Step 2 CS: Blow Me

Cherokee  28 Apr, 2007  Medical School

The damn monkey is off my back. I f’ing passed.

Step 2 CS, for those of you who don’t know, is a newly instituted (2004) part of Step 2, the second of three Step exams one must pass in order to become licensed to practice medicine. Personally, I think the damn thing should be its own Step. Have four Step exams to prove how insane the licensing process is, instead of pretending it’s part of Step 2. Before long, the geniuses at the NBME will split off the communications portion of CS and have a “Step 2: Empathy & Social Work” exam.

What does the test entail? It’s a $1000, daylong exam, which is structured as follows: 12 patient encounters, each 15 minutes each. During each encounter, you are supposed to do a history & physical, and after each encounter you get 10 minutes to write out your findings, workup, and diagnosis on a patient note. Ten encounters are graded, and two encounters are non-graded test encounters. (One-sixth of the exam, therefore, is horseshit to begin with.) The grading is pass or fail, and more on that in a bit. There are only five testing sites around the nation: Atlanta, Chicago, Houston, LA, and Philly. The test is insanely hard to schedule unless you do it many months in advance.

It actually took me two tries in order to do it. Yes, I failed the first time I took Step 2 CS. Because of that, some of you might think I’m kind of an idiot. Here’s what I have to say to you:

1. You’re correct: I’m kind of an idiot.
2. Clinical medicine blows and I don’t really care about patients*, and especially not H&Ps and patient notes.
3. I’m going into Path: I’m not gonna be an intern next year or a clinician when I graduate residency, so I don’t give a shit about all this.
4. Actually, forget all that. Blow me, just like Step 2 CS can do.

In all seriousness, this test is crap. I hope that someone sues the NBME over it and wins. Other than it being completely unnecessary, because medical school and residency prepare you to be a practicing clinician, there’s no way to know WHY you passed or (more importantly) WHY you failed. If you pass, which is about 80-90% of US students, all they do is put “pass” on your score report. If you fail, they give little bars in each of the three areas that really give you no good information. The three areas:

A. English Proficiency
B. Communication: You probably can fail because you don’t drape people properly, which obviously reflects your lack of proficiency in medicine. This section is graded by the standardized patient.
C. Data Gathering: A reasonably fair area to test, consisting of the patient encounter and the patient note. The patient encounter is graded by the standardized patient, who ostensibly has no knowledge of disease pathology or presentation (and any sort of degree?) other than the script and checklist he/she is given. The patient note is graded by clinicians.

Supposedly there is a percentage of medical students who are not competent enough to be clinicians, and this test allegedly weeds them out. I’m not a great clinician, I never have been, and I never really aspire to be. But I passed. So the test is about knowing how to pass the test. In fact, someone on the internet somewhere mentioned that someone without ANY medical training could grab First Aid for Step 2 CS, study for a month, and go pass the exam. I agree with that statement.

For those of you that have the exam coming up, do a few things: learn Step 2 CS for First Aid backwards and forwards. Use USMLE World or the Kaplan book as well. Most importantly, practice with a partner or spouse! Have an algorithm for taking a history and physical and do it every time. Know the steps you have to do (state your name, drape, etc.) and the questions you need to ask for each symptomatology complex outlined in First Aid. That is, chest pain = location, quality, intensity, time course, diaphoresis, position, medicines tried, dyspnea, palpitations, etc. That makes it SO much easier to rattle off questions instead of trying to remember exactly what you need to ask. Use First Aid or Kaplan’s mnemonic for history taking. Create lots of mnemonics.

Don’t underestimate the test. Know that it is possible to fail, as I did to begin with, but you can also make a ton of mistakes (as I did the second time) and still pass. 80-90% of US students pass the first time. When I took the test the second time, I changed a few things: I knew the mnemonics better for each symptomatology complex, I did better physical exams, I typed my notes instead of writing them, and I did a better closure. Closure is important! Read First Aid for more about that stuff.

I pity those of you who have yet to pass this evil test. May God have mercy on your souls. As for Step 2 CS: suck it long, and suck it hard.

*I actually care about people, I just don’t like dealing with sick patients. Part of me blogging for Hoover’s badass blog is to help convince some of you NOT to go into medicine. Or, at least, let you know what to expect. That’s pretty damn humanistic!

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16 Comments so far »

  1. Swinginislanddoc said

    April 28 2007 @ 1:20 pm

    I agree. I took this back in July. I’m an IMG so we always had to take the CS exam, but we also had to take the TOEFL (or whatever it’s called) and with the introduction of the CS on Step 2 we no longer do. Yes, even the born and bred US citizens had to prove they could speak English. It was a very stupid exam (one I had to pay $1200 for - apparently we have to pay the ECFMG or something…I don’t know really where the extra $200 goes). There were a couple of patients I really had to resist the urge to laugh at….

  2. phil said

    April 28 2007 @ 2:20 pm

    I despise all standardize patient testing. The interaction you have with a real patient is much different. They’re good for learning (i.e. 1st and 2nd year), but once your knowledge has progressed, it’s very annoying to be graded by people that don’t understand your thought process of trying to diagnose an illness.

  3. midwife with a knife said

    April 28 2007 @ 3:13 pm

    I think that the CS exam is utter BS. It’s a total scam for the NBME to get more money out of medical students who already graduate in crushing debt. (And I’m even old enough that I didn’t have to take it!)

  4. Half MD said

    April 28 2007 @ 8:52 pm

    Let’s do the math:

    (16,000 medical students) * ($1,000 each) = $16 million.

    There is no way in hell that a non-profit organization needs $16 million to pay for standardized patients’ salaries and clinicians to grade the exam. I always thought that 3rd year was a way to assess our clinical skills. I would like to see someone sue the NBME to get rid of this exam, too. Unfortunately, the cost and time commitment involved with getting this exam tossed is not going to be worth it for most people. Someone would have to be VERY eager to get Step 2 CS thrown out.

  5. Med Stud said

    April 29 2007 @ 12:42 pm

    Do you still need to take it even though you aren’t planning on residency?

  6. Cherokee said

    April 29 2007 @ 3:14 pm

    A lot of medical schools have it as a requirement, so even if I wasn’t going into Path I’d have to take it. But I passed, so that’s all I care about.

  7. Hoover said

    April 30 2007 @ 9:41 pm

    Grats on passing Cherokee. No more Step 2 ever!

  8. Zuwie said

    April 30 2007 @ 10:33 pm

    Cherokee, congrats on getting this thing off your back! It was a huge relief for me when I passed, especially since I had to wait two months for the score and had some “sure to fail me” screw ups during the exam.

  9. Parcho said

    May 1 2007 @ 10:09 am

    I can’t think of a time where I wasted more money on something than I did on Step 2 CS.

    I want my cash back.

  10. McNinja said

    May 2 2007 @ 5:42 am

    Hey now, you left out the part about where all of the US medical students going to US schools get a form from the ECFMG with a HUGE letterhead that says “This form signifies that the bearer has taken a test that just cost them $1000. They also got a shitty lunch. Thank you for the money.”

  11. Parcho said

    May 2 2007 @ 9:40 am

    Oh yeah…what McNinja said.

  12. Jose said

    May 3 2007 @ 12:20 am

    So, do you think that current physicians think they had it too easy? They’re sitting behind a desk somewhere saying, “You know, medical school and licensing were way too easy. I hardly had to do any work at all. I partied every weekend and never studied. We can’t have doctors like me around. I’m going to be old soon, and if I had to take care of myself I’d probably be dead in two seconds. We need to train these new physicians better than I was trained.” Gosh I hope they don’t think this. Why was their licensing more lax than ours, have there been huge changes in medical practice? NO, it’s just now the nbme wants to get paid more.

    As I look back at the last 2 years of medical school, they seem a lot easier now that they’re done than they did when I was struggling through them. Everyone looks at the past with rose colored glasses. That is a terrible mistake to make when the you are sovereign over a group of people younger, faster, and stronger than you. :) It’s only a matter of time until this BS is removed from the licensing requirements.

    The CS part of step 2 would be more accepted if the grading were more objective and less dynamic. It would also be good if it was free, or, since patients are benefiting from these wonderfully trained doctors, they could pay for it.

  13. MDwannabe..sometimes said

    December 27 2007 @ 1:36 am

    Failed the damn thing myself back in August. They took their sweet time getting the scores back to me (full 12 weeks). Soonest I could retake it is February. I have programs asking me about it and questioning whether or not they will match me. Won’t have a passing score back before rank order is due.

    This test is utter garbage in my opinion. I have never had any problems in clinic or on wards. I felt confident taking the test the first time.

    The worst part of this, is I don’t know what the hell I will do if I don’t pass it the next time around. I guess after spending all this time and money in medical training, I will be working at the local Wal-Mart trying to support my family and pay off my loans. To be honest, I’ve had a lot of anxiety and bordered on depression over this thing. Every other day, I screen myself with SIGECAPS to make sure I don’t need to go see someone… Just kidding… sort of.

    I wish very painful and bad things on the bastards at NBME.

    In the meanwhile, I am looking into alternative careers for losers that paid out the butt to go to med school, passed every test and rotation they were on, got great scores on Step 1 and 2CK and then failed the freakin’ CS exam…

  14. Lucas said

    May 5 2008 @ 12:36 pm

    Hey, I thought I was the only one with this ordeal. I took mine a week ago and as soon as I got out of the exam I started thinking about all those details I didn’t cover such as what type of diet do you have or some counseling in some cases, still don’t know if I will pass. Hope so cause I can’t deal for another $1200 and more money for hotel and travel expenses. My brother is a fellow in Rheumatology and he told me the last time he did CAGE questions on somebody was actually on the CS Exam. He didn’t even do Mini Mental or CAGE while doing residency. This thing blows and I hope I pass cause seriously I’m so tired of medicine and this stupid exams.

  15. Syed said

    July 11 2008 @ 3:43 pm

    Medicine sucks full time , and the months of waiting period to take Step 2 Cs Sucks even more , why cant the Bord open more testing centers apart from just few Sates?

  16. smallville38 said

    November 24 2008 @ 6:57 pm

    Step 2 CS exam is a very good idea. I am an IMG, currently in my first year of Internal Med residency. I took CS exam back in 2006, while i was doing my elective rotations in US. As some of you said please do not underestimate the exam, i took it and passed the first time, but for all those who complain about its existence, i must say: STOP!! you will ask my why am i saying this? well, to be a good physician you not only need basic medical knowledge, you need interpersonal skills and ability to conduct proper interview with a patient, know how to get the infomation, how to properly examine patients, how to come up with differentials, etc.
    There were people in my class who were getting 95 and 99 on their Step 1 and Step 2 CK and failed CS exam because they could not communicate effectively with patients, could not properly examine them, to say as far as they were afraid to touch patients,
    Thus, i my opinion CS exam is a good idea, but i agree, it should cost less.

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