- Joined
- Aug 12, 2014
- Messages
- 18
- Reaction score
- 53
Hey all. Having been in the position above, I wanted to write a post about my CS experience, the "tricks" and the outcomes. So, I took the test in June in Atlanta. I read through First Aid the week before the exam, but was on a rotation (EM) and couldn't do much more than that. I had been on some type of clinical rotation for two months, and felt like it was reasonable to take the exam. I was super (SUPER) nervous. I get horribly anxious about all the step exams and usually end up pushing them up by a week or so due to anxiety.
I am a good student (AGM), did well on all of my OSCEs throughout third year, have good Step I and Step II scores. I consider myself to be pretty good with patients and families. Our school usually does at least one OSCE for each rotation, along with a longer one to "prep" us for Step 2 CS. I did decently well on that, but felt flustered for sure.
So, here is what I did and didn't do by patient (with the caveat that my examples are general examples, not real cases I had):
1-8 went reasonably well. I felt like I had good diagnostic tests, a decent differential (read: it would have sounded reasonable to an family practice preceptor. For instance, if the complaint was headache (mine wasn't), the differential was migraine headaches, cluster headaches, or tension headaches. Not migraine, TBI, meningitis. They all gave me information to support a variety of diagnoses, and I felt okay about that part. I stuck with my acronym (PAMHFOSSS [pmh, allergies, meds, hospitalizations, family, obgyn, social, sexual, safety). I asked most to most patients. Not every one. I often asked about safety, just because that is something I've learned to do on rotations and think is important. I definitely think the thing that I did the absolute least of was the physical exam.My physical exams took less than two minutes (MAX). HPI was 8 minutes, ish. I closed for 4 or so, and came out of each room with an extra minute or so for the note (which I would 10000x do again).
9-12 were some degree of suck. Forgot to ask patients (who needed it) about suicide risk, didn't walk a patient that warranted it, forgot elements of physical exam, note, etc, apparently had a tablet case (I never saw or asked for a tablet), didn't do a neuro exam on a case that warranted it (honestly this case I barely did a physical at all) only listened to lungs in a case that warranted more, didn't percuss or tactile or anything, was unsure of a diagnosis for one patient whose story just seemed badly done. I forgot a lot of little things too--a breast exam here, a stool occult blood there, some labs I would have probably wanted, to designate what type (AP, lateral, upright) of x-ray I wanted, etc etc etc.
ICE (things I didn't do):
-listen to everyone's heart and lungs
-do a full ROS on everyone
-pan order CBC, CMP, etc
-do complete or even semi-complete physical exams
-remember to preform rectal/pelvic/breast exams every time they should have been considered
-remember to tell patients all of the work-up that I ended up writing down
ICE (things I did):
-made sure I had enough history questions to support my differential (I wrote down my top 3 based on the door note, and every time the diagnosis was in that bucket and usually some of the differential too)
-wasn't afraid to say 2 differentials rather than the 3
-was pretty conservative and only put the workup necessary to support/refute items on my differential.
-sometimes added health maintenance in the workup but made it clear that was what they were for (IE would write "colonoscopy for health maintenance" in the workup. Doubt it mattered, but to me that is a real part of medicine and how people fall through the cracks so it was my fight against the man moment).
CIS (things I did):
-tried to connect with patients who seemed willing (example: for someone who is dieting is easy to be like 'yeah omg I love carbs too it is so hard') and by the end I felt like myself and got a couple of giggles out of people which was a personal win. Some patients were not having it, so I let that go. I tried to be polite, asked the questions we are supposed to, but overall just let those encounters be a little cold. If the "coldness" is coming from the other side, don't worry about it.
-used hand sanitizer, summarized briefly before physical exam, and asked for the "challenge question". Chatted with the patient during the physical exam (if they weren't in distress) about their lives, where they were from etc [again, if they seemed willing]
-smiled and introduced myself as doctor (!!), I like the phrase, " Hi (Ms/Mr.X) , my name is xxx, and I'm the doctor taking care of you today". It felt okay to say and was a nice platform to begin the encounter.
CIS (things I didn't do)
-ask every single patient how xxx was affecting their life
-didn't lay on the sweetness too thickly
When I write it out (which I suggest you do if you're stressed), I realize that me thinking I failed is a little over the top. But I did. I was basically non-functional for a couple of days after and was filled (really, like shaking) with anxiety over the last few days before I got my score back. I really thought I failed. If I could show you how littered my search history is with horror stories of CS, I would. But it was bad.
Also, if you want to stay up till 1am EST the Wednesday AM that you get your test back, the step 3 registration and FCVS trick works. At 1am EST exactly (and I checked before and was horrified that it didn't work), I was able to register for step 3, my exam history changed to "Pass" on FCVS, and then at 11am today (exactly) I got my score report back.
I PASSED, with flying colors honestly. Stars all under high preformance. Nothing even close to borderline. YOU WILL TOO. I'm happy to check this final box for residency applications! You will be okay. Happy to talk you down if you need it.
I am a good student (AGM), did well on all of my OSCEs throughout third year, have good Step I and Step II scores. I consider myself to be pretty good with patients and families. Our school usually does at least one OSCE for each rotation, along with a longer one to "prep" us for Step 2 CS. I did decently well on that, but felt flustered for sure.
So, here is what I did and didn't do by patient (with the caveat that my examples are general examples, not real cases I had):
1-8 went reasonably well. I felt like I had good diagnostic tests, a decent differential (read: it would have sounded reasonable to an family practice preceptor. For instance, if the complaint was headache (mine wasn't), the differential was migraine headaches, cluster headaches, or tension headaches. Not migraine, TBI, meningitis. They all gave me information to support a variety of diagnoses, and I felt okay about that part. I stuck with my acronym (PAMHFOSSS [pmh, allergies, meds, hospitalizations, family, obgyn, social, sexual, safety). I asked most to most patients. Not every one. I often asked about safety, just because that is something I've learned to do on rotations and think is important. I definitely think the thing that I did the absolute least of was the physical exam.My physical exams took less than two minutes (MAX). HPI was 8 minutes, ish. I closed for 4 or so, and came out of each room with an extra minute or so for the note (which I would 10000x do again).
9-12 were some degree of suck. Forgot to ask patients (who needed it) about suicide risk, didn't walk a patient that warranted it, forgot elements of physical exam, note, etc, apparently had a tablet case (I never saw or asked for a tablet), didn't do a neuro exam on a case that warranted it (honestly this case I barely did a physical at all) only listened to lungs in a case that warranted more, didn't percuss or tactile or anything, was unsure of a diagnosis for one patient whose story just seemed badly done. I forgot a lot of little things too--a breast exam here, a stool occult blood there, some labs I would have probably wanted, to designate what type (AP, lateral, upright) of x-ray I wanted, etc etc etc.
ICE (things I didn't do):
-listen to everyone's heart and lungs
-do a full ROS on everyone
-pan order CBC, CMP, etc
-do complete or even semi-complete physical exams
-remember to preform rectal/pelvic/breast exams every time they should have been considered
-remember to tell patients all of the work-up that I ended up writing down
ICE (things I did):
-made sure I had enough history questions to support my differential (I wrote down my top 3 based on the door note, and every time the diagnosis was in that bucket and usually some of the differential too)
-wasn't afraid to say 2 differentials rather than the 3
-was pretty conservative and only put the workup necessary to support/refute items on my differential.
-sometimes added health maintenance in the workup but made it clear that was what they were for (IE would write "colonoscopy for health maintenance" in the workup. Doubt it mattered, but to me that is a real part of medicine and how people fall through the cracks so it was my fight against the man moment).
CIS (things I did):
-tried to connect with patients who seemed willing (example: for someone who is dieting is easy to be like 'yeah omg I love carbs too it is so hard') and by the end I felt like myself and got a couple of giggles out of people which was a personal win. Some patients were not having it, so I let that go. I tried to be polite, asked the questions we are supposed to, but overall just let those encounters be a little cold. If the "coldness" is coming from the other side, don't worry about it.
-used hand sanitizer, summarized briefly before physical exam, and asked for the "challenge question". Chatted with the patient during the physical exam (if they weren't in distress) about their lives, where they were from etc [again, if they seemed willing]
-smiled and introduced myself as doctor (!!), I like the phrase, " Hi (Ms/Mr.X) , my name is xxx, and I'm the doctor taking care of you today". It felt okay to say and was a nice platform to begin the encounter.
CIS (things I didn't do)
-ask every single patient how xxx was affecting their life
-didn't lay on the sweetness too thickly
When I write it out (which I suggest you do if you're stressed), I realize that me thinking I failed is a little over the top. But I did. I was basically non-functional for a couple of days after and was filled (really, like shaking) with anxiety over the last few days before I got my score back. I really thought I failed. If I could show you how littered my search history is with horror stories of CS, I would. But it was bad.
Also, if you want to stay up till 1am EST the Wednesday AM that you get your test back, the step 3 registration and FCVS trick works. At 1am EST exactly (and I checked before and was horrified that it didn't work), I was able to register for step 3, my exam history changed to "Pass" on FCVS, and then at 11am today (exactly) I got my score report back.
I PASSED, with flying colors honestly. Stars all under high preformance. Nothing even close to borderline. YOU WILL TOO. I'm happy to check this final box for residency applications! You will be okay. Happy to talk you down if you need it.
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