Tuesday, January 01, 2008


One requirement to graduate from most US allopathic medical schools is to take and/or pass the USMLE Step 2. In 2004-2005, the Clinical Skills portion of the exam, or the "CS", was added. The purpose of this piece of the exam is to have students demonstrate their ability to interact with patients and perform a focused physical exam in a standardized fashion. After all, many medical students never perform a history and physical in front of an attending physician. I've conducted H&P's in front of an attending only on psychiatry, really; most attendings rely on your presentation of your findings to gauge what questions you asked and what exam maneuvers you performed.

In reality, though, the test is (IMHO) complete and total BS. There are only 5 test centers in the United States: Philadelphia, Atlanta, Chicago, Houston, and Los Angeles. This year, it cost me $1005 to take the BS, and $470 to take the CK (Clinical Knowledge) portion. Most of us have to pay to travel to a city with a test center.

I spent the night in a motel, then on the morning of the test, I drove to the test center, which is not in a fantastic part of town; the neighborhood is nicknamed "Gunspoint" if that helps. You have to arrive promptly at 8 am, or they threaten not to let you take the test. I arrived and was told to strip off my watch, tape over my name on my stethoscope, put only my ID in my pocket, and put everything else in a locker. I was thus armed with an unlabeled white coat (if you have a badge or patch sewn on, they'll tape over it for you), a stethoscope, and my ID. They gave me a clipboard and two pens--we weren't even allowed to have our own pens, because god forbid that you cheat with your own pen. They put tags on our chests and left shoulders with our number for the day--I was number 1 of 26. Trying to be cute, the test staff repeatedly called us "doctors" as they ordered us to march to a different holding cell where we watched a video about how to conduct the encounters and played with the model room equipment. Finally, we were marched out to a long corridor with 13 rooms opening off either side and 13 computer desks against either side wall. We were lined up, warned strictly against "unauthorized or irregular behavior", and told to wait for the voice to tell us to start.

At the sound of the voice, you flip over the sheet on the door to learn about Patient X, a 26-year-old man in the clinic with a complaint of cough and vitals of X, Y, and Z. You knock, go in, introduce yourself, and it begins. The complaints are usually vague enough that several diseases could fit the description; our patient could have pneumonia, bronchitis, influenza, lung cancer, asthma, or GERD. The point of the exercise is not to narrow the differential, really, but to ask "the right questions". Don't forget to wash your hands in the freezing rooms before you touch any patient! There will probably be at least one encounter where either you have to talk to the SP over the phone, or see a "parent" while their imaginary kid is "getting his vitals taken by the nurse".

The fun thing is that each patient has their "tough question" to ask you. "Doctor, do you think I have cancer?" "Doctor, will I be able to go back to work [as a schoolteacher who has symptoms very consistent with mononucleosis]?" "Doctor, do you think I waited too long to bring my son in to see you? I feel so guilty! [Kid had a mild fever x 1 day with no other symptoms]" "Doctor, I can't be sick, I have to take care of my wife! Do you think it's serious?" These questions are designed to test your ability to quickly think of soothing BS--we can't rule out cancer, but I think it's unlikely; let's see what you might have, but there's a possibility you will need to stay home from work; your son appears to be okay, but I'm glad you brought him in today, you did the right thing; we need to work on taking care of your health so you can care for your wife, as I know that she's your top priority. Don't worry about sounding fake; just let the BS roll off your tongue. Oh, and always assess smokers' willingness to quit, advise promiscuous people to use condoms to protect against STD's, and never assume that the elderly businessman doesn't use tons of cocaine. There is no profiling here!

After you've examined your "patient" and addressed their "concerns", you will quickly recap everything you talked about and go over the plan: you'll need a chest x-ray/pelvic exam/rectal exam/antibiotics/biopsy/CT scan/blood work/immediate surgery, say goodbye, and exit. Unfortunately, I didn't always have time at the end, as I ran out of time in several encounters. Since I knew this would be a problem, I tried to include this info throughout the exam. This portion of each encounter is 10 minutes long.

After you leave the room, the fun part begins. On your desk is a computer and a blank H&P form. Choose one and begin to document furiously. I did one written note and 12 computer notes because that was easiest for me. You can do either one. You write up the H&P, including any pertinent family history/social history/medications/PMH/PSH, etc. At the bottom of the page, you are to come up with "up to" 5 differential diagnoses and "up to" 5 potential next steps. For some, this is easy: the 25-year-old female with belly pain, fever, skipped period, and pain at McBurney's point could easily have ectopic pregnancy, appendicitis, ovarian torsion, PID, IBD, etc. Try limiting yourself to 5 tests for her: she needs a pelvic exam, pap smear, rectal exam, fecal occult blood, urine pregnancy test, abdominal ultrasound, and CBC for starters. I squeezed multiple answers onto one line sometimes, but it wasn't really clear how this would be scored. Eh. You have 5 minutes for this section.

After 5 patient encounters, you are fed lunch and can go to the bathroom; after another 4, another short break; then the final 3, a short survey (where, conveniently, you can't give them your actual opinion, only the numbers 1-5 in response to their questions), and you're HOME! (Or at least off to the airport).

The day I took the exam, I think there were maybe 5 of us who were US medical graduates, out of 26. The BS is widely regarded as a substitute English proficiency exam designed for FMG's to US grads, and though I've known many good FMG's, there were several present during my test who couldn't follow directions like "leave your stethoscope on the table during the break" or "stand in front of the door, don't sit in the chair". Oy.

The whole thing just felt so forced and fake. I've had standardized patient encounters at my school which were better than others, but there's always that feeling of being played in some way, going through the motions. My favorite SP encounters were the ones where we were allowed to practice, and were given immediate feedback. There is hardly any feedback from the BS. I took the exam at the beginning of November, but my score apparently won't be released until the end of January. If you fail, you get a breakdown of the areas you failed in, but if you pass, that's all you find out. The score recheck procedure is somewhat fishy to me:

For Step 2 CS, score rechecks first involve retrieval of the ratings you received from the standardized patients and from the physician note raters. These values are then re-summed and re-converted into final scores in order to confirm that the reported pass/fail outcome was accurate. There is no re-rating of your encounters or of your patient notes; videos of encounters are not reviewed. Videos are used for general quality control and for training purposes and are retained only for a limited period of time. -2007 USMLE Bulletin

In other words, no one checks the standardized patients. They videotape the encounters solely to protect the SP's, not to also protect the students. The recheck process is only going to make sure that your score was added correctly, not to actually re-evaluate your performance. Multiple physicians grade your notes, but 1 SP grades each encounter. Who grades the SP's?

I have no idea whether I passed or not; I was (for no apparent reason) really nervous that day. According to the First Aid for the CS, the pass rate among US medical students is 96%. I'd be interested to see how many of those 4% who failed pass on the second try because they're more used to the format and/or less nervous (versus those who fail simply because they suck). Therefore, I wonder, who are they really weeding out with this test? If it's designed to pass us all, why pay $1000 for this privilege? My school's OSCE, or clinical skills exam, was much more difficult than the CS, and I received very detailed (and somewhat amusing) breakdowns of my performance.

Oh, and I took the CS before the CK because the date was available, and when I switched my schedule I was unable to move it again. You have to schedule it WAY in advance. I doubt I'd have done any better if I took it after the CK, because the studying was very different for the two tests. The CK was a lot like the Step 1: a long day in front of a computer screen.

I'm going shopping now, because tomorrow I start my sub-internship in pediatrics. Strange to think that I haven't really examined a kid in over a year. Yes, I did child psych, but those were mostly adolescents. Looks like the only kid on the unit right now is a toddler with a leg abscess. Let's hope that tomorrow stays slow.


Xavier Emmanuelle said...

Wow, sounds like a rather exhausting test. Hope you did well!

Good luck on your paeds Sub-I!

Basia said...

I feel so happy to hear the CCCCCCE (not the OSCE) was harder then the actual CS.

Midwife with a Knife said...

I was fortunate to take Step 2 before there was a CS. I'm glad, too, because it would have added $1000-$1500 to the cost of the test with travel and all.

Tiny Shrink said...

Yes, you are lucky.

Yes, it was easier than the CCCCCCCCCCCE.

Yes, it was rather grueling, but the best part is that it is OVER! Woo!