Step 2 CS

I failed Step 2 CS. Don’t be like me.

I took Step 2 CS in June of 2018 and failed. This was right after the folks at the USMLE made the examination more difficult in direct response to movement by students to eliminate the exam. I latter passed (barely) but the feeling of inadequacy for failing an exam that classically 97% of allopathic seniors pass was horrific. Oh and expensive as hell. Don’t be like me.

I imagine you don’t want to read everything below, so here is your trusty guide to the contents of my cry session:

Why should you even listen to my advice?
Crash course in taking CS
Background on CS
Resources I think are pretty dope zebra
My experience of failing and what that means for school

CRASH COURSE IN TAKING CS

Okay, so you are studying for CS or maybe you failed it and you don’t have a lot of time to figure out what happened. Oh and since there is no meaningful feedback in the event of failure maybe you just need somewhere to start. Here is a list of the top few things I ducked up and missed during my first round.

They are not testing on your ability to treat. You neither need to discuss a treatment plan nor do you need even think about treatment. CS is gauging your ability to communicate, collect, and workup disease. Tell the patient what you think it might be and that you need to run additional tests.
Timing is hard. Take less than a minute to read the vignette and jot down your mnemonics (The vignette is typically too vague to get a narrow differential diagnosis anyway). Timing will vary but try to get all history bits in 4 minutes, be halfway done with physical at the 5 minute warning, don’t forget to close the case. It goes crazy fast. I found the focused physical exam the most challenging to get down.
There are things you need to get every. single. time. Easy to miss, have a system (I liked the popular SIQORAA and PAMHRFOSS best – I previously tried SAMPLE and OPQRST from my EMT training and too often forgot important bits). Confirm the patient name and how they want to be addressed; shake their hand; ask open ended and closed ended questions; ask “What else would you like to talk about today” and set the agenda early; don’t interrupt (They are trained and will only drone on needlessly if you interrupt); ask about ETOH, Smoking, sex and counsel if indicated (May be totally unrelated to vignette!); wash hands after the history and before physical (No, washing on entry does not count – the hand gel is the fastest IMO); if patient denies you performing the physical exam, explain why a physical is needed and ask again; don’t attempt anything through the drape (Move it); close the encounter by repeating the important bits and asking if that sounds right (They can correct you!); tell them everything you want to do as work up in lay-language and why and what concerns they have; thank them and GTFO.
The note writing software is a pile. There is a demo on the NBME site. You have 950 characters and 15 lines max. I found the real life version even crappier as their were scrolling windows inside other scrolling windows. Practice writing notes in this monster. There is an abbreviation list but it is not helpful. Just use abbreviations that you know or have seen. If unsure just write it out but you really don’t have time to type all of them. A real doctor reads your notes so if the abbreviation is in common usage go ahead and use it. You don’t have time to type every abbreviation out.
Document everything. A big part of CS is showing that you can communicate electronically to other providers. If you did something, regardless if negative or positive, document it.
There are rarely positive findings. This is more anecdotal than anything. I got the impression that there are only so many ailments the can be simulated. I also get the impression that it’s hard to find reliable actors for simulated patients. Also, it keeps it spicy to keep your differential broad so don’t expect to find many positive findings from your physical exam.
*Money is no object. When ordering work-up tests don’t take into account the expense. Order what will rule-in or rule-out your diagnosis. This was alluded to by the Kaplan book and implicitly said by the recommended tests in the back of First Aid. This may change since over-ordering of tests has become such a hot-topic in medicine.
Always order a forbidden physical if appropriate. If a pelvic, rectal, breast, or other “forbidden exam” is indicated, make sure you say such on your note. This is pretty easy to forget in the moment so every time I started ordering tests I would first address the forbidden fruit exams.
You need a fast differential. There is barely enough time to document everything at the end of the encounter – this is no time to be stewing about what the differential might be. This will also help focus your physical examination while in the room. I found the quick cases in the back of First Aid and the associated Anki deck to be very helpful.
*The graders wont look at your recording. But they know if you lie. Supposedly they only look at the video recording in rare circumstances, so they are going off the checklist from the simulated patients and your note almost exclusively. Each grader is intimately familiar with that specific patient encounter and will notice if something you found was out of the ordinary.
They feed you. Both times I went to LA their was plenty of great catered food. I am a vegetarian and it was no issue. A lot of examinees bring snacks, but you may not need to.
There is only a small cubby for belongings. There is enough space for a small backpack and your pocket items. There is nowhere to put luggage (Which is silly since so many people have to travel to attend CS). I was able to leave my things with my hotel without an issue. I took what few things of value I had with me to the exam center.

*Unsure if totally true (Why are NBME exams so opaque?)

Background on CS

I think the details about the exam are better covered in First Aid or on Amboss. There are a few things I wished I knew:

Scheduling and logistics

When I first started to approach taking CS I thought I would have plenty of time to schedule my exam a few months in advance. I was way wrong. The dates during peak season (Summer-fall) fill up many months in advance. At one point I saw every available slot for all 5 locations filled, three months out. CS is good in that you can switch very late without penalty, unlike the other exams. The last time I checked, rescheduling 2 weeks or more before the exam is $0 (Free), $400 if between 3 days and 14 days, and basically the entire exam cost after. Spots shift around a lot but you have to refresh the page pretty often. Given that your exam fee covers a full year, book your ballpark slot as soon as you can and reschedule later if you have to.

There are only 5 testing centers as of this writing: Atlanta, Chicago, Houston, Los Angeles, and Philadelphia. The $1,300 fee for CS covers the exam, lunch, and a shoe box sized cubby for storage. Travel, food, a white coat, stethoscope and finding somewhere to stash yo stuff for a day is all on you. Don’t forget to request the time off if your school is as draconian as mine.

Another note on cost. I spent $1,300 to register for the exam, twice. I spent $200 on round trip flights, twice. I spent $120 on a not-nice TraveLodge, twice. I spent $50 to park at the airport, twice. All this at around 8% interest. All told, by the time I pay off the interest I will have spent around $6,680 on step 2 CS, not including study materials. For us, I believe the Step 2 CS examination cost was included in our dismemberment. I don’t think it covered what I spent, sadly.

Regrades are possible. Kinda.

For a fee (of course!) a student that has failed Step 2 CS can request a re-grade. They won’t look at your video, they wont look at your note sheet, they won’t look at the simulated patient checklist. The only thing they will do is re-add the total points in each category. According to some online Googling, it seems accepted that a change from failing to passing by requesting a re-grade has never happened in the history of CS.

Resources I think are pretty dope zebra

I found out that I failed CS after starting a gap year in Pathology which gave me a time advantage that I don’t think many other CS takers will have. This time gave me a chance to try out a host of resources, some good, some bad. The ones I felt were the most helpful and what I would recommend: AMBOSS (Free trial or $15/mo). For vignettes and background, Anki mini cases from FA (Free) for the quick differentials and tests to order. Kaplan Step 2 lecture notes ($35) for the physical exam and mnemonics. I felt that FA for Step 2 CS ($45) was most helpful for the mini-cases in the back half of the book (which are much better in anki form) but inferior to the other prior mentioned resources.

Resources that I engaged and found unhelpful or inferior consisted of Uworld for Step 2 CS ($50 for 30 days), Kaplan Step 2 Complex Cases, and First Aid for USMLE step 2 CS.

AMBOSS

One resource to rule them all

I really enjoyed AMBOSS for CS better that any other single resource. In fact, I wish I had discovered them much earlier for my other studies but that is another story. AMBOSS gives you a succinct lay of the land, how to manage time down to the minute, and most importantly they offer vignettes in a way that is far superior to all others as of this writing. When approaching a new case they give you a simulated note to fill out that is timed. When complete you can compare your note to their suggested note on a line-by-line basis. No other resource, including Uworld, is doing this, and it works very well. I felt that their notes we more realistic in that they were more robust than FA but were not unrealistic novels like the Uworld examples. They also have an app that can be downloaded for offline use. If you were going to have only a single resource to prepare for CS, make it AMBOSS. You can try 2 weeks free, Google a discount, or you can get 10% off AMBOSS here.

KAPLAN USMLE Step 2 CS lecture Notes

The go-to for those that require the printed page

Kaplan (as per usual) has very high quality books, and CS is no exception. There are some logistical bits about the exam that is missing in the Kaplan book but I feel they do the best job of targeting your efforts for the physical exam component. AMBOSS does not do a great job of covering the physical exam, FA is overly simplified, and Uworld was hands down the worst. I felt that Kaplan gave great suggestions for performing a physical exam that meets the requirements for CS in the least amount of time. For real, getting your physical exam time down while being comprehensive enough to get points is a really tough component. You don’t have time to do a ‘real’ exam and you won’t get enough points just casually placing your stethoscope and palpating the abdomen.

Kaplan also offers very systematic approaches to a variety of complaints and gives you mnemonics that give you a safety net, making sure you don’t miss low hanging fruit on a complex patient. The book is very readable and the vignettes are solid. If you want a single resource but hate online content, this is the book for you.

I felt the complex cases book was unnecessary and added very little value over practicing and I would not recommend it.

First Aid for the USMLE Step 2 CS

Less dope zebra, but the gold standard anyway

This is the book that everybody who took the exam prior to June 2018 refers to as the bible and “all you need” for CS. This was prior to the changes made by the NBME to make the examination more difficult. There were only two pieces of advice I received by my classmates and mentors on CS; don’t fail it (lol) and just read FA for CS on the flight down. The latter is bad advice. I envision that for the super-gunners of the world that this is just fine, but for many of us, this is paving the way for the opportunity to take this exam twice.

FA covers the logistics well but falls flat on good physical exam skills, time management, and note writing. I find that their notes are the bare-minimum for acceptability. By that I mean that they are sufficient if you are able to regurgitate them in full, but missing a single component of their suggested note may not meet a passing threshold.

That said, I found that the mini-cases that compose the second half of the book are bar-none top-of-the-line. Unfortunately they are in analog format and it is very easy to read through them and tell yourself “I would totally order that and have that differential”. Unless you practice these with another person, not very helpful. The Anki approach is great and a user has created a deck of most of them from an older CS book. It’s hard to say how accurate some of these are as they age since the way CS is grades is so opaque.

If you can get a used book on FA for CS for free and practice with a buddy, you have an okay plan but I would not purchase it, study alone, and use it as a single resource.

UWorld for Step 2 CS

Will get you there, but not the greatest

This feels like a resource that Uworld made just because they could and they knew people would buy it. I would go so far as to call it trash compared to the otherwise polished and extraordinary resource that Uworld is for other exams. The physical exam videos are half-assed and geared toward a full and comprehensive exam you would do on the ward for IM, not the fleeting seconds you have during CS. The vignettes are top quality (And pretty much the same as the other resources I mention) and they do offer a simulated note but it does not give the line-by-line comparison like AMBOSS. You could accomplish the same by reading FA and using the free simulator on the NBME site. I also felt that the notes were written as if there is no time limit or that you can type 1,000 words a minute. Uworld sacrifices succinctness for completeness, and it’s a fault. Your $50 could be spent better elsewhere.

Kaplan USMLE Step 2: Complex Cases

Adds little to the regular Kaplan book

Unlike the lecture notes book, the complex cases book is not bad per se, but rather is unnecessary for most people. It fills a niche that does not need to be filled in that it offers advanced study that is too specific to CS to be overly helpful on the wards and is unnecessary to pass CS. I feel that mastering the lower-hanging fruit offered in the lecture notes or elsewhere is a much better use of time. If you have exhausted every other resource and just want fresh fodder to engage, perhaps this is the book for you, but I would not recommend it.

My experience of failing and what that means for school

Classically the Step 2 CS exam has a 3% failure rate. Though they recently changed the cutoffs to come closer to 6% as part of retaliation against students attempting to eliminate CS, the exam remains low-bar. If my Deans are to be trusted, the USMLE people may have overcompensated and the true allopathic failure rate may be closer to 10%. As of this writing, the pass rate since the scoring change has not been updated on the USMLE website. But if this new pass rate is true, then not only are the USMLE people rolling in a cool $2.5M more each year (assuming everyone who fails will retake the exam) but also that this now places the USMLE Step 2 CS exam as the single most likely exam for an allopathic senior to fail! Using the 2018 MD/DO data Step 1 saw a 94% overall pass rate and Step 2 CK at 96%. Despite these recent changes, most medical students and faculty look at a CS failure in one of two ways; a student was either unprepared (whoops) and no big deal, or they give the side eye to you while thinking you must have fallen through the cracks and should have failed out many months ago. I am pretty open about my failing of CS and have gotten a very solid mixture of both.

Either way, I can tell you the negative impact to my psyche were incredible. Unlike doing poor on the other step examinations where I can blame an arms race in rising step scores or an archaic system hell-bent on obscure and arcane questions, CS is at the core of medical education – interacting with patients, establishing rapport, hashing out a differential diagnosis, and writing notes. I look at my failure today and tell myself that I have no business becoming a doctor.

As far as the technicalities, the impacts of failing CS were varied for the rest of my class. For me, I landed on automatic academic probation for a minimum 1 year, backdated to the time I took the exam. This prevented me from rotating away from my home institution/VA including out in the community. As someone interested in EM, this is a pre-signed career death certificate, as an away rotation is mandatory. By sheer luck I was able to retake the exam, pass, and petition to get off probation prior to rejoining the curriculum while on a gap year. It took around 5 months to go from re-take to off probation.

***

For my classmates, the tale was a bit different. Most of the people I knew took the exam well into 4th year, with results becoming available after interview season such that there was little worry of interfering with residency applications. However, due to the long turnaround time for CS coupled with it being a graduation requirement, this put some of my peers into very odd circumstances when they found out they did not pass. For some, they retook the exam, crossed their fingers and were able to graduate and start their residences on time. Through the grape-vine I heard that in the case where a student has failed, retaken the exam, but is waiting on results – the school was able to graduate them and they basically had to do admin work during the beginning of their residency as they would not be able to practice prior to a passing score.

There was also the extraordinary tale of one my friends who was midway through a re-take before realizing they had not ordered any exams or tests for any patient encounters on CS. They were so worried that they may fail a second time they looked into taking the exam again while still waiting for results of the retake (an expensive endeavor). Turns out, they don’t let you re-take until you post a failing score. Pretty great.

I will update this page as the full shit-show of failing CS comes to fruition during interview season. I have heard mixed reviews on how it will affect me. Stay tuned.

Why should you even listen to my advice?

Let’s be real, as individuals we like to hear from successful people on how to be successful. It seems counterproductive to listen to a mediocre person on how to be successful, right? I would totally disagree, mostly as most successful people have no idea how they got there, or credit the wrong reasons as to how they got there. However, I would also argue that since I barely passed my second go around, maybe I should shut my mediocre mouth and move on with life.

The vast majority of medical students pass CS, and since there is zero feedback from the USMLE and they don’t have to dwell on not passing that there is zero reason to listen to the advice of someone who passed the first time because they have no idea why they passed. CS is pretty holistic, so being good in most areas makes up for bad performance in a few minor areas. Perhaps they had a bomb differential but forgot to ask about ETOH use. Maybe they hit every checkbox item for the physical exam but didn’t review their conclusions with the patient. For many allopathic seniors, they glance over FA for CS, take the exam, pass, and shrug their shoulders. Asking them why they passed is an exercise in futility. They never had the chance to dwell on the subject and try to improve. And unlike the other step exams, there is no practice tests to judge how prepared you are!

But alas, despite all my efforts and studying, I barely budged the needle performance wise. So perhaps I am not the best to get advice from after all?