So...I just failed step 2 CS

[Mog16]

How much have I damaged myself? I've been relatively successful through medical school more honors than near honors in the pre-clinical years, mostly near honors with a couple honors in 3rd year and a 245 on step 1. Then I took last year off (between 3rd and 4th year) to get a master's degree in clinical research and I took the exam after having not had any clinical encounters for a year. I think it is quite likely that if I were to retake the exam in a few months (now that I'm back into 4th year clinical rotations) and prepare in a more focused manner for the exam I'd pass...but is the damage done?

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[Eilat87]

I think you'll be okay.

Those things are so god damn subjective..

How can anyone really take them seriously.

 

[RangerBob]

I agree that you probably haven't hurt yourself too bad--your application otherwise seems very strong. It's possible that the top institutions might not send you an interview if they automatically filter out applications that failed a USMLE, but even then, with a Step 1 of 245, that's far higher than most applicants, so I would think it makes up for CS, which most people feel is a silly exam.

If you're an FMG/IMG it might be a little more of an issue as programs will want to be sure you're proficient in English, in which case you should retake CS soon (but only when you're fully prepared) so that programs will see a passing score.

At the latest, because you failed the exam, you will want a passing score recorded by the time program's rank lists are being finalized (I'd recommend aiming to get your score back by mid-Jan, but the earlier the better). IMG/FMG's may possibly need a passing score to be considered for an interview--if I'm not mistaken (hopefully someone more knowledgeable can chime in), I think they need to pass Step I and both Step II's to apply.

 

[Mog16]

Thank you both for your reassurances. When I first got the news yesterday I was very distraught. I've talked to one of my PMR mentors and he gave a similar response and I'm starting to feel a bit better. He said that he'd address it specifically in the letter he'll write for me and discuss that he's observed my clinical skills while I was on rotation with him and he has no concerns (or similar positive wording).

Fortunately for me I am from a US allopathic institution so I don't have the additional hurdles that come with being an IMG or FMG. I'll just need to rearrange my 4th year schedule a bit to make sure I have adequate prep time to retake CS as well as ensure that my step 2 CK score is similar (or hopefully better) to that of my step 1 score.

As we don't have a residency program at my school and my mentor doesn't regularly deal with the applicant selection process he wasn't sure if I should address this issue in my personal statement or if I should just be prepared to explain it at any interviews I get. Anyone have suggestions?

 

[Eilat87]

You should definitely be prepared to explain it, should it come up during an interview.. but don't point it out on your PS.

Your PS is there like a supporting document of why you should get the job (indirectly), why would you point out this little blemish on your school career.

 

[Baritonebass]

you should be fine just apply broad and have an answer prepared... I failed CS... although that was after I matched but no one asked. Same situation was removed from clinicals... retook it my intern year with no difficulty.

 

[Mog16]

Ugh, I just re-took CS yesterday and walked out feeling like I'd failed again despite preparing significantly more than I did for the first time. I feel absolutely devastated and have no idea what to do if I failed again. At least my first fail would have had a reasonable explanation and be viewed as a fluke. If I failed it again I'll be a 2 time loser that all programs will assume is intelligent (based on board scores and clinical grades) but completely incompetent when it comes to clinical responsibilities (despite strong clinical grades).

I don't even know why I'm writing here. I feel so defeated and I needed to get some of this off my chest without breaking down in front of my fiance again.

 

[Leveledup]

Mog,

Try to compare this current exam with your previous one. Step 2 cs is very difficult to fail for AMGS and I'm sure you failed the first attempt b/c you were utterly unprepared. If you think this exam went even a little smoother (compared with the 1st) than I believe you should have passed it. I'm one of the few that was caught completely off guard by my FIRST case (pediatric....phone) and completely screwed that one up. So keep you chin up, we all feel like we failed cs but I'm sure you passed time around. Besides you can't change the past so go own your interviews for the time being.

 

[Paddington]

Don't overthink CS. You go in, you score points for saying hello, putting on gloves, asking about their history, putting the stethescope on their chest, etc. You don't need to know all that much.

 

[RangerBob]

Agreed--for my pediatric case all I did was obtain the CC and HPI--no PMH, PSH, growth history, meds, social, etc. etc. And I felt like I hardly had any pertinent negatives to include in my notes.

I think in general as long as you wash your hands, introduce yourself, act nice, auscultate under the gown (well, actually you're supposed to undrape the patient) and write a half-legible note with at least two possible diagnoses, I think you'll be ok. None of us who took CS together felt good about it. And I don't have any friends that walked out of it feeling confident. (For that matter, I don't know if I've ever met anyone who felt confident about any of the USMLE exams... Maybe I needed more friends applying to derm?)

Do your best to put this behind you and focus on the future. Whatever happened happened and you can't change anything. Hope for the best and believe in yourself--it sounds like you really prepared, which is more than 90% of US grads will do (I think most spend about 24hrs total, max, preparing).

I'd recommend you give yourself just one day to feel crappy/grieve about the exam (you have to let those feelings/worries out, as you're doing right now), and then move on. If you can't move on for yourself, do it for your fiance. Assuming they're not a medical student (and even if they are), they've been sacrificing a lot to support you. Treat them out for a nice dinner and celebrate their support for you. When I graduated, I let my wife choose the restaurant, and we celebrated her support of me over the previous four years. While my own efforts were not to be dismissed, I felt my graduation was more about my family's support and belief in me. If you're fortunate enough to have that village supporting you, show them your appreciation, and keep believing in yourself--because they do.

 

[Mog16]

Thanks again for the support guys. I looked back at my first test and I think I was at the very borderline of not passing that time (at least I assume so, it is near impossible to actually know based upon the score report the NBME provides). This time I did significantly more for both the encounter and the note so I can only hope it went better. I just keep getting hung up on the terrible possibility of 'what ifs'. Oh well, I need to move on and focus on performing for my away rotation starting next week. Thanks again everyone.

 

[j4pac]

Amg here.. Failed the CS. Failed the CIS and was borderline on the ICE. Took the test again back in March after preparing with 3-4 colleagues who passed at first attempt with flying colors and worked with my OSCE professor to remediate . I am still freaking out about all the mistakes i made. I realize this is a normal response to the test but I just can't sleep or eat right now. Having small panic attacks. Perhaps its because I took it the second time and so much is at stake for passing this exam.. but I can't even think..

I think I am significantly PTSDed from my first failure, esp since I had no doubt that I passed my first try..



So without giving away any cases, here are the mistakes that I remember:



- didn't wash hand for one case (got off rhythm)

- didn't do one MMSE and neuro exam that may have been required, although i don't know how critical it was since i don't think the pt had seizures

- flustered and may have rushed one case, answered the difficult question but added more detail to the difficult question

- didn't know the exact ddx for 2 cases, had 2-3 ddx for all cases except 2 where i only had 1, one of the 2 cases was really vague, had very little idea what was going

- missed atleast one hx question if not multiple for each case to r/o a ddx

- feel like missed one PE maneuver per case

- missed couple diagnostic tests per case, including rectal/pelvic exam for 1, on average had about 4-5 tests, few i had up to 7... but I still missed some critical diagnostic test which I slapped my head for when I left the exam

- since I was writing the note all shorthand to maintain eye contact, it was pretty messy and I had to decipher it while writing the PN. I remembered few ROS questions that I might have asked during the encounter, but wasn't sure but the note was mostly done from my blue sheet

- some I forgot to ask 1-2 components of the onset duration, frequency, progression since I was committed to asking open ended questions.

- didn't ask some relevant social history questions such as exercise, diet, lifestyle, living conditions, safety, although i don't think I had any abuse cases

- might have not counseled on few pt, esp smoking

- forgot to do gait for some who may have required it

- missed out some counseling on the end with regard to lifestyle (exercise and diet)

- finished pt note but ran out of character space so had to delete some ROS to fill in other things

- missed documenting few PE I did

- only asked pertinent ROS, but probably missed some questions here as well...

- didn't ask how the illness was affecting the pt's life and what the pt thought the illness was for any case

- forgot Ob/Gyn q for one case although i don't think it was relevant to the CC

- didn't use medical terminology in the PN when it could have been used (e.g emesis instead of vomiting)

- overall had about 10+ ROS questions that I probably asked to the CC to either rule in or rule out a diagnosis..

- had about 3 CC that I didn't expect/wasn't on FA, so I don't think I asked enough relevant ROS questions for those (maybe around 8)

What i did right:

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

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

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

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

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

- did LIQRAAA ODFP for all pain pts

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

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

- palpated thyroid when appropriate, did abdominal exam (inspection, auscultation, palpation, percussion) when appropriate with additional manuevers, checked CVA tenderness when appropriate, murphy's sign, etc.

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

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

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

- answered challenging questions appropriately

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

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

You need to get some help. I hope that you don't take that as an insult...but as helpful advice.

 

[ED50]

DO here so out test is a bit different but here are some pearls I have picked up (there is a video by one of the people who grades and these are his suggestions.)

1 wash hands
2 several instances of empathy in each encounter 'im sorry this is happening to you' 'this must be hard.
3. The video suggests that HPI, assessment, and plan and proper closing are where the bulk of the points are located. You need 3-4 differentials, 4 plans (tests, imaging, follow up, pt education, referrals). You also need to properly close with some statement like, 'do you have any questions.'

What this means is if you are running behind you need to skip a proper and complete PE and get to the closing which explains the next few steps.

Caveat: No one really knows how this exam is graded, but this was the best I could deduce.

Hope some of this helps

 

[DTiop]

I just had a question that I hope everyone can weigh in on. The new rules say that STEP 2 CS grading has changed. Is it true that the patient will now only have checklists for physical exams, and all the history taking skills will be graded on the note instead?

 

[Kissmyabjj]

I failed COMLEX PE the first time. I didn't really study for it because I had done really well on my clinical rotations. Big mistake. The second time around had no issues. I just used the PE review book and did some cases over the phone with a friend of mine. I know how stressful it is, but just follow all of the advice in that book and you will be fine. By the way, I matched into one of my top choices for PM&R.

 

[pk1989]

After several days of thinking about my errors I finally came up with a list that, for now, seems to be all i can remember i screwed up on: 1. Ran out of time to write the tests i'd order for 1 patient 2. Put CT and Xray of head when i meant spine 3. accidentally wrote an incorrect abbreviation for a differential (cant specify due to USMLE rules) 4. forgot to do a few key physical exam maneuvers i.e. heaves, thrills, pmi, when required 5. didnt ask anyone about quality of life being affected/in what way its affected them i.e. didnt ask if affects sleep or work, etc, never said im sorry about their chief complaint, i would just kinda throw in random apologies and sorries when it fit throughout the case or say things like we'll definitely try to help you now, thats the goal, we'll definitely try to get this fixed for u asap, i'll keep u in the loop, ill tell you the results as they come, etc etc etc and i also didnt ask what they thought it could be or how do u think this can be managed etf... wtf thats so counterintuitive....yea lemme baby them in layman terms then ask hey how do u think this treatment etc shud be?? Fogured a closure with what i thimk it is and the relative tests and asking if further questions/concerns will suffice 6. had 1 awkward moment with a patient that was unexpected during a left lateral decubitus pt said well this is awkward but i apologized right away for it 7. Didn't document things like scars or tattoes but mentioned it to the patient 8. was running out of space multiple times on the HPI so if say a person didnt smoke, drink, etc... i deleted those things from HPI so i can fit something more pertinent, so basically seems like i asked an entire social history but will not get credit for doing so because ran out of space to fit in other things and the things i did ask will not be known now even thought they were done 9. multiple differentials seemed off to me, some i could not think of more than 1 because felt so obvious, other times (possibly 2-4) was completely boggled by what to even put down as first one, and other times something i should have put on the list, i didn't and didnt realize it after, just kinda hoping the ones i kept still can fit the HPI, etc. 10. never put pertinent negatives into the differentials 11. several patients during the encounter (maybe 2) i forgot to ask a key question that would have lead to a certain better test being ordered aka the patient gave clues to something i, in my ever lasting nervousness and anxiety did not pick up on as hey buddy u may wanna ask about this or inquire about that. 12. I never summarized the HPI/physical findings, i just did the closure and told them what I think it can be/why i think its that/what tests id order/why id order them, not sure if doing a closure but not a summary will kill 13. Provided counseling for whoever i thought needed it for things like alcohol... but in case like alcohol i forgot to say the CAGE results... again something i did that won't be in note 14. didn't put in vital signs for every patient... probably had em all for only half and some of them i just put in w/e i thought was actually pertinent 15. Few times wrote "non-medical" terminology 16. scared **** out of patient by saying cancer.... but obviously wiggled around it saying its not for sure we have to run tests, etc etc 17. when i did my abdominal exam... instead of pulling from the bottom... i figured if the patient is already ungowned for the cardiac/resp exam, may as well help them lay down and just pull gown down a little more and do abdomen 18. didnt ask every female about their obgyn history, menopause etc, only if it was needed (or so i thought) 19. lot of my physical exams seemed kinda weakish, i did the typical heart/lungs... +s1/s2 no murmurs rubs gallops regular rate rhythm clear to ausc bilaterally (never wrote no wheezes rales or rhonchi tho whoops) 20. Forgot cn 11 on one patient and 8 on an other 21. Forgot to ask birth hx and development in peds case 22. Forgot to ask about medication compliance for a pt that obviously needed that question asked ...but that was a case i screwed up completely head to toe... 23. Phys exams were very basic usually i.e. rre s1s2 no mrg and clear to ausc bilaterally for heart/lungs 24. Feel like maybe half my dx were wrong...25. Forgot to ask 1 or 2 patients who looked in pain if i can help or make more comfy Im definitely gonna remember other things... but as it stands... it seems like i failed ICE or CIS or both

 

[pk1989]

Sorry!! it came out weird when i posted it originally...repost with spaces

After several days of thinking about my errors I finally came up with a list that, for now, seems to be all i can remember i screwed up on:
1. Ran out of time to write the tests i'd order for 1 patient
2. Put CT and Xray of head when i meant spine
3. accidentally wrote an incorrect abbreviation for a differential (cant specify due to USMLE rules)
4. forgot to do a few key physical exam maneuvers i.e. heaves, thrills, pmi, when required
5. didnt ask anyone about quality of life being affected/in what way its affected them i.e. didnt ask if affects sleep or work, etc, never said im sorry about their chief complaint, i would just kinda throw in random apologies and sorries when it fit throughout the case or say things like we'll definitely try to help you now, thats the goal, we'll definitely try to get this fixed for u asap, i'll keep u in the loop, ill tell you the results as they come, etc etc etc and i also didnt ask what they thought it could be or how do u think this can be managed etf... wtf thats so counterintuitive....yea lemme baby them in layman terms then ask hey how do u think this treatment etc shud be?? Fogured a closure with what i thimk it is and the relative tests and asking if furtherquestions/concerns will suffice
6. had 1 awkward moment with a patient that was unexpected during a left lateral decubitus pt said well this is awkward but i apologized right away for it
7. Didn't document things like scars or tattoes but mentioned it to the patient
8. was running out of space multiple times on the HPI so if say a person didnt smoke, drink, etc... i deleted those things from HPI so i can fit something more pertinent, so basically seems like i asked an entire social history but will not get credit for doing so because ran out of space to fit in other things and the things i did ask will not be known now even thought they were done
9. multiple differentials seemed off to me, some i could not think of more than 1 because felt so obvious, other times (possibly 2-4) was completely boggled by what to even put down as first one, and other times something i should have put on the list, i didn't and didnt realize it after, just kinda hoping the ones i kept still can fit the HPI, etc.
10. never put pertinent negatives into the differentials
11. several patients during the encounter (maybe 2) i forgot to ask a key question that would have lead to a certain better test being ordered aka the patient gave clues to something i, in my ever lasting nervousness and anxiety did not pick up on as hey buddy u may wanna ask about this or inquireabout that.
12. I never summarized the HPI/physical findings, i just did the closure and told them what I think it can be/why i think its that/what tests id order/why id order them, not sure if doing a closure but not a summary will kill
13. Provided counseling for whoever i thought needed it for things like alcohol... but in case like alcohol i forgot to say the CAGE results... again something i did that won't be in note
14. didn't put in vital signs for every patient... probably had em all for only half and some of them i just put in w/e i thought was actually pertinent
15. Few times wrote "non-medical"terminology
16. scared **** out of patient by sayingcancer.... but obviously wiggled around it saying its not for sure we have to run tests, etc etc
17. when i did my abdominal exam... instead of pulling from the bottom... i figured if the patient is already ungowned for the cardiac/resp exam, may as well help them lay down and just pull gown down a little more and do abdomen
18. didnt ask every female about their obgyn history, menopause etc, only if it was needed (or so i thought)
19. lot of my physical exams seemed kinda weakish, i did the typical heart/lungs... +s1/s2 no murmurs rubs gallops regular rate rhythm clear to ausc bilaterally (never wrote no wheezes rales or rhonchi tho whoops)
20. Forgot cn 11 on one patient and 8 on an other
21. Forgot to ask birth hx and development in peds case
22. Forgot to ask about medication compliance for a pt that obviously needed that question asked ...but that was a case i screwed up completely head to toe...
23. Phys exams were very basic usually i.e. rre s1s2 no mrg and clear to ausc bilaterally for heart/lungs
24. Feel like maybe half my dx were wrong...
25. Forgot to ask 1 or 2 patients who looked in pain if i can help or make more comfy

Im definitely gonna remember otherthings... but as it stands... it seems like i failed ICE or CIS or both