Step 2 CS- How to Pass and What to Expect

I took my exam back on March 24th. I refrained from writing a post about this only because I was terrified I had failed and didn't want to lead you astray with some tips/tricks/ me basically telling you to cool your jets when in fact I failed myself. But today is not that day. No. Ladies and gentleman, today is the day I tell you all that I PASSED. And it literally took three months and one day to get my score back.

--So the story with CS is this:
When you feel so emboldened, go on the ECFMG website and access your OASIS and fill out/ pay for the damn test. You drop $1480 (subject to increase) and get a 1 year window to take it. A week or two later, you get an email with your scheduling permit.

Next step is picking the testing site and date you wish to take CS. There are 5 testing sites in the country: Philly, Chicago, Houston, Atlanta, Los Angelas. Many of my peers told me Philly was the "hardest" site, that people were difficult, impolite, and I should take it in Atlanta since it's "easiest".  Well, I didn't listen and decided to take it in Philly since I was only living in New York at the time. It was a quick 2 hour drive from the city and I stayed overnight at the Sofitel Philadelphia which is a 12 minute drive from the center. The hotel gave me a complimentary car/driver to take me to my exam in the morning, which was very nice of them. For lodgings walking distance from the test, a lot of people stay in the Sheraton University City Hotel. But honestly, the prices between the two hotels was $30 at the time and the Sofitel is right in downtown Philly spitting distance from fun restaurants/bars/shopping/theaters/pretty buildings, and I slept in what was in the top 3 beds I've ever slept in. Seriously, if you are taking the exam with a friend or two and don't mind paying at extra $15 for a better hotel/location/times, then I can't recommend the Sofitel enough.
For other hotels walking distance and travel info check out what the USMLE people have to say, just over --> here.

--What to do for preparation?
Buy a book. Either get the First Aid for the USMLE Step 2 CS or the Kaplan USMLE Step 2 CS Core Cases. I chose the latter for no particular reason and I think it was fine overall for my prep. Read the book, cover to cover at least once. Practice cases with a partner should you wish to do so. I did not find this necessary, so I didn't practice with anyone. And I literally read the Kaplan book once. I read it the last 4 days before I took my exam. I don't recommend this. I was petrified I didn't know anything. To feel somewhat good about going into the test definitely read the book a couple times, and practice cases with a friend.

OR

If you are coming off an ER rotation where you were taking tons of histories/physicals and doing notes every 15 minutes, this is the greatest form of prep anyone could hope for. I had just finished two weeks in the Peds ER a couple weeks prior to the exam and just knowing how to ask all the relevant questions and doing the focused physicals in the space of a few minutes was gold. I didn't plan it this way, I just got lucky without even realizing when I scheduled my CS. You do the same exact thing in the actual test. So regardless of where you are in your rotations, if you've done/just finishing ER, just take the test.

--What to do the day before the test?
GRAB YOUR STETHOSCOPE, WHITE COAT, SCHEDULING PERMIT, CONFIRMATION NOTICE, and ID before setting out. Then drive/fly/take the train at a reasonably early hour and enjoy the day in whatever city you chose to go to. I drove down to Philly from New York on an early Sunday morning and arrived to the hotel by 10:30 am. I went alone, which was oddly exciting for me. My room wasn't ready yet so I spent a couple hours checking out the sites/shops. I grabbed lunch and a couple beers at the Nodding Head Brewery and Bar. All the taps are beers they brew there and I was pleasantly surprised by the selection. After that, I admit I was a bit buzzed and went to my hotel room and had a nap in the greatest bed known to man. I woke up and finished reading the cases in my Kaplan book for the first time (again, don't do that! Do as I say, not as I do). Once that was done I ordered room service, watched a movie, and called it a night.

--What happens test day? (This is the Philly experience)
BRING YOUR STETHOSCOPE, WHITE COAT, SCHEDULING PERMIT, CONFIRMATION NOTICE, and ID. Show time starts at 8 am so I suggest getting there a half hour or 15 minutes before. You check in with a nice lady in the front desk and then you are assigned a number. You walk into a square room lined with chairs with numbers on them and you just go and sit at whatever number you were assigned. People are in the other chairs and everyone is sort of staring at the ground or at the walls, trying very hard not to make eye contact with anyone. It's awkward. It's okay. These people will become your friends.
Your name will get called and they give you two number paper things to pin to your white coat. After everyone's pinned, you go to another room to store all your belongings and you watch a quick video on how the day will go. You learn all the rules, what to do, what not to do, they give you time to check out the table and other equipment that's put in each room. There's no need to bring food because lunch and snacks are provided.

You are given a clipboard, 12 sheets of paper (one sheet for each case) and a pen and then everyone lines up to go out into the hallway with all the mystery doors. There are 6 doors on each side of the hall, and every door has a corresponding desk next to it with a computer to write your notes.  There's a sliding panel on every door with the name, age, chief complaint, and vitals of the patient you're about to see. When the proctor calls time, you are allowed to open the panel and read all the information. Jot it down on your paper and once you're ready you FIRST KNOCK and then enter the room and say Hello Mr/Mrs so and so and introduce yourself as Dr. (ENTER NAME HERE). You know how the rest goes. You get strictly 15 minutes to take the history, do the physical, and to counsel the patient and tell them what you are thinking/what tests you will be ordering for them. Once you leave the room, you get any left over time from the interview plus the additional 10 minutes to write your note. The note includes the HPI, physical, differential diagnoses, supporting findings for that diagnosis, and  labs/tests you want to order. If you guys want to know what the note looks like, USMLE was kind enough to offer a practice note here.

You will do 5 cases in a row, then break for lunch. Do 4 more cases, then break for a snack. And end with the last 3 cases and you're free to go! People normally get out around 4 pm.

How is it scored?
CS is Pass/Fail only. There are no numerical scores. It's broken down into Integrated Clinical Encounter (ICE), Communication and Interpersonal Skills (CIS), and Spoken English Proficiency (SEP). If you fail any one of these sections, you fail the exam. If you do really well in one area, it does not make up for doing poorly in another.
If you are a native English speaker you obviously pass the SEP portion of the exam. To do well in the CIS section, you just need to be friendly. Be kind, be professional, SMILE (if its the proper situation), if a patient is in obvious distress, offer and do anything that will make them a little more comfortable whether it be shutting off a light in migraine cases, or letting someone lie down who is in pain. BE GENTLE when you do the physical exam. Deep palpation of the abdomen on a fake patient is not necessary and actually quite mean. If you can manage to be a decent, sociable human being you should also pass this section of the test which I believe is weighed most heavily. It is the patient him/herself who grades you on this portion. Lastly, for ICE, a physician will look over your note and decide how your gathering of information/physical led you to the 3 or so diagnoses you list. If the thought process seems reasonable and if you are fluent in your note, this should also be easy enough to pass. You don't necessarily have to get the diagnosis correct. I think there were about 4 cases I missed and one case in particular where I had absolutely no idea of the diagnosis. I don't think this portion is as important though because I know of students who wouldn't even get to the diagnoses or the tests ordered in a couple of their cases because they spent so much time on the HPI. And guess what? They still passed.

--My thoughts on the experience overall
 I was scared before, I was scared during, I was petrified afterwards. I swore I failed. Opening my email today and seeing "your score report is available" made me want to die (dramatic, I know). You can't imagine the wave of relief the swept over me when I saw that sacred word: PASS.

I'm not sure what it is about this exam, but everyone I have spoken to doesn't feel great afterwards. Yeah, it's nice to be done and that part of your studying is over with, but everyone knows that they forget something in in each of their cases. People wouldn't do a certain maneuver for the physical. They would forget to ask a certain question. They didn't have enough time to complete the note. As I said earlier, there were a few patients where I wasn't sure what they had! And to top it off, I consistently was the first person done in each of my interviews. The other students would spend the full 15 minutes with each patient and for whatever reason I'd get everything done in 10-12 minutes and be the first one back out in the mysterious hallway of closed doors. I'd smile sheepishly at the proctor, that sort of like "yea, I'm done wayyyyy too early... AGAIN"  and sit down to write my note. I had no trouble finishing my notes because of all the extra time I had, but I had this unsettling feeling that I didn't talk/counsel enough to my patients.

For Philly in general, I thought the center was great. I thought all the proctors and people who worked there were lovely. Very friendly, approachable, eager to help out. I felt like the patients were quite nice as well. I'm not sure why people say it's the hardest of the test centers, but I really did have a good experience there. Flying out to another site if you're in NYC isn't worth it.

--Tips
1. Don't forget to wash your hands every time. And as you're doing it, why not look over your shoulder a bit and have a little non-medical banter with the patient. That ish builds rapport.

2. If someone is thirsty, in pain, hating the light, do whatever is easy to make them more comfortable. Offer water. Offer them to lie down or stay standing. Offer to shut the light off. Offer them the world.

3.  When doing the physical don't be overly concerned if you're listening in the right location, if you really see anything in the ear, or actually feel a dorsalis pedis pulse. Do the motions. Try your best of course, but just do the motions. These are all healthy people. You're not finding anything on them anyway. The only thing on the physical that patients can fake is pain/tenderness. Just go with it.

4. Counsel them on anything really. Everyone's got some bad habit. If your patient smokes, ask them if they have thought about quitting. If they drink more than 2 drinks a day, CAGE them. If they don't exercise, tell them to. If the patient is actually overweight in real life (as awkward as it is), tell them about living and eating healthier.  When you are counseling, please be as polite and conscious of their feelings as possible.

5. At the end when you tell the patient what you think they have, it's okay to be unsure about it. Doctors aren't 100% perfect in real life.  Say it could be a number of things (you are free to tell them your differential), but saying that you want to run tests, do imaging before making a definitive diagnosis is fine!  Say it, be honest.

6. Be prepared to wait a lifetime for your score. They say it takes about 2 months, but it took 3 months for me. There are window periods of when you take the exam and a window of when you should be getting scores. Score reporting for 2014 can be found here.