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Old 06-24-2019
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Default Passing the Step 2 CS after failing first Attempt-UPDATE

I want to do something a little bit unusual. I want to write an update to an unpublished update to a post I made 5 years ago. My purpose in writing this isnít to brag or blog about my life but to give hope to people who may have stumbled hard along the way.

Just to get you up to speed: I failed the Step 2 in April 2014. I retook it and passed in July 2014. I wrote my initial post about failing/passing the CS in November 2014. I then wrote an update in May 2016 which I didn't post (I got distracted before hitting the send button). And now, in June 2019, I will post the original, the first update and a new update.

June 24 2019 Update

Medicine has been a weird and unpredictable journey. I think for those of us in the medical profession (or pursuing it), the psychological effect of this unpredictability is magnified by our nature as planners. We have a massive, overarching goal in our lives and we love to make beautifully intricate plans about how to achieve it. And frequently, we get to watch as our carefully constructed plans are mercilessly smashed to pieces. In 2014 my plans for residency (and my relationship) were crushed. I'll let you read my earlier update but things were not looking good. I really wanted to give up and start something new but I stuck with it and ended up matching.

Fast forward 3 years. I am on a train to a new city about to start the fellowship of my dreams at a top program in my sub-specialty. My 2016 girlfriend is now my 2019 fiancťe and she has taken a job in the same city and is waiting for me as I write this. Residency is over now but the rewards of my hard work during those years will stay with me for the rest of my life. Despite an apparent deficit in communication ability, interpersonal skills and medical knowledge according to the CS and CK, I was selected as my programís chief resident (completed during 3rd year) and scored in the top 10% nationally on my PGY3 In-Training Examination.

Nobody gave a crap about CS or CK during the fellowship interview trail and my efforts have reduced those demoralizing failures into obscure data points on an NBME server.

I want to share my story because A) I donít think a single test should define your entire life one way or another. And B) I think we (medical professionals/hopefuls) have a tendency to be very hard on ourselves. Anyone reading this post already got into med school and is automatically "smart" in my book. But what got me through the hard times wasnít some superstar intellect (because I donít have one), it was bleak, stubborn, persistenceóthat and a wise use of the tools I had at my disposal. Donít give up unless you truly donít want it anymore.



May 2nd 2016 Update

It's been over a year and a half since I wrote about about failing and then passing my step 2 CS. November 2014 was a difficult time for me. Sure I had avenged the crippling setback of failing S2CS and had gotten back on track...(at least on paper), but I knew I was in bad shape. Why choose me for your residency program? I'm an IMG (risk), with a few low clerkship scores (red flag), with few US advocates (risk), who failed his first attempt at CS (red flag++). This is before I was hit with two more devastating blows...
Firstly, my Step 2 CS scores did not come out until AFTER sending in my ERAS application. this did two things:
a) I got auto-weeded out of any program that screened for a Step 2 CS fail.
b) I also got auto-weeded out of any program that screened for a lack of a passing Step 2 CS.
Of course as soon as I got my results I stayed up all night sending out "update" emails to my programs but the damage was already done.

Secondly, I got my Step 2 CK results back---229. This was technically an above average score at the time for my residency of interest but much lower than my practice exams, lower than my Step 1 and quite frankly, unimpressive. I was counting on smashing the step 2 CK and informing programs that my red flags were flukes. They were flukes....right? TBH my self-confidence was at an all time low during that admission cycle.
Then rejection letters began pouring in. By December the only interview I had was a courtesy interview from a US Program my school has connections with.

In March my significant other matched to the US, I didn't...
I wasn't even devastated. The outcome of not matching had been so obvious that the NRMP email message of "We are sorry, you did not match to any position" didn't surprise me.
Of course I didn't give up there. I went to SOAP mode and valiantly submitted my SOAP rankings for 3 rounds. And after a stressful week I still hadn't matched.

By the end of the match and SOAP I was just drained. I wanted to think about/do something else. I spent the rest of March and April cruising through my 4th year electives and playing lots of video games. My relationship was on the rocks and we almost called it there. LDR between two 1st year doctors 10k miles apart... You do the math. However, she was very adamant that we could work through it and after getting over some of my self-pity I got to a place where I was willing to give it a try.

"Trying" meant having an endpoint. In this case, it meant reapplying and matching somewhere close to her. I felt like Sisyphus-- if he were to slip, tumble down the mountain slope, have the boulder land on his chest and then watch as the gods decided to double the height of the mountain peak. I couldn't match to the Continental US on the first attempt, now I was supposed to match near my significant other?

No more melodrama.

On March 15th 2016 I did match. I matched to the US, to the same State, to the same city and to a program 8 minutes away from hers.
I found out while I was on call. It was quite a surreal feeling.
Now that the dust has settled and I have a bit of free time I'm going to share a few aspects of my experience. Everyone's application, circumstances and ambitions are different but I hope people can learn from my mistakes and successes to improve your chances of pursuing your personal and professional goals.

Some Stats
-I applied to 180 schools
-Price of application was about 3k
-I had a total of 11 interview invites and was able to go to 8 of them.
-I ranked programs in 6 different states
-I spent about 5K on airfare/travel/lodging
-The programs were generally low-mid tier but most were university-affiliated
-I matched to my top choice but I am fairly confident I could have matched to 2-3 other programs if I ranked them #1. The others were a toss up, 50-50 maybe.

PERSONAL STATEMENT
1) Complete it EARLY
There are about 6 months between Match Day in March and the submission of the next ERAS application in September. Of note, I took a 1 year internship position in the country I was trained which started on July 1st, which gave me only about 4 months before things got heavy. I wasted March and April. Fortunately, I successfully removed my head from my @$$ in May.
The first thing I did in my reapplication effort was completing my new personal statement very early. It was done by June. I completed it over the course of several weeks in the luxury of a coffee shop. It was thoughtful, catchy, well-written and carried none of the linguistic baggage that a frantic, 3-days-before-submission PoS PS might have.

There was nothing wrong with my previous PS. It was completed 2 weeks before ERAS and was adequate but my 2016 PS was better in that it told a story, it acknowledged my shortcomings (something I had shied away from earlier), and played up some new strengths in my application (I will mention these later).

My time frame also allowed me to personalize my PS, which leads me to my next point.

2) Personal Personal Statements
One thing I did differently was target specific programs. I targeted programs near my girlfriend's program, in places I wanted to match and in places I had a higher chance of matching (connections, IMG-friendly, etc.). I would go onto the program's website and find out what they were proud of or what they highlighted and then I would explain in my Personal Statement why this appealed to me. While time-consuming, I think it helped. about 1/3 of the programs I interviewed at were also programs I had sent customized letters.

3) Telling a story
I wrote a more dynamic PS this time around. I was unapologetic about being an IMG and explained how it would inform my future practice.
In explaining my shortcomings I made sure to put a positive spin on it. I addressed the CS head on and then moved on. I think I walked a fine line but succeeded in the end. During my interviews I received positive feedback on my PS from 4 interviewers at different institutions. 2 of them specifically said that they didn't need to talk about my CS step 2 because of how "eloquently" I had discussed it in my PS.

RESEARCH

1) Publications
I was able to publish 2 additional papers (1 author and 1 coauthor). I have a strong research background and it was certainly something that I could use as a strength. For people without a research angle you'll have to find a way to play up your other strengths.

2) Start a project
I started a small (small small small) project as an intern with one of the Attendings at the hospital I was working in. I am interested in research but also realistic about working in a country that doesn't believe in a duty hour cap. Nonetheless, the act of starting the project and doing a literary review gave me some conversation topics later on down the line with my interviewers. It showed that I was indeed interested in research (not saying I was to score points), it spoke to my time management skills, my ambition and my potential at whatever institution I was interviewing at.

***CAVEAT: I would recommend AGAINST playing up your research ambitions at smaller programs that do not offer/encourage research. Why would they take a poor fit for their program? Handle this subject with care.

CLINICAL

1) Med school rotations
My clinical rotations were a mix of pass and high pass. This was from a combination of poor planning and late blooming on my end. However, during my 4th year I was able to get my act together and get honors in my sub internships. This allowed me to show a upward trend in performance as well as secure a juicy LOR from my Attending (co-stamped by the Department Head).

2) Taking a job as an Intern (and not taking a year off while reapplying) gave me a big advantage in clinical skills (and confidence boost). While my foreign training might have been a liability while applying as a medical student, my job as a foreign intern was something I could use as a positive. I was an applicant who succeeded in a foreign, tertiary hospital, in a system that had no cap on work hours, no cap on patient load, 36 hour calls, and all with a sink or swim attitude toward junior doctors and their emotional health. Would I want to spend the rest of my career in that system? Hell No! But it gave me a unique advantage over US-trained students applying out of medical school-- I was a sure thing. Programs knew that I was resilient and that if they accepted me I wouldn't have a break down during my first month, get homesick, freak out with the new responsibility, or get overwhelmed by the workload. What I went through this past year would not be legal in the US lol....

LETTERS OF RECOMMENDATION
All I can say about this is choose them wisely. I had the advantage of doing several clinical rotations in the US this helped me because I had US advocates and LORs from US physicians. If you have an enthusiastic LOR from a non-US doctor don't necessarily veto it. If you can (and he/she is willing) make sure to look through it for spelling mistakes and strange wording. Also realize that US LORs are very inflated with praise. Good = poor/mediocre, Great = slightly above average, Excellent = I liked him/her, Outstanding = great, Best student I have had in 10 years = Best student I have had in 10 years.

ADVOCACY
This is the most important and the least predictable and quantifiable factor in you matching or not matching. If your school/mentors are well connected, can write letters to program directors or make phone calls on your behalf then you have a high chance of getting interviews. If you do not have any advocates you might get overlooked even if your application is very strong. I had some form advocacy connection to about 1/2 of the programs I interviewed at. This really helps.

My girlfriend also worked very hard to speak to her PD and deans. The program I matched at usually doesn't interview applicants who don't pass CS the first time. They made an exception.

That being said, a connection can get your application read and maybe even a courtesy interview but no program is going to make a 3 year commitment to hiring an unqualified applicant or someone who might be a liability later on. You still need to deliver in your application and at the interview.

OTHERS

ERAS Considerations
Get as much as you can uploaded/selected early. Get your LORs in early, Get your PS in early, get your damn photograph in early, get EVERYTHING in early. Apply on time as SOON as ERAS opens. For the past 2 years ERAS has crashed on opening day but that didn't stop me from refreshing the screen every hour trying to hit the submit button. Btw, I submitted my application while on-call.

Interview Considerations
If you are working/studying outside of the US then your interview days will be constrained by your visit time to the US. PLAN YOUR VACATION TIMES OUT, GET THEM APPROVED BY YOUR SCHOOL/WORK and BOOK INTERVIEWS IMMEDIATELY AFTER THE INVITE.

For me it was a nightmare, and I had to juggle the unforgiving vacation policy of my Hospital with trying to cram as many interviews as I could into two 8-day time spans. In my case I was able to schedule 2 interviews early on during my first vacation block, then 6 during my second vacation block. Let me just say that again. I went to 6 interviews in 5 states in 8 days the second time around...then did x3 36 hour calls the following week to make up for the blocked time. It's crazy...but necessary.

Travel Considerations
Make an organized itinerary.
Expect to spend 5K at least
Don't expect airlines to behave so give yourself as much buffer time as possible

Email Updates
I made sure to send thank you emails to everyone I interviewed with (within 24 hours)
I sent tactical updates to the programs I had a higher chance of matching at
I didn't spam them and made sure my updates had content

Final thoughts
This past year wasn't easy at all. I pushed myself to the limits physically, mentally and emotionally. It was a lonely chapter of my life and there were multiple times I came close to just giving up--even if just to end the uncertainty. I learned a lot about myself during my intern year, not all of it good. I am more organized, productive, and efficient...but also a much less patient person and most importantly, medicine hasn't been fun for a while now.

And now I'm getting ready to repeat intern year all over again in a US program. I am definitely excited to start my new life with my girlfriend in the US. I sincerely hope to rediscover what made me want to enter medical school all those years ago...to help people, I think. In writing this, I hope I can do that to some extent.

Feel free to message me if you have any specific questions/comments




Original Post
11/4/2014


Greetings fellow Step 2 CS takers,

I want to just write a little bit on how I managed to pass the step 2 CS after failing it the first time. I've used USMLE-forums as a resource over the past few years and I would like a chance to give back.

Background:
I'm an American IMG.
I had a >240 on my Step 1
English is my 1st language
I failed my first attempt due to low CIS

1st Attempt:
Inadequate preparation time: I studied for my CS for about 2 weeks (but only 1 week intensely). I was very busy with projects and electives, and I let myself fall for the myth that the CS was just an English proficiency test. It wasn't even like I was goofing off, it was just poor overall prioritization. Watch out for that and don't shortchange the CS.
My inadequate prep caused several problems...
My interview wasn't as smooth as it could have been and I lost some time in each encounter, which hurt my CIS indirectly. If you want to be safe memorize a flowchart for each clinical problem and practice it until it's second nature--Abdo pain, dyspareunia, infant seizure etc.
I also cut corners practicing. I was cramming so I would often just jump into the hx/physical (i.e., the hard part) without going through all of the introduction formalities (how may I address you? Are you comfortable? Are the lights too bright? Can I write while we talk? etc). In the actual exam I didn't have a canned introduction which meant I started each encounter a little off balance.

Communication and Interpersonal Skills
I passed the ICE very comfortably but I failed the CIS by a wide margin. It wasn't even close. That really messed with my head. I kept asking myself how I could have bombed the communication/interpersonal skill aspect of the test when I thought I did fine? Was I arrogant or insensitive to the SPs? I certainly didn't think so, connecting with patients had always been one of my strong points. Unfortunately, the CS score report didn't offer any specific feedback regarding where I got dinged so I had to review the 12 encounters from memory.

Based on my fuzzy recollection there were a few things that stood out.
1) my time management wasn't great and I often had to short change the summary/plan at the end. Sometimes the bell would ring mid-sentence.
2) I was inconsistent in asking to do things for the patient (i.e. blanket, dim lights, offer water,)
3) I didn't always directly address the death of a loved one if it felt inappropriate or awkward: Ex: (65 year old patient) "Family Illnesses? Well my father died 20 years ago of a heart attack. Heh, my mother's doing well at 90 though"--- "Wow, 90 that's great!" vs "oh, I'm very sorry to hear about your father".
4) In the heat of the moment I forgot on several occasions to extend the foot rest portion of the bed before examining.


After soul searching and reading more about the test I came to several conclusions (some of which may seem blatantly obvious). These realizations helped me pass the 2nd time and I hope may help others.
1) Ultimately, the CS tests how well you can do the CS, not necessarily how well you can conduct a real clinical encounter.
2) Passing the CIS part means hitting all the items of the checklist, not necessarily demonstrating tact, let alone real CIS.
3) There is no way for them to give you credit for non-verbal cues, empathetic tone, word choice, pauses, clinical judgment etc. If you don't blatantly demonstrate empathy then you don't get checked off.
4) Don't neglect your summary

I think #4 is where I failed. In my training it wasn't as emphasized (which isn't a valid excuse) and I think i subconsciously deprioritized it during the encounters.

These were my mistakes. For you though, figure out what you did wrong, work on it and don't make the same mistake twice.

So after Failing...
Take a deep breath. Go to youtube. Search "You had best yourself". This gem from Full Metal Jacket's Sergeant Hartman will be your mantra for the next several months.

Day 1: You cannot reapply for a testing permit until 24 hours after your score is released. Use that surge of disappointment to your advantage and plan out your next move. Download Check4Change and practice using it. I'll explain C4C later. Make sure you have First AID CS (Which you should already have). I chose to buy a 30 day subscription to CSE videos. Honestly there's a lot of opinions on how useful these videos are. My feeling is yes, they are low production value, yes, the are imperfect but they do demonstrate what a passing performance looks like and that can be very helpful. I made it through about 1/2 of the cases during the 30 days. I also bought a 1 day Kaplan practice CS test. These fill up too so don't wait too long. You'll have to weigh the cost, which is around 1k before travel/lodging but I think it's worth it. I have severe doubts about their 5 day course but the practice test was useful. I took it about 1 week before my real test and it gave me confidence, practice and helped me clear up a few systematic errors in my game.

Day 2: Register for your USMLE token. This can take 1-3 weeks to arrive. Sorry, there's no way to expedite this process. It sucks, especially if you took your 1st attempt late in the game. Just hope that your stuff gets processed quickly.

Week 2-3: You'll get your email confirmation. Don't get excited yet. Spots fill up quickly, and unlike the Step 1/Step2 CK there aren't a million centers to choose from. There are only 5, remember? Most likely (especially if it's approaching Sept) you'll see that all the spots in every center are booked for months. This is life telling you it doesn't care about your plans. The solution is the aforementioned C4C program. Basically it's a program that refreshes a screen looking for any changes (i.e., open slots). Once again, figure out how to use this program. Have a tab open for every city and every potential month. For the next X days work next to your computer, eat next to your computer, sleep next to your computer etc. About 5-6 times a day you'll hear the annoying "Ch-Ch-Changes" ringtone that alerts you to the fact that somebody on this planet has dropped his/her CS reservation and there is a slot open. You have ~5 seconds to decide/confirm this reservation before someone else grabs it. Bellum omnium contra omnes.

Day X--Test Day. I remember being really nervous but much better prepared. My first encounter was mediocre and I ended mid sentence again but for every other encounter I controlled my pacing. I left thinking I failed it again for sure. Thankfully I didn't.

Best of Luck
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  #2  
Old 07-04-2019
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wow what an amazing story.
you hit on every point, I have had an equally unpredictable and merciless journey since falling in love with medicine, all I can say is wow, thanks for the encourage and for taking the time to share.


I do have to mention your comments on csevideo, its been five years since you used it, it amazes me that they are still around and Im impressed they are now top of line, they have 2019 films and an awesome website, I use the videos every now and then to check my clinical skills, my career is finally starting to take off so thanks again your story is a major encouragement.


I especially like your comments on how being in a fellowship no body really cares about your scores, thats incredible the work we put in to pass and in the long run its just one step to a whole journey of steps



all the best
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