Clinical Skills - Nightmare of the lot!

Trust me I underestimated many aspects of this exam and really earnestly repent doing so. I hope that by the end of this article, you will overcome the mistakes that I did and realize how to avoid common pitfalls and be better prepared compared to me. Few things I want to tell you before I start with my experience are the following

1. The cost: It burns a HUGE hole in your pocket. It is nearly double the other exams, not taking into account the additional travel and hotel expenses you would have to face while going to testing center.
2.  Don’t Wait. Schedule Early: This is one think I wished I knew earlier. Do try to schedule early, because oftentimes test dates are difficult to find. Furthermore it can take up to three months to receive your results. Also you have the eligibility criteria for a year and this is WAY more than the 3 month period that you get for the other steps. You can find out when your results will come by checking the following link: Reporting Schedule
   Also to get the desired date you can use an app called check4change. A brief intro on how to use the app is given HERE.
3. Know that the examiners are scoring you on 3 aspects and you have to pass all 3 components individually in order to clear the exam. The 3 components are: Communication Interpersonal Skills (CIS), Spoken English Proficiency (SEP), and Integrated Clinical Encounter (ICE). The exact details and directions can be found in First Aid CS and Neeraj notes.
4. Prepare Appropriately: Which leads me to my last most important part of the post – PREPARATION.   PRACTISE PRACTISE PRACTISE. There is nothing more important than this. Best would be to practice with a friend who is also taking the exam so that you both can correct each other or you can try practicing in a group. Make your test day feel so comfortable that it is like “just another day of practice.”

MY JOURNEY!

Let me start off by saying it had TOO MANY pitfalls and this is not ideal. But if I could get through this exam, then you can definitely!

My preparation time would be, say around a month on off and a PROPER week before the exam.

Preparation books - 

1. First Aid CS (use the latest edition since there are changes)
2. Neeraj Notes - Link is here or here
3. Online youtube videos (Mentioned in the post)

I initially started my preparation with one of my awesome seniors who guided me for my Step 1 preparation, who is Ms. X in my 1^st Step 1 post. Initially I used to play the role of the patient for her, so that I could learn from her how to actually take a case. After a week she told me that I should try asking her questions and play the role of the doctor. It was then that I realized it is not easy playing the role of the doctor. You had to ask all the right questions in a time frame of just 15 minutes. But as I practiced I figured out my short comings and became better with time or at least I felt like that. 

Later I had to study for my Step 1 and hence I could not practice with her. Furthermore she had to go for her electives. Anyhow moving on, I gave my Step 1 and thanks to god cleared the exams not with flying colors but with some colors none the less J And then there was the elective hunting in between and studying for CK.

Finally my close friend who was also preparing for the USMLE, suggested that we start practicing for the CS, which I thought was a good idea. So we decided we will try practicing say an hour or 2 daily by doing alternate cases as patient and doctor. That way within 15 -20 days on-off practicing we were done with most of the cases. Initially we thought of trying to do a simulated case scenario of at least 5 patients but do not think it went through, since we each had our own commitments to attend to. After that, in the month of June if not mistaken, I started earnestly preparing for my CK, I think earnestly would be an overstatement but none the less, I started preparing for it. Finally I gave my CK on the 24^th of July and then flew to the States on the 28^th of July. I did not touch my books for CS after my CK exam since I thought I anyhow knew everything and I deserved a break. How mistaken I was! My exam was on the 11^th of August and that too in Los Angeles where people on the forums have said is a definite flunking testing center for IMG’s, second only to Philadelphia. I wish that at least would have driven me to think of studying :(

On the 1^st of August I opened my books and everything that I thought I knew looked like Greek and Latin. I could not even remember how to take a proper case anymore! I had lost touch with my case taking skills!! With only 10 days remaining for the exam I started panicking like I always do. I tried talking to my friend but guess he was a little too busy to answer my questions which were kind of dumb now that I look back at them. I tried getting study partners online and on Skype by posting on Facebook, USMLE forums if anyone wanted to practice but to no avail. It seemed like no one was giving the CS other than me then which was kind of weird and scary. It was a night mare to be in my place to tell you the truth!

Finally, as always, I tell my parents of my unfortunate plight and as always they are supportive and they say do not worry, God is there! The next day while I was talking to my dad, I have no idea what got into him to say that, but he told me to let him be the patient and let me practice on him. Initially I thought it would be a disaster since my dad is a non-medico and it is kind of difficult to make him understand what I need him to tell me but boy was I wrong, my dad was a PRO at this!! Barring the 1^st case, for the rest of the cases my dad kept rattling out the complaints like a proper standardized patient. I was truly amazed by that! Now, seeing that my dad was getting all compliments from me, my mom feeling jealous joined the bandwagon and from no patients, I had 2 standardized patient to try my skills on :) Thankfully to God’s grace someone replied to my posts in the forums and said they would practice with me and I got more patients to practice on. I also called on my friends in India who readily accepted the challenge of being my patient so also my sister. Trust me this may sound really funny when reading, but when you are in my situation, you will realize Necessity is the mother of Invention! I gradually started picking up on speed and my timings were coming within 8 minutes for the questions and counselling, and I allotted around 7 minutes for errors, physical examination, knocking on the door and other routine stuff. Towards the end, my senior called me again and asked how was my studies going and then she gave me an awesome tip which I feel all of you must try asking your patients if everything is going downhill according to you – ‘Can you tell me what do you think is wrong with you?’ . This may seem like a dumb question but in the exam it was a life saver!! Could never thank her enough for this J

One of my study partners, sent me the link to an awesome video by a lady named Laura Miranda. I do not know who she is or what she is doing right now, but her videos are splendid! The one that I want you to definitely watch is this one which has all the mnemonics that you could use for your exam is THIS video. You can watch her playlist on how she prepared if you have time, but I did not go through it due to time constraints. There is another lady named Karine Darbinyan, who has very painstakingly taken the effort to make a playlist on videos regarding how to type the patient note which I had found to be very useful.  The playlist link is THIS

During my electives I had really sweet residents, fellows and Attendings, who knowing I had my exam, allowed me to tag along with them when they were talking to patients and made me realize that I had it in me to clear the exam. There are numerous to name but would want to say that they are at UC Davis and I pray they are all doing awesome!! This may sound funny but on the last day my Attending, who is a super awesome Nephrologist back in California, even had a mock patient interview with me in front of the residents and fellows. Guess many would back out from such an opportunity, but I grabbed it with both hands and tried my best to interact with her as the patient, using all the knowledge and dialogues I learned while following my residents and fellows. Though initially it was embarrassing, I felt that it was an awesome experience which helped me boost my low confidence that I was ready for the exam. My luck was so good that everyone even told me where I went wrong and what I could do to improve my patient handling skills.

Finally I flew to Los Angeles on the 9^th and stayed with my cousin who is a super chilled out dude! He even told me to relax and that my exam would go fine and I will be awesome. I have no idea somehow my entire family knows I will be awesome except me:O So on Saturday, he and his wife took me to see Hollywood and I got photos clicked with the Minions and had an awesome Saturday, free from tension. The next day I went for Mass, where I prayed fervently to God to pass me somehow and save my sorry ass as he always has. The priest in the church also gave the sermon which kind of echoed my thought to just blindly trust in God and he will do the rest. I was filled with confidence then. That evening I practiced one final time making my cousin the patient, to which he readily agreed and even provided me with the instruments that I could use during examination, thanks to his wife.

Doomsday August 11^th finally arrived. Before going to the exam center, my cousin and his wife prayed for me and then I went to the exam center. I was confident I would do okay types since I knew I just had to do 10 patient encounters decently well to pass the exam. Once I enter the center the receptionist gave me a broad smile and told me to show her my scheduling permit, along with the confirmation letter. I was then sent to a room where the guy checked my stethoscope and then gave me some ID number and I sat down with the rest of the test taker. It went exactly as it is picturized in the video given here 

In my exam center most of the test takers were Americans and some of them looked so confident that I wanted to wet my pants in anxiety. Later I do not know what got into me but I just made small talk with the 2 girls next to me who were sweet enough to talk back and then I felt calm and realized this is just an exam to see whether you can talk to a patient properly and guide him correctly on the next course of action. They do not expect to see a wonder doctor now, they want a kind comforter and I said to myself this is what you are good at, be cool, smile and comfort them. Another word of advice that my senior gave was do not go in as a doctor to boss them around but go in as a friend to comfort. She said if the patient is smiling at you when you close the door, you can be assured you will pass the exam.

When I started my encounter with my patients let me tell you this- My first patient was a disaster! I did not even get to the counselling aspect when my time was up:O My next patient went a little better, but after this my patient encounters started going better than the earlier ones and I started getting into the groove of asking questions and chatting with them. Let me give you an example I had a grandfather as a patient, and I asked on how were his grandchildren which seemed to brighten him up and whenever I did anything painful, I used to try to divert his attention to his grandchildren and finish the maneuver then. That way he was also happy and I got my work done too. When I came out of the exam I felt that I mostly will pass but as it is human nature I started doubting my abilities and started thinking that I would flunk since it started flashing by me the countless mistakes I did. I kept praying fervently to God to pass me and finally when I got my results on the 9^th of October and I saw that I passed I could not stop thanking him enough.

Last but not the least there is a site called Targetusmle.com I think you can try practicing your patient notes here, since when you click on submit, the PN comes to your email ID, which is really awesome. But I would recommend always practicing on the one given in usmle.org site since there are line and word constraints, which are not present in targetusmle.

People who read this post I would only request you to share this blog to your friends to help as many people as possible, since I was helped by my friends and seniors and only wish to help others. Finally my humble request is to please pray that I match this year along with my friends.J