Preparing for the USMLE Step 2 CS – Part III

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We now come to Part III of our discussion on “Preparing for the Step 2 CS” In Part I, we discussed how to prepare for the medical interview part of the clinical encounter. In Part II, we discussed the physical examination part of the clinical encounter. We will now tackle the social aspects of the clinical encounter which is usually called bedside manners.

We can further divide the social aspects of the clinical encounter into two. Those that you do in every clinical encounter and those that you do in specific situations. We will start with the first one.

So what are the things you do in every clinical encounter?

When you are at your station, the doorway will contain the name and chief complaint of the patient inside. Take note of it, writing it on the upper right side of the page so you do not forget the patient’s name or get it wrong. Knock on the door, then open it. Greet your patient. Use good day or hello, rather than good morning or good afternoon to avoid making a mistake (wrong time of dayJ) Introduce yourself. It’s best to be formal like ” Hello, Mrs. Jones, I’m Dr. Uy, How may I help you?”  Then followed by a question. Other variants could include, “What brings you to the hospital today?” or ” What seems to be the problem?”  Try to use the phrase that is easier for you to pronounce.

If you got a patient who likes to joke and answers “The bus” or “by cab” when you ask them what brings them to the hospital today, Just give him or her your widest smile and rephrase the question, like “How can I help you today?” You should not ignore them, nor join in the joke but keep the interview going in the right direction.

Now where do you position yourself for the interview? It is important to make sure that you face the patient as much as possible during the interview. It is also important that you are either at the same level as your patient or lower. Usually the patient is sitting on the examination bed and it is alright to be standing up as you will be level with them. However, occasionally they’ll be sitting in a chair and it is advisable then to sit down too. Always look at them when speaking to them and do not let your eyes wander around as that is impolite. Avoid any situation where you tower over them and they are forced to look up at you as that is considered impolite. The only exception is during the physical examination when they are lying on the examination bed.

It is good practice to ask open-ended questions during the interview. The main reason is that, by asking open ended questions, the patient will volunteer information you might miss if you answered close-ended questions that could be answered yes or no or with short answers. For example, it would be better to ask her  “Could you describe the pain?” rather than ” Is the pain throbbing or stabbing?” etc. Only when she gives a vague answer, do you ask more close-ended questions. Although, I’ve read in some forums about patients going out of tangent when asked open-ended questions, my own experience is that they are professionals and would not deliberately waste your time by giving irrelevant long winded answers.

Never, hurry the patient, nor cut them short in their answers as that is rude and impolite. In the exceptional case where you have a patient who is giving you the run-around with their answers, then gently tell them that you would like to know more about this particular illness. Remember, in all probability when they do that, it is part of the test to see if you can recover gracefully when a patient starts talking about things irrelevant to their presenting case.

It is very important to show care and concern for the patient and empathize with them. For example, if the patient said something like, their parents had died, you should say ” I am sorry to hear that.” Or if they said that they missed playing golf because of their current ailment, you can say ” well, we’ll try our best to make you better, so you can go right on back to doing the things you like.”  There are a lot of other situations that can happen and we will talk about them in detail and the proper responses you can take later.

It is also very important to give proper medical advise when the patient gives you information about them. Example includes, smoking, drinking, safe sex, contraception, child safety, etc. We will discuss in more detail under specific circumstances. Now the question arises, when do you give medical advise? Although some people prefer to give it before closing the interview or even after the physical examination, personally, I think it is best to do it immediately after such condition comes up in the interview. For example, if the patient mentions she smokes, then give counseling immediately. The reason is so that you get the easy points immediately. If you wait for later, you risk the chance of forgetting or running out of time and lose easy points.

Throughout the interview process, it is important to use transitions sentences not only to ease the conversation along, but as a means of building rapport and showing concern for the patient. For example before proceeding with LIQORAAA, you may say, “I’d like to ask you more about your present problem, is that alright with you?” When transitioning to the Past Medical History (PAMHUGSFOSS), you can ask ” I need to know more about your past to better understand your current illness, is it OK if I ask you some questions?” Now, when going into the Personal and Social history as well as sexual history, you can say ” I am going to be asking you some personal questions about your lifestyle and sex life, is that alright?”  Doing these are just being polite. Now in real life, you will have patients who will object, but the simulated patients will always say yes. Even the supposedly depressed patient I had said yes, when I was expecting him to object.

Now the biggest transition is when you finish the clinical interview and would now be proceeding to the physical examination. It is important to take this opportunity to ask the patient if he would like to tell you anything. You could say something like this ” I am now going to examine you physically in a little while, is there anything that you would like to tell me, or I may have missed about your current condition?” Sometimes, you may be surprised when the patient gives you additional information you forgot to ask. You can then continue the interview a little while to make sure you completed the information. Now, if the patient says that you’ve covered everything, say “Thank You for your cooperation, I’ll just wash my hands and we’ll start the physical examination”

Now we come to the issue of hand washing. Now the question is, which is better, to wash your hands or to wear gloves? You will read in a lot of forums that people to chose to wash their hands because it is faster. However, in reality it isn’t and the time difference is not too much if you are experienced in wearing gloves. I wore gloves in all my cases.

Don’t get me wrong I started out with the intention of washing my hands. However, I took my CS on March in Los Angeles and the weather was quite cold. Being from a tropical country, I started peeling. It was especially bad on my hands. It was actually embarrassing as a co-examinee tried to wipe away what he thought was a piece of tissue from my cheek. Instead it was actually skin peeling. And so washing my hands would not only make it worse, but some parts of my hands were raw and my fingers bled easily with minimal trauma. So I wound up wearing gloves instead.  So instead of being tied to the sink, I would be walking back to the patient, giving him instruction on what to do while putting on the gloves.

Now, washing your hands also takes up a lot of time. First you wet your hands, then you put on soap. Next you have to wash off the soap completely. Then you have to dry your hands. Plus your hands will be cold and you need to warm them before touching the patient. That takes time. Some people advocate to just simulate the handwashing, Barely wetting your hand. Letting the soap fall to the sink instead of actually soaping your hands. Then wet your hands again, so it is easy to dry off. That will save time. But I do not know if they take off points if you do that.

But taking off the gloves again takes time, you say. Not really, in one case, I took the glove with me right out of the examination room and left it on the table while writing the patient notes. The proctor actually told me to just leave it on the table. So take it off only if you have time. If not just walk out with it.

Now what do you say to the patient in the moment that you are washing your hands or putting on your gloves? The silence can be awkward so it is better to fill it with conversation. If the patient is on a chair you can instruct him or her to sit on the examination bed. Most of the time, the patient will be on the examination bed and you can use the time in small conversation to increase rapport. For example, if the patient tells you he likes to play golf, ask what his handicap is. Or if she talks about her grandchildren, ask her how old they are and how they are doing.

We will continue next time on social manners during the physical examination including the all important draping procedures. We will then cover specific situations during the clinical encounter and what you should do about them. Then to patient notes.

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About the author

    askdoc

  • lolo says:

    hii thanx for the posts. I want to ask about the time for cs study. I’m enrolled in kaplan 5-days cs course in (june 4-8), if i review the kaplan cs lecture notes in 4-5 days then take the course and after the course spend 5-6 days of rapid review, atotal of 15 days of study with the course, is this enough?? I’m IMG , my english is good ( not very good ) , I heared that the cs course will prepare the students well. please I need an advice, should take the exam 6 days after the course or delay it more. I did schedule for cs in june and if I reschedule now the nearest date will be in late july.I’ll take step 1 in (may,29), the cs in june or july and planing to take part 2 in september , still don’t know if I’ll be able to apply for match this year, in october , or it’s too late.sorry for all these questions but I really need an advice, thank you.

  • lolo says:

    please more one question, as we know that the may, june , july are the busiest testing times in usa/canada, right?? but this will not affect the scores for whom taking the exam in this period , I mean the FMG as they will compared with us graduate??? I think there is no difference as there is many taking the exam through out the year, just to make sure, I’m just afraid and want to get a good score.thank you again.

  • lolo says:

    hiii just want to ask about the High Yield Fast Facts course , my exam will be in the end of may but I want to enroll from the 1st of may for 2 weeks then renew it again until the end of may , can I enroll more than one time?? I need this rapid review,all your courses are for step 1 only right, thanx.

  • askdoc says:

    Hi lolo,
    Lots of questions. Well I took 14 days to review my CS. 90% is practice. Practice everything including writing notes. If your English is not good enough for you to pass at this time, then not even Kaplan course can improve your English fast enough to pass. If your english is tolerable with probably some bad pronunciation or accent. Then write a script for most situations and make sure you chose word that you pronounce well.

    Although the best chance for getting interviews is by having all steps finished by September 1 and applying within the first week of September, not doing so does not mean you have no chance. First, if you get high 90’s in Step 1 and passed CS by the time you apply in September and indicated you have scheduled Step 2CK, you will get interviews that is for sure. Once your Step 2 CK comes out you will get additional interviews so long as it is still high. If you get 80’s in Step 1, then getting interviews with just Step 1 becomes not so good.

    You are never compared with current examinees but with a pool of examinees from past exams. So it does not affect your score at all.

    The High Yield Fast Facts Course is set up for two weeks currently. I can manually extend your enrollment for an additional 2 weeks if you need it.

    Askdoc

  • lolo says:

    tnanx…… and sorry for all these questions. I’ll do my best in part 1 , start the high yield fact course in may and if I need any help will let u know. thank u again for the advice.

    lara

  • askdoc says:

    Hi lara,

    You’re welcome. Ask away, you don’t have to apologize for asking questions, it’s a pleasure to answer them.

    Askoc

  • roze says:

    hi, thanks everybody for those information. I want to ask about the cases, do they seem like those typical cases in first aid?

  • askdoc says:

    Hi roze,

    FA cases are too easy compared to actual exam. USMLE World Cases are a bit more complex than actual exam. Plus, there will always be cases that are unequivocal with unclear diagnosis. Good differentials more important than nailing diagnosis.

    Askdoc

  • roze says:

    dear askdoc,
    thank u for the valuble information . I am about to take step 2 cs by FEB and I am actually in a chaos I do not know what to read even upon reading I do not know what should i get please help me
    thank you
    Rose

  • askdoc says:

    Hi roze,

    Step2 CS is actually very easy unless you are an old graduate who has not seen clinical practice for sometime. If you are a fresh graduate or an old graduate with clinical experience, it’s not too difficult. The problem of foreign grads is that the US follow a systematic method in approaching and diagnosing cases and you need to follow that protocol in order to pass Step 2 CS. In fact the most common cause of failure for IMG’s is poor English. For AMG’s it is usually the clinical part that is the problem. The most important thing in Step 2 CS is practice. I’ve detailed what you need to do in the actual exam in this and related posts. Before the exam, you need to practice with a live patient. In my case, I recruited my brother and my sister and my niece to act as simulated patient. Practice also writing notes so that you can write that fast. 10 minutes goes by so fast, especially in a tense exam environment. My suggestion is use USMLEWorld Step 2 CS. Take the 1 month version. (You can print out the cases. Copy the ones that can’t be printed out by hand.) Borrow First Aid. Familiarize yourself with the differentials there. and you are good to go. If you are not sure how good your English is, have someone of another ethnicity listen to you. People of the same ethnicity usually have the same accents which while easy for them may be hard for others to understand.

    Askdoc

  • Mancy says:

    Dear Askdoc,
    I have only 15 days to take the CS test, do you think that is enough? I have both Firstaid and USMLE World, what do you suggest I should use? Also I have problem with typing, I am not fast.
    I would really appreciate your reply. Thank you.

  • askdoc says:

    Hi Mancy,

    Most probably yes. Most people review for two weeks. Important is practice, practice and practice. Try to finish the notes in 8 minutes or less. Practice writing hundreds of notes. 20 notes a day for 2 weeks should suffice.

    Askdoc


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