Hey people i am sharing with you the experience of Step 2 CS exam of a graduated student of shifa college of medicine.

Hello people,
Hope everyone is doing well. Since no one has written down their Step 2 CS experience, I on behalf of a few people who asked me to, will try to explain this easy but intimidating exam. I'm hoping it'll be of help to anyone who's planning on giving it soon and that it isn't too long.

First of all, I'd like to say CS is a JOKE! Lol, i'm not kidding, and ill elaborate on that later. A few things I'd like to advise students on, is to give this exam early on. Maybe during final year, or even before that in your 4th year holidays that you get for electives. This will help you to start the USMLE process which so many fear. You'll get an ECFMG number, your name on the record and hopefully a pass on the exam. This will help you gear up for the next steps and raise your confidence. The thing I find people fear most is actually starting the process, and they spend at least a year moping around till they make an ECFMG account.

Now back to CS, so before giving an exam it's logical to find out what it's all about in the first place. The first step should be downloading the USMLE Step 2 CS booklet from www.usmle.org and giving it a thorough read. The booklet clearly defines what is needed of you in this exam.

This exam is NOT a test of purely knowledge, but in reality is a substitute for other exams which test English proficiency such as the IELTS. The problem with the English proficiency tests were that they could not judge your ability to interact with people which is so needed in the medical profession. Basically they want to see whether you can talk, walk, act, and handle situations like a proper doctor that's all. Think of it as a drama with a script which you just have to act out. And that's really all you have to do.

Let me give you an idea of the exam. So the exam is made up of 12 patients which you have to encounter. The people you encounter are known as standardized patients (SP). They are just middle class people who sometimes have a medical condition, or just need to get paid lol (pays are as high as 20$'s an hour). Anyways so they train these people to act as patients. Each person gets a script and a checklist on which they mark the candidate. So remember it is the SP that marks you, except for the patient note which is marked by a physician in Philadelphia. So you go room to room take the
patients history, perform a physical exam and then write the patient note. All within 25 minutes. 15 mins with the patient and 10 mins for the patient note. The exam is about 8 hours long. 4 cases then a 30 min break, 4 cases then a 15 min break, and then the last 3 cases.

Preparing for this exam is easy, ill try to explain it in a different way instead of just writing which books to do and stuff to make it easier. It took me 2 weeks. The exam is marked in three separate sections, each which you need to do well on in order to pass. So you can't bank on doing really well on one part, but screwing the others over. Buy the USMLE FIRST AID for CS, that's the only book you'll need. Get a partner (preferably someone who has given the exam before, or anyone siblings, parents, friends, even your damn gardener will do).

The sections are:

1) Integrated Clinical Encounter (ICE):

This is the knowledge part of this exam. It deals with the stuff you've learnt in medical school, i.e history taking, physical examination, and writing the patient note. Also I think this is the part you should be least worried about.

History taking is different from what we've been taught in college. You need to be extremely fast because there's not a lot of time. The time with the patient is 15 mins. Supposing you spend 30 seconds outside before knocking, 1 minute introduction, you have only about 7 minutes to take the history. Keeping that in mind you have to prepare accordingly. The first aid book has 31 cases, starting with the case, a checklist and a sample patient note. Read one of the cases, and see what kind of a history they expect you to take. The trick is to use mnemonics and ill tell you were to get those. There is no way to truly predict the types of cases you will get, but its safe to know they will be very common. I got 4 fatigue cases, 1 abdominal pain, 1 shoulder pain, 1 neck pain, 1 neuro, 1 paeds case with the mom, 1 hoarseness of voice case, 1 multiple bruises etc. So don't spend ages on learning specific differentials, or mnemonics for stuff like ulcer behind the ear lol...do the common stuff. The questions should be fast and accurate. Always start with an open ended question, in review of systems you can ask closed questions. Be fast and clear the patients are trained to give you short answers. If they are rambling for hours, you can kindly interrupt them. If you notice that they are completely incoherent and talking bull****, think psych (one of my friends had a catatonic schizophrenic). To prepare for this part, make your self a template of what your going to ask in the history. Use mnemonics eg. for pain you use LIQORAAA (Location, Intensity, Quality, Onset, Radiation, Aggravating factors, Alleviating factors, Associated symptoms).

This website is jam packed with mnemonics and a whole load of other stuff, go through it and write them down accordingly: http://csprotocol.blogspot.com

Once you have a template. Give the book to your partner and ask him to respond to the questions with the answers from the book and to act like a patient. Pretend your partner is the patient, take his history, timing yourself. Ask the partner to mark the questions you asked. Once you're done. Check which questions you've missed and try to remember them. Make sure you time yourself so you know you're not taking long. Do this for all the cases in the book. Do it with multiple people so you don't get comfortable with that one person. The things I forget most is to ask every female their LMP. Ask every patient WADES (weight loss, appetite, diet, exercise, stress).

People say to write down stuff on the clipboard and paper they give you. But in reality I found that its really hard to write down anything. Just write the mnemonic, and you can tick or cross for positives and negatives writing down any values you'd like to remember, time, years, packs of cigarettes etc. Don't waste time on writing notes and ****, you should have enough of a short term memory to remember stuff and write it down a few minutes later.

Physical examination is pretty much a formality. Practice all the examinations on your partner. I wont tell you the specifics for each examination, but you do need to know which examinations do because you have about 2-3 mins to do the examination. DON'T spend ages on the examinations like we do in medical school. As a basic rule do the following:

1) Do the GENERAL PHYSICAL in EVERY case. Very fast, maximum 15 seconds. Don't take the pulse and BP, that's useless its already given. Check the eyes, pallor jaundice, mouth, hands, nails. Check JVP (it was raised for me in two cases) That's it. Do it fast. Always remember to do a running commentary about what your doing.

'Now im going to have a look at your eyes to check for pallor, seems fine. Can I see you hands please? I'm looking for lesions or pallor. Can you please open your mouth for me? Say AH, thank you that's fine' Be quick and keep the commentary up. This will help on the CIS portion.

2) Do the full exam for the system involved and two small parts of other systems.

E.g If the complaint is abdominal pain. Do a complete abdominal exam, plus Auscultate the lungs, and heart.

If the complaint is cough. Do the complete respiratory exam, auscultate the heart, and auscultate and palpate the abdomen.

3) Learn examination of joints

4) Don't examine if the patient is experiencing unbearable pain. Ask them if they can bear it, if they say no don't do it. Don't re-palpate the painful areas.

5) Be able to do the neuro exam within 2-3 mins. On neuro cases don't do anything else except the neuro exam. If you have time throw in a fundoscopy. Turn the lights down, when doing fundoscopy. Cranial nerves will take you 20 seconds. Etc Be fast.

6) Expose as much of the patient as needed. Abdomen should just be from the lower chest till the illiac crests. The front of the chest, make the patient lie down and raise the robe. Behind, untie the gown after asking permission.

Know for the physical exam that some patients will have real findings and some patients will have fake or simulated findings. E.g if the patient wants to show you he has decreased breathing sounds, when you ask him to take a deep breath, he will hold his breath and just move his chest like he is taking a breath. They fake reflexes really well, even if you don't hit the right place, they will elicit a reflex if its there. So don't worry about doing the neuro exam perfectly. They will pretend they have reduced strength and **** like that. Some patients will have makeup, red color for bruises, orange for jaundice. Lol its really very funny, it doesn't look like a bruise you're supposed to think that it is.

In short, know the steps of the physical exam. Practice how to do it fast.

Patient Note is where I got the least marks according to my performance profile. You can either type it or write it. Since I was used to writing more, I wrote mine. The reason I got less on this part was because I didn't practice them. Practice to write or type. Be short. Don't bull**** like we did in college 'The patient was in a usual state of health' etc. There are examples in first aid but I think they are way too long. Check the USMLE Step 2 CS booklet samples and try to write exactly like that. Make sure your history is correct order. I used to remember stuff from the history of presenting illness late and id just fit it into the family history and **** like that. So make sure you are organized and have stuff clear in your mind. Write down the differentials which are most common first down to the least common. You don't have to have 5 differentials or 5 investigations. You can also write examinations which you will need. Always write RECTAL EXAM for abdominal complaints, and always write VAGINAL EXAM for gynae complaints. Practice doing patient notes as well. Make them coherent and check the list of acceptable abbreviations to save time on the exam. Write clearly. Don't worry too much about the content. You don't have to get the diagnosis spot on you just have to be in the same neighborhood. Things which will make your note seem cool are things like pack years of smokes, amount of alcohol consumed etc.

2) Communication & Interpersonal Skills (CIS):

People find this the hardest because we are not used to this stuff. Be worried about this part, because this is where most of us fail. This is the acting part. What they want is for you to have history taking skills, ability to be neutral, show empathy, counsel etc.

The best way to give you an idea about how people take histories or introduce yourself please watch these video's, they clearly depict how you should act and speak when taking a history. Also read this short guide on the way to conduct a medical interview etc.

Videos: http://www.youtube.com/watch?v=CrqNa9a9PZY
http://www.youtube.com/watch?v=TzzH-XVnaY4
http://www.youtube.com/watch?v=7xldP_h39Aw
http://www.youtube.com/watch?v=PIQKubKaeFA
http://www.youtube.com/watch?v=o8eG7AbLDis
http://www.youtube.com/watch?v=SnJMzXcYfBI

These video's are just an example, and I learnt a lot from them. Obviously the patient wont blabber on for so long, and doctor wont take so long in the exam. But it shows the basic steps involved in the CIS portion.

The Calgary Cambridge Guide for the medical interview: http://www.gp-training.net/training/...gary/guide.htm

This is also a good resource. Use this, not all of it but the things you find important.

The CIS section basically you have to suck up to the patient and follow a script which all doctors in the world follow. You get graded from the time you knock on the door. The first thing you need to do is introduce yourself.

Introduction, be very short, make yourself a line and use it for all patients:

'Hi, My name is Dr. Ali (Shake hand) You must be Mr. Patient. I'm going to be your physician today. How are you feeling today?'

The patient will respond. Then say:

'I have a drape here to make you more comfortable'

Place the drape. DRAPPING is important and has marks. The drape is just a piece of cloth folded many times which you place over the patients legs. Unfold it twice and put it on the patients lap. Do it in the start because its easy to forget.

Use any name you want. You can call yourself Dr. House if you like lol, the patients don't know anything. I used Ali because that's my last name and it is short. Do the same. Start with an opening question.

'How may I help you today?'

Let the patient talk and talk and talk till he stops. Usually its short and they tell you about their presenting complaints. One of the hallmarks of a medical interview is to show you're listening, and engaged, you relay information back to the patient so that you know you haven't missed anything.

'Okay Mr. Patient, so you told me you have this and this, since these many days. I'd like to ask you a few questions about that, and then maybe ask you a few questions about your personal life if you don't mind. And then we can have a talk about what to do next and what options we have' – This is called a transition and it is important to do this in every change in the part of the history.

After this start hammering the patient with history questions from the mnemonics that you just learned. Use transitions.

When moving to past history: 'So now I'd like to ask you a few questions about you're previous health'

When moving to review of systems: 'Id like to ask you about your general health if you don't mind'

Sexual history: 'Id like to ask you some personal questions which might be important, rest assured I will keep this completely confidential'

Using transitions shows them you know what your talking about and know the basics of taking a history. Other things you should do facilitate the patients to talk. You can do this by verbal and non verbal ques: Moving your hands, nodding your head, saying yes uhum go on. Stuff like that.

All this stuff is written in the guide. Read it and watch the video's and see how the person is using these tricks.

After this do the physical exam:

Before the physical exam, ask the patient for permission, remember to pull out the foot rest if your making them lie down, also its nice to help them retie their gowns back:

'I'd like to examine you now if that's okay, before that I have to wash my hands'

WASHING HANDS is important. Always say it and then do it. It takes about 30 seconds to wash your hands. Don't use too much soap or it takes ages to wash off. Dry your hands properly.

As you may know the patient usually hits you with a CHALLENGING QUESTION, which you have to face. All the questions you might encounter are written in the book. Practice them. The ones I got were:

- Depressed patient with abdominal pain, he said he was pissed off because he got fired from his job. A place where he worked for 25 years, and his wife left him. He said what do I do now doctor.

- Kid with shoulder injury, Damn doctor I have an exam on Monday, how will I give it now? And if I don't they will kick me out of school. I responded by saying id write a letter to school and am sure they will consider it.

- Guy with hoarseness of voice, a church choir singer. Doctor will I ever be able to sing again? I responded. I cant say anything now for sure, but after a few tests well know better, don't worry about it im here for you.

- Old lady, I have to go home my dogs alone.

**** like that.

I used the hand washing time to make small talk with the patients. Ask them about their jobs and life. I asked the dog lady which type of dog she had. I asked the choir singer whether he played an instrument. I asked a taxi driver, how her job was going and whether it was interesting to meet so many different people. Use this to make an extra impression. Tackle the challenging questions well.

At the end always make a short summary of the positive points.

Then move on to the explanation and closure. Explain to the patient what he might have, or the possibilities and that you would like to run tests. COUNSEL the patients for bad habits like, smoking, marijuana, unsafe sex, alcohol. Close the session by saying nice to meet you and ill get back to you as soon as possible. Also, make sure you do small things to show the patient you care. If he's coughing offer the patient some water, if hes pretending to vomit offer a tissue. If the patient is crying offer a tissue. Stuff like that.

That's pretty much it for the CIS part.

3) Spoken English Proficiency (SEP):

There's really not much I can say here. If you're good at English, watch TV and read books this exam will be easy for you. But there are a lot of people who don't speak it too well. You don't have to be completely American to pass. If you don't speak English a lot, start speaking it with people around you. In the exam make sure your voice is clear and words are clear and smooth. You can go slow if you want. Grammar is not a problem. The patient grades you on how well they understood your English.

This is getting too long but I'm sure it will give you a good idea. Don't be intimidated by the other people at the center or the center staff. Just get your clipboard and badge and give the exam. If you've done this **** even for 4 days and have a basic knowledge about medicine and history taking you will be fine. Good luck.

that is awesome dude.
thanks for sharing