I noticed that there's a lot of anxiety-related threads surrounding Step 2 CS. I figured I would share my experience in case someone ever comes across this, in hopes that it will prevent someone from making the same mistakes that I did.
First off, I am a US citizen AMG. I sailed through medical school academically, was in the top 10% of my class. I scored a 245 on Step 1 and a 253 on Step 2 CK. Honored all my rotations except for surgery where I just plain passed (I hate surgery anyway). I had an emergency medicine rotation which ended two weeks before my first attempt at CS, so I figured I'd be good to go. Besides, CS is just an English proficiency test designed to ensure we have rudimentary physical exam and documentation skills, right?
Wrong.
I approached CS as though it was the ER. And in reality that makes sense, right? You have a relatively limited amount of time to see patients and write a note, which is exactly what the ER is all about. Everyone is in for an acute complaint. Histories and physicals should be minimalistic and designed at obtaining the correct diagnosis (and in many cases, in both attempts, I'm pretty sure I nailed the actual diagnosis).
If you go into the test with this mindset, you are setting yourself up for failure. Step 2 CS is not a real-life test. It is not about simply testing your ability to come up with a correct diagnosis. That is why I believe that many of the people who fail this test are towards the top of their class and the failure comes so unexpectedly for them. The first time I took the test, I failed CIS but passed ICE. The second time around, I passed both comfortably. Here's what I did wrong the first time and what I did to remedy it.
CIS: This is the area that left me most dumbfounded. I'm a warm, outgoing person around patients and I've always been told I establish good rapport. But CIS is testing how "nice" you can be in 15 minutes to a total stranger, not to someone you establish rapport with over hours to days. As such, the name "CIS" is misleading, as it's not so much testing your interpersonal skills as much as it's testing your ability to make the SP think you care about them. One of the biggest criticisms I have about this test is that it expects you to be that physician... you know, the doctor that puts on a cute face to you in the room but is probably talking **** about you to the nurse. To put it simply, you have to be fake -- and that's not how I am, personally, though I know a lot of people who are and probably passed the test the first time. CIS requires you to get into character; it's an acting test more than a medical test. I usually am in and out as soon as I have a differential and make a cursory explanation to patients and ask if they have questions. When I approached the test the first time, I probably spent at most 7 or 8 minutes with each patient. DO NOT DO THIS. Rather, fill any gaps with "niceties". Yes, the little niceties that may come off to most real patients as fake will score you points on the test. In fact, you should have a rehearsed set of niceties that you can use every time. Here's what I did differently that jolted my failing CIS to a comfortable pass:
ICE: I don't have as much to offer here as I passed this part pretty comfortably both times I took it. I felt this was the easier part as it's much more academic and more straightforward to prepare for. I've always been good at writing notes as my school really stressed this and we were doing it from day 1 of M3 year. I would practice making your notes look like the ones you find in First Aid, which is arguably the best resource. Taking an Emergency Medicine elective just before CS is really good for this, although a lot of EMRs are moving towards a checklist format which is DUMB in my opinion and it deprives students of the practice they need not only for real life but for this stupid test. Reviewing your basic psych history is useful too, as both times I had one or two "depression" patients. But of course, bear in mind that this test is NOT LIKE THE ER and you shouldn't approach it like it is.
You will do yourself a HUGE favor by having a system for history-taking. Though I didn't go in the exact order, I used the PAM HR FOSS (PMHx, allergies, medications, hospitalizations/surgery, ROS, family hx, OBGYN hx, social (work, drink, drugs, smoke), and sexual hx*) and wrote down the letters on the paper before entering the room. This will keep you from forgetting and will help the SP check off the list. SIQOR AAA is good for pain, but my medical school drilled the PQRST in us from the very beginning, so it was second nature to me and I used that. It seems to be sufficient, too. *If you're not from a western country, remember that it is important to ask the patient if they are sexually active with men, women, or both. Sexual activity with men is a risk factor for HIV (especially men who have sex with men) and for pregnancy (women, obviously). It also is important for CIS because this often gets neglected and patients often feel uncomfortable here.
I only CAGE'd SP's who drank more than two drinks per day. Ask every patient who smokes if they are interested in quitting and, if so, tell them you have resources to help them.
Practice your physical exam skills so that you can do them in your sleep. Do at least a five point physical on every patient (I would do at least general appearance, heart, lungs, neck, abdominal on everyone). Unlike in real life, you're probably not going to hear any murmurs or wheezes, feel lymphadenopathy, etc., so as long as you go through the motions, you're good to go there. It sounds like a lot but if you practice enough, you can do it pretty quickly. Remember, you're not going to see abnormal findings in most patients. When you do, it will usually be pretty predictable (e.g., pain in an abdominal patient, a "cough" in a chest pain patient, etc.). Just make sure and pay extra attention to the organ system in concern. If they have abdominal pain, for instance, pay extra close attention to that. If they have dizziness, pay extra close attention to your neuro exam, etc. Remember that the SP will be filling out a checklist for your physical exam, so do it quick. But, as I said, based on each individual SP's complaints, focus your attention on the relevant organ systems. (*I would learn to do a quick cranial nerve test in case a neuro case comes up, but I wouldn't do it on an abdominal pain patient for instance.) You can go into greater detail on a particular organ system if it's part of their chief complaint (e.g., egophony, tactile fremitus on a patient with a cough).
Get really fast at writing a normal physical exam template so it's reflexive. Obviously, remember only to document the areas that you did. Most of your physical exam findings will be normal. The bulk of your abnormal findings will be in the history. I would say abdominal pain is the most common area for symptoms to be feigned, so keep that in mind. I did the history in narrative format because it's what I'm used to, but you can do what's in First Aid if you want.
Try and fill in all three potential differentials. As long as you can put in one or two things from history or physical to justify it, then it's fine to put it as a differential, even if it's very unlikely. Just don't put something in as a differential without justifications, as you will lose points that way. Remember that age and sex can be risk factors and are fair game for justifying differentials. For workup, make sure and put tests that pertain to everything on your differential. Don't sweat if you put a test (e.g., CT, TSH) that you didn't tell the patient, as I'm pretty sure the grader is not going to know everything you told the patient.
That's about everything I have. Bottom line is I highly recommend going through all the cases in First Aid, working on your acting skills, and practicing your physical exam skills until it's second nature. Hopefully you'll get through this obnoxious and unnecessary exam. If they do keep requiring it, they really should offer feedback either written or a more comprehensive scoring system so you know what you did wrong and where to improve. But I highly support abolishing the darn thing altogether because I think all it is is a moneymaker for the powers that be.
Best of luck to all of you.
First off, I am a US citizen AMG. I sailed through medical school academically, was in the top 10% of my class. I scored a 245 on Step 1 and a 253 on Step 2 CK. Honored all my rotations except for surgery where I just plain passed (I hate surgery anyway). I had an emergency medicine rotation which ended two weeks before my first attempt at CS, so I figured I'd be good to go. Besides, CS is just an English proficiency test designed to ensure we have rudimentary physical exam and documentation skills, right?
Wrong.
I approached CS as though it was the ER. And in reality that makes sense, right? You have a relatively limited amount of time to see patients and write a note, which is exactly what the ER is all about. Everyone is in for an acute complaint. Histories and physicals should be minimalistic and designed at obtaining the correct diagnosis (and in many cases, in both attempts, I'm pretty sure I nailed the actual diagnosis).
If you go into the test with this mindset, you are setting yourself up for failure. Step 2 CS is not a real-life test. It is not about simply testing your ability to come up with a correct diagnosis. That is why I believe that many of the people who fail this test are towards the top of their class and the failure comes so unexpectedly for them. The first time I took the test, I failed CIS but passed ICE. The second time around, I passed both comfortably. Here's what I did wrong the first time and what I did to remedy it.
CIS: This is the area that left me most dumbfounded. I'm a warm, outgoing person around patients and I've always been told I establish good rapport. But CIS is testing how "nice" you can be in 15 minutes to a total stranger, not to someone you establish rapport with over hours to days. As such, the name "CIS" is misleading, as it's not so much testing your interpersonal skills as much as it's testing your ability to make the SP think you care about them. One of the biggest criticisms I have about this test is that it expects you to be that physician... you know, the doctor that puts on a cute face to you in the room but is probably talking **** about you to the nurse. To put it simply, you have to be fake -- and that's not how I am, personally, though I know a lot of people who are and probably passed the test the first time. CIS requires you to get into character; it's an acting test more than a medical test. I usually am in and out as soon as I have a differential and make a cursory explanation to patients and ask if they have questions. When I approached the test the first time, I probably spent at most 7 or 8 minutes with each patient. DO NOT DO THIS. Rather, fill any gaps with "niceties". Yes, the little niceties that may come off to most real patients as fake will score you points on the test. In fact, you should have a rehearsed set of niceties that you can use every time. Here's what I did differently that jolted my failing CIS to a comfortable pass:
- Address the patient warmly by name with a smile and say something along the lines of, "It's so nice to meet you." Most SPs are not the disgruntled type and I truly believe that no matter how trained the SPs are, there is an element of subconscious bias. You want to come off as likable right away to push whatever bias is there in your favor.
- Work on your "sad/empathetic" vocal tone and facial expressions. Get in front of a mirror. "I'm so sorry to hear you're going through this. Let's see if we can get to the bottom of this together." This is important, but if you say it monotonously, it will get you nowhere. This is also where practicing with non-medical friends and family members can come in handy.
- Use transition phrases and take the pressure off them. This is particularly important when you take a sexual history (which is necessary for every patient, seriously). "Now I'm going to ask you some questions about your sexual history which may help me understand things better, please keep in mind that everything you share with me will stay in this room and if you're uncomfortable answering, you don't need to." I actually had two patients where sexual history was relevant, so even though it may be uncomfortable for you, just bear in mind that the SPs are not uncomfortable because they are playing the role. Remember, they are ACTORS.
- Ask permission before beginning the physical exam and disrobing them. "Is it okay to start the physical exam?" "Is it okay if I untie your gown." This is so cumbersome and not like real life, obviously, but it scores points on CIS.
- Hand washing: Use hand sanitizer as soon as you enter the room, but wash your hands before starting the physical exam. Why both? Because once you do the history and get to know the SP, while you're washing your hands, you can throw in some niceties like, "So you're a teacher, what grade do you teach? That sounds like fun, do you enjoy it?" or "Congratulations on your retirement, that's very exciting!" or "You mentioned you have dogs, what breed?" Nobody knows if this plays a role in the actual CIS score, but it cannot hurt. Given the SPs see dozens of examinees, they're bound to get biased by the friendly face. But that's just my opinion. (I say use hand sanitizer first because if for some reason you forget to wash your hands or are running low on time, you won't be docked.)
- Eye contact is important, but there's a way around it. I would usually tell SPs something like: "Now I'm going to ask you some questions. I'm also going to be taking notes so I remember what you're telling me, so forgive me if I look down at my paper while you're talking." It's pretty hard to dock someone if they tell you that.
- Always apologize in advance before approaching anything uncomfortable. I had a guy with a sore ankle so I said, "I want to take a look at your ankle first so we can get it out of the way for you, is that alright? I'm sorry if this hurts." If they wince in pain, etc., apologize again: "I'm sorry that I hurt you/I have to put you through this."
- Summarize, offer a differential, and what you are planning on doing (you need to explain things as you would explain to a child...I know it comes off as patronizing in real life, but they're testing your ability to communicate in terms everyone can understand, so it is advisable for the test). Ask if they are okay with that plan.
- Before leaving the room, ask the SP if they have any questions or concerns? This is usually where you'll get the so-called challenge question. If they do have questions/concerns, after addressing them, repeat, "Do you have any other questions or concerns?"
- Don't just say "Nice meeting you, bye." Let them know, "If you have any questions at any time, please inform the staff and I will get back to you as soon as I can, okay?" Close again with another, "It was very nice to meet you, take care."
ICE: I don't have as much to offer here as I passed this part pretty comfortably both times I took it. I felt this was the easier part as it's much more academic and more straightforward to prepare for. I've always been good at writing notes as my school really stressed this and we were doing it from day 1 of M3 year. I would practice making your notes look like the ones you find in First Aid, which is arguably the best resource. Taking an Emergency Medicine elective just before CS is really good for this, although a lot of EMRs are moving towards a checklist format which is DUMB in my opinion and it deprives students of the practice they need not only for real life but for this stupid test. Reviewing your basic psych history is useful too, as both times I had one or two "depression" patients. But of course, bear in mind that this test is NOT LIKE THE ER and you shouldn't approach it like it is.
You will do yourself a HUGE favor by having a system for history-taking. Though I didn't go in the exact order, I used the PAM HR FOSS (PMHx, allergies, medications, hospitalizations/surgery, ROS, family hx, OBGYN hx, social (work, drink, drugs, smoke), and sexual hx*) and wrote down the letters on the paper before entering the room. This will keep you from forgetting and will help the SP check off the list. SIQOR AAA is good for pain, but my medical school drilled the PQRST in us from the very beginning, so it was second nature to me and I used that. It seems to be sufficient, too. *If you're not from a western country, remember that it is important to ask the patient if they are sexually active with men, women, or both. Sexual activity with men is a risk factor for HIV (especially men who have sex with men) and for pregnancy (women, obviously). It also is important for CIS because this often gets neglected and patients often feel uncomfortable here.
I only CAGE'd SP's who drank more than two drinks per day. Ask every patient who smokes if they are interested in quitting and, if so, tell them you have resources to help them.
Practice your physical exam skills so that you can do them in your sleep. Do at least a five point physical on every patient (I would do at least general appearance, heart, lungs, neck, abdominal on everyone). Unlike in real life, you're probably not going to hear any murmurs or wheezes, feel lymphadenopathy, etc., so as long as you go through the motions, you're good to go there. It sounds like a lot but if you practice enough, you can do it pretty quickly. Remember, you're not going to see abnormal findings in most patients. When you do, it will usually be pretty predictable (e.g., pain in an abdominal patient, a "cough" in a chest pain patient, etc.). Just make sure and pay extra attention to the organ system in concern. If they have abdominal pain, for instance, pay extra close attention to that. If they have dizziness, pay extra close attention to your neuro exam, etc. Remember that the SP will be filling out a checklist for your physical exam, so do it quick. But, as I said, based on each individual SP's complaints, focus your attention on the relevant organ systems. (*I would learn to do a quick cranial nerve test in case a neuro case comes up, but I wouldn't do it on an abdominal pain patient for instance.) You can go into greater detail on a particular organ system if it's part of their chief complaint (e.g., egophony, tactile fremitus on a patient with a cough).
Get really fast at writing a normal physical exam template so it's reflexive. Obviously, remember only to document the areas that you did. Most of your physical exam findings will be normal. The bulk of your abnormal findings will be in the history. I would say abdominal pain is the most common area for symptoms to be feigned, so keep that in mind. I did the history in narrative format because it's what I'm used to, but you can do what's in First Aid if you want.
Try and fill in all three potential differentials. As long as you can put in one or two things from history or physical to justify it, then it's fine to put it as a differential, even if it's very unlikely. Just don't put something in as a differential without justifications, as you will lose points that way. Remember that age and sex can be risk factors and are fair game for justifying differentials. For workup, make sure and put tests that pertain to everything on your differential. Don't sweat if you put a test (e.g., CT, TSH) that you didn't tell the patient, as I'm pretty sure the grader is not going to know everything you told the patient.
That's about everything I have. Bottom line is I highly recommend going through all the cases in First Aid, working on your acting skills, and practicing your physical exam skills until it's second nature. Hopefully you'll get through this obnoxious and unnecessary exam. If they do keep requiring it, they really should offer feedback either written or a more comprehensive scoring system so you know what you did wrong and where to improve. But I highly support abolishing the darn thing altogether because I think all it is is a moneymaker for the powers that be.
Best of luck to all of you.
