by Swapnil Lanjewar

First of all, I am very very thankful to lord that I passed my CS. I will share my experience to help my fellow colleagues out there preparing nervously for this exam. Now I know that there is already huge amount of excellent info regarding CS on this site. I will just narrate the plan I had followed.

Basic intro:

I dont think I need to explain the pattern of the exam. But, I would strongly suggest all of you to watch the official CS orientation video on USMLE site at this link-

 http://www.usmle.org/Orientation/2010/menu.html

PREPARATION:

   - Reading material: 

1) First Aid is THE BOOK for preparing for Step 2 CS. Even if you do only FA, Im sure you can pass. Infact  I personally know people who did only FA and still passed the exam. But it is always better to be on the safer side and read everything you can.

2) USMLE World Notes: The guidance for history taking and Physical is wonderful. Cases are respectable too. Would strongly advise to do it in addition to FA

3) Neeraj notes: Valuable addition. Good tips and few important cases like stress incontinence, picky eater etc.

These three together are sufficient and more than enough.

   - Approach:

First, do the history taking and Physical Exam explanation from FA. Then, proceed to the History and Physical Exam from UWorld.

Second: Then proceed to mini-cases in first aid and try to remember them as nicely as you can. For people who have not taken Step 2 CK, it is better to discuss few concepts you are not familiar with, with a guy who has taken CK. It will help you a lot.

DONT try to read any of the actual cases in FA or Uworld before you finish the above two. Case practice should strictly be to flex your neurons to build up history taking skills.

After you are done with the mini-cases, you are now ready to start with the cases.

   - Case Practice:

Set a timer for 10 minutes and 5 minutes after that, then 8 minutes and then finally 2 minutes. [This can be done in any Nokia Handset]. This is in accordance with the actual CS pattern. It is always better to practice with a live partner though skype partner will also be okay. (I did my entire practice on skype. Did live practice only for 2 cases and that too on a non-medico)

 Believe me, when I did my first ever case practice, I was not able to finish even the HPI in 15 minutes. It’s okay! We eventually catch up with the time limit after about 8-10 cases. So no need to panic initially.

Once you are able to finish it in 15 min, I will suggest trying to complete history in 9 min and exam in 4 min, i.e. total time of 13 min instead of 15 min. This will help you in actual CS exam.

Few extra tips:

It is always better to take the CS after you have had some USCE. It will help relieve some anxiety though not all ofcourse.

Most of IMGs fail on the SEP that is, spoken english proficiency. So trust you doubts regarding you own language skills. Many times i have observed that the local American people found it difficult to understand when I talked fast or in heavy Indian accent. So try practice talking slowly and clearly. Making an attempt to imitate their accent is not very effective option.

If you have not taken the TOEFL yet or got a poor score, I would strongly suggest starting practicing speaking in English with your friends. Believe me, SEP is a major killer on CS. When I was reading experiences of people who failed the CS, most IMGs said that SPs had a hard time to understand them and kept on asking them to repeat what they said.

I should add here that you don’t need to worry if you have any accent. They don’t expect you to speak rapid and fluent English like a local American or like you see in movies. The only thing that matters is that you should be able to convey your thoughts to the SP and understand theirs and that language barrier should not stand between sharing of information to and fro.

Also, try making your own notes for CS. Believe me, notes made by self will be remembered the best.

 I cannot stress more on the importance of making your own notes…

Tips to save time on step 2 CS

Always remember, time is the major killer on Step 2 CS. So plan your encounters and techniques to save time. I hope these tips will help you.

1) It is okay to spend first 45 seconds to note down the patient summary on the board. Now some people also advised me to write down 3-4 DDs before going in, but I did not prefer it.

2) The start and end of patient encounter is very very important and will have almost 7-10 checklist points together. So dont try to save on time here by cutting down on this important aspect. We tend to cut down especially on closure. Try to avoid that.

3) When asking serial questions, there is no need to repeat the entire sentences. Like some people go "Do you have any pain? Do you have any cough? Have you ever experienced any Shortness of breath?" Instead of that, just be polite and ask in a questioning tone, “any pain in chest? Any cough? Shortness of breath?". I think this is also given in UWORLD notes.

4) Try to be as focused and organized. Like for eg, if you get a case of chronic cough... At once, things like COPD, malignancy, allergy start flowing through your mind. The commonest mistake at this stage is to get excited and trying to jump on the next question. Eg: we ask 1-2 questions about cough and try to jump on things like h/o weight loss/ hemoptysis, h/o asthma and other allergies, smoking. But in the meanwhile, we forget to ask the essential 5-7 points regarding cough and may start moving in the wrong direction.

5) While washing your hands:

Now this is a controversial topic. Lot of people told me that you are not supposed to talk while washing your hands as it creates a bad impression.

But what I did was, while washing my hands; I did not face the sink keeping my back towards the SP. I stood sideways, so that the sink was on my right side and SP on my left side. This way, I could just keep looking at SP and asked lot of questions simultaneously. Thus I didn’t waste a single second while washing my hands. 3 of my friends also continued to talk while they washed hands.

Again, I would like to stress that this is my experience. Talk to your seniors personally to be more comfortable in this context.

The only way to avoid losing points on data gathering:

PRACTICE PRACTICE PRACTICE!!

Try to get into the habit of following a set pattern during your interaction the patient. I had my own set of steps which I followed strictly and it helped me a lot. Try to follow this and it will help you a lot.

1)    While standing in front of the door when there is announcement for the SPs to prepare for the encounter, try to keep your mind blank. Take deep breaths. Keep yourself calm and positive

2)    After the announcement to begin encounter: Open the slider to see patient info, write down his name, chief complaint and deranged vitals if any. Formulate 3-4 DDs. No need to write them. Just make mental note.

3)    Knock on door 3 times loud enough to ensure that SP heard you.

4)    Open door, enter with a smile

5)    Greet by saying: “Mr Smith? Good morning/afternoon! My name is Dr. **. I am your Physician today.

6)    “Let me first make you bit more comfortable here today.” Saying so, drape the patient.

7)    Take permission for taking notes “So, would you mind if I take down some notes while we talk?”

8)    “Alright, Could you please let me know what brings you here today? Or I see that you are having some (chief complaint). Could you tell me more about it?” (Using such open ended questions is very important)

9)    After he tells his chief complaint: “Oh, I am sorry to hear that. Mr Smith, I will try my best to help you out here”

10) Elaborate chief complaint. After that, proceed to associated symptoms. Then proceed to other questions which you find relevant.

11) Start with PAMHUGSFOSS. Now don’t forget to use transitional statements. Never forget to use these 5:

1] Now I would like to ask you some questions regarding you past medical history. Is it okay with you?

 2] (Before asking social history) Now I would like to ask some questions regarding your lifestyle. Is it okay with you? So do u smoke….. and so on

 3] Now I need to ask you some questions regarding the health of your family members which might provide me with some important clues. Is it okay with you?

 4]  Now I need to ask you some really personal questions. Is it okay with you? At what age did u start menstruating?........

 5] Now I need to ask few more really personal questions and I want you to be completely assured that all the information shall be kept strictly confidential. Is it okay with you? --- Sexual history….

12) Before starting Physical Examination: “Now I need to examine you shortly. For that, let me wash my hands first.” Proceed to washing hands. While doing the same: “In the meanwhile, could you please let me know few more things?” I used to perform review of systems while washing hands

13)  Alright, now let me start examining you. Proceed from top to bottom with running commentary. I used to be like “Now please let me examine your eyes. They look fine. Let me see your ears: look fine. Now could you please open your mouth and say aah and move your tongue side to side?” and so on. Remember, use the light from otoscope to examine patient’s oral cavity. Feel neck from behind.

14)  Examine only the relevant system in detail. Examine only 2-3 points from other systems. Ex in patient with pain in abdomen: Just take a peek at chest and say ”Your chest looks normal to me.” Auscultate both lungs, Say” Sounds clear to me”

15)  Don’t forget to listen to bruit in neck in case of CVS

16)  Examination of abdomen always starts with auscultation and then palpation.

Remember, focused examination is the key to save on time.

17) Summarize by saying: “Alright, now let me summarize the information which I have gathered till now. Please let me know if I am missing anything. You initially had pain in left side of chest which was continuous and ……. Can you please let me know if I am missing anything?

18)  Closure: Remember, this is very very important. “Okay Mr Smith, now based on the history which you told and the examination I performed, many possible causes are going through my mind. I think that *** must be the likely cause though you may also have ** or ***. So I would like to run some labs on your blood and also some imaging studies like Xray/CT/USG…. Once we have the results for those investigations, I would be in a better position to let you know what exactly is causing the problem after which we can start with the treatment.

19)  Do you have any questions for me?

20)  Alright MR Smith, I will see you soon.

Say good-bye, shake hands and leave with smile.

While writing notes, write the DDs and investigations first. And then proceed with your notes.

Few extra points:

-You have to learn to be spontaneous when history taking is concerned. Also, you have to individualize each encounter. The above proforma is just to help you so that you don’t forget any important point. But you need to individualize it. Eg: If you get a patient with severe abdominal pain in ER, you skip the shaking hands part.

-If patient’s primary care physician is out of town and hence you are addressing the patient instead of the PCP, just explain the same to the patient in 1 line

-Never hurry the patient.

After the exam:

The UWorld notes say that ‘No matter how well you prepare for this exam, you will always come out of the exam center frustrated and doubting if you are going to pass or not’

So true!!

The toughest part of this exam is waiting for the result. And all you can do is ‘suppression’. Trust me guys, everybody commits blunders on this exam… But still most of them manage to pass. I am telling you the same from ‘personal experience’ ;) So chill and enjoy your remaining stay in US…

Best of luck!