs I interviewed at because I am not eligible to match. Without a passing CS score before the ROL deadline, I automatically get kicked out of the match.


Medstudentquest said:
Superoxide,

Although unfortunate about your failures, like others have said on here, don't give up yet. It's difficult for those who are not in the whole med school/residency application process to understand how complicated all of this is. I'm sure it's difficult for your parents to understand. Congratulations on finishing medical school and all of your requirements. That in itself is a great accomplishment. You should be proud of yourself.

I think you should take this year to recharge, study for CS and pass, maybe get a job in something medically related, and possibly doing some networking. You seem to be a congenial person like someone else said, and I think that can be to your benefit. I think especially for fields like IM or peds, you still have a shot. I also wouldn't take CS again until you are sure you can pass.

Will you still be ranking the two programs that interviewed you? Hang in there. I don't think all is lost.
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Doowai said:
I can't speak for the more competitive residencies, but for FM and IM its certainly not the case. Gaining interviews and offers at those programs is really more a matter of schmoozing. I am old 47 (although I probably look more like 37 and physiologically perform like 27), passed step 1 and CS the first time but failed Ck the first time, went to the caribbean, got into residency 2 years post grad but quit shortly thereafter, now going on 3 years post grad. This year applied to fewer programs than last year and got decent offers.

I had interviews here in a previous year, walked out of the interview in the middle of it. The PD from that program called all around out here and told everyone not to pick me. I mean the guy blackballed me out here - its amazing how close programs are.

but none the less I had and still have good interviews this year. I even have interviews here - its a matter of selling yourself. Blackball or not, a few emails and phone calls and selling myself with some confidence and I am in the doors right where the blackballing occured.

Leaving a program might label me a "quitter" to the shallow of thought and inexperienced in life - but showing the PD's my enduring character (ex. did not quit through undrgrad, did not quit through a prior doctorate degree, did not quit through med school , did not quit through 16 years of owning my own business, 27 years of martial arts, 3 years of teaching in a heavy gang infiltrated inner city school, 19 years of marriage etc) quickly reverses any opinion of me being a "quitter". Especially when discuss why I quit - not quitting a program is easy for a 20 something whose only ties outside the program are to mommy and daddy - my life is way more complicated than most 20 somethings can begin to appreciate. The point of me telling you this : don't let them see you through some isolated incident - show them a facet of yourself that overcomes a perceived problem. Is an SUV a easy or hard car to sell - depends on the points you present. Sell yourself the same way.

Derm or rad is probably out because its hard (impossible?) to get a PD to look past where you went to school and step 1 scores. But to say you cannot get into any residency is just out of bounds. There are FM programs that pay you to interview there. And they have residents who went to some places that even caribbean students can look askance at. You may not be a "finish residency at all costs" type of person - - but if you are willing to finish residency at all costs I am more than happy to point you to several medicine programs that would probably be glad to gobble you up.

You get ECFMG certified and yes, you can get into medicine residency. Alot of it is schmoozing and selling yourself. SUV's are what everyone wants or everyone hates depending on what people think about them. You just have to get the PD and residents to think well of you - and seriously, you can fail and even get blackballed and get those exact same people to turn around and welcome you. Just pass your test and get the ECFMG.
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Thanks Doowai. It's good to see someone in a somewhat similar situation as me doing so well with the match. Although I am trying to stay positive, there are a few major hurdles I have to overcome:

(1) I failed Step 1: You had a first attempt pass. Failing Step 1 is much worse than failing Step 2CK
(2) You passed CS on your first attempt. I failed that test twice.
(3) You are an American citizen. I'm Canadian, so I have visa issues.

Granted that once I have ECFMG certification, I MIGHT look like a better candidate, but those are pretty glaring red flags.

I'm going to give it another final try.

Thanks and good luck with the match.
 
Hi Darth,

I've been thinking about what I've been doing wrong and I've come up with a few things.

When I went into the room, I had 2-3 differentials in mind and I would start off with questions relating to the CC before I went into the mnemonics. This is what I think I did:

If I had 3 differentials in my head, I would start with questions relating to the first differential. So if my differential was (and I'm just making this up):

(1) TB
(2) pneumonia
(3) Lung cancer

For each of those I would think of a set of questions. If I started with TB, and after 2-3 questions it looked like this person has TB (they had bloody sputum, weight loss, night sweats), then I wouldn't ask questions about the other two differentials, because I know that this person has TB. I ruled TB in, but didn't rule the other 2 out. Once I figured out the diagnosis, I went on to family hx, meds, all that stuff. Then onto the physical. I didn't ask about lung cancer, pneumonia etc. Or even if I did, it was very superficial. Maybe just 1-2 basic questions. Does that make sense?

This might be the reason why my data gathering part was so weak. It's been over 2 months since I took it, so I cant remember what I did and didn't do anymore, but that could be what I'm doing wrong.

Also, this time the score report shows the CIS part broken down into 3 components: Questioning skills, Information sharing skills and Professional manner and rapport. My questioning skills were borderline. You're probably right that I might be using medical jargon, but I am a little confused. There are several cases in First Aid where they ask about "radiation" and "side effects". I don't think this qualifies as medical jargon. Medical jargon in my opinion is using "Myocardial Infarction" instead of "Heart attack", "Nephrolithiasis" instead of saying "Kidney Stones" and "CBC" instead of "Blood tests". There probably were instances where I used medical jargon, but as far as I can remember, I always explained it right after using an unfamiliar term. According to First Aid, that's OK to do. So for example (again I'm just making this up), I'd say something like "Mr. X, I think you might have GERD. Do you know what that is?" If they said "No", then I'd give them a brief explanation.

You say that First Aid is not the definitive source for studying for CS...and that is very frustrating to hear. Everyone who I have asked for help have said all they used was First Aid and they passed with no problems ("Know First Aid inside and out and you'll do well on this test" is what I got from everyone). They also said that it's probably not the source that's the problem, it's the way I'm using it. Maybe I haven't been using it correctly or as thoroughly as I think I have.

I didn't have any problems coming up with differentials. You can give me any symptom and I can easily come with 3-4 differentials in 10 seconds. As I explained above, I probably didn't inquire enough about each and every differential once I figured out what the problem was. CS is not about getting the diagnosis right, but asking all the relevant questions. That's my problem...I can come up with relevant questions to ask, but I didn't ask them.

None of my clerkships were observerships. They were regular clinicals. I did H&Ps, came up with a plan/assessment, presented my patients on morning rounds etc etc. Everything was precepted with either a resident or an attending. Everyone from my school has had similar clinical experiences as me and they all seemed to have passed this test with no problems. You're right - this should be second nature to me by now, which is why this is so frustrating.

Thanks for your response.



DarthNeurology said:
Well, I think for Step 2 CS you might have to ask if they have noticed any changes in their health since starting a medication. I am pretty sure that you don't get points for asking a patient if their medication is causing any "side effects." Farmer Bob with a 10th grade education might not know (or the actors might pretend not to know) what "side effects" are.

Many people do not know what "radiation" means, and you certainly should NOT use this on patients. You must in real life and and on the test use "does the pain travel anywhere?" Did you seriously know what radiation of pain meant before med school?

Actually this is not that releveant for Step 2 CS as the patient usually has only one chief complaint. You have to evaluate the medications and know what the side effects are and then ask the patient if their lightheadedness started when they started some hypertensive. Your quoting first aid is meaningless as it is NOT the definitive source for studying for Step 2 CS. You have to read another review book and practice cases as it didn't work for you.

But for me each case was very clear cut and there were several very clear possible diagnosis on the differential. I think because you failed Step 1 and perhaps got a marginal on Step 2 CK that possibly your knowledge base was insufficient to ask the right questions.

I do know that you can not/should not ask multiple questions in one breath, you can't say "do you have any other symptoms, radiation of pain or numbness down the left arm or jaw". That would get no credit as it is interpreted as confusing the patient. And I know for a fact that you can't use "radiation" you MUST ask "does the pain travel anywhere" both on Step 2 CS and in the real world.

I did not ask for "blood pressure measurements" in a known hypertensive as the bp is on the door, once it was very high and I re-checked it in the office. But this makes no sense if it is not releveant, likewise I am not sure if hgba1c would be releveant for an acute CC.

Obviously something went very wrong with your performance. I think it is that you failed Step 1 and Step 2 CK and have such a knowledge deficit that you need to really buckle down and re-study for Step 2 CK and Step 3 and read several review books for Step 2 CS.

Honestly, I was afraid of Step 2 CS even though I got above a 250 on Step 2 CK and read much more than First Aid Step 2 CS . . . passing the test is more than just reading FA for Step 2 CS. When I did my medicine clerkship I worked up maybe 4-5 patients each night when I was on call, i.e. wrote the history and physical and orders. If you have never done this, i.e. just had almost observership type medicine clerkship like some IMGs then yeah, you are way behind. Point being is that this should be second nature by now. I used Case Files for Step 2 CS (I think??) it had like over a hundred different clinical scenarios. You have to read this and also Step-Up to Medicine just to stay fresh.

Tell us about a case that went wrong, i.e. that you couldn't figure it out and we could help more. From your post I would say one big problem is asking too many questions in a run-on sentence and from my point of view you made at least two errors of using medical jargon in your post and therefore during the real examnation used probably a lot of them.

Also, I don't think MI patients have numbness in the jaw or left arm, i.e. I think that it is actually pain, not a stroke like numbness so that doesn't help and if the patient doesn't understand "radiation" then that question is worse than useless.
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Hi dragonfly,

I didn't have any problems figuring out what the patient might have. I could very easily come up with differentials for almost each and every case. I can also come up with the appropriate questions to ask about each differential. I probably didn't inquire about each and every differential once I figured out what the diagnosis was. (Please read my post replying to DarthNeurology for a more detailed explanation)

The one thing I didn't do was practice with anyone. I just read First Aid, took notes and studied them. This is one thing my classmates have told me that I MUST do! I should go over each case in FA at least 3 times.

I'm going to take this test next spring or summer (probably summer), but early enough in the summer that I will have my score report before September.

Re: money - My family is not depending on me 100%. It's just that it would be nice to contribute a little bit every month. Help them with the credit card payment, take them out to a restaurant or a movie, buy them a gift. Little things which some people take for granted. I can't remember the last time my parents had a meal at a restaurant. It's also embarrassing asking my family for money. Last weekend I had to ask my younger brother for $5 for a train ticket to go downtown to meet a friend. It would be OK if I was a 15 year old kid, but I'll be 31 years old next March. It's humiliating.




dragonfly99 said:
superoxide,
don't post case scenarios from your test on here - that is not allowed and you could get in trouble, which we don't want.

Darth is being harsh, but I think he likely has a point about your having some knowledge deficits, and perhaps you didn't work up as many patients during your clinical clerkship as students did at some other schools. However, I don't think I did 4-5/night as a 3rd year med student...expectations probably vary a lot by school.

I think the $70 for case scenarios sounds reasonable. Also, you might want to consider one of the Kaplan courses, even if it's expensive, like $1000. You really need to pass the exam, and I'm sure you can if you just figure things out. Usually when we had these sort of clinical skills exam when I was a student, there was usually just 1 thing wrong with the standardized patient, and if you just ask them the right stuff, they will tell you/give away what it is. For example, CHF symptoms, ACE-I cough, etc. However, you've got to be able to figure out the diagnosis. As far as figuring that out, studying Step 2 CK and Step 3 materials might be helpful. Did you feel like you couldn't figure out what the heck was wrong with the patients during the test, and couldn't figure out what to ask them, or were you surprised that you got reamed on the "information gathering" part of the exam?

I also agree with Darth that probably the standardized patients are being trained to look for certain things, like any use of medical "jargon", etc. so if you used any that would be one thing to correct. In reality, some real patients do understand stuff like "medication side effects", but it depends on their educational level. On tests like this, always assume the patient knows NOTHING medically related and isn't very smart...LOL!

I agree with practicing with another person...if you could find anyone who has already taken and passed the test, they would be the ideal person. I'll bet you that the Kaplan folks and some others might have some good insight into this test, too.

You might want to wait a few months to retake the CS exam, as you really want to pass next time. What is the latest you can take it and still be able to "scramble"?

p.s. Don't expect your parents to understand the medical training system. They are most likely clueless, just like the general public. As far as money goes, you wouldn't be able to financially support other people very well during a residency either, as residents don't make that much money. I think you should just try for a research job now, and/or a hospital job of some type.
Click to expand...
 
exPCM said:
Superoxide,
I really hate to see your plans derailed by the Step 2 CS test because it is IMHO a completely bogus exam. There are thousands of physicians like myself who never took Step 2 CS and no evidence that the exam has lead to any improvement in the quality of physicians. I think Step 2 CS is a money grab disguised as a measure to improve physician quality and patient safety.
The bogus studies they rammed through to justify this exam are IMHO a joke
See: http://www.academicmedicine.org/pt/...WG2RtjlQ2vlz6rkm7!976670012!181195629!8091!-1
It makes sense to assess the clinical skills of a candidate for medical licensure before granting a medical license. However to assess these skills by examining 12 actors simulating patients is IMHO ridiculous and borders on fraud.
Click to expand...

I agree:D
 
JPR22 said:
I think the best thing to do now is to try to find a job. To have a good chance at next years match you'll still need to apply to a number of programs. It may be worthwhile to think about taking the mccee, and trying your luck in the canadian match.
However with the economy tanking, and your family relying on your for $, your best bet would be to start earning $$ now.
Click to expand...

Yes, the Canadian match is another option, but I would have to take the MCCEE, which is similar to USMLE Step 2CK. It's been almost 6 months since I took CK so a lot of the material has left my brain. Studying for the MCCEE would be like stuyding for CK all over again!:eek: But it is an option and I am considering it.

This whole job thing is not working out at all. Bad timing...VERY bad timing.
 
Just wanted to point out that there are a few options, albeit not terribly likely, that are still possible:

1. If one of the programs that interviewed you really likes you, they could consider taking you outside the match. You could sign now, and focus on passing CS before July. You will need to pass CS for a visa (and perhaps to graduate from medical school and/or for a training license, but that's not true for all schools/states), so you can't start your residency without it. You would need to plan to retake CS in March, so you'd have a passing score back by June. Even if you thought you might be a bit late on the timeline, it's not a huge deal for a program to start you in Aug or Sept if they know in advance.

2. In the scramble, without passing CS, your chances will be dismal. You should try, but don't get your hopes up. However, if one of the programs that interviewed you ends up in the scramble, there is some chance they'll take you rather than someone else whom they've never met. You might want to tell those programs that should they end up in the scramble, you'd love to join them. Can't hurt to ask.

3. Have you considered trying to work as a medical transcriptionist? Assuming you can type reasonably quickly, you'll certainly have the lingo down. Many jobs require prior MT experience, but I wonder if some employers would consider your medical training as equivalent? I also wonder if you could use Dragon Dictate on your PC, if your typing skills are not great.
 
superoxide said:
Hi Darth,
If I started with TB, and after 2-3 questions it looked like this person has TB (they had bloody sputum, weight loss, night sweats), then I wouldn't ask questions about the other two differentials, because I know that this person has TB. I ruled TB in, but didn't rule the other 2 out. Once I figured out the diagnosis, I went on to family hx, meds, all that stuff. Then onto the physical. I didn't ask about lung cancer, pneumonia etc. Or even if I did, it was very superficial. Maybe just 1-2 basic questions. Does that make sense?

This might be the reason why my data gathering part was so weak.

Also, this time the score report shows the CIS part broken down into 3 components: Questioning skills, Information sharing skills and Professional manner and rapport. My questioning skills were borderline. You're probably right that I might be using medical jargon, but I am a little confused. There are several cases in First Aid where they ask about "radiation" and "side effects". So for example (again I'm just making this up), I'd say something like "Mr. X, I think you might have GERD. Do you know what that is?" If they said "No", then I'd give them a brief explanation.
Click to expand...

Even if a patient looks like TB you have to ask the "other questions" related to the other topic differentials, there were usually a couple of good 2nd and 3rd choices. . . You can't "rule in" TB on a history and physical, if I had a TB patient I would hypothetically tell the patient that we need to do a skin test (PPD) and do a chest x-ray. As in the real world you have to also get the whole picture. Weight loss and bloody sputum go with lung cancer too . . . You can't really say that the patient does have TB in this setting or otherwise.

In the real world even if you have a 95% correct guess for a patient with community acquired pneumoniae, you still ask about TB etc during the history and physical, it is better to be thorough up front, so yeah, I think you may have messed up by not asking enough questions and getting a clear answer.

It really doesn't matter what your opinion is regarding medical jargon. You are supposed to put everything into layman's terms so the patient can understand. You should have realized that the patient in CS are trained to be very "non-medical" in their thinking.

I don't "pimp" patients in the real world or on the test, I don't say "You have GERD, do you know what that is?" Waste of time and insulting. I really say, "I think you may have GERD or gastroesophageal reflux disease which means that the acid in your stomach moves up your esophagus and causes that burning sensation . . . " Helps when you then have to explain about using proton-pump inhibitors.

I did NOT like First Aid for Step 2 CS that much, although I read it, I used a pocket book that had like 60 cases and like 50 questions to ask, so when I took the exam I had alot of questions, some stuff you might not think of quickly even if you aced clinicals. Read this and a couple more review books and maybe practice with friends who passed. I was able to type the note for my exam, and I type probably north of 80 words a minute, so yeah had time to do a good note.

There is *always* something you can do better. I felt like I failed the exam although I tried to pack in as much as a I could, I actually was done first out of about 24 other folks and felt that I would fail as I wanted to get out and write the note, but I didn't so I think that CS awards overall completeness, it is not just about getting "the diagnosis" while there is one obvious answer like a healthcare workers exposed to TB with chronic cough you have to think about asthma, pneumoniae, etc . . . same way in real life on the floors, sometimes you are fooled.
 
You seem like a genuinely nice and decent person. I think there are many others on this forum who have recognized that in you. Try to stay positive. Put together a solid plan. Pray if you believe in God. Find inspiration in things outside of medicine. Try watching the movie, Facing the Giants. Take some pointers from the coach. You will land a residency if you believe in yourself and in something way bigger than yourself. May you find the strength and courage to believe in yourself and to have God carry you through this.
 
DarthNeurology said:
Supposedly you are not punished for asking irreleveant questions during Step 2 CS. However, if you waste too much time with pointless questions then you don't have time to ask what is important. The good thing is that the standardized patients don't go "ummm . . . " but answer questions must faster than a normal patient would. Even so, I was hard pressed to finish the examination a couple times and everything I asked felt releveant.

Be aware that Step 2 CS has been made more difficult by the examination administrators, I think the change was in summer 2008?? So this may have contributed to the fail, however, if you got your results and got what apparently were very low scores on one portion then something is wrong.

If you barely passed Step 2 CK, then this would hurt you on Step 2 CS as your knowledge base may be sufficient or it may take you extra time to think of the possible differential. Residents and attendings have a thought in mind about the 5 most likely diagnosis when seeing a patient for the first time in the ED, such as for abdominal pain, and base their questions on this.

Same thing with Step 2 CS, once a patient tells you the chief complaint you should instantly think of half a dozen things automatically. Like if someone says they have "chest pain" you should be thinking beyond MI to about a dozen other possibilities as well and real specific questions like if they have a salty taste in their mouth occassionally, if the pain comes on after eating, when lying down, do they have SOB, after they exercise?? None of these questions are in those lame mnemonics.

Just asking what "exacerbates your pain" is a sure way to fail Step 2 CS as it is too medical in my opinion.

In the examination you can't just do the mnemonics (sorry about the prior spelling!) and then sit down at the computer and figure out what it was. Certainly residents can't do this as you need to be thinking while you question patients about their chief complaint. This is why a mnemonic is counter-productive as you are busy worrying about the mnemonic and then forget to think to ask the important questions.

I have seen so many people post on the Step 2 CS forum who said that they followed the "PAMHUGSFOSS" and then failed. . . Realize that there is a check-list of questions that the patient has and you only get credit for asking those questions. You won't get credit for asking about urinary tract infections in a patient with pneumoniae, on the test and in real life usually. (Although you may have time to do a full ROS in the ER, this printed on most H and P forms and is not the skill you need to learn to be a doctor).

The PAMHUGSFOSS is NOT recommended by the USMLE, but rather was someone's attempt to sell a review book for a new test. Asking all of these questions in no way will assure a pass on that portion of the examination. If you had a patient with chronic cough who has TB, and you didn't ask about exposure or past PPDs or weight loss or blood tinged sputum, then yeah you failed that part.

Asking these questions are almost useless if you aren't thinking and/or haven't done so many history and physicals that you can do it automatically. PAMHUGSFOSS doesn't work IMHO. I feel that the testing folks are making sure cases are original enough that if you just use mnemonics you will waste your time, look stupid, and fail the exam.

Step 2 CS is as much of a thinking examination as Step 2 CK IMHO . . .
Click to expand...


Passing step2cs has got nothing to do with the performance on usmle step2CK.
This exam is about communication.
This exam is not about checklists only.
It is neither a test of one's knowledge nor a test of one's fluency in english.
There are people who got 230's on step-2ck and failed this test.
Moreover, every year there is some percentage of AMG's who do fail this test.
Enough timed practice of each and every case scenario is key to passing this exam.
This exam is about being with the patient and following the patient's leads.
This exam is about maintaining eye contact,speaking slow and loud,showing respect,helping the patient,refraining from using medical jargon,using simple and short sentences,not interrupting the patient,listening ,admitting your mistakes,addressing the patients concerns,and having a confident approach ,etc.

Superoxide, I hope that now you will take this exam after much timed practice and keeping in mind the above criteria.

Best of luck and have faith in ALLAH!
 
Last edited:
I never had to take the Step 2CS,
but did take multiple standardized patient exams in medical school.
If the Step 2CS is anything like those, I agree with the previous/above post.
I don't think the OP will find the answers to passing the Step 2CS in any book.
These tests are more about timing (i.e. being able to do all of what they want you to do in the alloted time) and establishing rapport with the patient, so that you "come across" well to the patient. I'm sure there is some baseline level of medical knowledge/ability to get basic diagnoses that are necessary also, but I don't think that is the main part of these types of tests/exams.

If I were the OP I'd fork over the money to take some sort of live class where you get to practice on standardized patients, if there is such a thing. I'd do it even if I had to scrounge for any job...i.e. any hospital job, pizza delivery guy, Starbucks coffee server, whatever.
 
dragonfly99 said:
I never had to take the Step 2CS,
but did take multiple standardized patient exams in medical school.
If the Step 2CS is anything like those, I agree with the previous/above post.
I don't think the OP will find the answers to passing the Step 2CS in any book.
These tests are more about timing (i.e. being able to do all of what they want you to do in the alloted time) and establishing rapport with the patient, so that you "come across" well to the patient. I'm sure there is some baseline level of medical knowledge/ability to get basic diagnoses that are necessary also, but I don't think that is the main part of these types of tests/exams.

If I were the OP I'd fork over the money to take some sort of live class where you get to practice on standardized patients, if there is such a thing. I'd do it even if I had to scrounge for any job...i.e. any hospital job, pizza delivery guy, Starbucks coffee server, whatever.
Click to expand...

Ma'am, you have got it right.
 
Last edited:
Superoxide,more than 60% questions are repeated in each and every encounter.
In step2cs not only does it matter what you ask,but how you ask it matters as well.
Also, always remember to dissect the chief complaint and first ask questions about it .

Good luck,and never give up.

"Great things are done when men and mountains meet,
This is not done by jostling in the street."
 
Last edited:
What I would say super oxide, you need to practice it with a partner in a timed fashion.
 
superoxide said:
So I'm out of the match for 2009. Not sure what I'm supposed to do or what my future in medicine is (if any). I passed Step 1 on my second attempt, Step 2 CK on my first attempt and I have 2 failures on the CS. So I already have 5 attempts and 3 failures.
Click to expand...

I haven't read the entire thread and I don't even know if you're still reading posts in this thread, but be mindful of the requirements for licensure in the different US states.

Most states impose both limits on the number of attempts to pass the USMLE Steps as well as limits on the total time (years) it takes to pass all three Steps. You've already had 2 attempts at passing CS. Also you have a total of 5 attempts and still need to sit for Step 3 (as well as pass CS). That basically makes you ineligible for a license in Illinois and Idaho.

The more times you fail and the longer it takes you to complete the Step series, the harder it will be to find a state that will license you, even if you finish residency. Just FYI.

http://www.fsmb.org/usmle_eliinitial.html
 
Update:

Sorry for not posting for the last few weeks. I was on vacation and just got back 2 days ago.

I haven't signed up for my CS retake yet. Don't have the money, but something should work out by next month or so.

I've emailed my friends from school who have passed this test and they have given me some good advice. Some of them have also offered to practice the cases with me.

It looks like everyone used First Aid to study for this test. I just must not be using it the right way. Also I need to actually practice the cases, which is something I never did for my previous 2 attempts.

Although I am trying to be optimistic, I remain terrified of failing this test a third time.
 
Shinken said:
I haven't read the entire thread and I don't even know if you're still reading posts in this thread, but be mindful of the requirements for licensure in the different US states.

Most states impose both limits on the number of attempts to pass the USMLE Steps as well as limits on the total time (years) it takes to pass all three Steps. You've already had 2 attempts at passing CS. Also you have a total of 5 attempts and still need to sit for Step 3 (as well as pass CS). That basically makes you ineligible for a license in Illinois and Idaho.

The more times you fail and the longer it takes you to complete the Step series, the harder it will be to find a state that will license you, even if you finish residency. Just FYI.

http://www.fsmb.org/usmle_eliinitial.html
Click to expand...

Thanks Shinken. I am aware of the requirement for licensure. I have already looked at the link that you provided here. Yeah, not being able to do residency in Illinois is a killer. Idaho I'm not concerned about because my school is not even approved in that state. There are four states where my school is not approved and I think Idaho is one of them.

Thanks for lookin' out.:)
 
aPD - thanks for your response.

1. I only interviewed at two places. One was for peds and the other was for FM. The peds program has offered prematches in the past, but the FM program doesn't do prematches. I believe that my interview at the peds program was excellent, but I never got any positive feedback from them. I emailed the chief resident there three times regarding some questions that I had, but I never got a response back. Also I had emailed one of the faculty there to "put in a good word in" for me at other programs so that I'd get more interviews, but I never heard back from them either. I even called the office and left a message asking one of them to call me back, but no one ever did. I don't want to rush into my third attempt at CS. I'm going to take some time and seriously think about how to approach this test. Also as a Canadian citizen, I have to pass the MCCEE in order to qualify for a J1 visa. I haven't taken that test yet. Right now I'm just concentrating on CS.

2. I haven't even signed up for my CS retake yet, so I'm not sure when/if I'm going to have a passing score. I'm just going to write this year off and try again for 2010.

3.I looked into MT jobs. Almost all require an MT diploma and 1-2 years of work experience. My job search has been completely fruitless.

Thanks for the advice.



aProgDirector said:
Just wanted to point out that there are a few options, albeit not terribly likely, that are still possible:

1. If one of the programs that interviewed you really likes you, they could consider taking you outside the match. You could sign now, and focus on passing CS before July. You will need to pass CS for a visa (and perhaps to graduate from medical school and/or for a training license, but that's not true for all schools/states), so you can't start your residency without it. You would need to plan to retake CS in March, so you'd have a passing score back by June. Even if you thought you might be a bit late on the timeline, it's not a huge deal for a program to start you in Aug or Sept if they know in advance.

2. In the scramble, without passing CS, your chances will be dismal. You should try, but don't get your hopes up. However, if one of the programs that interviewed you ends up in the scramble, there is some chance they'll take you rather than someone else whom they've never met. You might want to tell those programs that should they end up in the scramble, you'd love to join them. Can't hurt to ask.

3. Have you considered trying to work as a medical transcriptionist? Assuming you can type reasonably quickly, you'll certainly have the lingo down. Many jobs require prior MT experience, but I wonder if some employers would consider your medical training as equivalent? I also wonder if you could use Dragon Dictate on your PC, if your typing skills are not great.
Click to expand...
 
Darth, thanks for the advice. I thought I was being "the doctor" and "educating my patients" by making sure that they understood everything I said. I never thought of it as being insulting, but you're probably right. I'm making this more complicated than it has to be.

Is there any way you can find out the name of that book you used (the one with the 60 cases and 50 questions)?

I'm planning on using CS and usmleworld and maybe this other book that you mentioned.

Thanks.

DarthNeurology said:
Even if a patient looks like TB you have to ask the "other questions" related to the other topic differentials, there were usually a couple of good 2nd and 3rd choices. . . You can't "rule in" TB on a history and physical, if I had a TB patient I would hypothetically tell the patient that we need to do a skin test (PPD) and do a chest x-ray. As in the real world you have to also get the whole picture. Weight loss and bloody sputum go with lung cancer too . . . You can't really say that the patient does have TB in this setting or otherwise.

In the real world even if you have a 95% correct guess for a patient with community acquired pneumoniae, you still ask about TB etc during the history and physical, it is better to be thorough up front, so yeah, I think you may have messed up by not asking enough questions and getting a clear answer.

It really doesn't matter what your opinion is regarding medical jargon. You are supposed to put everything into layman's terms so the patient can understand. You should have realized that the patient in CS are trained to be very "non-medical" in their thinking.

I don't "pimp" patients in the real world or on the test, I don't say "You have GERD, do you know what that is?" Waste of time and insulting. I really say, "I think you may have GERD or gastroesophageal reflux disease which means that the acid in your stomach moves up your esophagus and causes that burning sensation . . . " Helps when you then have to explain about using proton-pump inhibitors.

I did NOT like First Aid for Step 2 CS that much, although I read it, I used a pocket book that had like 60 cases and like 50 questions to ask, so when I took the exam I had alot of questions, some stuff you might not think of quickly even if you aced clinicals. Read this and a couple more review books and maybe practice with friends who passed. I was able to type the note for my exam, and I type probably north of 80 words a minute, so yeah had time to do a good note.

There is *always* something you can do better. I felt like I failed the exam although I tried to pack in as much as a I could, I actually was done first out of about 24 other folks and felt that I would fail as I wanted to get out and write the note, but I didn't so I think that CS awards overall completeness, it is not just about getting "the diagnosis" while there is one obvious answer like a healthcare workers exposed to TB with chronic cough you have to think about asthma, pneumoniae, etc . . . same way in real life on the floors, sometimes you are fooled.
Click to expand...
 
Last edited:
Abram Hoffer said:
You seem like a genuinely nice and decent person. I think there are many others on this forum who have recognized that in you. Try to stay positive. Put together a solid plan. Pray if you believe in God. Find inspiration in things outside of medicine. Try watching the movie, Facing the Giants. Take some pointers from the coach. You will land a residency if you believe in yourself and in something way bigger than yourself. May you find the strength and courage to believe in yourself and to have God carry you through this.
Click to expand...

Thank you for your encouragement! As I mentioned in another post I am trying to stay positive, but I remain absolutely TERRIFIED of failing this test for the third time.
 
Good luck SO! Have you considered sniffing around the bigger academic medical centers to get a spot as a study coordinator or research assistant? Those sorts of jobs usually require a BA and they won't pay much more than $30,000 a year but they do look nice on a CV, and they might let you keep some contact with patients.
 
I agree he/she should look for a research job.
I never had to take the CS b/c I graduated the year before they required it, but I agree w/the comment above about you needing to practice with a live "patient" (friend/classmate, etc.). Ideal would be somebody who has taken the test already, and/or take a class where they have live "patients" (aren't there such prep courses for the CS exam?). It's normal to be terrified in this situation, but I think you can do this. You might in the past have been overthinking the whole thing...in my experience these sorts of tests were at least 50% about doing all the things on their little checklist (i.e. smiling, shaking the patient's hand, making good eye contact, etc.) and NOTHING extra. There is SOME knowledge base required too, but mostly they are looking for you to be able to do the things on their little exam checklist, and not for you to evaluate and treat medical conditions.

It would be really nice if they would give specific feedback to people who failed this test. It doesn't make sense to give a test for evaluation purposes, and then not give the people specific feedback about what their deficiencies were...
 
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