--Raja Shakeel Mushtaque, M.D Disclaimer: This Disclaimer: This document is written to highlight some important points regarding USMLE step 2 CS Exam and some suggestions for the exam, this document will also point out some common errors document i s not meant to discuss discuss any exam exam case case neit neit her i t wi ll go thr ough each each made in exam. Th i s document and eve everr y detail detail of the exam exam or preparati preparati on materi materi al. Main purpose of this document is to explore components and sub-components of the exam and try t o highlight some valuable points.
USMLE Step 2 CS exam is getting tougher day by day. If you are thinking that it’s easier than other USMLE exams than you should re-think over it, it’s an unpredictable exam and smallest blind-spots (mistakes) repeated in every encounter can ruin whole exam. Amazing thing is that if blind-spots are not caught by your study partners than standardized patients will ultimately notice it because those are well trained actors. We all know about the main things of Step 2 CS like, there are 12 encounters, and examinees are judged over three main areas ICE, SEP and CIS. We also know that how we have to conduct each encounter and how to pr epare for this exam. This document will try to put light over those blind-spots that are our big mistakes and can put our exam at risk. These are some rules of the game.
So much talked but so much overlooked and less practiced in the exam. Whole theme of this component is that how much you give respect to the patient, how do you treat patient and will that person come again to see you? …It includes your dressing way, concern about patient, your greeting way, how you are showing the empathy, how much you give respect to patient while examination, how you are explaining the condition to the patient and how do you counsel & how do you answer patients’ queries.
Following are some blindspots that are not practised well before exam: Bui ldi ng Rapport: This comes with practice. I would advise that don ’t rush with questions on patient suddenly when you enter in the room. Give him/her time to adapt with you and give yourself time as well to accommodate with situation. Greet patient and introduce yourself and then ask about PATIENTS COMPLAIN and then carry on from there and ask other things. Try to relax patient if you see patient is in distress, anxious or depressed. Eye Contact: Comfortable level eye contact is really important for exam. When patient is talking and you are taking notes and not paying full attention then you are in serious trouble. Try to make it habit that if patient is talking then don’t write and you can make some silent pauses to write some brief notes as you have already taken permission of taking notes in the beginning. Holding clipboard between you and patient is not recommended as it is considered obstacle between doctor and patient; hold the clipboard more on one side rather than in front.
Voice: Monotonous voice is not liked by people in the west; your voice should be vibrant and wavy. Try to speak the transition sentences in high tone and ot her stuff in low tone. Lower the voice tone on bad news or when you are showing empathy. Empathy: This is an important part of CIS. You can show it with facial expressions, you can show it with kind words and you can show it with light shoulder touch. Try to make appropriate facial expressions when you hear bad news or something good from patient. Tapping lightly over shoulder is good point for showing empathy. You can utter good amount of empathetic words/sentences but make sure it won’t compromise your time. Empathy is a scoring part of CIS so practice it more and more. It should be noted that you should not repeat SAME transition sentences/empathetic words again and again, as it will lose its effect. There are few moments in encounter where you can show your empathy more, like, when you hear patient’s presenting complain, when patient tells you about his/her deceased parents, or when he/she is sad or concerned, these are some point earning moments though. Respect: Maximum amount of respect that you can show in the encounter is during examination part. The exposure of body part for patient is inconvenient so try to be more respectful in this part, and practice appropriate draping techniques for physical examination during your preparation for exam. Respect can also be given by uttering simple words like “Thank you” , “You are Welcome” , “ I am sorry” , these words/sentences will increase your performance in CIS, so use them appropriately. Remember that if you commit any mistake then apologise at that time, it will nullify your mistake to greater extent! Drawing leg rest, drawing foot rest or pulling out back rest for patient and draping patient well in examination shows how much you are concerned to the patient and shows your respect for the patient. It is also recommended that you should not interrupt the patient when he/she is talking. Although patient won’t make big stories but if he/she is making then you can say “I am sorry to interrupt but can you tell me about---this---more”. Gathering information: Always ask relevant and appropriate questions; don’t ask awkward questions, judgemental questions (like direct questions about anything) and MULTIPLE Questions at a time (remember that nausea and vomiting are two separate questions). Try to give a chance to the patient that he/she speaks more about the condition and tells you his/her own story and it’s done by asking open ended questions, thus more information is gathered by asking less questions. It’s our habit that if we are asking list of questions concerned about hypothyroidism then we will ask about vaginal dryness all of sudden, these questions should be asked with more courtesy and respect, that is what they are expecting from you in the exam. Ex plor in g the concer ns: Sometimes standardized patients may give you some non verbal clues, like anxiousness, depressed, angriness, confusion and fear, you have to explore that concern and address them properly. If patient is depressed and his/her face is down and you are unable to make eye contact then take permission from patient and sit down on stool and make appropriate eye contact.
M edical T er ms: It is very much recommended that you should not use any medical term and explain it in Lyman term. If you are using any medical terms then explain it afterwards. Differential Diagnoses are also explained in Lyman terms and it is not necessarily to explain all DDs and investigations that you are considering meanwhile but explain only important things. Counselling: Counselling consists of two things: General counselling about smoking, alcohol, age related screening, safe sex and substance abuse and specific counselling related to any disease. Try to make it habit of counselling for general things when you are taking social history. Specific case counselling is done when you are closing the encounter after you have explained the differential diagnoses and investigations. Each case has specific counselling points that you can learn while preparing for exam. Br eaki ng bad news: When you are about to give bad news like bad differential diagnosis then you should briefly describe the symptoms again then correlate it with diagnosis and then break the news. It is better way to talk about bad differentials rather than directly saying “you have AIDS”. Notice if patient is more depressed about diagnosis then you should have a moment of silence and tap gently over his/her shoulder and ask for tissue or water. Closure: Always spare 2-3 minutes for this. After talking about differentials and investigations, ask patient whether he/she has understood you and has patient any questions or concerns and also add that whether you have addressed all concerns!!! Make sure that you are providing management plan only that patient has to agree upon, you don’ t have to impose it on patient, so always ask about willingness of patient for that plan. Treating as a person : It is highly recommended that patient should be treated as a person not just a patient. This means that you should also ask other things beside his/her illness, like, asking about hobbies, asking how this condition is affecting his/her life, with whom he/she is living, asking about occupation and other things. Confidence: This comes when you feel that you are a doctor and you are there to treat the patient and you are not an examinee then you won’t shake or sweat while performing in the clinical encounter. Assurance: Don’ t give false assurance and don’ t hesitate to give assurance where it is needed . We use commonly in our talk to patient “Don’t worry” this is kind of false assurance term, so one should avoid it. Tell patient that you are there to help him/her and you will do your best to him/her in any possible way.
Examinations: When you are going to start examination then try to explain patient that what you are going to do. Ask from patient “is it okay for you” before many if not all of the steps and thank him/her for allowing you to do examination. Always try to do relevant examination, like if patient presents with cough then do respiratory exam but do it completely and one can also do HEENT exam as it comprises of 30-40 seconds. It is also recommended that one should do some specific tests in every case to support the diagnosis more accurately. Using transition sentences, paraphrasing the patients’ sentences, summarizing the history are also important part. And I should not talk about good and professional dressing, as we all are aware about it!!
Simplest approach to this part should be SPEAK CLEAR, LOUD, SLOW and in POLITE tone . And try to eliminate the grammatical mistakes when you are speaking English. Too much hesitation, taking too many pauses, and stammering while speaking make your english compromised and shows lack of confidence too. It’s not necessary to twist your mouth to utter American accent english if you are not good at it. Try to learn pronunciations of some words that we pronounce totally different from American English. Some exampl es are Schedul e (Skedule), A sthma (A sma), Cou gh (Cogh not caugh ), E cho (A cho) (not eecho), Weight, Pai n (n ot Pen), Di et (D ayet), U r in e, F ast/Past/Last, taste (not t est) Record (Recr d). Check out onl ine pr onun ciati ons for th ese and other wor ds.
This mainly compromises of patient notes; some people say that data gathering and physical examination are also part of it . This component is marked by physicians, so it should be written in such a way (like you have to write medical terms).
There are few suggestions for this: H istory of Pr esenti ng I ll ness (H PI ): Write positive findings in first few lines, and write in such a way that physician can get an idea that what would be differential diagnoses and then write those negative points which exclude other diagnoses. You can mention alcohol/smoking/sexual/family history in HPI if you consider that it will help you to justify the differential diagnoses and mention below in other history parts “ NEGATIVE EXCEPT AS MENTIONED ABOVE” Ti me saving ti ps : One can use CAPS LOCK ON in exams, so you don’t have to turn it off and turn it on repetitively. One can use copy/paste option so it ’s possible to copy certain common things among differentials and paste it accordingly. It is also important to note if you have finished your patient encounter earlier than you can go out and start writing patients’ notes early, but it is also important not to rush when dealing with patient so you have to balance it properly. Some Scoring Tips: Write appropriate medical terms in patients’ notes like writing no erythema/exudate instead of clear throat is better way to write it. When you are mentioning fever present in the patient ’ s note then also write about is it high grade/low grade, night sweats/rigors/chills present or not, is it intermittent or constant. One can earn more points on patient notes by writing relevant Differential Diagnoses rather than writing more differentials and you can earn more points if you support your differentials with strong points. I nvesti gation s: Write suitable investigations in less invasive and cost effective manner to more invasive pattern in accordance with any case.
Here is some important stuff regarding patients’ notes:
Never give patient an impression that you are confused, not confident, unconcerned or you are in rush. Give patient proper time, respect, and attention and above all do act like a doctor, don’t feel like examinee. Always apologize if you are committing any mistake while patient encounter it will nullify your mistake to greater extent. Each encounter is well balanced script and anything done by patient might be some clue so try to evaluate it properly. Practice this exam very well, this exam is all about practice, practising on skype isn ’t very much fruitful, you need real study partners. Try to practice with multiple partners and get feedback on your performance from every one in every section. It is said that judge yourself , you can do it by recording your own patient encounter through cell-phone voice recorder then let yourself judge where you are making mistakes. I learned this thing in this exam!!
Practice your patient notes on standard keyboard rather than on laptop, this will help you in the exam. This exam is like handling the show so you should control your nerves and make it perfect by practicing more.
First Aid
Furqan Hyder Shirazi Notes
Neeraj Notes Majid Bhai Notes Blue Sheet Mnemonics Videos: There are some good videos on Youtube.com, you should search them and there is an amazing video on “How to approach a patient ” by Bitz clinical guide group, it ’s a must watch video for CIS component.
https://www.aamc.org/download/357558/data/park.pdf
usmle.org
Hope Joliet, Notes compiled by Dr. Sameer Shafi, MD.
My soul effort is to pass best of my knowledge to others that I have learned from some experienced persons and from my experiences just to make it easy for others. If this effort is helpful to you then remember me in your kind prayers for my future endeavours …. Thanks!!
Raja Shakeel Mushtaque, Dow Medical College-Class of 2011
