USMLE.EU

Why there is another exam, when there are Step 1 and Step 2 CK already?

The former tests evaluate your knowledge. You choose appropriate answer out of given options, click, and go to another question. Konwledge is important, but in order to practice a patient-centered medicine, rather than disease centered medicine, physician must have good bedside manner, communicate with patient efficiently, politely and make them at ease when they are ill and vulnerable.

How is it scored?

1. Integrated patient encounter includes data gathering and, organizing them, and note writing
2. Communication and interpersonal skills.
3. Language: mutual understanding.

What is the part IMG most frequently fail?

How difficult is the CS exam?

For US med students, it is a piece of cake, worth about 1 day of studying, as 98% of them pass. Some may argue it gives little to the US students or the patients, and costs a lot. This is because US students have several similar SP encounters in their curriculum when they receive feedback. Since they have already done several "CSs" at med school, and there is little new.

For international students, the situation is different. Most of them are not used to speak in English with patients. Morever, direct contact with a patient, history taking and counseling might be less organized in international med schools. This is the reason why only about 80% IMGs pass ), despite considerable independend prepartion.

What are the challenging features?

1. Language. Even if you are good in English, prompt, fluent and self-confident speech, understanding patients and few commercial drug names (tylenol, TUMS, ...) are all challenges.
2. Flow of history taking. Organized history taking (SIQORAAA, PAMPHRFOSS) is a must. Another challenge is asking Review of symptoms: it must be quick, without hesitation, and yet cover DDx.
3. Flow of focused physical exam. As the time is limited, only 1-3 organ systems are usually examined. It has to be done fluently, with pauses only before each maneuver for informing patient on what is going to be done next.
4. Patient note. It is good to stick with some pattern, e.g. the same you used for history.
5. Time management with SP. Don't waste too much time asking details of PMH. The whole encounter should take 12-15 minutes.
6. Time management with patient note. Extremely challenging. It took me about 20 minutes in the begining and I got to 9+-2 minutes in the end fo my preparation.
7. Memorizing common DDx and initial diagnostic tests. If you passed Step 2 CK, you will grasp it quickly.

How to prepare for these challenges?

1.-5.: Practice with a partner. Find someone, preferably who prepares for the exam, ideally with native English and good performance, and practice cases from First aid as in the exam. Practicing all 43 cases is usually anough and gives good confidence for the exam.

1. Get an elective in US (most relevant is internal medicine and emergency medicine), and see the patients in the Clinic. This will help with English fluency in clinical environment.

6. You may practice writing notes on your own. Read it from book first ( First Aid for USMLE step 2 CS (FA) or Kaplan's Core cases), and write it into the official practice form within 10 minutes. If your note is not perfect, don't worry - the sample notes are nor perfect neighter.

7. "Mini cases" in FA are good for memorizing basic patterns of patient presentations, and appropriate diagnostic tests. They migh be enough. However, knowledge from Step 2 CK might be sometimes usefull.

When I am ready for the CS exam?

This was a difficult questions I was wondering about, given I knew only few IMGs who I could compare with and who took the exam.

Generally, you should be confident in fluent conversation in English, both clinical (history taking) and leisure (that's what makes the SP want "to come see this doctor again" and gives you points). If you are unsure, practice all cases in FA with a partner, and always write a note. If you can do 2/3 of encounters and notes in time, with minor mistakes, then you are ready. The cases on the exam are usually a bit easier then those in FA.

Another good perspective is advice by Stepan Capek: "Make a plan and stick to it".

How important is the result of Step 2 CS?

This is controversial. Some says noone cares about CS, some says as all US students pass, and falling may show you are inferior to US medical graduates. Not making CS on first attempt really does not look good and might hurt your residency application.

Most importantly, it depends on the specialty you want to go into. Statistics from 2013 shows that in some specialties, 80% of programs does not care about CS, while in other specialties 80% check the number of CS attempts.

Bottom line

Be confident, professional, and as nice to the SP as you can: show (or pretend) empathy, help them lie back and sit, always say what are you going to do, and appreciate whatever they have done well ("I am very happy you called us about your child today". "It is excellent that you quited smoking. You are very strong. As a physician, I am still a bit concerned about your drinking, which might be related to your current condition. Would you like to see our counsellor who can help you to cut down?". "Oh, you run a restaurant with seafood? I love seafood". Depressed patient lost his wife 4 months ago: "It must have been very hard time for you. I understand you are sad."). And smile, if you can think of any reason at that time :)

Anough advices. Now it is your time to show yourself. How about starting practicing now? :)