Most Common Mistakes in Step 2 CK Prep

People have been badgering me for sometime now on writing more about how to prep for Step 2 CK. Some even wants me to start a Step 2 CK prep course. However, due to time constraints and the Step 1 Prep Course, it has not come to pass.

Lately there had been too many people asking questions about their Step 2 CK preparation and problems they are encountering. Although I still don’t have time to write a full article on it, I have decided to tackle the 4 most common reason that people do poorly in the Step 2 CK. I am also reposting an article about “What to do for Step 2 CK” an older post that needs some rewriting but is still relevant

1. Not Studying Enough Detail. The most common mistake people make in studying for Step 2 CK is not studying enough detail. You see so many reviewers in the market that purport you can ace the exam by studying the little material it contains. That is a lot of bull. Medicine is a very broad subject and Step 2 CK covers all the most common and even some rare cases.Those little reviewer just does not give you enough detail to do well in this exam. An exception is Kaplan Notes. Very good detail. However, you need to know 85% of it in order to know enough to pass. Higher if you want a higher score. And that is impossible to do unless you do a minimum of 3 revisions. I will discuss the various study materials you can use in another post.

2. Difficulty with next best step in management type of questions. Next best step in managment type of questions acount for about 20% of Step 2 CK. This type of questions involve cases that describes the management done on the patient so far and asks what you think is the next best step in dealing with this particular patient. Remember the next best step depends on what was the result of a previous diagnostic workup or response to treatment. There is a big difference between knowing how to treat and managing a patient. There is also a big difference between knowing what lab tests to perform and working up a patient. Treating a patient  involves knowing what drugs and treatments to use. Managing a patient takes into consideration patient response, adverse reactions and other factors and altering the treatment accordingly. Working up a patient involves knowing implications of positive and negative results of previous tests and what lab or diagnostic test should be ordered next.

Most people study for step 2 CK by reading reviewers or books. And that is the appropriate way to study the clinical content for the Step 2 CK exam. But one needs to do the extra step of constructing algorithms in order to be able to master next best step in management style of questions. You can answer the next best step in management type of question without using algorithms but it will take longer and more analysis to be able to answer them. And as we know, in the USMLE time is what you lack. I will write more on how to write algorithms in another post

3. Knowing too little pathophysiology or mechanisms of diseases. One of the biggest reason why I emphasize pathology and pathophysiology in Step 1 aside from the fact that it is the biggest subject in Step 1 is that it is also very important in Step 2CK and Step 3. This accounts for 20% of Step 2 CK and covers mostly systems pathology unlike in Step 1 where the main emphasis is in general pathology. Also in Step 2, the pathophysiology tested are more clinical in nature, ie how they account for various signs and symptoms and complications of diseases. Cases will also include what I would call “Applied pathophysiology”. I have written examples of this in an earlier article. This is usually a problem for those older grads who decide to take Step 2 CK ahead of Step 1 and did not bother to brush up on pathology. Also for those who took Step 1 first but did poorly in pathology. The solution is therefore to make sure that you are solid in pathophysiology. Goljan’s Rapid Review for Pathology is a short but good book to brush up on pathophysiology, although it covers general pathology as well which is not needed in Step 2 CK.

4. Atypical presentation of common diseases. According to Cecil’s Textbook of Medicine, there are four types of cases you normally encounter in clinical practice. In order of frequency, they are (1) common diseases with typical presentation, (2) common diseases with atypical presentation, (3) rare disease with typical presentation and (4) rare diseases with atypical presentation. They also occur roughly in the same number in Step 2 CK with slightly more type 2 cases than normal

In Step 1, most of the cases you encounter presents classically. But in real life you rarely see classical cases where all the key signs and symptoms are present. Even in Type 1 cases, not all the signs and symptoms will be there. However, enough will be present so diagnosis is not so difficult. The big problem in Step 2 CK for most people is type 2 cases where common diseases presents atypically. For example, although sarcoidosis is most common in young, black female. They do occur in males, older people and other races. So in Step 2CK a sarcoidosis patient may be an old, white male instead. You need to be able to diagnoses the case even with atypical presentation or you won’t be able to answer the questions. These is usually a problem with medical students with limited clinical experience and old grads who have not practiced medicine for some time.

Other ways clinical cases are tougher in Step 2 CK is the addition on both relevant and irrelevant normal findings. The addition of irrelevant abnormal findings that will not change the diagnosis. You need to be able to discern what facts are important and what are not. Remember in an actual live patient, they may present with symptoms that is irrelevant to their main complaint and you need to decide what is relevant and what is not.

The best way to correct this problem is to study classical cases and know what symptoms and signs are absolutely essential in making a diagnosis. When doing qbanks and you misdiagnose a case, it may make sense to find out where you got it wrong and write down the minimum symptoms and signs you need to make the diagnose, so you don’t make the same mistake again.

These 4 are the most common reason for getting low score. Although there are other less common weak points that can cause lower score, they will be discussed in another post.