By Jocelyn Compton
According to the USMLE website, “Step 2 CS uses standardized patients to test medical students and graduates on their ability to gather information from patients, perform physical examinations, and communicate their findings to patients and colleagues.”
On test day, you’ll see 12 patients for 15 minutes each and then have 10 minutes to write a note. Many medical schools will provide mock exams to help prepare their students; others encourage students to use a clinic day at a primary care physician’s office to simulate test day. However, inevitably Step 2 CS will present a few surprises that are unlike the real world clinic patient. This is entirely because Step 2 CS is not the real world clinic.
The most striking difference I encountered was the reticence of the patients. In preparation for the exam (and seeing real patients!), I was advised to ask at least four open-ended questions before moving to more pointed questions to narrow my differential. I had an arsenal of open-ended questions, like “what brings you in?” “what else has been bothering you?” “have you noticed anything else lately?” “tell me more” or just the strategic nod of the head to encourage a fuller HPI.
We all know and love these questions, and we can usually get patients to tell their story for 6-7 minutes. This was not the case with the standardized patients.
After the initial story telling (about two minutes of interview time), I was caught completely off-guard when I was met with a locked safe in response to my open-ended questions. In fact, I got the distinct impression that asking any more than two open-ended questions was annoying, and they were met with a curt response. However, a quick transition to the review of systems will reveal a host of other associated symptoms that could not be elicited by open-ended questions.
This brings me to my first point: the patients will not go off script. They have a very specific, limited amount of information that they are willing to tell only if asked the correct question. Once your line of questioning reaches the bottom of the information well, the patient will shut down. It’s your responsibility to know when to start on a different line of questioning.
The second major pitfall I encountered was interviewing patients that had a complaint in my particular area of interest. Without fail, I ran out of time interviewing these patients because I gave in to the temptation to do a detailed exam with specific maneuvers. For example, if you’re interested in orthopaedics and you have a patient with shoulder pain, you’ll be tempted to do every shoulder test you know (of which there are many to cover in a comprehensive exam). My impression is that in the face of complex maneuvers, the standardized patient no longer knows what is supposed to “hurt” or not, and so you will not only waste time doing maneuvers that won’t give you points, but may also be confusing.
Stick with the basics! And never leave out your heart, lung, and abdomen exam in a rush to do an intense thyroid or ankle exam.
Finally, be sure to practice writing the note. We all have ample experience writing notes, but each part of the note on the exam has a character limit. In all likelihood, when you see a patient in the clinic, you write much, much more than the character limit on the CS exam. Take time to practice succinct notes in bullet point format. For me, panic reared its head when I was only halfway through the HPI and couldn’t type any more information.
CS is the final component of your medical boards in medical school. Be your regular personable and caring self, and patients will always respond in kind.