Step 2 Clinical Skills

Or: We know you do this every day, but you still have to come show us you’re a basically decent english-speaking human who learned something during medical school.

For more information from the USMLE on Step 2 CS, here’s the official site.

The only thing in this picture you take in with you is the coat and stethoscope. Time to leave all the other notes behind.

As a first-year medical student, I remember hearing vague rumblings of the part of the education where you have to see a standardized patient and demonstrate your clinical abilities.

And I was terrified.

I have to know what questions to ask? I have to decide what’s the right physical exam to do? I have to use equipment without bashing anyone in the head?

These were my fears.

Fast forward 3+ years, and right between my honeymoon and starting this Pediatric Infectious Disease rotation in Ohio, I headed out to Los Angeles to take this exam.

Step 2 Clinical Skills is the final component of Boards taken during medical school, sometime towards the beginning of 4th year. It consists of 12 standardized patient encounters––15 minutes in the room for history and physical, 10 minutes to write a note. Our closest location is Los Angeles, but it’s offered at a few sites around the country on multiple dates.

I want to share a little rundown of my day, but here’s the bottom line:

From the time our wonderful Physical Diagnosis staff first teaches you to use that dang blood pressure cuff in first year, you are preparing, and when it comes time to take the test, you’ll be ready.

Though you may still put the blood pressure cuff on backwards. True story.

Step 2 Clinical Skills by the Hours

At the link at the top of this entry, you can watch the orientation video that gives a pretty good rundown of the day. This is more an editorialized experience.

Day before: I think it’s a good idea to travel to wherever you are taking the test and find the building the day before; it will decrease your test-morning anxiety. I took my test on a Thursday, so on Wednesday afternoon I headed out to LA and checked into an airport hotel. I picked the Hacienda Hotel because it was cheap and super close to the site. Like if my car broke down I still could have walked close, but it was super old and a little sketchy, so use your own judgment there. I brought my husband with me, and his statement was, “I’m really glad I didn’t let you come here alone.”

6:00 AM: Alarm sounds and I got up. The plan was to be there at 7:30 AM, with plenty of time for getting ready and eating breakfast.

6:45 AM: With breakfast at the attached diner completed and my taste buds sufficiently assaulted with terrible coffee, we headed across the street to Starbucks for something palatable. I spotted someone else carrying a short white coat and looking nervous. Good to know I’m not alone.

7:25 AM: I entered the Pacific Corporate Tower building 125 after John dropped me off, walked onto the elevator and did not see a button for the 13th floor. It only went to 10. Turns out there’s 2 banks of elevators––one for 1-10, one for 11-20. I’m so small town, I had no idea. When I finally found the right one, someone spotted my coat and wished me good luck on the way up.

7:29 AM: There were a few other students sitting around in the hallway on floor 13, and the sign said the doors would open at 7:30, so we just waited.

7:30 AM: After showing our test permits and ID to the secretary, we were directed back to an initial holding room and assigned a number. There we all sat around for awhile in assigned chairs while everyone arrived, we got white stickers to cover up names and logos on our coats, and we read some instructions. I used the time to appreciate how different everyone was. It was someone’s 45th birthday, there were multiple foreign accents, some long coats and some short. It would be another interesting day for the standardized patients.

Some time after that: We gathered up our things and went to the orientation room. (That’s right, holding room, THEN orientation room. 2 rooms.) We were allowed to keep food, lip balm, mints/gum and meds at our assigned chairs in this room. Everything else got put away safely in a locked room. I kept a pack of gum, some chapstick, and all the food I’d brought––trail mix, snap peas, a luna bar and an apple. During this time they also showed us the orientation video, available at the website at the top of this post.

8:30 AM (I think? Really all these times are going to be guesses): After making sure everyone had a chance to use the restroom and take a deep breath [I'm telling you, these proctors were super nice] they lined us all up in order of our numbers and took us to our starting stations.

And…..GO!

Without saying anything about the cases, I think the combination of OSCEs in 3rd year and the MACY we took in July (a California-based sort-of practice CS with 8 stations) gave us a pretty good idea what to expect.

I was nervous, but I finished in most rooms right before the signal that time was up. Of course, as I typed my note I kept thinking, “Oh I forgot to ask that!” “Oh my gosh what if it’s this, I didn’t even do a ______ exam!” So pretty much the usual. I chose to take the approach of a little more time outside the room jotting a differential and physical exams I might want to do. Then once in the room, I pretty much didn’t write unless there was a med list.

Around 11 AM: After 5 stations, we had a 30 minute break. There was food provided: sandwiches, salad, fruit, cookies, but I kept it light with some salad and my luna bar. What if I slipped into a food coma in the middle of a patient encounter?

I’ll be honest, at this point with 7 to go, I felt like the day would never end. However, I think at this point at least the nervousness was mostly gone.

11:30 AM: 4 more stations. I think it was around station 7 that my history-taking really started to drop off. I didn’t expect to feel so brain-tired so early, but I found myself stumbling over words and sitting in longer and longer silences while I regathered my train of thought. I kept finishing with enough time, I just didn’t feel as energetic. There was one station I wasn’t quite sure if a full CV exam was really indicated, but didn’t know what to do next, so I just sat there thinking while I listened to the patient’s carotid. It’s possible she thought I fell asleep. Not sure.

1:30 PM: Another 15 minute break. I had some snacks and began to see a light at the end of the tunnel––3 to go!

1:45 PM: Another 3 stations. I am not kidding you, I think my final patient of the day thought I was a little slow. I must have summarized/repeated his answers at least 3 times to make sure I had the story. He was starting to look at me like I wasn’t quite with it. That’s not to say his case was complicated––my brain was just really tired.

3:00 PM: After turning in our final scrap paper we were allowed to retrieve our bags, given our proof of attendance printout, and we could leave.

Then John and I took a 3 hour IKEA shopping trip because my new apartment didn’t have any furniture. It was very therapeutic.

Overall, I certainly don’t think I crushed it––there was something I thought of later that I didn’t address on every patient, and on a couple I really wasn’t that confident in my differential. However, the process felt familiar, so in October when I finally get the result we’ll see if my feeling reflects reality.

For now I’ll say this: trust the process. I think you’ll be ready.

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  1. Pingback: 2 Steps Closer to Residency | MD2B

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