Manuscript of Step 2 CS!

--Raja Shakeel Mushtaque, M.D

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
made in exam. This document is not meant to discuss any exam case neither it will go through each
and every detail of the exam or preparation material. Main purpose of this document is to explore
components and sub-components of the exam and try to highlight some valuable points.

Manuscript of Step 2 CS!

USMLE Step 2 CS exam is getting tougher day by day. If you are thinking that its easier than other
USMLE exams than you should re-think over it, its 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 prepare 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.

Communications and Interpersonal SkillsSo 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:

Building Rapport: This comes with practice. I would advise that dont 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 dont 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 other 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 wont 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 patients 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 wont 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; dont 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 its done by asking open ended questions, thus more information is gathered by asking
less questions.
Its 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.

Exploring the concerns: 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.

Medical Terms: 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.

Breaking 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 dont 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 wont shake or sweat
while performing in the clinical
encounter.

Assurance: Dont give false assurance

and dont hesitate to give assurance
where it is needed. We use commonly in
our talk to patient Dont 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!!

Spoken English Proficiency:

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. Its 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 examples are Schedule (Skedule), Asthma (Asma), Cough (Cogh not caugh), Echo
(Acho) (not eecho), Weight, Pain (not Pen), Diet (Dayet), Urine, Fast/Past/Last, taste (not test)
Record (Recrd). Check out online pronunciations for these and other words.

Integrated Clinical Encounters:

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:

History of Presenting Illness (HPI): 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

Time saving tips: One can use CAPS LOCK ON in exams, so you dont have to turn it off and turn
it on repetitively. One can use copy/paste option so its 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 patients 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.

Investigations: 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:

Key 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,
dont 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 isnt
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.

Study Materials:

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, its a
must watch video for CIS component.

References:

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