THE USMLE

STEP 2 CS
SURVIVAL
GUIDE FOR
MEDICAL
STUDENTS
A HANDBOOK FOR MASTERING &
PASSING THE STEP 2 CS EXAM

by: Paul Ciurysek, MD

Copyright © Dr. Paul Ciurysek, Step2CSPrep.com, & The USMLE Preparation Company, Inc.
Table of Contents

Chapters:

1. Understanding the basic structure of the exam - Page 5

2. Understanding the ICE component of the CS exam - Page 12
3. Understanding the CIS component and how to do well - Page 20
4. How to master the ‘Soft Skills’ - Page 54
5. The use of Mnemonics on the CS exam - Page 75
6. How to master the patient note - Page 92
7. The anatomy of the CS encounter - Page 126
8. Mastering challenging questions & scenarios - Page 152
9. An introduction to the physical exam - Page 176
10. Introduction to the Phone case (Pediatrics case) - Page 187
11. Introduction to the consultation case - Page 198
Final words - Page 201
Introduction

My goal in writing this book is to shed some light on the complexities of the USMLE

Step 2 CS exam that often go unnoticed by medical students. Historically, the Step 2 CS

exam is thought of as the ‘easiest USMLE exam’. This may be true for a number of

students however it has become increasingly more difficult and challenging over the past

several years and this trend will likely continue for the foreseeable future. An exam that

is perceived by most as being the easiest of the USMLE lineup means that a failure may

be looked at with greater concern, which is why it is my goal is to shed some light on the

importance of this exam and ensure that nobody takes it for granted. My hope is that we

can get this book into the hands of each and every medical student who wants to practice

in the United States so that they don’t blindly prepare for the CS exam without first

having a strong understanding of what it really takes to succeed, as well as an

understanding that while perceived as the ‘easy’ USMLE exam, that this isn’t an excuse

to take it for granted and to not invest as much time and energy into ensuring a passing

grade as possible.

This book is the result of helping countless students to understand and apply the

principles needed to succeed on the CS exam. It is also the culmination of my experiences

in helping students to overcome a seemingly endless number of challenges that are faced

when preparing for the CS exam. Although the USMLE Step 2 CS exam is practical in

nature, the importance of first understanding the theory behind the exam cannot be

ignored or understated. If you can develop a rock-solid understanding of the theory, you

can then proceed with your preparation knowing that you have the correct knowledge

and understanding of what it takes to succeed. With strong theoretical knowledge and

sound practical skills, you will have a significant advantage over most other students

who either fail to take the time to master the theoretical aspect of the CS, or who simply
take the challenging nature of the exam for granted altogether. I believe that this book

addresses a major gap in a medical student’s education, which is the development of the

skills necessary to specifically address what is expected of them on the CS exam; a topic

that cannot be addressed with a physical exam and diagnosis class or clinical rotations in

the hospital setting. The CS exam, like any other exam, has specific requirements that

must be met in order to succeed, and those skills are simply not covered in any great

detail during a student’s medical school curriculum. I advise you to move through this

book slowly, to take notes and/or highlight the information that is most important to you,

and to be sure to put the necessary effort into your preparation so that you don’t become

another victim of the CS exam due to lack of preparation.

From my years of experience in helping students prepare for their Step 2 CS exams, I

can confidently say that the majority of students who struggle are only struggling because

they don’t have a strong understanding of exactly what the exam is looking for and/or

they don’t know how to execute the steps needed to satisfy that criteria. This is usually

due to a lack of first recognizing the criteria outlined on the USMLE.org website, which

in turn results in students aimlessly practicing and trying to figure out what it takes to

put together a strong encounter. If you understand the theory behind the CS exam and

you know what they’re looking for, then you have the first piece of the puzzle. From

there, it is important that you can execute in order to satisfy those criteria, which is the

second piece of the puzzle. If you are missing one of these pieces of the puzzle or you

aren’t able to execute each step of the encounter with excellence, then your exam result is

at risk. This book is going to address both of these pieces of the puzzle and will give you

the knowledge and tools needed to execute as needed on exam day in order to put

yourself in the best possible position for success.

 1
Understanding the
Basic Structure
of the CS Exam
One of the biggest misconceptions about the Step 2 CS exam is that it is easy; one

of the common lines heard from students is, “As long as you can speak English, you don’t

have to worry about this exam.” That was the opinion of the CS exam over the last decade

or so, however in recent years it has not only become more challenging, it has slowly seen

an increase in the number of students who are failing. As a practical exam that requires a

specific set of skills in order to properly navigate the encounter, not understanding what

they are looking for could spell disaster, with the worst consequence being a ‘FAIL’

attached to your Step 2 CS exam history. Of course, a failed exam on the road to your

medical Residency isn’t the end of your medical career, but it is another hurdle that you’ll

have to overcome in some way, shape, or form. Explaining your way around a failed Step

1 exam can be done with a rock-solid performance on your next attempt, indicating that

perhaps you just had an ‘off’ day. However, with the CS exam, there is no numerical

value attached to the score report, simply a ‘PASS’ or ‘FAIL’. With only one result or the

other, there’s no way to determine if you barely made a single mistake your first time

around or completely and utterly blew it, which makes judging the results of your CS

exam failure very difficult. On the other hand, if you failed your initial attempt then

passed the second attempt, there’s no way to know if you made an amazing leap in your

competence or if you just squeaked by. Because of this inability to judge your
performance outside of simply a ‘PASS’ or a ‘FAIL’ grade, it is of the utmost importance

that you secure a ‘PASS’ on your first attempt. That isn’t to say that if you’re reading this

book and you have a history of failure that you’re not going to match into a Residency

program, it simply means that if you’re reading this book you need to pass your CS exam

on the next attempt, whether it is your first or fifth.

The goal of this book is quite simple… It is to provide you with a broad overview

of what is expected of you on the exam, as well as step-by-step strategies to implement

into your preparation that should help you meet the USMLE’s standards. I’m fully

confident that this book will give you a significant boost in your understanding of what

it takes to succeed on the USMLE Step 2 CS exam and should give you the confidence

you need to tackle it head-on.

The Basic Structure of the Exam

The CS exam is structured to mimic a ‘real-life’ patient encounter: Interview,

Physical Exam, and Patient Note. The big difference between a real-life encounter and a

Step 2 CS patient encounter is that your CS exam encounters are limited to fifteen

minutes, at which point you must exit the room and begin to work on your patient note.

In reality, if you need thirty minutes to complete an interview and physical exam, you

can take it. On the exam, whether you’ve got a simple or complex case, you need to

squeeze everything into this fifteen-minute timeframe. Because of the time constraints

placed on students during the exam, the entire way by which you approach the exam will

be different. In reality, you walk into the room and move through the encounter at a pace

that works for you and for the patient. On the exam, however, you need a structured

approach so that you can fit everything into the limited time you get with the patient. If
you were to go into the exam without a strategy, hoping that your hospital experience

would give you everything you need to succeed, you’d be putting yourself into a very

difficult position, since your clinical rotations are not designed to properly train you for

the CS exam.

The point I’m trying to make here is quite simple: The USMLE Step 2 CS exam is

not just a demonstration of your ability to interview a patient, do a physical exam, and

create a patient note. It is an exam that requires certain things to be done, and these things

need to be done in a small window of time. Underestimating this exam can make your

life a lot more difficult than it needs to be. It is better to be overprepared and find the

exam to be quite easy, than to be underprepared and find the exam to be difficult or

downright impossible

Not taking the time to properly understand how the exam is structured, what is

expected of you, and how to meet those expectations, can result in an unexpected failure.

Even if you’ve been led to believe that the CS exam is a ‘piece-of-cake’ and that as long

as you speak English you don’t have to worry about it, why take the risk of

underpreparing or not preparing at all, when you could learn and master everything you

need to succeed with just a few short days of effort? Whether you think the exam is going

to be easy or not, it is essential that you assume the worst and put in a tremendous

amount of effort in order to ensure your success. As I just pointed out, it is better to

overprepare and find that the exam is too easy, than to underprepare and encounter an

exam that you’re not quite prepared for. If you were to walk into the CS exam without

being prepared, the odds of failing would rise significantly.

Most students believe that the exam is broken down into 2 main sections: The

History and the Physical exam. On a more detailed level, such as we’ll discuss later in this
book, it is advantageous to break the encounter down into five main sections: The

Doorway, The Entrance, The History, The Physical Exam, and The Closure. We won’t go

into the details of the five main parts of the exam just yet, however it is important that

you start to think of how you’ll break down your encounter so that when we go into the

details of each section, you’re not left wondering what each one encompasses. By

breaking the encounter down into smaller chunks, you can simplify the entire process,

which increases your odds of success.

The Core of the CS Exam

At the core of the CS exam is the ability to demonstrate your competence to

properly care for the patient. When you enter into that room and you begin to interact

with the SP, your job is to show them that you know what you’re doing both from the

medical side of things and from the humanitarian side of things. It isn’t enough to do the

‘perfect interview’, you also need to demonstrate empathy, listening skills, and

communication skills. At the same time, it isn’t enough to be the most likable person

they’ve ever met if you can’t make your way competently through the history and

physical exam.

From the standpoint of what to expect from your exam, you can mentally prepare

yourself by understanding that the majority of your cases will be those types of cases seen

in a family clinic setting. Common clinical complaints such as headaches, stomach aches,

fatigue, and depression provide a small glimpse into the types of cases you should expect

to see on your CS exam. This book is going to arm you with the tools you’ll need in order

to fully understand and navigate your way through the exam, however it is up to you to

ensure that your clinical skills and knowledge are as strong as you can possibly make
them. Later in this book I’ll give you some strategies for helping you to strengthen your

differential diagnosis skills, however diving into the details and putting in the work to

ensure you’ve mastered that information is up to you.

The Pyramid of Success

Just as with anything you hope to learn, excel at, and master in your life, the skills

needed to do well on the CS exam must be built upon a strong foundation of basic

principles. In this book’s introduction, I outlined the importance of understanding each

and every piece of information provided to us on the USMLE website before doing

anything else, and how many students who struggle with their CS preparation do so

because they haven’t taken the time or

effort to first understand what it is that the

USMLE is looking for from them. This

means they haven’t started their

preparation on a solid foundation of

understanding the basics of the exam. In

order to walk into the CS center on exam

day and put your absolute best foot

forward, it is essential that what you take

into that exam is built on a rock-solid

Step 2 CS Pyramid of Success
foundation of understanding exactly what the

USMLE organization provides us with as the foundational principles of the exam, which

are the CIS, ICE, and SEP components. We’ll dive into the specific details about these

exam components in the next few chapters, but first I’d like to introduce you to a very
simple visual that will help you realize what steps are needed in order to succeed on the

exam.

If you take a look at the figure to the right, what you’re looking at is my Step 2 CS

‘Pyramid of Success’, which depicts the pieces of the puzzle and their importance if you

hope to get ready for your exam with the least amount of struggle possible. As with any

structure, the base is extremely important because without a strong base to support

everything else, the whole structure can collapse at any minute. Thus, when you think of

your exam in terms of a structure, realize that the basic foundation that keeps everything

else in place is a solid understanding and mastery of three main categories: 1.

CIS/ICE/SEP skills, 2. Soft-skills, and 3. The Patient Note.

Once you’ve got a solid understanding of exactly what the USMLE is looking for

regarding the CIS, ICE, and SEP components of the exam, you’ll move on to developing

an understanding and then mastering the hard and soft-skills. The ‘hard-skills’ include

skills such as understanding how to break down and structure the encounter for

maximum efficiency, while ‘soft-skills’ include skills such as building rapport and

demonstrating empathy. In later chapters, I’ll be going into great detail about developing

these skills so that you can implement them into your exam preparation. The third

component that builds our solid CS preparation foundation is understanding what it

takes to put together a rock-solid patient note, which is necessary if you hope to get

maximum points on your exam. The patient note is an area of immense struggle for many

medical students, but after you’ve finished reading this book, you’ll have a crystal-clear

understanding of how to create a strong patient note that will get you full points on the

exam. Once you’ve built the solid foundation from the ‘Pyramid of Success’, it is at that

point that your practice will help you to develop habits and muscle memory that will

serve you well on your exam. The most important aspect of practicing for your CS exam
is ensuring that the way by which you’re practicing is as close to perfect as possible; this

is achieved through building the solid foundation that we’ve been discussing. Practice,

along with feedback, will ensure that you are able to improve any areas of weakness and

fine-tune your skills so that come exam day, you’ve identified every issue you’ve had and

have put in the necessary work to correct them.

One last thing before we move onto discussing what it takes to master the I.C.E.

component is having the right mindset when it comes to your CS exam preparation and

patient encounter practice. One of the biggest issues I’ve faced with my students over the

past several years is trying to help students who have ‘practiced for months with their

friends’ is trying to break their bad habits. You see, practice for the sake of practice is

nothing but a waste of time. Instead, I want you to start thinking in terms of ‘perfect

practice’, which means that you practice with intent and purpose; not just for the sake of

going through motions. If you start practicing with a friend or colleague but don’t have

a strong grasp on what the USMLE is actually looking for from you, then you’re

practicing without knowing what you need to be doing. Instead, the goal should be to

learn what you need to do first, grasp that information fully, and then to implement that

information into your practice. If you’ve been practicing by simply going through cases

without knowing exactly what you’re doing, then you need to reframe your approach.

If you practice without any direction in hopes of figuring out what you’re doing

along the way, you’ll only spin your wheels and most likely will not achieve the level of

competence that you otherwise could. If on the other hand you begin to practice with the

specific goal of strengthening and solidifying what you know to be the correct way of

doing things, then all of that practice will help you improve by leaps and bounds with

each patient encounter you do. Think of your practice as a long journey; if you have a

roadmap with a drawn-out route, it is much easier to inch towards your destination with
every passing minute. But if you have a goal of reaching that same destination without a

roadmap or a planned route, it is unlikely that you’ll ever reach your journey’s

destination. Thus, let’s first draw out a map (learn the foundational skills) and devise a

route aimed directly at your goal (implement the foundational principles into your

encounter practice), then once all of that is in place, we’ll start following that roadmap

and get closer and closer to our goal every single day (mastery).
 2
Understanding the I.C.E.
Component of the CS Exam
The easiest, yet most overlooked part of building our Step 2 CS foundation is

looking at everything that the USMLE organization is actually spelling out for us on their

website. They actually tell us, without hesitation, what can be done to gain points on the

I.C.E. and C.I.S. components of the exam, yet so many students simply overlook this

important information. Additionally, they also tell us what will cause us to lose points,

which is another piece of the puzzle that can help us to put the right pieces in place when

building our foundational knowledge.

In order to correctly build your foundation, it is essential that we start from the

very beginning and leave no stone unturned. Let’ dive in and take a look at the I.C.E.

component of the exam, starting at the beginning with an understanding of exactly what

the I.C.E. component is and what the USMLE is trying to accomplish with this component

of the exam.

The I.C.E. component, which we’ll refer to moving forward simply as the ‘ICE’,

stands for ‘Integrated Clinical Encounter’, and represents the student’s data-gathering

and data-interpretation skills. The ultimate goal of this component of the exam is to

ensure that you have the skills required to gather the necessary information and to use

that information to make accurate diagnoses. This means you have the necessary skills
that allow you to properly gather data from the standardized patient (SP), to extract the

correct and necessary information based on physical exam findings, and to properly and

accurately transfer all of that information onto a well-planned and well-thought-out

patient note. Strong ICE skills require that you can sift through the sea of information

that you might encounter during your time with the patient and determine what is

relevant and what is just fluff. The caliber of your questions and your ability to turn the

learned information into strong diagnoses will ultimately determine how high your ICE

score will be. While the skills necessary to ensure a strong ICE score will be broken down

and covered in great detail in a later chapter, having a strong understanding of exactly

what they’re looking for will make your ability to navigate the ICE that much easier.

One of the more challenging aspects of the ICE is that you not only have to perform

well for the SP, but you’ll also have to impress the Physician who is tasked with grading

your patient note. Thus, you have two people to impress if you want to get maximum

points on your ICE component. To put it as broadly as possible, the ICE requires that you

do the following:

v Gather the necessary information when questioning the SP

v Gather the necessary information from the physical exam

v Use the gathered information to create a strong patient note

Of course, that is just the start, and as you’ll see shortly, there are many small things

that you need to do in order to meet those goals. We’ll dive into those details shortly so

that you’ve got a simple-to-follow plan of action.

As I mentioned earlier, one of the biggest mistakes that students make when getting

ready to prepare for the CS exam is failing to thoroughly review the information put out
by the USMLE organization and understanding what will increase and decrease their ICE

and CIS scores. The following lists of information can be gathered by visiting the

USMLE.org website, and I suggest that you take a thorough look through everything on

their website since they could change something at any time.

According to the USMLE.org website, all of the following will help to increase your ICE

score:

v Using correct medical terminology

v Providing detailed documentation of pertinent history & physical exam findings

v Listing only diagnoses supported by the history findings

v Listing diagnoses in correct order of likelihood

v Support differential diagnoses with pertinent findings obtained from the history

and physical exam

According to the USMLE.org website, all of the following will lead to a decrease in our

ICE score:

v Using inexact, non-medical terminology

v Listing improbable diagnoses without supporting evidence

v Listing appropriate diagnoses without supporting evidence

v Listing diagnoses without regard for order of likelihood

v Listing multiple diagnoses in one line

v Listing a third differential diagnosis when there’s only two likely

v Listing overly expensive or aggressive workups

 Based on these do’s and don’ts given to us by the USMLE organization, we can

process that information and put together some fairly easy-to-follow rules that will help

us gather as many points as possible on the ICE component of the exam. When explaining

to my students what they should be doing in order to do well on the ICE portion of the

exam, I typically boil it down to the following rules:

v Ask great and relevant questions

v Ask good follow-up questions when the SP says something

v Perform focused and correct physical exam maneuvers that will gather the most

important information for the case

v Develop an ability to understand and interpret the information being provided to

you by the SP

v Learn to adjust your course based on feedback provided during the encounter

v Learn which physical exams should be done based on the case being presented

v Ensure you can outline common and likely differentials based on the given

information

v Ensure that you are able to and do provide strong and sufficient support for all

given differential diagnoses

At this point, you may be wondering how you’re supposed to gather sufficient data

to ensure that you get all of your points, and more importantly all of the relevant

information for each particular case. The details of data-gathering will be explored a bit

later in the book, but for now let me give you a few basic strategies that will put you in

the right mindset as we move forward:

 I. Develop a solid and repeatable strategy for attacking each case

II. Develop a strategy to ensure that you won’t miss any relevant questions

(this is where mnemonics will come into play)

III. Develop a strategy for quickly and easily finding needed information once

you sit down to write your patient note

I)

Developing a solid and repeatable strategy for attacking each case simply means

having a plan-of-attack that you will implement with each and every case. You see, one

of the biggest mistakes that students make when preparing for the CS exam is trying to

take a different approach with each individual case, when in fact they can all be

approached with the exact same strategy. Consider the fact that there are well over one-

hundred potential cases that you could be given on exam day. If you were to try and

develop a different strategy for each case, you’d never accomplish the task, simply

because it is too much to try and accomplish. Instead, and we’ll cover this shortly, you

want to approach each and every case in the exact same way, which is with a structured

approach that ensures you are implementing the correct behaviors that will get you as

many CIS and ICE points as possible. Luckily, the exam is very similar throughout,

meaning that each case, while different in chief complaint, is testing the same skills. Thus,

if we can create, learn, and master a strategy and implement it with each and every case,

we’ll essentially make ourselves fail-proof; this all assumes that you take what I’m going

to give you throughout this book and dedicate yourself to mastering and implementing

it.
II)

Developing a strategy to ensure that you never miss a single question may sound

challenging and nearly impossible, however it is actually quite simple. Mnemonics,

which are easy-to-use memory aids, are going to be your best friend when taking the CS

exam. I’m sure some of you reading this will despise the suggestion of using mnemonics

and feel as though it is not the correct way to do things, and that using mnemonics is

unnatural.

But here’s the thing… I’m not suggesting that you use mnemonics for your real-

life patients or that you should be using them for the rest of your career, I’m simply

recommending that you use this wonderful and highly effective tool to ensure you

maximize your chances of passing the CS exam. If you’ve got the ability to use tools

throughout your CS exam that will make you more efficient, more accurate, and overall

just plain better, why wouldn’t you want to use them? Many students feel that using

mnemonics will make them look unnatural, however when used correctly, this won’t be

the case at all. I’ll give you a strategy in a later chapter that will teach you how to properly

use mnemonics so well, that not only will the SP not realize you’re using them, but that

will actually make you look much smoother and competent throughout the entire history

component of your exam. If I was to offer you a superpower that ensured you didn’t

forget to ask a single question on your CS exam, that ensured your interview was as

smooth as butter and saved you time, would you want access to that superpower? I’m

sure you would. If you said no, you’re crazy! Well, mnemonics are that superpower and

in a later chapter I’m going to outline exactly how to use them to your benefit. I guarantee

that I will convince you that for the sake of the CS exam, you need to adopt the use of

mnemonics.
III)

This strategy is designed to ensure that when you sit down to write your patient

note, you aren’t left scanning your interview notes several times over trying to isolate the

important information you need for your patient note. That, my friend, is the easiest way

to run out of time and submit an incomplete patient note. If you don’t complete your

patient note, you should consider that entire case to be a failure because without a

completed patient note, you really haven’t finished the job. While I will be explaining this

strategy in more detail in a later chapter, for now I can tell you that the easiest way to

ensure you can quickly and easily identify any relevant information needed for your

differential diagnosis support is to circle that support as it comes up throughout the

patient interview. If you take one second to circle something that you can see as being

strong support for your suspected differentials, you would eliminate the need to scan the

interview notes as you’re trying to type your patient note. Imagine if you have three

differential diagnoses and you need three pieces of support for each one. If you were to

scan your interview note every time you wanted to find a piece of support, that would

be nine times, and if it took only five seconds each time you scanned the note to find what

you were looking for, that adds up to forty-five seconds! That’s almost a full minute

wasted by not using this strategy. As I said, I’ll be going into some more detail about

exactly how to implement this strategy in a later chapter, but for now you’ve at least got

an idea of what it’s all about and that will prime you for diving into the details a bit later.

These three strategies, when correctly put into practice during each patient

encounter, will improve your ability to gather information quickly and accurately, thus

ensuring you are able to maximize your I.C.E. points on the exam.
 3
Understanding the C.I.S.
Component of the CS Exam
Several years ago, when a student walked into our facility for their Live Step 2 CS

Preparation Program with a failure already on their record, nine times out of ten it was

due to a failed CIS component. Over the last ten years or so, it seemed like the majority

of students were failing as a result of some behavioral issue that lowered their CIS scores

enough that they didn’t pass the exam. As of late, things have taken a complete 180° turn

and the most common causes of failure I’m seeing is on the ICE component, mainly due

to either poor in-room interview skills or poor patient notes (or both). There are however

still a large number of students who fail as a result of the CIS component. The nice thing

about the CIS is that it revolves around behaviors, which can be changed more easily than

a lack of clinical knowledge or poor typing skills, which are often the issues with the ICE

component. Despite all of this, the CIS still makes up a large chunk of your CS exam

points, and a failure to understand and know how to implement the right skills towards

gaining the maximum number of CIS points can have devastating consequences for your

CS exam result.

What is the C.I.S?

This C.I.S. component of the Step 2 CS exam stands for ‘Communication &

Interpersonal Skills’, and while it is relatively simple to teach the skills needed to excel in

the CIS, it is by no means an easy feat to master those skills. This is akin to trying to lose
weight: In theory, it is very simple to lose weight; simply expend more calories than you

take in and you should lose weight. In theory it’s quite simple, but as the vast majority of

people know, it is easier said than done. Well, the same goes for the CIS component of

the CS exam. The skills are relatively simple and straightforward to learn, as they are

mainly just behavioral skills, but actually mastering them and understanding how and

when to integrate and implement everything can take time and requires a lot of effort in

order to master. Don’t worry though, if you read every word in this book, not only will

you know exactly what needs to be done in order to do well on the CIS component, but

you’ll have a simple-to-follow outline that will help you to constantly improve those

skills. One of the things that makes the CIS component a bit challenging is that your

points don’t come from any one individual action, but rather from the entire group of

small actions that are taken throughout the encounter. This means that while you might

enter the room with a big smile on your face and give the SP a firm handshake, if you

make a major error during the encounter such as hurt the patient while performing a

maneuver, it could erase all of the other actions that were taken. So, not only do you have

to ensure that some major boxes are checked, but you have to ensure that as a whole, you

did everything well. This is a challenge, but it is one that I’m going to help you tackle

head-on in the next few chapters.

One major tip I’m going to give you now though that will get you thinking about

the CIS portion of the exam is to ‘Always aim to make the SP feel as comfortable as possible’

throughout the encounter. An SP who feels at ease with you throughout the encounter

and who feels as though you’ve got their best interest at heart is more likely to overlook

minor errors here and there as oppose to an SP who doesn’t feel comfortable throughout

the encounter. So please, keep that major tip in mind as you move forward in this book.

One strategy that I’ve shared with my students over the years that makes this a rather

easy task to accomplish is to simply pretend that the SP is a family member. When you
walk into that room, treat the person you’re looking at as though it’s your mom, dad,

brother, sister, grandma or grandpa that you’re trying to help. If you can put yourself in

that frame of mind, you should have no trouble making the SP feel as comfortable as

possible.

What makes up the CIS?

This CIS, which you now know stands for Communication & Interpersonal Skills, is made

up of a few key components, including:

v Fostering the relationship

v Gathering information (similar, yet different from the ICE component)

v Providing information

v Helping the patient make decisions about the next steps

v Supporting emotions

What does all of this mean? Well, we’ll dive into the nitty gritty details shortly, for

now though it is important that you understand what the CIS expects of you so that

moving forward you have an understanding of each and every component that needs to

be mastered in order to maximize your CIS points on the exam.

The way that the CIS component of your exam gets graded is a bit of a mystery to

most students and medical schools, mainly because the USMLE organization doesn’t

provide any specifics about their methods for gauging a student’s performance. Over the

years however we’ve been able to determine that, simply put, the SP has a checklist that

they go through following an encounter with a student and likely check either a ‘yes’ or
‘no’ box pertaining to a laundry list of tasks or behaviors that should have been

demonstrated throughout the encounter. The goal that I strive for when teaching my

students is to have them perform sufficiently to get ninety-five percent or more of those

boxes checked, with of course one-hundred percent being the ideal goal. You’ll also find

out shortly that because this is a subjective exam, that there are certain ways by which

your behavior throughout the exam may provide you with a boost based solely on getting

the benefit of the doubt in certain circumstances. For example, it is obviously not possible

for someone to remember whether a student performed all one-hundred (that is an

arbitrary number) of the items on the checklist, especially since many of those items came

and went in a matter of seconds. Thus, often times the overall feel of the encounter can

give an SP a push to either that ‘yes’ or ‘no’ checkmark. Please keep in mind that this

information is derived from my own personal experiences teaching hundreds and

hundreds of students over the last decade.

Over the years, no matter how many times I’ve gone through a certain case, with each

student there’s always one or two things that I’ll fail to recall. Often times, I’ll make my

guess based on the overall quality of the encounter; this is both the drawback and benefit

of a subjective exam – you can take control if you know what you’re doing, and you can

completely blow it if you don’t. Often times, if a student missed a good chunk of what

needed to be done during the encounter, had I forgotten whether a specific item on that

list was done or not, I’d usually assume that it was not. On the other hand, a student who

walked into the room and knocked my socks off from the very beginning was often times

given the benefit of the doubt of having done something, even if I could not recall.

Remember, this isn’t information coming from the USMLE organization itself, however

because all humans can forget something that happened when being exposed to a vast

number of stimuli within such a short period of time, it makes sense that if it could

happen during your CS exam training, that it could likely happen inside the exam center
on test day. The sooner you realize that this test is one where understanding human

nature and human behavior is as important as knowing how to perform a physical exam,

the faster you’ll catapult yourself into a position to succeed.

How do I get my CIS points?

Many students don’t quite understand what they need to do in order to maximize

their CIS points, and simply assume that it includes smiling and helping them sit down

or stand up during the encounter, but there really is a lot more to it than that. In fact, it is

best not to think about the CIS component as doing ‘certain things’ throughout the

encounter, but to think of it as taking a certain frame of mind. Allow me to explain what

I mean by having a certain ‘frame of mind’. You see, there are of course certain things

that you want to do throughout the exam that will boost your overall CIS score, and we’ll

talk about those shortly, but the CIS component of the exam is of a behavioral component

more than anything; and this behavior should be one of kindness. Kindness means many

things to different people, but my version of kindness means you treat the SP/patient

exactly how you’d like them to treat you if the roles were reversed; that approach should

actually make it much easier to gain more CIS points throughout the encounter. If you go

into the room with the mindset that you’re going to come out having been as kind as

possible, taken the time to get to know the patient a little bit, smiled and maybe even

shared a laugh or two, and demonstrated empathy when it was warranted, you’re going

to do very well on the CIS component. It is highly unlikely that if you’re friendly, kind,

and empathetic, that the person to whom you’re expressing these behaviors will dislike

you. Think back to times in your life when you encountered someone who smiled, was

pleasant, asked you how your day was going, and did it all with complete sincerity; did

you come away from those experiences in a good mood or a bad mood? I’d be willing to
bet that those behaviors improved your mood. In fact, I’m willing to bet that any time

throughout your life when you weren’t in the greatest of moods, that coming across

someone who demonstrated the qualities we’re discussing here always improved your

mood, even if just a tiny bit. Thus, before we dive into the details of those specific actions

you need to take to excel in the CIS component, keep in mind that the most important

part of success here has to do with the mindset and attitude that you bring into the exam

room.

Now, although your demeanor is ultimately the most important part of the CIS,

there are certain things that I teach my students to do throughout the exam that I like to

call the ‘CIS Pillars’, meaning they are actions that will stand out in the SP’s mind, and

that will ultimately put your CIS performance over the top. So, what I’m going to do is

give you a breakdown of each ‘CIS Pillar’ and give you a brief explanation so that you

come away from this chapter knowing exactly what you need to be doing during the

encounter to perfectly complement your all-star demeanor.

C.I.S Pillar #1 – A Masterful Entrance

As the old saying goes: ‘You’ll never get a second chance to make a great first

impression’, and when your medical career is riding on your performance during this

exam, you better be sure that you know exactly how to make a great first impression.

Without getting too much into the psychology of likability, it really is important that you

understand a few important pieces of information since so much of your exam does

depend on being liked by the SP.

 I remember one student I had a few years back who had the absolute worst

entrance I’ve ever seen, and I strongly believe that had he not corrected that prior to his

exam, he wouldn’t have passed the CIS component of the exam. As you’ll come to learn

in a later chapter, the way by which you enter the room is with three knocks on the door,

followed by your entrance. The vast majority of students walk through the door and at

the very least face the SP as they close the door behind them. This student, who I’ll refer

to as John (not his real name), had a very unorthodox way of entering the room that for

some reason really rubbed me the wrong way. And it wasn’t just me, I received similar

feedback from the other students who were observing John’s cases, saying it seemed very

awkward and instantly made him seem like he had a bad attitude. What John was doing

is he was entering the room, but as he entered the room he was staring at the floor, walked

in, turned his back to me (the SP), closed the door, then grabbed a chair and sat down, all

without so much as a glance in my direction. Now, while he didn’t do anything that was

rude or disrespectful towards me, it didn’t make me feel good. And that’s what you really

have to understand, is that the SP cannot control their feelings towards you, so you need

to do everything in your control to ensure that they don’t subconsciously dislike you, for

whatever reason. The crazy thing is that John was actually fun and pleasant to be around,

but without being able to show that to the SP, it didn’t matter. You absolutely, positively

must master the entrance so that the SP can see you for the awesome person you truly

are.

A group of experiments were performed by some Princeton Psychologists aimed

at determining how long it took before a stranger formed an impression of you the first

time you met. Now, when I ask students about this, the common answer is within five to

ten seconds, give or take a few seconds. However, what the Princeton Psychologists

determined was that an opinion about a stranger is formed in only one-tenth of a second;

yes, 1/10 of a second. Not surprisingly, the judgements that we place upon a stranger are
mainly based on facial appearance. Now, I know that you might be thinking that they’re

judging you based on attractiveness, but that isn’t necessarily true. What you are being

judged on is the appearance of your face and facial features, all of which can be altered

by the mood you’re walking into that room with. For example, if you’re nervous and

intimidated by the SP, you’re likely going to show it on your face, which may mean

you’re looking way too serious and not friendly. On the other hand, if you walk into the

room with a big smile, eyes wide and making direct eye contact with the SP, the first

impression you make will be much more positive. And this is why it is of the utmost

importance that as soon as you open that door, you’ve got a genuine smile on your face

and you’re making eye contact with the SP. It is extremely difficult to be greeted by eye

contact and a big smile without instantly feeling good. Think back to a time when you

were walking down the street or in a store and for some reason or another, a stranger

passed you and smiled; I’ve had this happen before and for some reason or another, it

brightens your day and makes you feel nice. That is the goal we’re trying to achieve with

a bright smile and eye contact at the very onset of the encounter. This CIS Pillar will start

your encounter off in the absolute best way possible.

And here’s the best part…

You’re going to encounter SP’s who are told to act mean, rude or angry, and that

isn’t likely to change with a smile. However, remember that we’re dealing with real

people during this encounter, and even though they’re acting a certain way, that bright

smile and eye contact will make them feel better, both about you and themselves in that

moment. If you can override the SP’s acting skills by creating a genuine feeling of warmth

and happiness based solely on the way you enter the room, you’re setting yourself up for

success.
 So, you want to knock on the door three times, wait one to two seconds or until

you hear the SP call you in, smile nicely and open the door, ensuring that your eyes

immediately lock with those of the SP. One of the keys to a genuine smile is to smile with

your eyes. It is often times quite simple to know when someone is faking a smile or not;

the eyes give it away. Someone who is giving a genuine smiling will also have creases

around their eyes, indicating a full-face smile. Someone who is faking a smile will smile

only with their mouth, and even though you may not have thought about this or noticed

it before, you can tell when someone is faking a smile. Thus, I want you to mentally take

yourself to a place that makes you happy before you walk through the door, as this will

ensure that your smile is genuine. Once you’ve made eye contact, say ‘hello’ using the

SP’s name, which you’ll get from the doorway information. Walk in, gently close (never

slam) the door behind you, then approach the SP for a handshake. Some students don’t

like to shake the SP’s hand, or anybody’s hand for that matter, however it is another one

of those things that will help you to build a better connection with the SP, which is only

going to work in your favor throughout the encounter. Think back to a time in the past

when you’ve met someone for the first time and they didn’t reach out to shake your hand.

Although it may not have had any negative meaning tied to it or the person wasn’t trying

to be rude, it still may have come across as odd or rude from your perspective. Now, keep

in mind that these aren’t thoughts or feelings shared by everyone, however in case one

or more of your SP’s does perceive a lack of handshake to be a sign of rudeness, let’s

eliminate any possibility of this perception by shaking their hands with that nice bright

smile and locked-in eye contact.

The next step is to transition from the ‘entrance’ into the ‘interview’. Now, I’ve

mentioned how the CIS is composed of many small behaviors done correctly throughout

the encounter, and you’re going to start to see what I mean by this right about now.
C.I.S Pillar #2 – A Solid Start to the Interview

Before you dive into the interview questions, there’s a couple of important things

I want you to do. Once you’ve finished shaking hands, ask the SP if they’re comfortable

in the room and if there’s anything that you can do to make them more comfortable. The

vast majority of the time, they won’t need you to do anything, however if the patient is

there for a bad back or a headache, this opportunity to dim the lights or help them to lay

down may get you some bonus CIS points. Even if there’s nothing that you can do for

them, just the fact that you asked it should get you more CIS points. Once you’ve

completed that question, it is ideal that you ask the SP if they mind that you take a seat

and begin to ask your questions. Now, a quick aside: There are some students who prefer

to stand during the interview, there are some who prefer to sit, but I always recommend

that students sit for a couple of, what I believe, are very valid reasons. The first is to bring

you closer to eye level with the SP, which will make them more comfortable on a

subconscious level. If you’re towering over them by standing, it could potentially make

the SP feel uneasy, so you want to avoid that possibility at all costs. Second, we

recommend that you sit because the day is going to be quite long, and any chance you

can take to sit and rest your legs and back is one you should take. It might also be much

easier to take notes, ask questions, and make consistent eye contact from a seated position

versus a standing one. That rounds out the strategy used to ease your way into the actual

interview.

One of the more important criteria set out by the USMLE organization is to ask

open-ended questions, which are questions that prompt the SP to speak openly, as

opposed to a closed-ended question that can be answered with one or two words. An

open-ended question may sound something like this: “Mr. Smith, please tell me a bit
more about the headache that brought you into the office today”. This open-ended

question is going to get the SP talking about their problem, and most importantly get you

the points you need by asking this type of question. I always recommend that the first

question a student asks their SP is open-ended. Not only does it get the ball-rolling, but

because the very first question you asked was open-ended, it will likely stand out more

than if you were to limit the open-ended questions to the middle of the encounter. Once

you’ve asked the opening open-ended question, it is important that you quickly take

control of the line of questioning so that you can properly manage your time throughout

the encounter, which is of course very limited. The best way to do this is to quickly start

asking questions based on your case-specific mnemonics, which we’ll discuss a bit later.

I suggest that you throw in a couple more open-ended questions here and there, ideally

near the beginning of each different section (HPI, Past Medical History, Social History).

An open-ended question to start each of those sections followed by mnemonic-specific

questions will ensure that you get your CIS points while still staying in control and using

your time wisely.

C.I.S Pillar #3 – Giving Thanks & Asking Permission

The next part of the encounter is the Physical Exam, which brings me to a couple

very important points that you need to keep in mind. The first is the extreme importance

of washing your hands prior to beginning the physical exam. The hand-washing step is

of the utmost importance on the CS exam and it is imperative that you never forget to do

it. I’m going to give you a couple pointers later about how to use the time when you’re

washing your hands to either gather your thoughts or build rapport with your SP. The

second important point brings me to Pillar #3, which is the importance of asking

permission. Asking permission, which simply means asking the SP if they mind that you
begin doing something, will create a sense of teamwork, instead of making all the

decisions on your own without getting their input. There’s nothing tricky to

understanding and implementing this Pillar, however it is important that you do know

how and when to ask permission. So, every single time you’re about to do something

different, such as change the line of questioning or start examining a different system, it

is ideal to ask permission. Here are a few examples of when to ask permission as well as

sample ways by which I recommend you do so:

v You’ve finished asking the HPI questions and you need to start the review of

systems questions. A sample way to ask permission would be: “Mr. Smith,

thank you for answering those questions. Now I’d like to change directions and

ask you a few basic head-to-toe questions, would that be ok with you?”

v You’ve finished asking the PMH questions and you need to ask the social

history questions. A sample way to ask permission would be: “Mr. Smith,

thank you for answering those questions. If it’s ok with you, I’d like to now ask

you a few questions about your social history, which will give me a better look

at how you’re living on a day-by-day basis, would it be ok with you if I

proceed?”

v You’ve finished the history questions and need to move onto the physical exam.

A sample way to ask permission would be: “Mr. Smith, thank you for

answering all of my questions, you’ve been very helpful. Now I’d like to move

on to the physical exam portion of the encounter. Would you mind if I did a

quick exam of your heart, lungs, and abdomen?”

 v You’ve finished examining the lungs and would like to move onto the

abdominal exam. A sample way to ask permission would be: “Mr. Smith, thank

you for allowing me to listen to your lungs. If it’s alright with you I’d like to

move on and begin the abdominal exam. Would that be ok with you?”

Those examples should give you a very good idea of how and when you should

be asking permission. And you probably also realized in those examples that I’m always

thanking the SP for allowing me to either ask them a certain line of questions or examine

a particular system. I suggest that you make it a habit to always thank the SP when

they’ve allowed you to ask them questions or perform exams, as it comes across as polite

behavior and will likely be met with plenty of thanks. Now, just to ensure that you know

exactly when you should be giving thanks and asking permission, below I’ve outlined

when to ask permission and when to give thanks throughout the entire encounter. Be

sure to review this often, especially as you begin your CS preparation so that you can

implement it into your practice and build that important muscle memory into your

encounters.

When to ask permission:

Ask permission at the start of each of the following: HPI, ROS, PMH, Social History,

Physical Exam, and at the beginning of each new system to be examined.

When to thank the SP:

Thank the SP for allowing you to ask questions following each of the following: HPI,

ROS, PMH, Social history.

Thank the SP for allowing you to perform a physical exam following completion of a

system. For example, if you have to examine the heart, lungs, and abdomen, you want to

thank them for allowing you to examine the heart after completion of the cardiovascular

exam, for allowing you to examine the lungs after completion of the pulmonary exam,

and for allowing you to examine the abdomen after completion of the abdominal exam.

When you’ve examined the final system, instead of thanking them for allowing you to

specifically examine that system, thank them for allowing you to perform the physical

exam as a whole. That would sound something like this: “Mr. Smith, thank you for

allowing me to perform the physical exam”.

C.I.S Pillar #4 – A Solid Closure

If there’s one single area that I’ve seen students struggle with the most, even some

of the best students, it’s with the closure. For some reason, students struggle to wrap up

the encounter’s findings in a smooth and concise manner. The great thing about the

closure is that you can develop a strategy and implement it every single time to ensure

efficiency. The strategy that I recommend for putting together a solid closure each and

every time is with the use of a script. Having a script that you can turn to for every single

encounter’s closure will not only allow you to get the points you need by wrapping up

quickly and touching on the most important points, but it will allow you to create

simplicity because you’ll be doing the same thing for each and every case. With a closure

script, you can practice over and over, taking you to a point where you don’t even have

to think about how to close, and that will eliminate one major hurdle that many students

encounter in the exam. Many students get to the end of the encounter and because they

haven’t prepared properly, end up hurting their overall scores because they took too long

to close, which either causes them to run out of time or causes them to speak excessively
and without total coherence. Thus, it is highly recommended that you adopt a closure

script, practice and master it, and use it for each and every case during the exam.

One of the greatest benefits of using a closure script, aside from efficiency and

simplicity, is that you know how long it will take to close the encounter. For example, if

you have no repeatable plan for closing your encounter, you could end up taking two to

three minutes, or more, just to wrap up the case. If you’re finishing up your physical exam

and have only one-minute left, how are you going to get through everything in just one

minute? The answer is that you likely won’t, and that will be devastating to your overall

score. On the other hand, if you’ve practiced your closure forty to fifty times during your

CS preparation, you might know that on average it takes you ninety seconds to close the

encounter. If you are running tight on time, knowing exactly how long it will take you to

close will allow you to adjust your approach or speed up in order to finish in time. It will

give you some peace of mind knowing that if you’ve only got two minutes left in the

encounter that your ninety second closure can be done with a few seconds to spare.

Ultimately, the script gives you more control over your fate than if you were to simply

‘wing it’ and hope for the best. And this actually brings up a very important point that I

constantly tell students, which is that in order to do well on the CS exam, one of your

goals should be to have systems in place that allow you to control the direction of the

encounter and manage your time correctly. If you’ve practiced for the exam but you don’t

have a time management strategy or strategies that will help you get out of tricky

situations, then you’re not adequately prepared. Throughout the remainder of this book

I’m going to share with you each and every strategy that I’ve developed over the years

to help students effectively and efficiently navigate their way through the CS exam. Most

students believe that if they have good clinical knowledge, can ask the interview

questions, and can perform a physical exam, that they’ve got all they need to succeed,

however because this is an actual exam, you need to have strategies and systems in place
to put those skills to good use. Just like with the Step 1 or Step 2 CK exams, you shouldn’t

just sit down and start answering questions, you need a strategy for how to properly

tackle multiple choice questions, how to manage your time, when to take breaks, and

what to do if you get stuck on a question that is eating up a bunch of your time. The time

management and strategic aspects of the exam are equally as important as actually

knowing the material.

C.I.S Pillar #5 – Building Rapport

Pillars 1-4 have given us a very important look at certain things that need to be

done from the moment you knock on the door until you walk out of the room. There are

however additional ‘C.I.S. Pillars’ that you need to know in order to ensure maximum

points are gained on the CIS portion of your exam, and we’re going to dive into the last

two pillars right now. Pillar #5, which is arguably the most important pillar from the

standpoint of being liked throughout the exam, is the ability to build rapport with the SP.

Now, in case you’re not aware of rapport-building, it is simply the ability to find a

similarity between you and the SP and to use it to build a bridge that connects you both

on a more personal level. In a later chapter titled ‘Mastering the Soft Skills’, we’ll take a

deep dive into rapport building and I’ll give you some great strategies for helping you

build rapport with each and every SP, even if it isn’t one of your strengths. If you’re not

a naturally outgoing person, building rapport could seem like a huge task. However, with

a little bit of guidance and practice, you can implement the same strategy with each SP

and it will allow you to easily build that rapport.

C.I.S Pillar #6 – Empathy & Sympathy

The final C.I.S. Pillar is empathy and sympathy. Empathy, simply put, is the ability

to put yourself in someone else’s shoes and experience something from their perspective.

Throughout your entire CS exam, it will be of the utmost importance that you can

effectively demonstrate empathy. Sympathy on the other hand is the ability to feel sorry

for someone else’s misfortunes, despite never having experienced the same misfortune

yourself. As an example, let’s say you’ve got a patient struggling with feelings of sadness

and you come to learn that recently their beloved dog died and they’re having a hard

time coping with the loss. If you’ve ever had a dog that you loved and who died, you can

understand exactly what the patient is feeling because you’ve lived the same scenario,

and as a result you can be empathetic to their situation. If on the other hand you’ve never

owned a pet and you cannot understand what they’re going through, you can still let it

be known that you feel sorry for them, which means you’re being sympathetic. Thus, it

is very important that you understand the difference between empathy and sympathy so

that you don’t accidentally tell the patient ‘I know how you feel’, when in fact you haven’t

lived the same scenario. If you were to accidentally say something along those lines and

the SP asks you how you coped with it, you could find yourself in a very uncomfortable

predicament. So be aware of the differences between empathy and sympathy so that you

don’t accidentally put yourself into a very awkward situation.

As with Pillar #5 (Building Rapport), we’re going to dive into how to develop your

empathy and sympathy skills in a later chapter. I’m not only going to help you

understand how to better demonstrate these skills, but I’ll show you how to strategically

insert them into each encounter so that if they are something you struggle with, you’ll at

least have a plan in place that can help you to get the ball rolling.
The Ultimate Goals of the C.I.S

We’ve just covered a lot of information and it may seem as though there is a lot to

unpack and master, and there is, but I’m going to break it all down and make it much

easier to handle as we move through the book. On the surface, the CS looks like there are

a million little things that you need to know and know how to do well if you want to

pass, but there are tips and strategies that you can put into place that will actually make

this exam an enjoyable process to prepare for and hopefully an enjoyable exam to take.

Doing well in the CIS component of the exam using everything we’ve discussed

so far is ultimately designed to accomplish a few main goals, including:

v Making the patient feel as comfortable with you as possible

v Making a connection with the patient (get them to like you)

v Making the encounter feel like a team effort

v Allowing the SP to talk/share

v Demonstrate that you truly do care about them

v Demonstrate that you’ll be a good physician & that you can competently

care for a patient

In looking at these ultimate goals and thinking back to everything we’ve discussed

thus far, I think you’ll start to see that as long as we can master those Pillars and

implement them throughout the encounter, that we will indeed be able to achieve all of

these goals.
 Now, while these Pillars will provide you with a look at the big actions you need

to take in order to maximize your CIS points on the exam, there are still important skills

that need to be mastered in order to capitalize on the integration of each one of those

pillars. One of these skills is understanding and being able to ‘Foster the Relationship’.

So, let’s take a look at what the USMLE means when they say ‘Foster the Relationship’,

and what they outline as ways by which we can achieve this goal. Then I’ll give you the

strategies that I give my students to ensure that they are able to properly ‘Foster the

Relationship’.

Fostering the Relationship

According to the USMLE.org website, fostering the relationship can be achieved by doing

the following:

v Listening attentively

v Showing interest in the patient as a person

v Demonstrating caring, genuineness, concern, and respect

Having that information is all well-and-good, but unless you know how to actually

do these things in the context of the exam, it doesn’t really give you anything of value.

What I want to do to help you is take that information and try to break it down into

actionable steps that you can use right away to instantly improve your ability to foster

the relationship with your patient.

From my perspective, we can take the three main points outlined by the

USMLE.org website a step further by adding in the following:

 v Demonstrating the right demeanor and tone throughout the encounter

Let’s break down the three steps outlined by the USMLE.org website, as well as

the additional step that I’ve listed here so that you can see and get a better understanding

for how to implement them into the exam, as well as see just how simple it can be to foster

the relationship.

Fostering the Relationship Goal #1: Listening Attentively

Listening attentively can be simply achieved by ensuring that when the SP is

speaking, that you are clearly listening. The easiest way to achieve this goal is by looking

at them as they speak. One of the biggest mistakes you can make when the SP is speaking

is to look down at your notes for an extended period of time. Although you may be taking

notes, you’re still not making that very important eye contact that lets them know that

you’re listening. A great tip I can give you to limit any damage done by looking down

and taking notes here and there is by telling the SP at the very beginning of the interview

that you’re going to be taking notes as the two of you talk. That sets up the expectation

that you are in fact listening, but that on occasion you may be jotting something down in

your notes as they continue to talk. You see, you don’t have to be perfect at all times, and

in reality, it would not be very efficient to make eye contact as the SP talks, then to look

down and takes notes as they sit in silence. Instead, you need to develop your ability to

hear them speak, look down and write a note quickly, then to regain eye contact as soon

as you can. Thus, if you’re going to take a note, you should be looking down, otherwise

it seems a bit awkward that you’re writing on your pad but not looking down to see what

or where you’re writing (trust me, this happens). As soon as you finish writing your note,

look back up at the SP as they continue to speak. You’ll get into a rhythm of looking up
at the SP and looking down at your note in a back-and-forth manner; as long as you make

eye contact on a regular basis, you will get your points for this component.

Fostering the Relationship Goal #2: Showing Interest in the Patient as a Person

I truly believe that one of the easiest ways to get someone to like you is for you to

show interest in their lives. There’s a very famous book written by Dale Carnegie titled

‘How to Win Friends and Influence People’. A major point that he makes in this book is

that by showing interest in someone else’s life and asking questions so that they’ll speak

about themselves is one of the best ways to seem more likable. If you talk about yourself

all the time, you may be seen as less likable by others. If you ask questions and get people

talking about themselves, not only will they be delighted to do so, but you will also be

seen as friendlier and more likable. And this is one of the main points that the USMLE

says should be done in order to ‘Foster the Relationship’: Show an interest in the patient

as a person.

On the CS exam, you can easily accomplish this goal by asking the SP a few

questions that will get them excited and talking about themselves. Here are a few great

questions that you can put into your arsenal and use with each and every SP. Remember,

you’re only seeing the SP one time, each new case will be a new SP, so you can use the

same strategies and questions over and over.

v Tell me a little bit about your children

v Do you enjoy your work?

v How many grandkids do you have and what are their names?

v What do you like to do for fun in your spare time?

v Where did you grow up?

 v Have your seen the latest movie XYZ?

Asking each SP you come across one or two of these types of questions will likely

get them talking right away, and the more fun and light the topic, the better. Never get

too personal with your questions unless it is in the context of the history and relevant to

the case. For the sake of showing interest in the patient, fun questions that they’ll enjoy

talking about will be the absolute best way to show interest and also build a bond

between you and the SP. I strongly suggest that you choose a couple of ‘go to’ questions

that you’ll ask over and over in the exam. Be sure that you have questions that can be

asked based on the patient’s age and gender. You don’t want to ask a seventeen-year-old

male if he has any kids or grandkids, while at the same time you don’t want to ask an

eighty-year-old female if she’s seen the latest Marvel action movie. I’d suggest that you

ask the older individuals about kids or grandkids, and the younger individuals about

their friends and hobbies. By sticking with those age-appropriate and fun topics, you’re

not likely going to run into any issues.

One of the big questions that students ask is when they should actually be

implementing these types of rapport-building questions, and I have to say that this is an

excellent question. You don’t want to stop in the middle of the HPI and ask the SP what

they like to do for fun because not only is it not the right time, it is a very awkward

approach. Instead, one of my favorite strategies is to take the twenty to thirty seconds it

takes to wash your hands and ask one of these questions. Not only will this eliminate any

awkward silence that may occur as you wash your hands, but that is dead time anyway

that you’re not asking history questions or performing the physical exam, so it is the ideal

free time to get to know the patient on a deeper level. Immediately after asking the patient

if you can begin the physical exam and wash your hands, as you head over to the sink,

ask them one of these rapport-building questions and then let them speak. Based on their
responses, you should ask one or two follow-ups aimed at building the connection

between you and the SP even further. Now, there’s no need to break into a two-minute

back-and-forth conversation, so don’t get carried away if they say something that

interests you; keep it short but make sure that the goal of showing interest in them is

achieved.

Fostering the Relationship Goal #3: Demonstrate Caring, Genuineness, Concern &

Respect

I think that one of the major flaws with this goal’s outline is that it says

‘demonstrate’, which often times makes students try and act like they care, act like they’re

being genuine, act as though they’re concerned, and act like they respect the SP, when in

fact these characteristics do not come across sincerely if they’re simply being acted out.

Instead, and this goes back to something I touched on previously with your frame of

mind, you should walk into that room and should respect, care for, and show concern for

the SP as though they’re a member of your family. I understand that it can be difficult to

fake these feelings, especially if they don’t come to you naturally, but I truly believe that

if you take that frame of mind that each of the SP’s you’re dealing with on exam day are

extended family members, that you might be able to be more caring, have more concern,

be more respectful and genuine than you ever thought possible.

Now, I wish that I could actually write out ways by which you could be caring,

genuine, concerned and respectful, but unfortunately those behaviors are better learned

by observing than by being explained in a book. I will however give you a few pointers

that I think will come across throughout the encounter and demonstrate some of these

requirements:
 v Address the SP as ‘Mr.’, ‘Ms.’, ‘Mrs.’, etc: Even a young person should be

addressed like this; only call them by their first name if they ask you to do so.

v Avoid causing any pain during the physical exam: If a painful area must be

examined, let the patient know what you’re doing and have them stop you if

the pain becomes too much for them.

v Say phrases such as “I’m so sorry to hear that” or “I’m so sorry you’re feeling

that way”: These types of phrases can be said if an SP tells you they’re in pain,

suffering, or going through something difficult in their lives and it

demonstrates your concern and care.

v Explain everything you’re doing throughout the exam: This shows the SP that

you respect them; many students will not do this, and they will likely lose

points as a result.

v Say the words ‘please’ and ‘thank you’ often: There are no two words or

phrases that demonstrate respect more than ‘please’ and ‘thank you’. Say them

often and reap the rewards.

Fostering the Relationship Goal #4: Demonstrate the Right Demeanor & Tone

Now we’re moving into my own personal strategies for nurturing and improving

the relationship you build with the SP, the first of which is demonstrating the right

demeanor. What is meant by ‘demeanor’ is simply your outward behavior; which means

how you behave throughout the encounter. Now, you might be thinking that you’ll just

put on a happy face and always be upbeat, however it is important that you read each
SP’s body language and demeanor in order to determine whether they should be met

with upbeat happiness or a more mellow approach. If the SP is there because of severe

depression, you being loud and joyful is not likely going to be appreciated, while at the

opposite end of the spectrum if your patient is there to refill their medication and is happy

and upbeat, you shouldn’t be laidback and mellow, you should match their level of

energy. It is of the utmost importance that you try and match the SP’s demeanor as closely

as possible, as this will create a greater level of comfort felt from the perspective of the

SP. Remember, you want to behave in a way that makes each SP feel as though you care

and respect them, and the way by which you behave in the encounter needs to be

carefully thought out in order to achieve this goal.

My recommendation for mimicking the SP’s demeanor is to gauge how they react

when you walk in the room smiling, and how they carry themselves within the first thirty

to sixty seconds of the encounter. Within that short amount of time, you should be able

to get a very good idea of the kind of energy they’re bringing to the room and based on

that you can adjust your own demeanor to match theirs. Now, be careful, I’m not

suggesting that if the patient is depressed that you should act depressed, I’m simply

suggesting that you try and mirror their level of energy, within reason. Thus, if the patient

is depressed or very laid back, act a bit more laid back, but don’t act depressed. If the

patient is happy, put on your smile and mimic their level of happiness. The reason why

this is so important is because of a term known as ‘mirroring’, which is a psychological

tool that can create the feeling of a ‘bond’ or ‘connection’ between two individuals, but

one that is felt at a subconscious level. It has probably happened to you many times

throughout your life without even knowing it. Someone you meet behaves similarly to

you and that brings with it a certain level of comfort that puts you at ease. You instantly

feel a connection with this stranger and you don’t quite know why, but it’s there. That’s

exactly what you want to create in those fifteen minutes spent with the SP. And because
mirroring works instantly, if you are aware of it and implement it right away, you might

find that creating a connection between yourself and the SP becomes a little bit easier.

This is a technique that takes a little bit of awareness and practice, however, so I’d suggest

that you try it out next time you’re spending time with someone one-on-one and see if

your mirroring technique yields a more joyous and/or positive experience for you and

your counterpart. Try mirroring the way they sit, the hand gestures that they use, the

tone of their voice, etc.

Showing an Ability to Help the SP Make Decisions

Showing an ability to help the SP make decisions is another important aspect of

the CIS portion of your exam and it is therefore important that we discuss exactly what

this means and how to do it. Essentially what this is referring to is helping the patient

make decisions about what should happen next in the context of their care. For example,

if we’ve just done our closure and outlined what we believe our top three differentials

might be, it is our job to let them know what needs to be done as the next step. The vast

majority of the time this means telling the SP what tests need to be performed and why,

then ensuring that they are in agreement with your decisions. The best way to do this is

to of course give the SP a reason why you need to do all of these tests, which is covered

in the closure script we’ll go over a bit later in the book.

Not only is it our job to explain what tests we would like to perform and why, but

we must ensure that everything being explained to the patient is fully understood and

that the SP is willing to proceed with your decisions. Often times, when you do your

closure and outline the possible differentials and the workups exams you’d like to

perform, the SP will have a question or two, so if this happens to you, realize that it is
perfectly normal and to be expected. Your job is to directly answer the SP’s questions and

ensure that they understand everything you’ve told them completely and without any

doubts. This can be easily achieved, as you will come to see with our closure script, by

confirming with the SP that they understand and have no further questions or need no

further clarification. Once you’ve explained everything to the SP, answered their

questions, and confirmed that they don’t have any more follow-ups, you’ve done your

job.

Demonstrating Information-Providing Skills

The next important CIS skill you’ll need to master for your exam is the ability to

properly relay information to the SP, which is often times easier said than done. One of

the big issues I see students making when they first begin their Step 2 CS preparation is

falling into the trap of assuming that everybody understands basic medical jargon, when

in fact they simply do not. It’s easy to forget just how much medical language you’ve

picked up over the first two to three years of your medical school education. So much in

fact that we often don’t even remember if we knew some of the terminology before we

began medical school or not; I know I’ve fallen victim to this many times. Nonetheless, it

is extremely important that for the sake of your CS exam that you tone down the use of

medical terminology and instead aim to explain everything in the most basic language

possible; this is what we refer to as ‘layman’s terms’. This simply means that you should

be explaining things and relaying information to the SP in language that even a ten-year-

old would understand. Instead of saying ‘encephalitis’, you’d say ‘swelling of the brain’.

Instead of ‘palpitations’, you would say ‘rapid or racing heartbeat’. If you use medical

terminology instead of speaking in layman’s terms, one of two things will happen. Either

the SP will tell you that they don’t understand the word you’ve used and ask for a simpler
explanation, or worse they won’t say anything and simply dock you a point for not

speaking in a way that they can understand.

Another important aspect of demonstrating your information-providing skills is

to speak clearly and in an understandable manner. When you speak, you want to be

looking directly at the patient and you want to be as clear as possible. Do your best to

avoid mumbling or speaking too softly, as this will cause the SP to ask you to repeat the

question, which is not something you want to happen during the encounter. If you find

that the SP is asking you to repeat yourself once or twice, take that to mean that you aren’t

speaking clearly enough and that you need to try harder to be clear when you speak. One

of the simplest ways to ensure that the SP hears and understands what you’ve said is to

ask them. A simple ‘Do you understand?’ or ‘Does that make sense?’ following an

important statement will help you to ensure that they do in fact understand.

Another important aspect of the information-providing skills portion of your CS

exam is matching the amount of information provided to the patient’s needs, preferences,

and abilities. What this means is that you need to gauge how much interest the patient

has in the information you’re providing, as well as their capacity to understand it. If

you’ve got a seventy-nine-year-old male who is presenting with the signs and symptoms

of Alzheimer’s disease, it is highly unlikely that he’ll understand a majority of what

you’re trying to explain, and in this case you would realize this and keep the information

you relay to the bare necessities. If on the other hand you’ve got a nineteen-year-old

female who tells you that she’s planning on going to medical school and is demonstrating

an interest in her case, you can share even more information; the goal is to match the

depth of information that you share with the patient’s level of interest and ability to fully

understand.
 The final piece of this information-providing skills puzzle is taking an extra step

to ensure that everything you’ve communicated to the patient is fully understood. You

should ensure that the SP understands what you’ve said by asking them if they need you

to clarify anything. They may ask you to clarify something that was said during the

encounter. If they do ask for clarification, try to explain that piece of information in as

simple a way as possible, then once you’ve completed the explanation ask them if they

fully understand. Hopefully they say ‘yes’, but if they still seem lost, try rephrasing it

another way, perhaps even simpler this time around. Always re-confirm that they

understand when you’ve had to explain something more than once. Once they confirm

their understanding, thank them and move on with the case.

Demonstrating an Ability to Support Emotions

You will have to deal with a variety of different patient emotions throughout your

CS exam, that’s just a reality that you are going to have to accept and deal with. It is for

this reason that your CS preparation should include a variety of different practice cases

that includes the SP acting out a variety of different feelings and emotions. You should

have your practice partner display every single emotion you can think of as many times

as possible. The more opportunities you give yourself to deal with a severely depressed

patient, an anxious patient, an angry patient, or a manic patient, the more familiar you

will be with them and the easier it will be for you to deal with them on the exam.

What you want to achieve throughout your CS exam preparation and practice is

the ability to reflexively deal with a variety of different situations and scenarios. As an

example, what would happen if the first time you ever encountered an angry patient was
during the actual CS exam? My guess is that you’d likely deal with it in a less-than-perfect

way, simply because we never do our best when facing a challenge for the very first time,

especially one that catches us by surprise. Think back to any challenging situation you’ve

been faced with in your life and then think about how you dealt with the same situation

on all subsequent occasions. You may have made mistakes the first time, or perhaps

simply didn’t react in the best way, but after having been exposed you were able to learn

from it and get better each time thereafter. This is the exact same thing that you want to

prepare for on your CS exam. Expose yourself to as many different cases and different

types of patients as you can while practicing, and it will help you learn how to best deal

with them and hopefully prepare you for the worst that might happen on exam day.

Ideally, you’ll prepare yourself so well that the patients you have to deal with on the

actual exam don’t seem so bad in comparison. This is why it is so beneficial to practice

for the CS exam with multiple people and why students who prepare with me and my

program for the CS exam typically don’t find anything to be overly challenging on exam

day, since I go above and beyond to present them with challenging patients and scenarios

that make anything else they’d face seem less intimidating by comparison.

Often times we won’t quite understand why a patient is experiencing or

demonstrating certain types of emotions, and in this case your best bet is to simply ask

them to share with you what and how they’re feeling. For example, if you walk into the

room and you encounter a hostile and angry patient, this could be very challenging to

deal with if you aren’t sure what the right approach to take may be. In this instance and

in any similar type of situation, your best bet is to address it head-on. Saying something

such as ‘Mr. Smith, I can see that you’re angry, would you mind telling me why?’, can be

a very effective way to approach an angry patient. What will most likely happen as a

result of your direct questioning will be an answer, which then gives you the opportunity

to address it and move forward. Any time you’re faced with an emotional SP, the best
thing you can do is ask them why they’re experiencing those emotions, try to be

empathetic to their reasoning, and try to talk them through it if possible. If the emotions

they’re experiencing are due to something relating to you or your staff, you want to

apologize and let the SP know that they now have your full attention. If on the other hand

their emotions are due to something outside of your office, ask them if they’d like to tell

you about it and take a minute or two to listen. There’s a strong chance that the CS exam

will throw you a few of these challenging scenarios, and while we can never know with

one-hundred-percent certainty what to expect, most of the strategies that I’m sharing

with you in this book will at least give you the ability to deal with anything that might

come up, even if it is something that was never expected. In a later chapter, we’re going

to discuss exactly how to deal with challenging questions and challenging scenarios. I’ll

provide you with strategies and tools that will ensure you are well-equipped to deal with

a wide variety of possible issues that may come up on your exam.

Taking Situation-Specific Actions

Situation-specific actions are an important part of gaining the maximum amount

of CIS points on your exam and refers simply to your ability to recognize that the SP

needs something from you and delivering the need. For example, a patient may come in

to see you because of a headache, and they may mention that they are sensitive to light.

In this scenario, it is your job to recognize this and offer to dim or turn off the lights.

Another classic example is a patient who comes in with back pain and who is struggling

to sit upright on the table. For this patient, the right thing to do is ask them if they’d like

to lay down in order to be more comfortable. Another example is the coughing patient,

for whom you should offer a glass of water and tissue. There are a number of potential

situations like this that could arise, and it is your job to be aware of everything happening
in that room and address anything that comes up. The key to ensuring that something

doesn’t slip by you is to be on the lookout for absolutely anything displayed by the patient

that strays from normal. For example, if the patient seems to be sniffling, you should ask

them if they’ve got a cold and if they’d like a tissue. Perhaps it is the actual person who’s

suffering from a cold, not an act by the SP. In this instance, your recognition of this fact

will surely help your case.

The single best piece of advice that I can offer you as it relates to this issue is to

walk into each room in a state of hyperawareness and to question the SP about anything

that could be a test of your CIS skills, such as the examples I’ve just listed for you.

Performing Painless Maneuvers

If you want to fail your exam, cause pain to the SP during the physical exam;

there’s nothing that will kill a great performance faster than eliciting unnecessary pain. If

you want to pass your exam, you must learn how to perform a physical exam that is void

of pain and discomfort. Of course, this is easier said than done, but I’m going to give you

a couple very easy and practical solutions for dealing with a patient who needs a physical

exam yet is in a bit of pain.

First, I need to clarify what I mean by ‘Don’t cause pain to the SP’. You are

undoubtedly going to have to perform a physical exam on a patient who’s in pain, that is

just a given considering the nature of the exam. You don’t however want to cause any

unnecessary pain, which is quite different from simply causing pain. For example, if

you’ve got a thirty-two-year-old female with severe right lower quadrant pain, you will

have to examine the area. You will of course do so very gingerly, but in this instance, it is
expected that you will examine the area in question; to avoid examining the area in pain

altogether would result in a significant loss of points on the exam. The difference between

eliciting pain during the exam versus eliciting unnecessary pain during the exam comes

down to how you explain your intentions and how cautious you are about the painful

area. If you tell the patient ahead of time that you have to perform a physical exam but

that you understand exactly where the pain is coming from and that you’re going to

approach the area with extreme caution, it sets the expectation that you have to examine

the area but that you’ll be very careful. Additionally, you should start as far away as

possible from the area in pain and slowly make your way towards it. Letting the patient

know that if the pain becomes too much that they can ask you to stop is also an excellent

idea, as this allows the patient to determine how much or how little they can tolerate.

Now, the opposite of that approach would be one whereby you essentially avoided

telling the patient what you planned to do, didn’t start as far away from the painful area

as possible, and didn’t have them give you feedback along the way. Without the patient

knowing exactly what you were planning and without giving them permission to

provide feedback along the way, you’re likely to cause undue stress and anxiety, and it

is likely to lead to the patient feeling as though you weren’t truly trying to avoid hurting

them during the physical exam. Even if your intention was not to elicit pain, leaving the

SP out of the physical exam decision-making process can make for an uncomfortable

scenario. If they don’t know what you’re doing and you suddenly move to the painful

area, it could cause them to be surprised and that alone could negatively contribute to

their perception of the pain.

You might have noticed that what I’m suggesting you do in this scenario is include

the patient in the decision-making process, share with them as much information up-

front as you possibly can, ask permission to begin the exam, and fill them in on absolutely

everything you’re doing. This is essentially pulling all of the CIS skills that this chapter
has covered and incorporating them into a very important situation. You can see how it

becomes essential that you understand and become capable of implementing all of the

basics into the exam in order to avoid losing points; both during a regular situation and

a more challenging situation such as this.

 4
Mastering the
Soft Skills
We’ve touched on the soft skills already in our CIS chapter, however because a

mastery of the ‘soft skills’ is so important, I believe that they deserve their own chapter

and a deeper dive into what they are, why they’re so important, and how to master them.

If you’ve skipped ahead to this chapter, I’d recommend that you go back and read

everything prior to this one, as it starts with the most basic fundamentals that you should

have a firm grasp on before diving into some of the specifics. If you’re planning on

reading forward, you might be wondering exactly what are these ‘soft skills’? Well, the

soft skills are those skills that you need to master that are going to be weaved throughout

your encounters as necessary in order to create a well-rounded experience for the SP.

Hard skills on the other hand are those skills that form the framework for the encounter,

which we will discuss in our chapter titled ‘Anatomy of the Encounter’. Hard skills

ensure that you know exactly what needs to be done in order to put together a proper

and cohesive encounter, whereas the soft skills are going to be used whenever you deem

them to be necessary. Thus, our soft skills include things like Building Rapport,

demonstrating Sympathy & Empathy, being Sincere and Genuine, and using an

appropriate Tone throughout the encounter. These soft skills are all extremely simple to

grasp and understand, however they aren’t always easy to master. We’ve touched on all
of these soft skills before, and if you feel as though you have a solid grasp on them

already, then this chapter is going to take things a step further. If you’re not quite sure

where all of these soft skills fit in, check back with Chapter 3 and be sure that you

understand how important they are for your overall CIS score.

Now, it’s always important that we know exactly why we do certain things,

because without a strong reason for why we do something, it’s often times easy to

overlook doing them in the first place. So, here are some of the most important reasons

why we need to master and implement our soft skills:

v It increases our bond & connection with the SP

v It allows the SP to drop their guard and have an easier time opening up

during the interview

v It makes us appear more ‘human’ and less robotic

v It allows us to become more likable

Now let’s get started with a detailed look at each one of our soft skills. We’ll take

a look at each skill, go over why each one is so important, and discuss a variety of ways

by which we can master and implement each one of these skills.

Building Rapport

If you fail to build rapport with your patient, you will struggle to receive top CIS

marks. Rapport is the ability to find a commonality between yourself and the SP and use

it to build a connection. Its official definition is, “a close and harmonious relationship in

which people or groups concerned understand each other’s feelings or ideas and
communicate well”. That definition is a bit much for our needs, but it gives you an idea

of the true definition. Since you only have fifteen minutes to complete the entire

encounter, you don’t have too much time to waste when trying to build rapport, which

is why you want to get started as soon as you walk into the room. In Chapter 3 we

discussed the exact what by which you should enter the room (smile, make eye contact,

firm handshake, ensure they are comfortable, ask to be seated). While that isn’t exactly a

rapport-building exercise, it does set the stage for easier rapport-building because it gets

the encounter started off on the right foot. It is much easier to build rapport with your SP

when they’re happy that you walked through the door and not another miserable medical

student forcing themselves to get through the day. Now, you might be wondering how

on earth you’re supposed to build rapport when the first five minutes or so of the

encounter is spent asking questions about the reason for their visit, and that is a great

question. The reason why you’re wondering is because it is a challenge, and the majority

of students who aren’t well-prepared for their CS exam don’t know how to accomplish

this task; lucky for you that you found this book.

Now, the way by which you’re going to start building rapport is going to depend

on one simple factor, which is whether or not the SP gives you any personal information

prior to getting to the social history. The social history, which is the last group of

questions that you’ll ask before starting your physical exam (we’ll go into the structure

of your questions later), is where you will be able to build rapport, simply because this is

where you ask questions such as whether they’re married, single, going to school, have a

job, have kids, have grandkids, have hobbies, etc. Let’s say that you’re asking questions

throughout the HPI, review of systems, and past medical history, and the SP doesn’t stray

at all from simply answering the questions you’ve asked. That’s not a problem, it simply

means that we’re going to wait until the social history to start building some serious

rapport. However, let’s say that you’ve just sat down and now is the time when you’re
going to start questioning your SP, and you’ve started with a solid open-ended question:

“Mr. Smith, why don’t you tell me what brings you in today”. Mr. Smith then proceeds

to tell you that he was at work when all of a sudden, he started to experience nausea,

vomiting, and diarrhea. Assuming Mr. Smith isn’t deathly ill (he shouldn’t be), you could

say something along the following lines: “Mr. Smith, that sounds terrible, I’m so sorry

that you’re experiencing these symptoms. If you don’t mind me asking, where do you

work?”. In this instance, Mr. Smith gave you an opening by saying his symptoms began

while at work. Had he not mentioned his work specifically, it would have been quite odd

for you to ask him where he works at that particular moment. However, he gave you the

opportunity and it is your job to take it and to start planting some rapport-building seeds.

Ideally, Mr. Smith tells you where he works and then you ask him a couple of friendly

follow-up questions for the sake of showing interest in his personal life. A couple of great

follow-up questions to this scenario may include the following:

Ø How long have you been working at XYZ, Mr. Smith?

Ø Do you like working at XYZ, Mr. Smith?

Ø Which department do you work in at XYZ, Mr. Smith?

You see, all of these follow-up questions are most likely irrelevant to Mr. Smith’s

signs and symptoms, however they are important because it shows Mr. Smith that you’re

interested in more than just giving him a diagnosis and moving onto the next patient.

Now, the reason why this is so powerful for the sake of the CS exam is that most of the

other students in your test group are not likely to sneak in these little rapport-building

questions here and there, which means that when you ask them, not only are you building

rapport, but you’re standing out to the SP amongst all of the other test-takers. How

powerful do you think it will be if you’re the only medical student who took an interest

in the specific department that Mr. Smith works in? How powerful do you think it will
be when you’re the only student who asks Mr. Smith how many years he’s been at his

current job and if he enjoys doing it or not?

I’m not guaranteeing that you’ll be the only student to ask these types of questions on

exam day, but I do guarantee that if you are capable of doing this with each and every SP

you see that day, that you will be putting your best rapport-building efforts to work,

which will most likely payoff for you in the end. What if Mr. Smith didn’t mention

anything about work when you asked him that opening question? If he didn’t, that’s not

a problem, because we have the social history which will give us plenty of opportunities

to build some rapport. The social history component of our history, which we’ll talk about

more when we get to the mnemonics and patient note creation portion of the book,

consists of the following questions:

Ø Weight changes (increased or decreased)

Ø Appetite changes (increased or decreased)

Ø Dietary habits/changes

Ø Smoking history

Ø Alcohol history

Ø Drug history

Ø Travel history

Ø Occupational history

Ø Exercise habits

Ø Stress levels

While you don’t want to build rapport about your favorite beer with the SP, you do

have a few excellent opportunities for rapport-building within those social history

questions. For example, if the SP mentions that they vacationed anywhere recently, you
could ask some follow-up questions and find out if they enjoyed themselves, if they’d

recommend it as a travel destination, and what would be some fun activities to partake

in if you decided to go. Traveling is a passion for many people, so if the SP mentions

travel, you’ve got a fantastic opportunity to build rapport. Occupational history is of

course another great way to build rapport, as you learned previously with Mr. Smith. If

work didn’t come up before this question in the social history, you should take a few

seconds to ask them about their work on a deeper level than just ‘what do you do for

work?’. Exercise habits can also be a great way to connect with your SP. For example,

many people these days participate in a variety of different exercise trends, including

Yoga, Pilates, and CrossFit. If they bring something up that you’re either doing or

possibly interested in doing, ask a couple questions. Heck, even if you have no desire to

start practicing Yoga but the SP tells you that they love Yoga, ask a couple questions and

show some interest.

As you can see, there are more than enough opportunities within the social history

questions alone for you to build some rapport with the SP. If you’re finishing up your

history and you haven’t had at least twenty to thirty seconds of back-and-forth banter

about something that builds a connection between you and the SP, then you didn’t

maximize your time in the question-asking portion of the encounter.

Building rapport with another person makes you more likable in their eyes. When

you’re liked by someone, you’re easier to trust, which makes it easier to open up and give

you more information. At the core of this approach is the ability to get the SP to trust you

and open up to you with as much information as possible with the least amount of effort

on your part. If I trust you one-hundred-percent, I’m more likely going to tell you

everything you need to know as opposed to waiting for you to ask me every single

possible question; this is just human nature. The term ‘pulling teeth’, which means having
to ask an excessive number of questions in order to get the information we want, is exactly

what we want to avoid on this exam. Luckily for us, this is a human-based exam, and

while that does carry with it some flaws, such as subjectivity, at the same time it means

we can hack into common human behaviors and use them to our advantage. Now please

keep in mind that I’m not suggesting that we’re trying to take advantage of the SP in any

way, shape, or form. I’m simply suggesting that each person shares some similar traits,

such as the desire to be treated with respect and dignity, and we can use this to our

advantage, which we’ll do by employing the ‘soft skills’ that we’re talking about right

now. Not only do these soft skills work exceptionally well throughout your CS exam, but

they are also applicable to your everyday life. Having trouble getting through to

someone? Ask them about their day; get them to talk to you about themselves and watch

them open up. Remember what I said about the Dale Carnegie book ‘How to Win Friends

and Influence People’; people love to talk about themselves, and it is in our best interest

to use this knowledge to help us help others. The better you become at extracting

information from other people, the better you become at being able to help them,

especially if medicine is your chosen field.

 I’m sure that the previous examples have given you a good idea of how you can

start building rapport, but I want to once again remind you that good rapport-building

starts the moment you enter into the room. The sooner you can show the SP that you’re

friendly and likable, the sooner you can attempt to build rapport and actually get the SP

to willingly participate. Don’t forget that a strong first impression is the most powerful

tool you have in your CS arsenal. Since you only get fifteen minutes with the SP, you

need to ensure that you’re perceived the right way from the very beginning. Remember

all of the following recommendations to ensure that you make the best possible first

impression:

v Smile when you enter the room (Remember: smiling people are perceived

as friendlier; it is more difficult to be angry when someone smiles at you)

v Make eye contact with the SP

v Give the SP a firm handshake (Remember: people with firm handshakes

appear to be more trustworthy)

v Ask the SP if they’re comfortable and/or if you can do anything to make

them more comfortable (Remember: this demonstrates that you are a caring

individual within the first ten seconds of the encounter)

v Ask permission to sit down (Remember: asking the SP for permission

throughout the encounter is a sign of respect)

Building Rapport – The Hand-Washing Technique

Between the last question of your history and the first step of the physical exam, it

is essential that you wash your hands. Now, what the majority of students do during this

brief twenty to thirty second window is remain quiet. Many students use this time to

think about what physical exams they’re about to perform or try to figure out what the

diagnosis may be, however I’ll show you a way to have that figured out before you wash

your hands. What this leaves us with is a short window of opportunity whereby we can

continue to build rapport with the SP. In order to get the absolute most out of this brief

yet important period of time, I suggest that you develop two or three ‘go to’ questions

that you can call upon immediately to ask the SP. Essentially what we’re going to do here

is ask the SP a question that is designed to build rapport, however the goal is to make this

seem casual and off-the-cusp. While I do recommend that you create your own standard

questions that you can ask the SP, here are a couple of my favorites, as they always lead

to interesting dialogue:

v So where are you from originally, Mr. Smith?

v What do you like to do for fun, Mr. Smith?

v What do you have planned for the rest of your day, Mr. Smith?

If you learned during the history questions that the SP has children or

grandchildren, or has traveled someone recently, you could ask a question based on that

information, but taking it a step further:

v If they have grandchildren: Do you have anything fun planned with your

grandkids this weekend Mr. Smith?

 v If they have children: Do you have anything fun planned with your kids

this weekend Mr. Smith?

v If you learned that they recently traveled somewhere: What was your

favorite part about visiting {insert location} Mr. Smith?

Remember, you don’t have a long time to waste here, but by asking a simple

question such as the ones above, you will fill that otherwise quiet time spent washing

your hands with a highly valuable rapport-building question. Remember to have a few

standard questions prepared ahead of time so that you don’t have to worry about coming

up with something on the spot.

Empathy & Sympathy

We’ve touched on both empathy and sympathy in a previous chapter, but now I’d

like to re-visit this and go into a bit more detail so that you understand what it is, the

importance of demonstrating both throughout your exam, and exactly how and when to

show it.

Ø Empathy: Is the ability to understand and share the feelings of another

Ø Sympathy: Is feeling compassion for someone’s hardships despite not knowing

how they feel

The main difference that I want you to recognize between these two is that you can

demonstrate empathy by having gone through something similar in the past, meaning

you’ve stood in their shoes and can truly understand what they’re going through. It is

possible to feel empathy by placing yourself in someone else’s shoes, however you do
want to be careful not to act as though you know what it’s like to lose a spouse if you

haven’t experienced the same. Sympathy can be given by anyone and doesn’t require that

you’ve lived through that same experience, it simply requires that you can show that you

feel bad for their misfortunes.

There are some very clear benefits of being able to properly show empathy and sympathy

during your CS encounters, including:

v It further builds a bridge between you and your patient

v It makes you more trustworthy & likable

v It shows the patient that you truly do care

Imagine how nice it would feel if you were the SP and you were dealing with some

serious health issues and your medical student Physician told you that they are so sorry

that you’re struggling with this problem and that they understand how bad it can be

because their parent also struggled with the same problem. And they further told you

that they’re going to do everything in their power to help ensure you’re feeling better as

soon as possible. Even though it doesn’t immediately fix your problem, just knowing that

the medical student Physician really does care and wants you to feel better will likely

make you feel a bit better. Compare that to another medical student Physician who barely

recognizes the severity of your struggle and simply continues to ask questions without

really showing you how much they care and feel your pain. Between those two, who

makes you feel better? And more importantly, between those two medical student

Physicians, which one would you rather be? You see, it isn’t about doing these things just

for the sake of doing them, it really does make you a more likable, more trustworthy, and

a more effective Physician.

 It can be quite difficult on the CS exam and in life to show someone how much

you truly do care with words alone. Often times what you say isn’t as important as how

you say it, and so an equally important component of being sympathetic or empathetic is

also having the right tone for the situation. I’m sure you can understand that taking a

softer, more compassionate tone will come across as much more genuine and sincere than

if you were to say the same words but without changing anything about your voice. If

you soften your voice, slow down a bit, and show concern, it is going to be much more

effective than if you don’t change the tone or cadence of your speech, and show no

concern via your facial expressions. So, as you practice your CS cases in preparation for

your exam, be sure that you are not only saying things to show empathy and sympathy,

but that you’re also understanding them and showing them by changes in your body

language. If you remember back to our third chapter about what the USMLE organization

is looking for as part of the CIS component, you might recall that they specifically list on

their website the following as part of Fostering the Relationship: “Demonstrate caring,

genuineness, concern, and respect”. Well, what I’ve been outlining here about being

empathetic and sympathetic, but also showing it via your facial expressions and tone of

voice, is covering exactly what the USMLE is looking to get from you. Being able to truly

demonstrate empathy, not just saying empathetic words, is exactly what you should be

striving for during your CS preparation. If you don’t feel as though you’re an empathetic

or sympathetic person, then you have to work on these skills. It isn’t acceptable that you

simply don’t work on these skills because it makes you uncomfortable. These skills are

an essential part of your CIS component and are at the very core of being a caring

physician. The best recommendation I can make when working to improve these skills is

to practice with a variety of different people so that you can get feedback from people of

varying backgrounds who may interpret your demonstration of empathy and sympathy

differently. If you practice with only one person and that person lacks the ability to feel

or show empathy, then it’s unlikely that they’ll be able to point out any areas of weakness.
 The ultimate goal is to address something that’s troubling the patient with a soft,

understanding tone that says, “I hear and understand your pain and I’m here for you.”

This may seem challenging on the surface, however the point can be made by using

phrases such as the following:

v I’m so sorry that you’re going through this.

v I’m so sorry to hear that.

v That must be so difficult, I’m sorry to hear that.

Now that we’ve covered why and how to show empathy and/or sympathy, we

come to an even greater challenge, which is knowing when it is and when it is not

appropriate to demonstrate either. Now, keep in mind that it is always appropriate to be

empathetic or sympathetic, but you must find that balance between truly being

empathetic and overdoing it and running the risk of looking like you’re faking it. Well

timed and well done displays of empathy and sympathy will go a long way in building

your CIS points, however overdoing it by repeatedly saying the same thing when a

patient repeats their complaint over and over again will not appear as sincere as the first

or second time you do it. On average, it is likely that you can demonstrate empathy or

sympathy two to three times during an encounter and still come across as genuine and

sincere. If you do it more than that, the SP may start to feel as though you’re just doing it

for the points, which will of course have the opposite of the intended effect.

Often times students find it challenging to be empathetic or sympathetic, which is

why I always recommend that students have a plan in place so that no matter what,

they’ll be able to demonstrate empathy or sympathy without overdoing it and running

the risk of looking disingenuous. As I’ve said previously, having a strategy for the vast
majority of what you’ll do during the CS exam will ensure that you cover the major steps

needed to ensure a good score. So, what’s the secret to getting the first demonstration of

empathy or sympathy out of the way at the very beginning of the encounter? It is quite

simple and is based on the chief complaint. Let’s assume you’ve just taken your seat and

you start the interview with an open-ended question such as this: “Tell me what brings

you into the office today Mr. Smith?” What Mr. Smith is going to do now is tell you what

brought him into the office, which has to be something negative. Nobody goes to the

doctor for something positive, so you know up-front, before you even step into the room,

that your SP is about to tell you how they’re hurting or struggling in some capacity. As

soon as the SP tells you why they came to the office, you should take that opportunity to

demonstrate either empathy or sympathy. The following is a step-by-step example of

how this may occur:

You: Tell me what brings you into the office today Mr. Smith.

Mr. Smith: Well, for the last couple of weeks I’ve been getting these nagging headaches

that come and go and they’re really painful.

You: I’m so sorry to hear that, Mr. Smith. I can only imagine how much pain and

inconvenience this might be causing. Please rest assured that I’m going to do my best to

figure out what’s going on and hopefully get you feeling back to normal as soon as I can,

does that sound good to you?

Mr. Smith: Yes, it does. Thank you so much.

You can see how simple, easy, and effective it can be to take that very first piece of

information provided by your SP and turn it into a fantastic display of empathy or

sympathy. When you combine this with your outstanding entrance into the room, you’ve

likely impressed the SP more than he or she has been impressed all day. Very few

students will be able to come up with all of these little steps, which means you’ll be a
standout amongst all the other test takers. Aside from the very first encounter you have

on test day, all of the SP’s will be seeing you as their second, third, fourth, etc. student on

that day, which means that you’ll be compared to at least one other medical student

taking the test that day, and as long as you outperform them by implementing all of these

strategies I’m giving you, you will surely be a standout. If you look great as compared to

all of the other medical students your current SP has seen, it can only do positive things

for your overall score.

Now, as I’ve mentioned previously, you don’t want to overdo it with the empathy

and sympathy, as this is not one of those instances where more is always better. What

this means is that if you’ve offered empathy or sympathy for something already, such as

Mr. Smith’s headache in the example above, then you don’t necessarily need to do the

same again. If Mr. Smith mentions his headache two or three more times throughout the

encounter, it will come across as odd if you simply repeat the same answer over and over

again. Instead, err on the side of caution and don’t offer empathy or sympathy more than

twice for the same complaint. There is one exception to this rule, and it is if or when the

patient displays a physical complaint based on their chief complaint. What this means is

that if five minutes into the encounter Mr. Smith grabs his head and writhes in pain, you

should absolutely acknowledge this and once again offer your empathy or sympathy.

The key is to do so with different words. Thus, don’t repeat your initial demonstration of

empathy by repeating the exact same phrase. Instead, use your best judgement and let

him know that you can see how much pain he’s in and that you’re so sorry, and that

you’d like to finish the encounter so that you can get him the help he needs (or some

variation of that). Thus, you should show your empathy when the chief complaint is

given, then only once more for the same complaint if it is expressed to you in a physical

way. If Mr. Smith tells you during the interview that he recently lost his spouse, that

would be another excellent time to show empathy or sympathy. If he also tells you that
he lost another relative a couple months ago, that too should be addressed with empathy

or sympathy. The key is to limit your empathy/sympathy to new information and/or a

repeat of the information only when it is expressed in two different ways (i.e. Mr. Smith

tells you he has a headache and then the he physically shows you how bad his headache

is during the encounter).

In Chapter 3’s ‘Fostering the relationship’ goal #4 – ‘Demonstrate the right

demeanor and tone’, we touched on some of the benefits that can be gained by using a

certain demeanor and tone, as well as the benefits of mimicking the SP’s body language.

I’d like to do a quick review of that information here since it is so tightly linked to your

‘soft skills’ because, well, they are also soft skills. Let’s review and see if we can reinforce

everything we need to know to best implement these skills.

Demeanor: As was mentioned previously, your demeanor is simply the outward

behavior that you’re projecting throughout the encounter. As I said, you would think that

it’s ideal to put on a happy face and be cheerful throughout the encounter, however it is

in your best interest to ‘read the room’, as they say, and try to match the SP’s demeanor

with your own. Now, this isn’t to say that if the SP is depressed that you too should act

depressed, on the contrary. It does mean that you should bring yourself down to a level

that will make the SP feel as comfortable as possible. If the SP is depressed, you should

remain positive, however you don’t want to act bubbly and tell jokes when that is clearly

not going to go over well with the SP. On the opposite end of this is a cheerful patient

who may be seeing you to refill their prescription. If you encounter a happy SP, it is

essential that you bring yourself up to the same level as them, as this will ensure that you

make the SP as comfortable as possible. It will not do you any good to act shy and timid

while you have a happy and outgoing SP. This doesn’t mean that you have to completely
change who you are, but it does mean that you need to be able to adapt to the different

personalities that you’re likely to encounter throughout the day.

Tone, voice loudness, & pitch: One of the most important tools you have that will help

you to be able to change your demeanor on the spot will be your ability to change your

tone, the loudness of your voice, and the pitch of your voice. This simply means that if

the encounter is going well and you and the SP are getting along nicely and actually

having a decent time together, and then the SP starts crying because she recently lost her

spouse, you need to be able to adjust to the situation. This goes hand-in-hand with the

demeanor that you project outwardly but will help you to express this change to the SP

almost instantly. A famous study once determined that ninety-three percent of

communication is non-verbal, with thirty-eight percent of a person’s non-verbal

communication coming from their tone of voice and the other fifty-five percent of non-

verbal communication comes from body language. While this study has since been

rebuked, it does open our eyes to the fact that non-verbal communication is extremely

important, especially for the CS exam when perception plays a major role in your CIS

score. For example, if the SP tells you that her spouse recently died, you should soften

and slow down your voice in order to express your sadness for the patient. You can’t tell

the patient how sorry you are for their loss if your voice is loud and sounds happy.

Lowering your voice, changing to a softer tone, and slowing down your speech during

these moments will go a long way in ensuring that you come across as sincere and

genuine when the SP gives you some bad news. Just as with the need to be able to change

your demeanor on the spot, you must practice this skill so that by the time your exam

rolls around you understand when and how to make the adjustment. Be sure to get

continuous feedback from all of your practice partners so that they can let you know if

you’re being sincere and genuine enough; if they say you need to get better, set aside
some time to practice this specifically and keep working on it until you’re one-hundred-

percent comfortable with it.

Body language: As previously mentioned, a famous study determined that a good chunk

of our communication is non-verbal in nature. Remember, the study has since been

proven to be inaccurate with respect to the numbers, however the study did find that a

very large chunk of our communication comes through in our body language, which is

why we want to be aware of it throughout the exam. Now, I know you’re probably

thinking “I have enough to worry about already, now I have to worry about my body

language?”, and the answer is yes, you do. However, as I’m going to explain to you

momentarily, it isn’t all that complicated.

As was mentioned previously, mirroring is a very important and cool strategy that

we can implement in order to build a subconscious connection between us and the SP. It

is a subconscious and non-verbal way of telling someone else that you’re similar to them,

and this synchronicity tends to provide feelings of security and belonging, both of which

will only work to increase the bond between you and the SP. You’re actually probably

using the mirroring technique without even knowing it; think about the last time

someone yawned in your presence and you ended up yawning. One of the most powerful

ways to use mirroring during your encounters, which will ensure that you get the SP in

as good a mood as possible, is smiling. Think back to the last time you looked up and saw

someone smiling at you. What did you instinctively do as a result? You most likely

reflexively smiled back. Thus, when you walk into that room with a big smile on your

face, hopefully the SP mirrors that behavior and it puts them in a better mood right away.

Another interesting aspect of mirroring is that when two people are behaving in

harmony with one another, they will get the feeling that a ‘vibe’ is present between them.
Being on the same ‘wavelength’ with your SP is going to help you to quickly and easily

form a bond that will make the process of interviewing them and performing the physical

exam much easier. The final point I want to make regarding mirroring is its ability to alter

someone’s mood. When you observe someone’s body language and it tells you that they

are in a negative state of mind, such as displaying anger or sadness, then you will most

likely adopt that state as well. For this reason, it is important that you display body

language that expresses happiness and confidence so that you put your SP in a positive

state of mind. When you take the position of someone who is confident and happy, you

will begin to change into that state. At the same time, if you take a position of sadness or

one that lacks confidence, you will begin to feel that way. Thus, it is extremely important

that you know which types of body language express confidence. In order to walk into

your SP’s room and show them that you’re confident through your body language, be

sure that you’re using all of the following:

Ø Eye contact: This one goes without saying and I’ve been saying this one over and

over again. Good eye contact tells the person across from you that you’re

interested in their presence and comfortable being around them. Remember that

staring at someone non-stop is not the correct way to make eye contact. Experts

say that you should maintain eye contact at least sixty-percent of the time.

Ø Lean forward: During your encounter you should be sitting a couple feet away

from the SP so that you don’t invade their personal space, however you can lean

forward slightly when they’re speaking to you, as this demonstrates your interest

and attention in what they have to say.

Ø Stand up straight: Interestingly, people who have a certain level of anxiety will

unknowingly slouch and make themselves smaller, which is very obviously

 perceived by onlookers as a sign of anxiety and a lack of confidence. By standing

up straight, you exude confidence.

Ø Avoid fidgeting: Shaking your leg or having some sort of fidgeting behavior

demonstrates nervousness and anxiety. When you do this, it turns the SP’s

attention away from what you’re saying and onto the fidgeting, which is not a

good thing. Be very aware of whether you’re fidgeting or not and be sure to avoid

it at all cost.

Ø Avoid your pockets: Putting your hands into your pockets demonstrates

anxiousness and a lack of confidence. Even though it might make you feel more

comfortable, avoid putting your hands in your pockets during your encounters.

Ø Make slow movements: Moving unnecessarily fast is a sign of anxiousness, so

when making hand gestures or larger movements, take it slow.

Ø Watch your hands: One of the biggest ‘tells’ of anxiousness, fear, or nervousness

is touching one’s face or neck. During poker matches, players often look for this

sign, as it demonstrates that they’re likely holding a weak hand. The same goes for

your exam; avoid touching your face or neck unless of course you have an itch that

you can’t avoid.

Ø Have a firm handshake: As I mentioned in an earlier chapter, a firm handshake is

an absolute necessity when you walk into the room and introduce yourself to the

SP. A weak handshake is a sign that you lack confidence, so you want to be sure

that you always shake hands with a locked wrist and a firm grip.
 All of this information may be overwhelming to you if this is the first time you’re

really thinking about these sorts of things, but it is much better to learn about them now

as opposed to trying to figure out how you ended up failing the CIS component of your

exam. My recommendation to you for improving your tone and body language is to get

someone whom you trust to be as critical about your performance as possible so that you

can gain the valuable feedback needed to improve your skills. If your mom thinks that

everything you do is absolutely wonderful, it is probably not a good idea to have her be

the judge of your demeanor. A friend or colleague may be the best option when it comes

to this type of critical feedback.

 5
The Use of
Mnemonics
On the CS Exam
Over the years I’ve only had a handful of students who displayed a severe disgust

towards and a refusal to the use of mnemonics. The most common reason for disliking

the use of mnemonics is that it will make the interview seem ‘unnatural’. Let me tell you

right now, if your interviewing skills are coming across as unnatural or robotic, it is not

the fault of the mnemonics, it is a fault in the way by which you’re asking the questions.

In this chapter I’m going to do my best to convince you why you absolutely, positively

need to be using mnemonics on your CS exam, as well as give you a foolproof, step-by-

step strategy for implementing the mnemonics in a way that is natural and undetectable

by the SP.

If you’ve ever tried to navigate your way to someone’s house for the first time

without knowing specifically where it was located, even if not too difficult to find, you

likely took longer to get there than if you had a roadmap or directions to that house. Well,

the same concept can be applied to the use of mnemonics on the Step 2 CS exam; you

might know where you want to go during the encounter, but with mnemonics you won’t

make a wrong turn and find yourself completely lost. Additionally, you might think that

you know the best way to go from point A to point B, but without testing different routes

for getting from one place to another, you don’t know for sure which is ideal. This same
concept can be applied to the CS exam, and over the years I’ve had the pleasure of helping

students who’ve struggled with navigating the Step 2 CS exam by giving them tools and

strategies that have been shown to get them from point A to B in the most efficient and

easiest manner possible; the mnemonics are the best way to have a ‘roadmap’ for the CS

exam encounters. Now, my intention here isn’t to force or convince you that my way is

the best way, but I do want to point out all of the facts and give you some examples of

why adopting the use of mnemonics for your CS exam is going to be the single greatest

way to ensure you don’t miss questions and ensure that you can smoothly navigate your

way through each encounter.

‘But it doesn’t feel natural’

That is a fairly common phrase coming from students who think mnemonics

shouldn’t be used on the CS exam. These same students often times think of the

mnemonics as a crutch instead of a tool; funny enough though, aren’t crutches tools for

those who struggle to walk? The easiest way to convince students that they should be

using mnemonics on their exam is to have them do a practice case first without using

mnemonics, then have them do a practice case with the mnemonics written out on their

note pads. The overwhelming majority of the time, when they don’t use mnemonics, they

miss anywhere from twenty to thirty percent of the necessary questions. Then, when

they’ve got the mnemonic right there in front of them, they miss zero percent of the

questions. Which sounds better to you? Missing twenty to thirty percent of the questions

needed to get your points, or missing none of them? It’s a no-brainer, and most

importantly it proves a very important point, which is that mnemonics aren’t used

because you’re a weak student, they’re used because your goal is to pass the CS exam

and the mnemonics will help you achieve that goal. You see, in real-life scenarios, I don’t

recommend using mnemonics, simply because you have more time and each case is a bit
more involved than they are on the CS exam. The CS exam however is just that – an exam.

And exams require that you understand what needs to be done to get the points needed

to ensure a passing score. Mnemonics aren’t just reserved for students who can’t cut it,

they’re a tool that will help you pass your exam, whether you’re a weak student or at the

top of your class.

At this point in your medical career, you may or may not yet have taken either the

Step 1 or Step 2 CK exams; if you haven’t then you’ll still understand the lesson I’m about

to provide. You may or may not know that the USMLE has their own unique way of

asking questions, typically in the most confusing way possible. It is for this reason that

most students implement a multiple-choice-question test-taking strategy and do

hundreds, if not thousands of USMLE-style practice questions. One of the top USMLE-

style practice question banks is USMLE World, which has questions that are designed to

mimic the style of the actual exam and they also use the exact same software. Now, let

me ask you a question: If a student determines the best way to answer a multiple-choice-

question by doing some research and then does thousands of practice questions leading

up to his or her exam, does that mean he or she is using a shortcut? Or is the student

using all of the available tools at their disposal to increase their odds of success on the

exam? One could argue that doing thousands of practice questions is taking away from

their ‘true knowledge’ of the material, since they should just know how to answer a

question if they truly know and understand all of the testable material. From my

experience, I’ve never met a medical student who refused to do practice questions

because it wasn’t the ‘purest’ way to tackle their USMLE exam and was a ‘shortcut’ to

their success. Instead, almost all students recognize the value in using a test-taking

strategy and doing thousands of practice questions because it makes them sharper and

more aware of their shortcomings prior to the exam. Well, the same argument can be said

about all of the available tools used during the CS exam. If the tool is available and will
benefit your overall performance and increase your odds of success, why in the world

would you stop yourself from using it? Is using a motorized drill instead of a hand-held

screwdriver when building an entertainment unit cheating simply because the motorized

tools make the job easier? Of course not! And the same concept applies to the use of

mnemonics in your CS examination. You could cross your fingers and hope that you can

remember the several hundred questions that you’ll need to ask throughout your entire

twelve case CS exam, or you could eliminate the need to memorize everything and simply

use the tools to make your life easier. Remember, by using mnemonics you aren’t going

to be punished. Heck, the SP will not even know you’re using them if you’re doing it

right. Thus, why wouldn’t you want to use mnemonics if 1) The SP doesn’t know and if

they did wouldn’t care, 2) You can only stand to gain more points by using them, and 3)

They make your life much easier.

Why you should use mnemonics?

I believe that I’ve provided you with enough examples as to why using mnemonics

is necessary. At the absolute core of their use, however, is the fact that they will eliminate

the need for you to memorize a bunch of questions and help you to move more efficiently

through your CS exam cases. If your goal is to make the CS exam infinitely more difficult

than it needs to be, then by all means, don’t use mnemonics. If your goal is to pass the CS

exam on the first attempt, then mnemonics are a must.

How to use mnemonics

As I’ve pointed out previously, mnemonics are akin to having a roadmap leading

you to your destination. A well-planned route from point A to point B not only makes

your life easier, but it relieves the stress you may have of not knowing if you’ll in fact be
able to make it to said destination. Imagine going from case to case and hoping that you’ll

remember all of the necessary questions needed to get all of the information you need.

Why would you want to try and memorize all of the questions needed to develop support

for a case of BPH when you could simply use the ‘FINISHHD PUBS’ mnemonic and know

that you’ll never forget an important GU-related question?

Now that I’ve hopefully convinced you that using mnemonics will make your Step

2 CS exam preparation and your actual exam infinitely easier to navigate, it’s time to

provide you with a step-by-step plan for using the mnemonics in the absolute best way

possible. There are essentially three steps that you need to remember when it comes to

using mnemonics on your exam:

1) Ensure that you can immediately identify which mnemonic(s) should be

used based on the chief complaint.

2) At the doorway, write down your ‘Basic mnemonic’ plus a ‘Specific

mnemonic’ if one is applicable (more on this shortly).

3) Use the mnemonic(s) to guide your questions throughout the encounter.

Now, it is important that you understand the basics of mnemonic use on the CS

exam. First, we have what we refer to as the ‘Basic mnemonic’. This Basic mnemonic will

be used for each and every case, without exception. The ‘Basic mnemonic’ is the

mnemonic that will cover your History of Present Illness (HPI), Review of Systems (ROS),

Past Medical & Surgical History (PMH, PSH), and Social History (SH). These patient note

components (HPI, PMH, PSH, SH) create the ‘basic anatomy’ of your patient note’s

history component. As I’ve said, each and every case (except for the phone case) will

require that you use this ‘Basic mnemonic’, which looks like this:
 The ‘Basic’ mnemonic

As you can see from that mnemonic, we’ve got absolutely everything we’ll need

to cover in our very basic line of questioning. Now, there’s a couple things to keep in

mind at this point:

I. If the case does not involve ‘pain’, such as if it was a sadness or fatigue case, you

would eliminate the letters ‘L’, ‘I’, ‘Q’, and ‘R’, which are pain characteristics

(Location, intensity, quality, radiation).

II. Many cases will require that you add a ‘Special’ mnemonic on top of this Basic

mnemonic. The ‘Special’ mnemonic should be added onto your sheet to the right

of the HPI (LIQORPDFCSAAA) mnemonic, as it will be included into your HPI

paragraph. The ‘Special’ mnemonic added to the example below is for a ‘back

pain’ case (TUNA FISH).

 ‘Basic’ mnemonic + ‘Special’ mnemonic

Thus, in using the example above, our HPI (history of present illness) would include all

of the following pieces of information that you gathered during your interview:

Ø Location

Ø Intensity

Ø Quality

Ø Onset

Ø Radiation

Ø Progression
 Ø Duration

Ø Frequency

Ø Chronic vs. Intermittent

Ø Setting

Ø Alleviating factors

Ø Aggravating factors

Ø Associated symptoms

Ø Trauma (hx of trauma)

Ø Unexplained weight loss

Ø Neurologic signs

Ø Age (> 50yrs)

Ø Fever

Ø IV drug use

Ø Steroid use long-term

Ø History of cancer

While it is important that you ask all of these questions, it won’t be essential that you

include each and every one into your actual HPI if there’s nothing positive to report, but

that’s a discussion for another chapter. For now, as long as you understand how we’re

going to be using the mnemonics for the purpose of gathering all of the necessary

information, you’re making progress and in good shape.

It Begins at the Doorway

The first minute after the announcement is made allowing you to begin is going to

be the single most important minute of your entire encounter, because that’s the time in

which you’re going to gather your thoughts and organize yourself for the entire

encounter. This is when you’re going to design your roadmap for the encounter so that

once you’re inside the room, everything that needs to be done is laid out for you step-by-

step. We’ll discuss this again a bit later in the book, but for now let me give you an idea

of what you should do at the door in order to ensure that you set yourself up for success

inside the room.

Understand which system is being tested

This is simply a matter of looking at the chief complaint and asking yourself which

system needs to be examined during the encounter. For example, if a patient is seeing

you because of a three-day history of diarrhea, you know that this is a GI case, and that

you will need to add the GI-specific mnemonic to your note (in addition to the basic

mnemonic).

Write down the physical exam(s) that need to be done

As you’ll come to learn, you always want to do a basic heart and lung exam in

addition to the system-specific examination that’s needed. In the case of a GI-related

complaint, this means you’ll do a basic heart and lung exam, as well as an abdominal

exam (we’ll cover the details of the exams in a later chapter).

Devise a short list of most likely reasons for the complaint

The purpose of writing down three to five of the most likely reasons for a person’s

complaint is two-fold: 1) It allows you to focus your encounter on those possibilities, and

2) It allows you to focus your energy on the different components of the encounter,

instead of worrying about what the diagnosis could be when you’re trying to ask

questions and do a physical exam. For example, if I walked up to the door and saw a 24-

year-old female with a three-day history of diarrhea, I might jot down on my note the

following: Bacterial gastroenteritis, parasitic infection, antibiotic use, laxative abuse,

osmotic diarrhea. Those are of course just examples, but you should see the point of doing

this; it allows you to concentrate on doing a good job in the encounter instead of trying

to think about differential diagnoses, because you need to be one-hundred-percent

focused on the SP. In addition to a short list of likely reasons for the complaint, you could

also jot down some of the workups that might need to be done, if you have time.

Another smart use of your time at the door is to write down the correct

mnemonics, devise a short-list of the most likely differentials, and mentally prepare

yourself for the encounter. Once you’ve got those aspects covered, it’s time to knock on

the door and begin.

One of the other common reasons why some students want to avoid using

mnemonics is because they believe that if they are using mnemonics to guide their line of

questioning, that they’re going to seem robotic, as though they’re following a script. Well,

it is true that you’ll be following a ‘script’ in a way, but that doesn’t mean that it needs to

be rigid and robotic in nature. Just look at television and movies; they’re all using a script,

but they know it so well that they simply use it as a guide to their performance; they’ve

learned the information so well that if they were to forget something, uttering a single
word or two from that script would allow them to continue talking without a problem.

That’s the same level of mastery you’re going to develop with your mnemonics. Keep in

mind that writing out the mnemonics doesn’t mean writing out the entire word for each

specific letter, it simply means that you’ll use the letters as a reminder for what they each

mean. Therefore, you’re not going to actually write out the words like the example below

to the right, you’re actually going to write it out like the example below on the left.
 You see, when you actually learn what each letter in all of your mnemonics

represents, you’re not actually going through it robotically and just asking each question

as you see the words, you’re going to use them to guide you, but the way by which you

actually ask the questions will be in your own style. So, let’s say you’re dealing with a

headache case and you sit down to begin your interview and you of course ask the SP to

begin by telling you more about the headache. After they’ve finished answering your

open-ended question, you’re going to then begin to fill in any blanks by following the

mnemonic. In this capacity, the mnemonic is being used as a roadmap; starting with ‘L’,

which is the location. As you begin by asking where exactly the headache is located, the

SP will tell you. As you look down to jot down the note about the location, as you’re

writing that note you will take a quick peek at the very next letter, which is of course the

‘I’, which stands for ‘intensity’. You see, the SP has no idea at this point that you’re using

a mnemonic to guide and remind you which question comes next, because you’re doing

it at the same time that you’re writing the note, which is completely acceptable. Thus,

from the perspective of the SP, you’re simply writing down their answer to your question

and then you’re looking up and asking the next, and so on and so forth. When done in

this exact manner, you will make your way through the mnemonic, going letter by letter,

asking every important and necessary question, all without the SP having any clue that

you’re using the mnemonic to guide you. You need to practice if you want to get better

and more comfortable doing this, but it doesn’t take long to catch on and once you do,

you’ll start to find the entire interview process to be rather easy.

So you see, the use of mnemonics during your CS exam isn’t taking a ‘shortcut’ or

forcing you to be ‘robotic’, it is actually an extremely effective tool that will help to

simplify your exam process and ensure that you’re covering all of the necessary questions

that will ensure you get the points you need. If you recall earlier in the book, I mentioned

how the SP’s will be answering a questionnaire following each encounter, answering
either ‘Yes’ or ‘No’ as to whether you did certain things or asked certain questions. The

mnemonics are designed to ensure that the questions that they’re looking for are actually

asked. Therefore, by sticking to the mnemonics, not only are you ensuring that you make

things as easy for yourself as possible, but you’re also ensuring that when the SP goes to

answer your post-encounter questionnaire, that they’re almost exclusively checking the

‘Yes’ box.

Now let’s take a look at the most important mnemonics that you need to know for

your CS exam. The following few pages will provide you with the mnemonics, what each

letter stands for, and a few case examples that would require their use.

The Basic Mnemonic – HPI, PMH, Social History

L - Location P - Past medical/surgical W - Weight changes

I - Intensity A - Allergies A - Appetite changes
Q - Quality M - Medications D - Diet changes
O - Onset H - Hospitalizations
R - Radiation I - Infections S - Smoking
P - Progression T - Trauma A - Alcohol
D - Duration S - Sleep D - Drugs
F - Frequency F - Family history
C – Chronic vs. Intermittent O - OBGYN history T - Travel
S - Setting S - Sexual history O - Occupation
A – Alleviating factors S - Sleep E - Exercise
A – Aggravating factors D - Depression (mood) S - Stress
A – Associated symptoms
The Specific Mnemonics – Depression The Specific Mnemonics - GU

S - Sleep (more, less) F - Frequency

I - Interest (loss) I - Incontinence
G - Guilty feelings N - Nocturia
I - Incomplete emptying
E - Energy (loss) S - Stream
H - Hematuria
C - Concentration (difficulty) H - Hesitancy
A - Appetite (decreased, increased) D - Dysuria
P - Psychomotor changes
S - Suicide P - Pyuria
U - Urgency
B - Burning
S - Strain

The Specific Mnemonics – Dementia The Specific Mnemonics - GI

D - Dressing A - Appetite
E - Eating B - Bowel habits
A - Ambulation C - Constipation
T - Toiletry D - Diarrhea
H - Housing E - Eating habits
S - Shopping F - Fever
H - Housekeeping G - Gas
A - Accounting H - Heme in stool
F - Food I - Incontinence
T - Transportation J - Jaundice
M - Medications
N - N/V
P - Pain in abdomen
The Specific Mnemonics – Back Pain The Specific Mnemonics – OB/GYN

T - Trauma L - LMP
U - Unexplained weight loss M - Menarche
N - Neurologic signs P - Period length (days)
A - Age (> 50yrs) R - Regularity
T - Tampons/pads per day
F - Fever V - Vaginal discharge/itch/dry
I - IV drug use C - Cramps
S - Steroid use long-term S - Spotting
H – History of cancer P - Pregnancy
A - Abortions/miscarriages
P - PAP smear

HAVOC (if menopausal):

H - Hot flashes
A - Atrophy of vagina
V - Vaginal dryness
O - Osteoporosis
C - CAD

VCVEDC (if dyspareunia):

V - Vaginitis
C - Cervicitis
V - Vaginismus
E - Endometriosis
D - Domestic abuse
C - Cancer

The Specific Mnemonics – Fatigue The Specific Mnemonics – Suspected abuse

A - Appetite S - Safety inquiry

B - Bowel changes A - Afraid (of partner)
C - Cold intolerance F - Fractures
D - Depression E - Emergency plan
H - Hair falling out
V - Voice changes G - Guns in the home
A - Alcohol abuse
R - Relationship (how is it?)
D - Depression/drugs
S - Suicidal ideation
The Specific Mnemonics – MSK Pain The Specific Mnemonics – Psychotic feats.

C - Chest problems/cough/pain A - Appearance

I - Insect or tick bite B - Behavior
T - Travel/trauma C - Co-operation
R - Rash
U - Ulcers in mouth S - Speech
S - Sexual behavior T - Thought
H - Hair loss A - Affect
P - Photosensitivity M - Mood
T - Temperature reaction (to cold) P - Perception

L - Level of consciousness
I - Insight
C - Cognition
K - Knowledge fun/base
E - Endings (suicidal?)
R - Reliability
The Specific Mnemonics – Peds/Phone case

C - Colds
U - Urinary problems
B - Bowel changes

F - Fever
E - Ear pulling
V - Vomiting
E - Ear/eye discharge
R - Rash
S - Seizure/jerky movements

P - Past medical/surgical/hospitalizations
A - Allergies
M - Medications

I - Ill contacts
F - Family history

B - Birth history
I - Immunization history
G - Growth & development

D - Daycare
E - Eating habits
A - Appetite
L - Look of the baby
S - Sleep habits
 6
Mastering the
Patient Note for
the CS Exam
The patient note was once an afterthought when it came to the Step 2 CS exam, as

the majority of students were focused almost exclusively on their communication skills

and not too concerned with much else. These days however, things have changed, with

all components of the CS exam (CIS, ICE, SEP) being closely scrutinized and assessed for

competence. As the USMLE organization tightened their criteria for the CS patient notes,

the number of students failing the ICE component of the exam has slowly increased, to a

point now where I’d definitely say that the number one problem that I’m seeing in my

CS preparation programs are related to the patient note. Many students are struggling to

put together a strong HPI, develop a strong list of differential diagnoses with proper

support, and struggling with grammar, punctuation, spelling, and typing speed. And

although things like grammar, spelling, punctuation, and typing speed need to be

worked on from your own end, all of the other components that make up an outstanding

patient note can be learned in a relatively short period of time and mastered within a few

days. At the end of this chapter I’ll provide you with a couple sample patient notes done

in both formats (bullet-point format, storyline/paragraph format) so that you have a

reference point for what a strong patient note should look like.
 You might be wondering what actually makes a “good” patient note. The answer

to that question is both simple and complicated at the same time. Simply put, a good or

great patient note is one that paints a picture of the patient’s presentation, details

everything needed to allow the reader to fully understand the situation and provides a

strong list of highly likely differential diagnoses with excellent accompanying support.

A good note is also clearly written, organized, and easy to read. Now, on the surface,

you’re probably thinking that of course these are the components needed for a good

patient note, everybody knows this. And if that’s what you’re thinking, then you’re

absolutely right, but knowing what should be done and actually being able to do it are

two completely different things. This conflict of understanding what needs to be done

and knowing how to do it is what’s causing so many students to struggle these days with

their patient notes. I can say with certainty that of the several dozen patient notes I

currently grade on a weekly basis, at least half require extensive changes in order to put

together a patient note that is worthy of receiving full points. The great thing is, however,

that the patient notes are highly dependent on structure, and as long as you understand

how to follow this structure, then there’s no reason why you can’t create outstanding

patient notes. As we move forward with the patient notes section, I want you to keep in

mind that no matter how complicated things may seem at any given time, I’m going to

break it down for you so that you understand what type of structure they want for the

note and how to accomplish this task.

Biggest Mistakes Students Make on Their Patient Notes

Before we actually dive in and start creating our patient notes, I’d like to go over

what I’ve come to find over the years are the most common and biggest mistakes that I

see students making on their patient notes. I will outline these mistakes and provide you

with a detailed analysis of what each one means and how to avoid making it.
Mistake #1 – Poor spelling, grammar, and punctuation

This group of mistakes is probably the most preventable of all the mistakes

because they don’t require any medical knowledge, they simply require that you have a

grasp on writing in the English language and that you double-check your work to ensure

none of these errors exist. Often times these mistakes are made because students have

weak typing skills and must look at the keyboard and type with only one or two fingers.

If you are not currently able to type without looking at the keyboard and/or you aren’t

using all ten of your fingers to type, it is extremely important that you work on improving

your typing skills immediately. The reason why you need to have decent typing skills

prior to sitting for your CS exam is because there are a couple things working against you

during your exam: Time and anxiety. You’re most likely going to take up all fifteen

minutes of the allotted time in the encounter room, which leaves you with only ten

minutes to write your entire note, which is more likely nine minutes and thirty seconds

once you’ve taken the time to exit the room and sit down. The other factor working

against you is anxiety, which is going to play a role in your exam whether you think it

will or not. Thus, it is extremely important that you go into your CS exam with as few

flaws as possible. In order to address and fix this problem, you can head over to Google

and search for free typing lessons, which will yield a variety of different results. Now

remember, you don’t have to become a professional stenographer for your exam, you

simply need to be a strong enough typist that you can type without looking at your

keyboard and with the use of all ten fingers. The reason why you need to be able to type

without looking at your keyboard is because you’ll need to transfer notes from your case

notes onto the computer note. If you have to look back and forth again and again, you’ll

lose a lot of time. If you waste one or two seconds each time you have to look back and

forth between your note and your patient note, you could be wasting more than one full

minute just looking back and forth. This minute could be the difference between putting
together an excellent note and not being able to finish the note altogether. Thus, I strongly

suggest that you begin to work on your typing skills right away if you’re not meeting the

previously mentioned level of skill.

Now, the reason I spend so much time stressing the importance of being able to

type correctly is because a slow typing speed will directly impact your ability to double-

check your work. Many times, students have to rush through their notes because they

know they’ll come close to running out of time, and by rushing through the note you’re

more likely to make mistakes that go unnoticed. Incorrect spelling isn’t the only issue you

have to be concerned with on your note; you also have to ensure proper spacing and

correct grammar throughout the note. One of the common issues I see on notes is not

using the right amount of spacing after a comma or period. Remember to always put a

space following the comma and the period, otherwise it is not correct. For example, the

following is not the correct way to use spacing in your work: “Hello,my name is John”.

The correct way to space is as follows: “Hello, my name is John”. I realize that most of

you reading this won’t be making these types of mistakes, but they’re common enough

that I feel compelled to point these things out. Another major issue I see in patient notes

is not starting a new sentence with a capital letter. For example, the following is not

correct: “hello, my name is John. do you want to go to the park?”. The correct way to

write this is as follows: “Hello, my name is John. Do you want to go to the park?”. These

are simple issues with simple fixes, but if you don’t recognize these things before your

exam, they could have a negative effect on your overall patient note score. Now please

keep in mind that I’m not suggesting that your grammar needs to be 100 percent perfect,

but errors that a fifth grader wouldn’t make cannot be made on your note. Simple

spacing, starting a sentence with an uppercase letter, and ending a sentence with a period

are not high demands of a medical student.

 Another important issue that you must avoid is writing with incorrect English.

This is referring a lack of understanding of which words should be used and when. For

example, saying “He needs to go bathroom 7-10 times a day” is not proper English.

Instead, you would say, “He needs to go to the bathroom 7-10 times a day” or “He needs

to use the bathroom 7-10 times a day”. These aren’t issues that this book will correct, it is

your responsibility to ensure a strong understanding and grasp of the English language,

otherwise you run the risk of failing the SEP and ICE portion of your exam.

Mistake #2 – Sloppy & inconsistent structure

As you’ll see shortly in some of our patient note examples, the way the note looks

at first glance is highly important; you want it to be as pleasing to the eye as possible. A

great first impression with your patient note is extremely important. Imagine for a second

that you’re about to read a story in a magazine and you see that the paragraphs aren’t

well-aligned, they contain a variety of different formats, such as bullet points

intermingled with paragraphs, and it is difficult to navigate. If you were to see this, it is

highly likely that you’d be turned off and perhaps not move forward with reading that

story. Well, the same goes for your patient note. You will have a physician who is going

to have to read and grade your note, doesn’t it make sense to provide them with a note

that is easy to navigate and easy to read? Does it make sense that a sloppy note that is

difficult to navigate won’t get as good a grade as a well-structured note that is very easy

to navigate? Thus, it is absolutely critical that you understand how important it is that

your notes not only contain excellent content, but that they are pleasing to the eye and

easy to read. You should strive to make the reading of your patient note as effortless as

possible because you want to make the job of the person grading your note as easy as you

possibly can. Nobody gives top grades when you make them work two times harder than

they have to work. Take a look at the two patient-note history examples below. The first
note is sloppy and difficult to navigate, while the one below it is well-organized and

much more pleasing to the eye. Keep in mind that you can create your note in either

bullet-point or paragraph format; it doesn’t matter which of the two you choose, it simply

matters that you create a great note:

NOTE #1: This is an example of a poorly-written, poorly-structured

history.
NOTE #2: This is an example of a well-written, well-structured
history.
As you likely noticed when comparing notes #1 and #2, there is a stark difference

between the two, even though they cover essentially the same information. You can see

that the vast majority of the information from note #2 can be found in note #1, but it isn’t

all that easy to navigate. Note #1 contains a mix of bullet points and single phrases

without bullet points, which makes reading it more difficult and challenging. It isn’t to

say that you can’t get the same big picture with both notes, however note #2 makes it

exponentially easier to see the big picture because it is consistent and well-organized.

Everything is laid out in note #2 in a way that allows you to really understand what you’re

reading. For example, you’ll notice in note #2 that all of the past medical and social history

components are neatly outlined with the appropriate information (ex. Smoking: 40pk

year history, still smokes). When you preface the information with this kind of
organization, there is zero challenge in reading and understanding exactly what’s being

said. If you look at note #1 on the other hand, the past medical and social history

information is just written without any type of organization. You do essentially get the

same information in both but note #2 is much easier to understand and even though it is

actually a bit longer, because it is so well organized it is much easier to read. On your

exam, you have nine-hundred-and-fifty characters for your history and the same number

for your physical exam. In both notes #1 and #2 above, this threshold of nine-hundred-

and-fifty characters was not exceeded yet note #2 appears to be much denser than #1.

Since you are given this specific number of characters for the history, you don’t need to

try and shorten it by fifty or seventy-five percent. You should take the space that’s given

to you and ensure that you’ve outlined all of the necessary information to paint a perfect

picture of exactly what’s happening with your patient. Now, some of you might be

looking at note #2 and wondering how you’re supposed to write that many characters

and still have time to finish the rest of the note. Well, that robust history in note #2 took

me just over two minutes and thirty seconds to complete. That means I was able to create

a detailed and thorough HPI without sacrificing any of the time I’ll need to fill out my

physical exam and differential diagnosis components. I’m not an exceptionally fast typist,

but I do possess the degree of skill that I’ve recommended you develop in order to be

able to easily type your patient notes without flirting with the risk of running out of time.

You can become exceptionally efficient at creating patient notes as long as you heed my

advice and dedicate sufficient time to practicing.

Mistake #3 – Using abbreviations not listed on the USMLE.org website

At the end of this explanation I’ll provide you with the exact list of abbreviations

that are currently listed on the USMLE.org website so that you can see exactly what is

and what is not acceptable. The reason why I added this mistake as one of the ‘biggest
mistakes’ I see students making is because students tend to overlook this list of

abbreviations and instead decide that they’ll use any abbreviation that they deem

acceptable, even though it isn’t on the USMLE.org list. It is almost as if students don’t

take this list too seriously, because from my experience they’ll continue to use unlisted

abbreviations despite the risk it poses to their note’s success. Here’s the thing, the list on

the USMLE.org website says that this is ‘not a comprehensive list’, but unfortunately this

is the only list that they give us that explicitly says ‘you can use these’ without penalty.

Since they give us a list of what they’ll accept, but then tell us that the list isn’t

comprehensive, how are we supposed to know if something will or won’t be accepted?

The unfortunate answer is we won’t know. As a result, I’ve always told students that the

only way to be safe on the CS exam is to stick to only the abbreviations that are on that

list. Even if you think that another abbreviation surely won’t be mistaken, it isn’t worth

the risk. Additionally, students tend to use the same abbreviation for different meanings,

which is another big ‘no no’. I’ve seen students use a variety of different seemingly

innocent abbreviations over the years, such as ‘m’ or ‘f’, and while ‘m’ is on that list and

refers to ‘male, and ‘f’ refers to ‘female’, students have used these two abbreviations for

a large variety of unaccepted meanings. In the context of their notes, it was obvious what

they meant at the time: Male, minute, month, female, Fahrenheit, etc. For the most part

the context of an abbreviation’s use will allow the reader to determine what it means, but

what if you tell the reader that your fifty-five-year-old patient has been experiencing

rectal bleeding for ‘5m’. Does this mean it’s an acute case of five-minute rectal bleeding,

or is this a chronic five-month rectal bleed? In this particular instance, it is impossible to

know, and unfortunately for the person who decided to use the ‘m’ abbreviation

incorrectly, the physician grading your note will not be tracking you down by email or

telephone to ask what you in fact meant by ‘5m’. Is this the kind of minor oversight that

you want to ruin your CS exam and cause a failure? If you use seemingly innocent

abbreviations on all of your notes and they create any degree of doubt in the reader’s
mind, it could spell big trouble. The point I’m trying to express to you is the same one

that I’ve been trying to express with my students for the past several years when it comes

to abbreviations on the CS patient note: You’ve got a list of what they’ll accept with one-

hundred-percent certainty, why risk a failure over something as small as writing ‘m’

instead of ‘months’. This is one of those risk/reward scenarios whereby the risk of using

an unlisted abbreviation simply isn’t worth the reward. The best that happens is that the

reader doesn’t think twice about it, the worst that happens is that they’re a stickler for the

rules and mark it as unacceptable, causing you to fail the note. Don’t risk failing your

patient note over something as silly as an abbreviation that can just as easily be typed out

in one or two seconds.

If it were up to me, I’d recommend that nobody use any abbreviations on their

Step 2 CS patient notes for the simple fact that what you might have used in hospital

rotations in one city might be different from what someone else used in another city.

Many people prefer to use a variety of different abbreviations depending on what they

learned while in medical school and in rotations, and although there are generally

accepted abbreviations that we’re all expected to know, it seems like the CS exam isn’t

the time when you want to test out this theory. If you did your hospital rotations in the

Southwestern part of the United States, say in San Diego, CA, and the person grading

your patient note did his Residency and fellowship training in the Northeastern part of

the United States, say in Bangor, ME, there’s likely some big differences in what each was

using throughout their training. This is all speculation on my part however because I

don’t want you to overlook just how risky it is to use abbreviations without extreme

caution, mainly because it doesn’t take that much extra time to just write out the word

and avoid any possibility of confusion, which eliminates any and all risk that comes with

the use of abbreviations. If I could have it my way, I’d eliminate abbreviations from the

CS patient notes altogether because I’ve seen so much variation of different abbreviations
that it makes me nervous, but I understand that this is unrealistic, and will therefore

strongly recommend that if you don’t find an abbreviation on the list below, that you

simply do not use it. If you’re writing your patient note and you can’t remember if an

abbreviation was on the list, err on the side of caution and write out the entire word.
Here is an image taken from the USMLE.org website outlining what they definitively will

accept on your patient note. If it isn’t found on this list, I strongly recommend that you

don’t use it.

List of abbreviations accepted on the Step 2 CS exam. Source: USMLE.org

Mistake #4 – Not ordering your differential diagnoses from most-to-least likely

It doesn’t matter if your HPI is the best-of-the-best or if your physical exam is

written to perfection, if you don’t come up with accurate differential diagnoses based on

the information presented throughout the case, you will lose a lot of points. The reason

for this is simple: the USMLE wants to make sure that you know what you’re doing! The

CS exam, as I’ve mentioned, is becoming more challenging as the years pass, and a big

reason for this is simply because they aren’t willing to overlook poor diagnostic skills and

a lack of basic clinical knowledge. By the time you take your CS exam, you should have

completed, at the very least, your core hospital rotations. This includes specialties such

as Internal medicine, Surgery, Pediatrics, OB/GYN, and Psychiatry. If you’ve gone

through all of those rotations, you’ve been exposed to a wide variety of different patients

and cases, and you should have a fairly good idea of what’s going on. If you can’t handle

twelve relatively straightforward cases such as those that you’ll come across on the CS

exam, you’re going to find yourself in a sticky situation, which is one that’ll likely require

you to retake the exam. It is for this reason that you absolutely, positively must have a

solid grasp on your clinical knowledge prior to taking the CS exam. You don’t have to

have written your CK exam prior to taking the CS exam, but it is in your best interest to

prepare for both exams simultaneously, simply because there is so much clinical

knowledge (CK) that needs to be known for success on the CS exam.

Now, assuming that you’ve got a decent grasp on your clinical knowledge, it

unfortunately isn’t enough to be able to come up with a few somewhat likely diagnoses,

rather you need to come up with very accurate diagnoses. Gone are the days when you

could list a migraine, tension, and cluster headache all on the same note in the case of a

headache presentation. As you probably know, these are a few of the most common types

of headaches, but they also present very differently from one another. What this means
is that in the past you may have gotten away with that lazy list of differentials, but these

days it simply won’t cut it. You need to be spot-on with your differentials and equally as

important you need to list them from most-to-least likely. If you’ve come up with the top

three differentials based on your case but you don’t list the most likely as number one,

but rather number two or three, you will lose points. It doesn’t merit full points if you’ve

listed the top three differentials yet they aren’t in the correct order of likelihood. There

will always be something in your encounter that will make one differential better than

the other. If you begin to practice for your CS exam and you’re finding it difficult to

differentiate between similar diseases, then you need to work hard to improve your

recognition of the most common signs and symptoms of common diseases. This is the

reason why studying for your CS and CK exams at the same time is so beneficial. Many

students make the mistake of trying to memorize separate cases and the most common

differentials that go with each case, but that does you no good when the CS exam changes

things up and throws you a case that you may not have practiced. With the information

and skills provided to you in this book, you will be able to handle any case that comes

your way, however it is always possible that a unique type of condition shows up that

you didn’t practice during your CS preparation. Because anything could theoretically

happen, it means you’ll need to have that knowledge at your disposal, which is again

why the CK is so important with respect to the CS exam. I’m probably starting to sound

like a broken record at this point with my constant repetition of studying for the CS and

CK side-by-side, but I want to make one more point very clear and then we’ll move on to

the next common mistake.

Possibly the most important paragraphs you will read in this book:

Success in any endeavor requires that you know what you want to accomplish,

which in this case is passing your CS exam, and that you have a strategy/plan in place to

make it happen. For the CS exam, I want you to keep the following in mind as you begin

to prepare for your exam, as this will simplify the entire process and ensure that you do

not waste any time:

The CS exam consists of two main components: 1. Knowing how to navigate through

the CS (i.e. Knowing how to perform all of the necessary steps), and 2. Knowing the clinical

information needed to diagnose the patient. This book is your complete how-to guide for

understanding exactly what you need to do during the CS exam in order to get as many

points as possible. Clinical knowledge aside, if you don’t understand the structure and

how to navigate your way through an encounter, excellent CK knowledge won’t be able

to save you. In an upcoming chapter, I’m going to dissect the entire patient encounter

and provide you with a step-by-step plan of everything you need to be doing during the

exam in order to ensure that you get your points. Knowing how to properly enter the

room, which we’ve already discussed, is an essential part of getting full CIS points.

Knowing how to properly transition between your interview and physical exam would

be another part of the CS exam that you need to understand, among many others. This

book spells all of this out, and if you read this book from front-to-back and take notes

along the way, you’ll have my thousands upon thousands of hours of hands-on

experience teaching students how to successfully navigate the CS exam at your disposal.

Essentially, training for the CS exam itself requires that you understand how to properly

structure an encounter so that you maximize your points. The second part is having a

rock-solid grasp on your clinical knowledge. I strongly suggest that you try to book your
CS and CK exams very close to each other, for the simple fact that you need to be at the

top of your CK game if you want to be at the top of your CS game.

Thus, preparing for your CS exam should be thought of as two separate processes:

1. Mastering the steps in the patient encounter

2. Mastering the clinical knowledge needed to come to a diagnosis

If you recognize that there are two main steps to properly preparing yourself for the

exam, then you’ll save yourself a lot of wasted time. Many students will try to prepare

for the CS by doing case after case after case, trying to memorize the ‘most common

diagnosis’ for each type of case, but this isn’t the way to do it. If you try to approach it in

this manner, you’re going to be easily tripped up when they throw you a curveball. So,

to maximize your efforts, remember to first work to master the steps of the CS encounter,

then work to master all of the possible clinical knowledge that you’ll need to know to

diagnose each patient. For the sake of simplicity, you can use any of the commonly used

CK review books available on the market to prepare for the ‘clinical knowledge’ part of

your CS exam. You’re not going to see any rare or exotic diseases or disorders on the CS

exam, just your run-of-the-mill common diagnoses, which is why a basic CK review book

will work just fine.

Mistake #5 – Not strongly & specifically supporting your differentials

Another extremely common issue I see on patient notes is a lack of both sufficient

and specific support for a differential. One of the most important aspects of your patient

note is your list of differential diagnoses, and right alongside that is the importance of

supporting those differentials. If you’ve listed something but you cannot support it, then
it probably doesn’t belong on your note. I always tell students that you can put absolutely

any diagnosis on your note as long as it is well-supported. Even if you conclude that the

patient may have a rare tropical disease (Sidenote: this is not going to happen on your

exam, but I want to stress my point), as long as you can support it then you can list it.

Now, what constitutes support and what many students try to use as support often times

vary greatly, so I want to give you a fully detailed explanation of exactly what kind of

support you should be listing and how much support you should be listing.

Grading patient notes on a daily basis allows me to see a wide variety of different

approaches taken in the differential support. Some students struggle to list one or two

good pieces of support, while some students tend to list almost everything in the entire

HPI. But what you want to do is find that happy medium where your support is specific

enough that it strongly points to your diagnosis without listing vague, general findings.

For example, if you’ve got a patient who presents with a headache, there is likely going

to be some very specific support that will lead you down the path of a migraine, tension,

or cluster headache. They don’t have any super-specific overlapping features aside from

the fact that they all cause a headache. Therefore, if your patient tells you that they’ve got

a severe unilateral headache and that they’re overly sensitive to light, sound, and smells,

you’ve got some very specific support there for a migraine headache. But listing

‘headache’ as support alone is too vague. Similarly, if you have this same patient and

your second differential diagnosis is tension headache, using only ‘headache’ in your

support is much too vague and non-specific. Migraines are very specific in the way they

present, as are tension headaches, so using ‘headache’ as support for both doesn’t really

do us any good. Now, you may be thinking that you’ll throw that in there to ‘bulk up’

the number of pieces of support, but trust me when I say that trying to ‘bulk up’ any part

of your patient note with generalizations and fluff is not going to be overlooked by the
physician who is grading your note. They will recognize these things and you’ll likely

lose points if you’re doing it excessively.

Now, it’s important that you visualize exactly what I mean when I say ‘specific’

pieces of support for a differential diagnosis, because if you understand what you need

to do, you won’t waste your time trying to figure out if something warrants being in the

support or not. This of course requires that your clinical knowledge is quite strong, since

it will need to be strong if you hope to be able to differentiate between similar conditions

by two or three main findings. Thus, if we’re dealing with a patient who has a severe,

throbbing, unilateral headache and he is also experiencing photophobia and

phonophobia, then your support for a migraine headache would look like this:

Differential diagnosis #1: Migraine headache

Support for differential: Severe unilateral headache, photophobia, phonophobia

That limited yet highly specific support is clearly pointing towards a diagnosis of

a migraine headache. Nobody is going to look at this support and think otherwise. Now,

of course those are just a few of the pieces of a much larger story, so let’s also include the

fact that this patient is also feeling lethargic and recently quit his two pots-per-day coffee

habit. Suddenly, on top of strong support for a migraine headache, we may also be

dealing with a caffeine withdrawal. In this instance, our support for caffeine withdrawal

would look like this:

Differential diagnosis #2: Caffeine withdrawal

Support for differential: Severe headache, recently quit drinking coffee, lethargic
 You see, you don’t need to be overly inclusive in your support, but you do need

to find those specific pieces that when read by the physician, look highly supportive of

your differential. I always recommend that students aim for a minimum of two to three

strong pieces of support, preferably three, such as is demonstrated in these two examples.

Specific support does not include things like ‘headache’, as that is too vague and doesn’t

really give us anything specific to work with. So, I want you right now to take a moment

and repeat this to yourself five to ten times so that you never forget and more

importantly, never make the mistake of using vague support for any diagnosis: “I will

only use strong, specific pieces of support for my differential diagnoses”. As long as you

don’t forget this very important piece of information, you’re ahead of a good number of

your peers.

Mistake #6 – Adding a 3rd differential diagnosis when it isn’t well-supported

This is another one of those instances where students think that they can beef-up

their note by adding a 3rd differential when in fact it is not well-supported or supported

at all for that matter. I can’t tell you how many times in my many years of helping

students prepare for the CS exam that I’ve had to draw a big circle around a 3rd differential

that had no business being on that note. One of the classics I see is a headache case

whereby the patient also has hypertension, and the listed differentials will be as follows:

1) Migraine headache, 2) Subarachnoid hemorrhage, and 3) Brain cancer. Of these three,

which one stands out as being highly unlikely to you? If you said brain cancer, you’d be

correct. Even though brain cancer does of course present with a headache, it is highly

likely to present with a variety of different neurological findings, as well as a headache

that has been present for more than two hours. The odds that the first headache you’ve

experienced in over ten months is brain cancer are very slim. On the CS exam, an

‘extremely unlikely’ diagnosis is not something you want to put on your list of ‘most
likely’ differential diagnoses. So why do students do this? Well, the answer I get ninety-

nine-percent of the time is ‘I didn’t want to leave it blank’. My follow-up question is

usually ‘But you didn’t put any support beyond a headache’. The response to this follow-

up is usually silence. And I don’t say all of this to try and embarrass or make the students

feel bad, but I put them on the spot so that they understand that this is not what is

supposed to be done on the exam, and that if it is done, points will be lost.

The USMLE.org website explicitly says that you need two differentials, but that a

third is only warranted if it is well-supported. This isn’t information I’ve pulled out of

thin air and forced upon you, it is straight from the horse’s mouth; I’m just the messenger

trying to get you to avoid this very bad habit. You see, if you provide two outstanding

and highly likely differentials with excellent and specific support, you’re going to get full

points. However, if you were to provide those same outstanding differentials along with

some outstanding support, followed by a third differential that is unlikely and poorly-

supported, you just lost some of the points you gained from your solid number one and

number two differentials. The point of all of this is quite simple: Only list a third

differential diagnosis if you can support it. If you can’t, then don’t add it.

Mistake #7 – Selecting workups that are too expensive or overly aggressive

This is another big mistake I see students making regularly on their patient notes.

I’d actually bet that this is a bigger issue than students improperly listing support for

their differentials, but not by much. The reason why this is such an easily avoidable

mistake is because once again, the USMLE.org website explicitly says that you should

always choose the less expensive of two tests and that you should choose the less invasive

of two tests. If you can get the exact same degree of information for your diagnosis with

an x-ray as you can with an MRI, you better choose the x-ray. If you can get the same

amount of information for your diagnosis by getting a urine sample as you can by doing
an invasive cystoscopy, you sure as heck better choose to get a urine sample. Although

you would think that this wouldn’t need to be said, students often times make the

mistake of thinking that more expensive tests are better or that invasive tests will be more

accurate. Sure, an MRI gives us a much better picture, but why do an MRI on a broken

femur when an x-ray gets the job done? It’s a pure waste of money. And hospitals don’t

want someone working for them if they’re going to throw money down the toilet by

ordering expensive and unnecessary tests. Therefore, you have two important jobs to do

when it comes to ordering your workups: 1. You need to know which exams are actually

needed to rule your differentials in or out, and 2. You need to remember to choose less

expensive and less invasive as long as they will get you the same information.

You might be asking yourself why it’s so important on the CS exam that you order

the less expensive of two tests, or that you order the less invasive of two tests, when

you’re not actually going to be doing any of this on the patient in reality. Well, the answer

is quite simple, and that is that when you order incorrectly, it tells the person grading

your note that you don’t know what you’re doing. To succeed on your CS exam, you’ll

need to have strong clinical knowledge, and a big part of the clinical knowledge exam

(Step 2 CK) is knowing what the ‘next best step’ should be in making a diagnosis. Often

times this ‘next best step’ or ‘most appropriate next step’ is a diagnostic workup. If you

don’t have that CK foundation, then you’re going to lack the necessary knowledge to put

in the correct orders following a patient encounter. And while you will of course learn a

lot of these diagnostic workups later in your medical education, it is expected that you’ve

got the fundamentals down by the time you write this exam. If you don’t have a solid

grasp on which workups need to be done to help rule a differential in or out, then you

need to study your clinical knowledge information. Any of the available CK study guides

will give you more than enough to help in this area, so there really is no excuse.

Overlooking details such as this is why more and more students are failing the CS exam
these days. A few years back, the rumor was that you could pass the CS exam without

doing any studying as long as you spoke English, but these days they will more closely

scrutinize every aspect of the encounter and patient note, so there’s no room for error.

Please realize that I’m not trying to scare you with all of this information, on the

contrary, I’m trying to open your eyes to just how complex this exam can be so that you

don’t take it for granted and end up failing it and making your life harder as you try to

get into Residency. This exam is either ‘Pass’ or ‘Fail’, so if you end up with a ‘Fail’ on

your record, it doesn’t say whether you were right on the cusp of failing or if you were

absolutely terrible. This is bad for you because it will never be assumed that you ‘just

missed’, it will likely be assumed that you have some major interpersonal communication

flaws that could potentially be trouble for you and the hospital down the road; this is a

risk many Residency programs aren’t willing to take, especially when a lot of your

competition will have no history of failures on their CS exams.

The Patient Note realization that most students never come to on their own

One of the biggest reasons why students struggle to create outstanding patient

notes is because they think that the patient note portion of the encounter begins as soon

as they sit down at the computer. While it is true that once you sit down at the computer

you’re officially ready to start typing, the fact of the matter is that if you’re just starting

to think about the note at this stage in the encounter, you’ve already lost.

Allow me to explain.

The patient note is the result of everything you’ve done leading up to that point,

which is everything from the doorway to the closure. Most students never realize that the
quality of the patient note is directly related to how well they navigate the entire

encounter from beginning to end. And the most important part of setting yourself up to

write a great patient note is what you do at the doorway prior to even stepping foot into

the room. The better you are at each particular step of the encounter, the better you will

be in all subsequent steps of the encounter. Thus, if you set yourself up properly at the

doorway, you’ll have a much stronger interview. If you set yourself up well during the

interview, your physical exam will be much easier to execute. And if you set yourself up

properly at the door, execute your history component perfectly, and perform the correct

physical exam maneuvers, you’ll have everything you need to put together a top-quality

patient note. Therefore, what you do at the door prior to entering the room will be directly

reflected by the quality of your patient note.

By recognizing that the patient note is a direct reflection of how well you organize

yourself throughout the rest of the encounter, it should make sense why we are spending

so much time discussing each part of the encounter and ensuring that we are organized

and implementing strategies to come as close to perfect as we possibly can.

What to do at the door to set yourself up for success

Hopefully you’re convinced that what you do at the door will have a major impact

on the overall quality of your patient note. The next part of the equation is actually

knowing what you should be doing outside the room to get yourself setup. The first thing

to keep in mind is that you should aim to accomplish everything within one minute. If

you can get yourself setup in one minute, it will save you at least ninety-seconds of

wasted time throughout the encounter, which is a pretty good tradeoff.

Here’s a step-by-step list of everything you should do in the one-minute you have prior

to entering into the room:

I. Read the chief complaint and take note of any abnormal vitals

II. Document the patient’s age and name

III. Based on the chief complaint, write out three to five of the most likely

reasons for the complaint (i.e. Your initial differentials)

IV. Determine if there’s a specific mnemonic for the chief complaint

V. Write down your basic mnemonic first, then your specific mnemonic if one

exists for the case

VI. Draw a box in the lower right-hand corner of your note for additional notes

and/or counseling notes

As you can see, there’s not a lot to this, but by taking the time to set yourself up properly

at the door, you’re going to avoid any of the following potential problems:

§ You won’t forget to ask any important questions (thanks to the mnemonics)

§ You won’t forget the patient’s name, which could be a devastating blow to

your score (thanks to writing down the patient’s name)

§ You won’t have to walk over to the information chart because you’ll have

all the abnormal vitals listed on your note (because you took the time to

document them)

§ You won’t draw a blank about the most likely differentials for the patient’s

particular set of signs & symptoms (because you took the time to outline

everything before you entered the room)

 Now, you might think that you could skip all of this because you won’t forget any

of the important questions, vitals, or the patient’s age or name, but trust me when I say

that in the heat of the moment, it happens to the best of us. Why let your ego get the better

of you in a situation that is so important to your career? It simply makes no sense to risk

it because you don’t think you’ll forget anything. I’ve seen some outstanding students

draw a blank or forget to ask an important question in the heat of the encounter as a result

of the stress and anxiety that comes with the exam. Feel free to do whatever you like once

you’ve passed the exam, but until then, use the tools and strategies at your disposal to

increase your odds of success.

Now, as long as you take the steps outlined above, you should have no problem

keeping yourself organized throughout the entire encounter. There are however a few

tips I’d like to share with you now because despite creating a structure plan from the

onset, many students still have trouble staying organized throughout the encounter. As

long as you follow these steps for staying organized, you should have no trouble getting

through your encounter.

How to stay organized while taking your interview notes

At the core of staying organized during your encounter is a reliance on the

mnemonic(s). Without the mnemonics, it’s easy to find yourself jumping from HPI to

social history to review of systems, etc. The goal of your questions is to stick to one section

first, then to the second, then the third, etc. By sticking to one section at a time, not only

do you make it easier for yourself because you’re not going to be jumping around your

entire note, but you look to be more organized from the perspective of the SP. The entire

reason why I’ve talked about the importance of mnemonics over and over again is

specifically for this discussion of staying organized during the interview.

 Let’s say you decided not to use the mnemonics during your interview, what does

that end up looking like? Well, first of all, it requires that you expend additional mental

energy trying to remember each and every important question on the spot, which seems

like a big waste considering you have a long day ahead of you. And equally as important

is the fact that it makes organizing your line of questioning that much more challenging.

For example, even though it isn’t all that challenging to remember Onset, Progression,

Duration, Frequency, Chronic vs. Intermittent, Setting, Alleviating & Aggravating

factors, and Associated symptoms, in the thick of your interview remembering these

simple questions becomes much more challenging. If you don’t keep all of your HPI

questions together, all of your review of systems questions together, all of your past

medical history questions together, and all of your social history questions together,

everything gets mashed together and it becomes even more challenging to remember

what you’ve asked and what you haven’t. Many students who refuse to use mnemonics

end up repeating the same questions two or three times, which is a big ‘no-no’ on the

exam. Nothing annoys a patient more than being asked the same question over and over

again. Not only does it make you look incompetent as a student, but it makes the SP feel

like they’re begin ignored; this is not what you want. So, the way you’re going to stay

organized is quite simple; you’re going to write out your mnemonics on your sheet while

standing at the doorway and it should look something like this:

 Writing out your mnemonic in this fashion will give you a simple-to-follow

approach for asking the questions. What you’re going to do is simply start at the top and

make your way down the list. Thus, you’ll follow your first mnemonic

(LIQORPDFCSAAA) and ask each question in that specific order, which ensures that

nothing goes missed. You’ll ask your patient the following questions: Location, Intensity,

Quality, Onset, Radiation, Progression, Chronic vs. Intermittent (this is a couple letters

down and should be asked prior to frequency and duration, however it fits better into the

mnemonics as ‘PDFCSAAA’ as opposed to ‘PCDFSAAA’), Frequency, Duration, Setting,

Alleviating factors, Aggravating factors, and associated symptoms. Another important

reason why we write out our mnemonics like this is because it gives us some division

between each component of our note, which makes it easier to do what we call a ‘warm

transfer’ or a ‘smooth transition’ between each component of the interview. This means

that you should think of your HPI as one section of the note, the ROS as another, the PMH
as another, the sexual history as another, and the social history as another. Now, the next

part of the puzzle here is knowing how exactly to execute the ‘warm transfer’, which is

actually fairly straightforward. You always want to introduce each new part of the

encounter that you are planning to do next, and you want to thank the SP at the

conclusion of each part, which breaks up the entire encounter into smaller chunks, makes

it more manageable for you, and more pleasant for the SP. Thus, as an example of how

this should go, let’s assume that we’ve just finished asking our HPI questions and we

want to dive into our review of systems next. You might say: “Mr. Jones, thank you for

answering all of my questions. If it’s alright with you, now I’d like to ask you a few head-

to-toe questions so that I can get a better sense of whether anything else might be going

on, is that ok with you?” The SP always says yes, and then you proceed. Then, following

completion of the ROS, you’d again thank the SP for answering all of your questions and

introduce the next section, which is the past medical history. Thus, you’d say again:

“Thank you Mr. Jones for answering those questions. Now if you don’t mind, I’d like to

ask you a few questions about your past medical history, is that ok with you?” And you

just keep doing this over and over throughout the interview. Not only does this break the

entire thing into smaller chunks, but it reinforces your politeness and demonstrates that

you are trying to work together with the SP as a team throughout the encounter, which

is extremely important for the sake of your CIS score.

Deciding on ‘bullet points’ or the ‘storyline/paragraph’ format

This is a common question I get because students are always wondering which is

preferred and which should be used to get the most points. Since the USMLE

organization explicitly says that either can be used, it is expected that neither is preferred

over the other. The biggest concern is whether you’re using each of these correctly or not.

Many students think that the bullet point format allows them to create a very ‘bare bones’
type of patient note, which isn’t the case at all. In fact, since the goal of the patient note is

to paint a descriptive picture of the patient’s scenario, it could be argued that bullet points

make this entire process even more challenging. That could be argued, but as you’ll see

shortly, I’m going to outline exactly what you should be doing for each option so that no

matter which option you decide to go with, you’ll understand exactly how much detail

is needed to ensure that you get as many points as possible on the note.

The first thing we need to consider when it comes to the patient note is which

option is best for us, the bullet point format or the paragraph/storyline format. In my

personal opinion, they’re both extremely effective if used correctly, so it ultimately comes

down to your personal preference. I always tell my students that whichever they choose

should come down to that which they find easiest to use. A few years back I probably

would have recommended that most students use the paragraph format if they were

strong at typing and had a strong command of the English language, but after a few years

of weighing both options, I think that using the bullet point format might be a bit easier,

however that’s just my opinion. Remember that ultimately it doesn’t matter which you

choose as long as you do a great job of conveying the important information. So, with

that said, let’s take a look at some of the ‘pros’ and ‘cons’ of using each format on your

patient note.

Pros of using the bullet point format:

ü Faster and easier to jot down each point

ü Less chance that you’ll demonstrate spelling or grammatical deficiencies

ü Easier if you’re a slow typist

Cons of using the bullet point format:

ü Many students believe it is a shortcut allowing them to submit less

information (this is not the case); so it could cause harm to your note

ü Greater chance that you won’t paint as good a picture as with the storyline

format

Now, although there are a couple of cons to using the bullet point format, these

‘cons’ typically only apply to students who don’t understand how to properly use this

format. Once you know how to use this format, as well as the storyline format, then it is

going to simply be a matter of preference.

Now let’s take a look at some of the ‘pros’ and ‘cons’ associated with using the

paragraph/storyline format.

Pros of using the paragraph/storyline format:

ü It reads like a story (easier to make it flow)

ü Easier to paint a picture with words

Cons of using the paragraph/storyline format:

ü Takes longer to ensure that the story flows & reads well

ü May require greater thought to create (thus taking more time)

So, as you can see, there are pros and cons to each option you choose, and

unfortunately there’s always going to be some sort of drawback associated with either,
but as long as you have the know-how to maximize the pros and minimize the cons,

you’ll be in good shape.

How to smoothly transition your interview notes onto your patient notes

Many students don’t think of having a strategy for efficiently transferring their

encounter notes onto their patient note, which makes sense because it’s not really

something that anybody ever talks about. It’s usually expected that you can easily take

the notes from your interview and type them into the online patient note portal, but as

with everything else on the exam, many students run into difficulties. Since this book was

written to be the only guide you’d ever need to master each and every aspect of the exam,

I want to take some time to explain exactly how you should approach this step of the

exam so that you don’t run into some of the issues we commonly see.

First, I’ve been stressing over and over how important it is to use the mnemonics

during your interview, and I’ve stressed how setting yourself up properly at the doorway

will help to ensure that you can stay organized during the interview. As long as you’ve

followed those steps, you should be sitting down at the computer with a well-organized

note. This well-organized note is going to be your ticket to quickly, efficiently, and easily

writing your actual patient note.

The key to success here is quite simple…

You’re going to start at the very top of the HPI mnemonic, which is either with the

location “L”, or if it’s not a pain case, the onset “O”. Then, simply move from one letter

to the next and add that information into your patient note. One of the biggest struggles

students have is when they aren’t well-organized in the interview and their notes are all
over the place, they end up having all of their information spread out all over the place,

and this type of chaos usually results in a poorly-written patient note. Imagine how

difficult it’s going to be to write your patient note if you have to scan your entire

encounter note each time you want to write out a point on the patient note. Not only will

you be unable to write a note that flows perfectly through each part of the interview, but

you’ll waste a lot of valuable time going over your encounter note again and again and

again. This approach is going to cost you at least one to two minutes of extra time that

would otherwise go towards perfecting your note.

Instead, what I’m going to recommend you do is simply start at the top and make

your way down the entire mnemonic, transferring each point from your encounter note

right into your patient note. For example, let’s assume that the note below was created

during our encounter. As a result of creating a well-organized encounter note, we can

create a well-organized patient note. As you can see, the information from the encounter

note is lining up exactly with the order of the information in the patient note. This

approach makes the creation of your patient note extremely easy and very efficient. You

won’t have to worry about what goes where because you’re going to follow the exact

same approach each and every time. As I’ve said many times throughout this book, the

way to simplify your life when it comes to the CS exam is to have strategies and systems

in place for as much of the exam as possible. As long as you do this and ensure that you

can execute everything flawlessly, this exam is going to be fairly straightforward and easy

for you to navigate.

Take a look at the encounter note (left) and the patient note (right). Notice how all

of the information in the patient note is written in the exact same order as it is laid out on

the encounter note. By following this strategy, you simply cannot lose. You will have a

nicely organized patient note, and equally as important you will not miss a single piece
of information. It would be impossible for you to forget to add anything to your patient

note if you’re just moving from top-to-bottom and transferring the information from one

spot to the other. Keep in mind that this is only the interview portion of the note, the

physical exam is also part of the note but is much easier to navigate during the creation

process.

Should I start with any particular section when creating my patient note

This question is usually asked by students who are struggling to finish their notes

in the allotted ten-minute timeframe. Usually, this question is followed by a another

about whether or not it is alright to leave a certain part of the note empty if they can’t

finish it in time. Many students inquire about whether any particular section of the note
is less important than another, and the answer is no. Consider the case of a note in the

hospital setting; would it be appropriate to leave any part of the note unfinished? No,

that would result in someone getting into a lot of trouble. Thus, no, there is no particular

section of your patient note that can be omitted due to a lack of time. If you aren’t

finishing your notes in time, you shouldn’t be looking for a way to take shortcuts on the

note, you should be looking for a way to improve your typing skills. As I’ve said before,

it is imperative that you have at the very least some average typing skills. By average, I

mean that at the very least you can type with all fingers and without looking at the

keyboard. If you’ve ever asked or wondered whether you can skip any part of the note

and still pass, then it is likely that you need to figure out how to improve your typing

skills. The easiest way is to use the Internet to search for ‘free typing lessons’ and dedicate

an hour or two each day to improving this skill. Not only will this skill help you perform

much better on your CS exam, it will serve you well for the remainder of your life. I can’t

even begin to estimate how much more work you can accomplish and how much time

you can save over the course of a year, five years, or a decade when you can type with

average to above-average speed and skills.

 7
The Anatomy
of the CS Encounter

So far, we’ve talked about the basic structure of the exam, we dove deeply into

understanding the basics of the CIS and ICE components of the exam, we’ve discussed

the soft skills at length, we’ve discussed how important the mnemonics are in setting up

and organizing your entire encounter from beginning to end, and we’ve discussed

exactly what goes into a rock-solid patient note. Now it’s time for us to take everything

we’ve learned so far and plug it all into a structured outline of everything that needs to

happen during the course of the encounter. This chapter is going to spell out for you

exactly what steps you need to be taking from the moment the announcer says, “Students,

you may begin,” to “Students, your encounter is over, you must now leave the room.”

This chapter is going to create a structure that will enable you to move through each

encounter knowing exactly what you need to do each time, without fail. As long as you

follow the structure that we’re going to be discussing in this chapter, you will be covering

the basic steps that you’ll need to know in order to touch on all of the important aspects

of the patient encounter. Having this structure outlined for you will ensure that even if

you’re having a tougher-than-expected encounter, you’ve got this structure that you can

tap into to help steer you back on track.

Now, before we dive in and start our discussion about the patient encounter, I

want to stress to you the importance of this single image below. This image should be
written out by you again and again, you should be able to recite this in your sleep, and

you should have this image memorized so well that no matter how much stress or anxiety

you’re experiencing in the middle of the encounter, that you’ll be able to remember it. If

you don’t quite get it, I’m saying that it is essential that you master this image. Without

having this structure memorized, all of the work you’ve been doing up to this point will

not be maximized because the structure of the encounter is that important. So, with that

said, let’s dive in and begin dissecting our ‘Anatomy of the Encounter’.

The Anatomy of the Encounter

§ PAUL… THIS IS ON THE OTHER SLIDESHOW

Before we dive into the different components that make up the encounter, I want

to explain a concept I created called ‘bookending’. Now, bookending is simply a mindset

that I want you to go into each encounter with that reminds you to make an outstanding

first impression and an outstanding final impression. In the following pages I’m going to
outline exactly how to ensure a great first and last impression, but keep in mind that both

are equally as important. If you enter each encounter with an understanding of just how

important the first twenty seconds and the last twenty seconds are to your overall

encounter success, that awareness alone will have a positive impact on your overall score.

DOORWAY (1 minute)

Let’s start with the doorway, which we’ve touched on quite a bit already. Now

you get to actually see it in action. When done correctly, this should take no more than

one minute. As you know, the time spent at the doorway is arguably the most important

of your entire encounter because it’s your opportunity to properly set yourself up for

success. As you can see from our image above, the three main goals that you want to

accomplish at the doorway include the following:

I. Write out your mnemonics

II. Develop your initial list of differential diagnoses

III. Divide your page into different section to stay organized

As I’ve said, we’ve touched on the doorway quite a bit already, but because it is so

important, I want to cover these goals one more time. So, let’s review each of these

components so that as we move forward, there is absolutely zero doubt in your mind

about how they need to be handled.

 I. Write out your mnemonics

The mnemonics serve a multitude of purposes, but the biggest include keeping

yourself organized, ensuring that you don’t forget any of the important questions that

need to be asked, and ensuring that you’re well-prepared to transfer your case notes onto

the patient note. Remember that you always want to write out the basic mnemonic, which

includes the following: LIQORPDFCSAAA (however LIQR are only used if there is pain).

Then, you need to ask yourself if the case requires the use of a special/specific mnemonic.

If it does, you should write it out directly to the right of your basic mnemonic and be sure

that all of those questions are asked as part of the HPI. Thus, the basic mnemonic and the

special mnemonic should be asked prior to moving on to the ROS and Past Medical

History.

II. Develop your initial list of differential diagnoses

Writing down an initial list of potential diagnoses is an extremely valuable strategy

because often times students have ideas when they see the initial complaint while

standing at the door, but then once they’re in the moment during the encounter, they

can’t remember. Thus, if you have a few initial thoughts about what could be going on,

write them down so that as you move through the encounter, you’ll be able to quickly

review them in case you need to ask any specific questions in order to rule something in

or out. For example, let’s say that you’re dealing with a 32-year-old male with chest pain.

At the door, you might be thinking about costochondritis, pericarditis, or trauma. If you

forget about these inside the room, you might overlook an important question such as a

change in pain when shifting the body or when leaning forward. If on the other hand you

take this advice and write down your initial thoughts, all you have to do is refer back to

those notes in the encounter and it’s right there reminding you what you were thinking.
This isn’t a groundbreaking strategy by any means, but it is not uncommon for students

to draw a blank in the middle of the encounter, so anytime we can do something to

decrease the risk of leaving something out, we should do it.

III. Divide your page into sections

This one isn’t completely necessary, but some students like to divide their page into

four quadrants: One for the HPI, one for the PMH, one for the social history, and one for

additional notes. If you follow the mnemonics approach that I outlined earlier, then this

isn’t completely necessary. If you feel that it would help you out, then by all means go

for it.

THE ENTRANCE

Next up is the entrance, which you might remember from earlier is a short period

of time in which we can set the tone for our entire encounter by doing a few important

things. By sticking to the strategy that we’ve outlined for you above in the ‘Anatomy of

the Encounter’ image, you’ll create a great first impression which will hopefully carry

over into the remainder of the encounter. Let’s now take a look at each component

outlined in ‘The Entrance’ and ensure that you know exactly what to do for maximum

effect.

Knock on the Door

You would think that this goes without saying, but I’ve seen many students over

the years actually perform a very poor ‘knock’ on the door, which usually didn’t set a

very good tone for the first part of the encounter. Here’s what you should do: Knock on
the door three times with average force. When I say ‘average’ force, this means that you

don’t want to be pounding the door, but you also don’t want to be so quiet that the SP

doesn’t hear you. By using an average amount of force when you knock, you’ll let the SP

know you’re coming in, but you won’t startle them with a Herculean knock.

If you knock too softly, the SP may not hear you at all. If this is the case, it looks

like you simply walked into the room without knocking, which is of course going to

negatively affect your score. If you knock too loudly, you run the risk of startling the

patient, which could easily put someone into a bad mood right away. The last thing you

want to do before you even step foot into the room is anger the actual person who is

acting as your SP and holding your future in their hands. All of these issues are easily

avoided with an average knock. Also, be sure to knock three times. There is no science

behind knocking three times, but it seems to be the right number to let the person know

you’d like to enter the room.

Always smile as you enter

It is very hard to see someone smiling at you and to remain neutral or angered.

The majority of your SPs on exam day aren’t going to be angry, but some may be neutral.

Your goal with these SPs is to let them know right away that you’re friendly and in a

good mood. A smile as you enter the room could completely alter the feeling in the room

for the better. At the very worst it doesn’t make much of a difference, but it won’t make

things worse. At the very best it will elevate your SP’s mood, which can only do good

things for your overall encounter. Not only can this increase your chances of doing well,

but it will make the encounters more enjoyable because spending time with happy and

positive people is much more desirable than the opposite.

Introduce yourself as ‘Doctor’

Even though you’re most likely still going to be a medical student at the time you

take the CS exam, you still want to introduce yourself to the patient as ‘Dr. XYZ’. Keep in

mind that this is in the context of the CS exam, not when doing your school’s required

rotations (you should still let patients know that you’re a medical student until you’ve

graduated). There is no specific reason why they want students to address themselves as

‘Doctor’ during the CS exam, however it sounds much better to say: “Hello, my name is

Dr. Paul,” versus “Hello, my name is medical student Paul.” One sounds great and the

other sounds a bit clunky to say aloud. So just remember that for the sake of the CS exam

that you should introduce yourself as ‘Doctor’.

Shake hands firmly while maintaining eye contact

A firm handshake is a sign of confidence, so it is essential that you do everything

that you possibly can throughout the encounter to demonstrate your confidence to the

patient. A firm handshake shouldn’t be so firm that it crushes the other person’s hand,

but it should be firm enough to express confidence. Whether you’re male or female, you

should strive to have a nice firm handshake.

Eye contact is another essential tool in your ‘confidence’ arsenal. Maintaining eye

contact tells the other person that you’re confident and that they’ve got your attention.

Now, experts recommend that you maintain eye contact approximately sixty-percent of

the time, which means that if you’re speaking to someone or they’re speaking to you, that

you should maintain eye contact. During the encounter, you’ll be asking interview

questions and writing down notes. During the period of time whereby you’re looking

down to write your notes will be that forty-percent break in eye contact. Thus, as you ask
a new question, make eye contact, then look down to write the patient’s answer. If you

maintain this pattern of looking up when you’re speaking to them and they’re answering,

then looking down to take your notes right after they’ve finished speaking, it will look

very natural and also ensure that you’re maintaining the right amount of eye contact.

Ask if they’re comfortable in the room

The first thing you want to ensure is that the SP has the blanket on their lap, which

for the most part we hear that they do this automatically these days. If that’s in place,

immediately after finishing shaking hands you want to ask the SP if they’re comfortable

in the room and if there’s anything that you can do to make them more comfortable. Now,

there’s a couple of very good reasons for doing this, the first being that if something is

making them uncomfortable, such as the temperature or the brightness of the lights, it

can allow us to gain some CIS points right off-the-bat because we can address something

that is bothering them, which demonstrates how attentive we are to their needs. The

second reason for doing this is simply because it’s a nice gesture. When you have guests

in your home, you always ask them if there’s anything you can get them, and you’re

essentially using the same approach here. It is important to realize that a good number of

students will not be doing this, which means that it’s another opportunity for you to stand

out from the crowd. Anytime we can do something that requires little effort but that can

have a big impact on how positively we are perceived, we should be doing it.

Ask permission to sit down

As with everything else during the encounter, you want to ask the SP’s permission

when taking a seat. The reason why we do this is because it is a sign of respect. Most

students will either dive right into asking questions while standing, while others may
take a seat on their own. But you will be taking a seat after politely asking the SP if they

mind or not. Is this step going to be a make-or-break move on the exam? Absolutely not,

but it is these small things that we can do here and there that will start to add up

throughout the encounter and make us look great overall.

THE INTERVIEW (8 minutes)

Explain what you saw on their chart to ensure accuracy

One of the trickiest things I’ve ever heard the USMLE do in the CS exam is put

information on the doorway that misrepresented the patient and their complaint, which

often times led to some very confusing encounters. Luckily, we know better and so we’re

going to put a safety measure into place to ensure that what we’ve read on the door is the

same as what’s going on inside the room. Thus, it is as simple as explaining to the patient

before you even begin asking questions what you gathered from the doorway

information and double-checking to ensure that everything is correct. This can be as

simple as saying this: “Mrs. Johnson, I read on your chart that you’re here because you’ve

been experiencing stomach pain, is that correct?” And then you simply let the patient

confirm whether you’ve got the correct information or not. Now, the great thing about

putting this safety measure into place is that if for some odd reason they’re trying to trick

you and the patient tells you that the information you have is incorrect, then all you need

to do is ask the patient what brought them in. At that point they’ll simply proceed to tell

you what’s going on and you can move forward with the case. So as long as you get

clarification at the beginning of the case, you don’t have to worry about running into any

unforeseen problems.
Tell them that you’d like to ask them some questions

The interview needs to start the same way we’ve been discussing the rest of the

encounter throughout this book, which is with politeness and asking permission. Now,

remember that it is imperative that you sprinkle open-ended questions throughout your

encounter, and the first question of the encounter is the perfect time to begin. Remember

that the two parts of the encounter that will be remembered most vividly are the

beginning and the end, which is why we need to make sure we do a few things within

the first twenty to thirty seconds of the encounter’s start and within the last twenty to

thirty seconds of the encounter’s end so that we are sure to get maximum points. This is

a concept I call ‘Bookending’, and I’ll go into this in a bit more detail in a later chapter,

but for now just understand that these are two of the most crucial points in your

encounter.

Before we dive into the details of the interview, I want to take a moment to explain

how you should be asking questions throughout the encounter. The reason why I’m

compelled to even write this section is because believe it or not, some students have

trouble asking a question in a clear and concise manner. Here are a few of the ways by

which you can ask questions:

For the sake of our question examples below, XYZ will represent the

interchangeable topic of the question.

Ex. 1: “Would you mind if we XYZ?”

This could be “Would you mind if we started the physical exam?”

Ex. 2: “Would you mind if I XYZ?”

This could be “Would you mind if I started the physical exam?”

Ex. 3: “Would it be ok if we XYZ?”

This could be “Would it be ok if we started the physical exam?”

Ex. 4: “Would it be ok with you if I XYZ?”

This could be “Would it be ok with you if I started the physical exam?”

Ex. 5: “Is it ok with you if I XYZ?”

This could be “Is it ok with you if I start the physical exam?”

Ex. 6: “Is it ok with you if we XYZ?”

This could be “Is it ok with you if we start the physical exam?”

As you can see, this doesn’t have to be tricky or overly complicated. The most

important thing is to ensure that you’re asking permission to do anything during the

encounter. The more permission you ask, the more respect you demonstrate, the higher

your CIS score climbs.

The first question you ask should be open-ended

You should begin the interview with an open-ended question, and in my opinion

the single best way to start every interview is like this: “Mrs. Johnson, would you mind

telling me more about your stomach pains?” Then let Mrs. Johnson speak for as long as

she needs. Often what ends up happening is the patient will tell you when it started, what

type pain they’re experiencing, and a couple more details. As the patient explains what

she’s been experiencing, you should be taking notes. Usually this is going to only be three
or four important points, which you’ll document and repeat quickly as you proceed

through the interview. The next step in the process is quite possibly the single most

important part of the entire encounter, because it is the time when a student either grabs

hold of the encounter and takes control or slips up and lets the SP take control. What I

mean by this is quite simple, I mean that you need to be the one who asks the questions

immediately after the open-ended question, otherwise you’ll let the SP speak without any

specific direction, which only costs you time. So, what you should do following

completion of the patient’s open-ended question answer is say that you’re so sorry to

hear about all of this (you’re slipping in some empathy), and that if it’s ok with them

you’d like to ask a few follow-up questions. In reality, what you’re doing is taking control

of the interview because now you’ll be asking the specific questions outlined by your

mnemonic. So that you understand completely and clearly, here’s how the dialogue

between you and the SP should sound if you’re doing this the right way:

You: Mrs. Johnson, I read from your chart that you’re experiencing stomach pains, is that

correct?

Mrs. Johnson: Yes, that’s correct

You: Would you mind telling me a little bit more about what’s been going on with your

stomach?

Mrs. Johnson: Sure. I’ve been getting these really sharp pains on and off for the last few

days and I’m not sure why.

You: Ok, I’m so sorry to hear that. I’m going to do my best to try and figure out what’s

going on so that we can get you feeling better as soon as possible.

Mrs. Johnson: Thank you.

You: Would it be alright with you if I asked you a few more questions about your stomach

pain so that I can get a really clear picture of exactly what’s going on?

Mrs. Johnson: Sure, that would be fine.

You: Great, thank you.

After they’re done, you want to take control & start moving through the mnemonics

And then you begin at the top of your mnemonic and ask the questions that Mrs.

Johnson didn’t quite answer when she responded to your initial open-ended question.

I hope that you can see how powerful this strategy can be when done correctly.

Not only do you satisfy the requirement of asking open-ended questions, but you asked

it right at the onset of the encounter, which is going to most likely stand out in the SP’s

memory. Then, by using the correct language, you can smoothly transition the patient

into your mnemonic and gather the remainder of the needed information without

anybody noticing that you actually planned out this sequence of events from the

beginning. As I’ve said many times already throughout this book, the more strategies you

can have in place for your CS exam, the easier it is going to be for you. You see, this

strategy that I’ve just outlined can be used flawlessly with each and every encounter. Try

to think of a situation whereby the approach taken here won’t work. I doubt you’ll come

up with anything, because in the thousands upon thousands of practice cases I’ve put

students through, I can’t think of one time when this wouldn’t work as long as it was

done correctly.

You might wonder if this would work on an angry patient, and it definitely would.

Whether the patient is angry, sad, anxious, or mean, it doesn’t change the fact that they’re

there for a reason and the logical sequence of events is for them to explain why they came

to see you, then for you to ask some follow-up questions. I strongly suggest that you re-

read this last section and practice it over and over again, because not only will this serve
you extremely well on your CS exam, but it will transfer over into your real-life scenarios

and work equally as well.

Separate each section into its own set of questions

We’ve discussed the importance of breaking up the interview into different

sections (i.e. HPI, PMH, Social hx). We do this for a couple of reasons: 1) To help us

maintain some structure, and 2) To repeatedly show the patient how respectful we are by

thanking them for answering questions and introducing each new line of questioning.

I’ve said it many times and I can’t stress enough just how important it is that you’re

consistently reinforcing your abilities in the eyes of the SP. This means that it’s in your

best interest to consistently behave throughout the encounter in a way that solidifies your

position as a top-notch medical student that is going to make a fine doctor. You want to

walk out of that room and leave no doubt in the SP’s mind that you’re going to do great

things one day. And the reason why you want to leave this impression is because

immediately after you walk out of the room the SP is going to head over to the computer

and grade your performance. Would you rather the SP grade you where they had to try

and think back about whether you did or didn’t perform certain behaviors or would you

rather the SP grade you without having to think back about anything because you

reinforced your skills again and again. You of course want the latter, and this is why it is

so important to weave these things into your encounter wherever you can. Most students

don’t realize that by chunking the history into different sections that they can

demonstrate more respect by thanking them for answering and then asking permission

to proceed. Many students start at the first question and don’t take a breath until they’re

all done. This is a recipe for mediocrity and will significantly decrease your ability to

confirm in the mind of the SP that you’re as good as they come.

 Separating the interview into a few different sections will, as you now understand,

allow you to give thanks and ask permission more often than the average student, which

will help ensure that you get all of your points. Here are the different sections that you

can break your interview into:

1) HPI: This will be from the point of the onset all the way until the associated signs

and symptoms. You will start your encounter here and once you’ve asked the final

HPI question, you will thank the SP for answering those questions and ask them

if it is ok that you ask some more questions, which brings you to the ROS.

2) Review of Systems (ROS): The way I like to ask the ROS is quite simple, and that

is by simply moving from head-to-toe, asking as many questions as I can think of

on the spot. This usually means starting at the head with headache and making

my way all the way down to the feet, where I might ask about swelling of the

ankles or numbness/tingling in the feet. The way I always ask permission to start

the ROS is by asking the SP if it’s alright that I ask a few general head-to-toe

questions that they can answer with a simple ‘yes’ or ‘no’. I tell them that this will

give me a better idea of their general, overall health. The answer to this question

is of course always a ‘yes’.

3) Past Medical History: This usually consists of questions ranging from previous

hospitalizations all the way to mood changes; you can find the proper mnemonic

in the mnemonics chapter of this book. Then once again, after this section has been

completed, you’ll thank them for answering all of your questions and then move

onto the social history.

 4) Social history: This is the final section of the interview portion and consists of

questions that give you more information about the patient’s day-to-day lifestyle.

I always recommend that students introduce this line of questioning just like that:

“If it’s ok with you, I’d like to ask you a few questions about your social history,

which will give me a better idea of how you’re living on a day-by-day basis”. As

with all of the other sections of the interview, the SP will of course give you

permission to proceed.

And that’s all there is to it. You can take a long list of questions that are seemingly

endless, break them up into smaller sections, and make it more pleasant for both you and

the SP, while reinforcing your excellent CIS skills at the same time.

Always do a smooth transition between each section

This is a bit redundant since I’ve been explaining how to do this for the last couple

of pages, but it’s important that you fully understand the purpose of the ‘smooth

transition’ between each component of the encounter. The smooth transition, if you

haven’t guessed, is the process whereby you effortlessly take the SP from one part of the

encounter into the next. If you do this the right way, it should go unnoticed and keep the

encounter running seamlessly.

There are only two things you need to do in order to perfectly execute the ‘smooth

transition’, including:

I. Thank the patient for allowing you to [insert previous activity]. If you’re in the

middle of the interview, this would look like this: “Thank you Mrs. Jones for

answering those questions”. If you’re in the middle of the physical exam it might
 look something like this: “Thank you Mrs. Jones for allowing me to listen to your

heart”. This first step essentially puts a cap on the previous section and indicates

that it has come to an end.

II. Ask the patient permission to begin the next sequence of events. If you’re in the

middle of the interview, it would look like this: “Would it be ok with you, Mrs.

Jones, if I asked you a few questions about your social history?”. If you’re in the

middle of the physical exam it would look something like this: “Would you mind

if I examined your abdomen now, Mrs. Jones?”

As you can see, the smooth transition simply offers a way to tell the patient that one

part of the encounter is over and a new one is about to begin. The key difference in this

approach is that instead of simply telling the SP what you want to do, you’re including

them in the decision-making process, which ensures that they feel respected and

appreciated. There’s nothing worse you could do in the encounter than make the patient

feel like they don’t have a say in what goes on in the room. By using the smooth transition

approach throughout your case, it will not only look like your encounter is more well

put-together than all of the others, but it will also feel good to the SP, which surely can’t

hurt.

Once complete, ask if there’s anything else they’d like to tell you

After the interview portion of the encounter has come to an end, it is extremely

important that you don’t just end it and move on. What you want to do is ask them if

there’s anything else they’d like to tell you that you may have overlooked. This is a great

opportunity for the SP to possibly mention something additional that they may have
forgotten to tell you during the interview, but more often than not there’s nothing left to

say at this point.

Thank them for answering all of your questions & transition into the PE

After you’ve asked the SP if there’s anything that you might have missed in the

interview and they’ve told you ‘no’, then that concludes the interview portion of the

encounter. At this point we need to once again implement a smooth transition, but this

time it is into a completely different section of the encounter. The nice thing about the

smooth transition is that whether you’re moving into a different line of questioning or

moving from the interview into the physical exam, the way you do it is exactly the same.

Thus, after completing the interview you would say something like this: “Thank you,

Mrs. Jones, for answering all of my questions. You’ve been very helpful and I’m starting

to get an idea of what might be going on. I still need to find some more information, so if

it’s ok with you I’d like to begin the physical exam. How does that sound?” The SP will

of course tell you that you can proceed, at which point you’ll have perfectly executed a

smooth transition from your interview into the physical exam.

THE PHYSICAL EXAM:

Wash your hands

One of the key differences between your typical smooth transition and the smooth

transition into the physical exam is that you must wash your hands. Now, students often

ask whether they should use soap and water or hand sanitizer, and the answer is that it

doesn’t matter. The only concern here is that you actually clean your hands. Now, this
brings us to one of the most important opportunities we have during the encounter;

downtime to chit-chat with the SP.

Students tend to forget that the SP is still a regular human being and that they’re

just acting a part. This is important to realize because the twenty to thirty seconds that

you take to clean your hands is your opportunity to tear down the metaphorical ‘wall’

that your SP is putting up as an ‘actor’ and get to know the real person underneath the

act. How are we supposed to do this? It is quite simple, we’re going to ask the SP an open-

ended question and get them talking about themselves. Now, the single most important

step you need to take in order to effectively pull this off is to have some questions ready

to be used before you go into the exam, which ensures that no matter which type of

patient you’re dealing with that you’ll be ready to build some rapport. I would strongly

suggest that you come up with three questions that you can rely on to use with your

patients. Which of these questions you use will depend on the age and gender of the SP.

For example, you’re not going to ask a nineteen-year-old male and a seventy-five-year-

old female the same question, since they’re not likely to have much in common. Thus,

having a question that you can ask a younger person, a middle-aged person, and an

elderly person will ensure that you’ve got something to ask no matter who is in that room.

Immediately after you’ve asked permission to go wash your hands and are on your way

to the sink, ask your rapport-building question. For example, if you’re dealing with a

thirty-five-year-old female who mentioned that she has two kids during the OBGYN

questions, why not take this time to ask her something about her kids. Great questions

might include their names, what types of activities they like to do, or what grade they’re

in at school. The goal of the question is to get the SP talking about something that will

make them happy. Once the SP has answered your question, ask them a follow-up based

on what they just told you. This can be as simple as telling them that it sounds like they’re

very proud of their children, or something along those lines. The key here is that this is
light and fun and should actually reveal the real person underneath the actor. You see, it

is highly unlikely that the acting SP has created an entire backstory about their fake kids,

where they go to school, what they do for extracurricular activities, etc. As such, when

you get a response to any of these questions, you should take this to be a real conversation

with the real person, which is likely going to help you to build rapport. All of this happens

over the course of only twenty to thirty seconds, but the impact that it can have on the

overall encounter can be dramatic. In fact, if you did a great job during those twenty to

thirty seconds, it is likely going to carry over into the physical exam, which means that

you’ve gotten through to the SP and now you’re really ‘vibing’ and having a good time

together. And trust me, there is nothing wrong with building such a rapport with the SP

that you’re both actually having a good time during the encounter. If you get to a point

in the encounter where you’re actually enjoying yourself and you can tell that the SP is

also enjoying themselves, you’re doing a fantastic job.

Unfortunately, you still have to finish the encounter, so you’ll need to proceed and

move into the physical exam. Even if you spark a friendly conversation, be sure to keep

it brief so that you don’t waste too much time.

Give an overview of what the PE will look like

As with everything else in the encounter, you want to let the SP know exactly what

you would like to do and then ask them permission to proceed. At the onset of the

physical exam you should outline the exams that you’re planning to do and then ask

them if you can begin. This would look something like this: “Mrs. Jones, I’d like to

perform a brief heart and lung exam, then do a more detailed abdominal exam, is that ok

with you?” At this point, the SP will give you permission and you will proceed. A very

important point to keep in mind is that many of your patients will be in pain, and it is
highly likely that you’ll need to examine those areas. In order to avoid causing pain and

severely hurting your CIS score, you should tell the SP that you’ll need to examine the

area but that you’ll do so as gently as possible. Let the SP know that if you elicit pain at

any time to let you know so that you can stop. As long as you give this warning prior to

starting the exam, they will be aware and won’t hesitate to let you know if you’re causing

any unnecessary pain. This is a step that many students miss, but it could be the

difference between a dreadful physical exam and a perfect physical exam.

Remind them what you’re doing at each stage & thank them each time

You’re likely going to be examining at least two to three different systems during

the physical exam portion of your encounter. At the very least, you should be doing the

basic heart and lung exam, followed by the system-specific exam in question. As you

complete each different system’s exam, thank the SP for allowing you to do it and then

reintroduce what you’ll need to do next. This will look something like this: “Thank you

Mrs. Jones for allowing me to listen to your heart. Would you mind if I listened to your

lungs now?” And you want to repeat that process upon completion of each system’s exam

and at the onset of each new system you would like to examine. The reason for this

approach comes back to the core principles of the CIS component, which is to show

respect to the patient. Imagine you’re in your doctor’s office and he examines you all over

the place without telling you what he’s doing. I’d guess that this might make you

uncomfortable, and at the very least curious about what’s going on. On the other hand,

if your doctor was to tell you what he’s doing as he’s doing it, you’d probably feel like

you’re more involved, and that usually makes you feel much more comfortable with the

process.
Finish strong and transition smoothly

Once you’re done the physical exam, be sure to thank them once again for allowing

you to perform the physical exam. At this point you’re once again faced with having to

transition between two major components of the encounter: Physical exam à Closure.

This can be easily accomplished by following our rules for making a ‘smooth

transition’. You’ve just finished the physical exam and you’ve thanked your SP for

allowing you to do it. At this point, all you have to do is ask the patient if you can take a

seat and discuss your findings with them; they will of course agree. This might look

something like this: “Thanks Mrs. Jones for allowing me to perform the physical exam,

I’ve got everything I need. Would you mind if I took a seat and discussed all of my

findings with you?” If you follow this word-for-word, you’ll have no problem

transitioning without any awkwardness.

THE CLOSURE:

This is by far the most commonly messed up part of the entire encounter and the

reason why is quite simple: students don’t have a strategy. You see, it’s really easy to go

into your exam without putting too much of your efforts into mastering the closure

because most students don’t think of it as a very important component, when in fact it is

quite possibly the most important component. Let’s say you did a decent job throughout

your entire encounter and you come to the closure and you don’t do very well, what do

you think will be the consequences of this? Well, the first consequence is that you didn’t

provide them with all of the information that they might have needed in order to give

you full points. In my mind though, the worst consequence of messing up the closure is

that this is the final point of interaction between you and the SP, and if you don’t do a
good job, the last memory that they have of you is a poor one. You absolutely, positively

have to provide your SP with an excellent closure that wraps up the entire encounter

beautifully and leaves the SP with a great and lasting final impression about your

performance.

In order to ensure that you put together the best possible closure, let’s take a look

at each component of the closure and dig deep into each one in order to ensure that there

isn’t a single component that you don’t understand fully and with complete confidence.

After the PE is done, ask permission to take a seat

This is a continuation of the physical exam and bridges the gap between the PE

and closure and is an important step in starting the closure the right way.

Using the Closure Script

I started to see more and more students struggle with putting together a strong

closure and finally decided that I needed to do something about it, which was to create a

script that students could master and use as the framework for closing any encounter.

I’m going to discuss the closure script, but I want you to realize that this was written in

my own words, so as you read the script, try to focus on the framework first and foremost.

This means focusing on the big components of the script, such as introducing the

findings, discussing the next steps, and closing the encounter. I would strongly suggest

that as a first step you memorize the script exactly as it is written. This will help you

understand what the closure should feel like coming out of your mouth, and as you gain

more and more confidence in saying it aloud, try and make it your own. Put your own

personality into it and change up any words that you feel more comfortable saying. As
long as you keep the important components in place, then you’ll be getting the most out

of the closure script.

Before we dive into the closure script, let me paint a picture for you. You’ve just

finished the physical exam and you’ve just taken a seat. You should grab your clipboard

and quickly jot down anything abnormal that you found so that you have it for your

patient note. Once that has been completed, you’ll begin the script below.

“Ok Mr. Jones, I’ve taken a thorough history and physical exam and based on everything I’ve

gathered, I believe we could be dealing with any of the following possibilities: #1_______________

#2_______________, or #3_______________, but until we run some tests we can’t be 100%

certain of anything. So, what I’d like to do is run a couple tests (insert test names and reasons

here) to gather some more information and once we have the results and know more, I’ll get in

touch with you right away so that we can discuss things further. Does that sound like a good plan

to you? Do you have any questions for me at this time? I’d also like to remind you that I

recommended that you try to quit smoking, so if you’d like some help with that, please let me know.

Do you have any questions or concerns that I can address for you at this time?” (say goodbye,

shake hands, and exit).

Once you’ve reached the end of the script where you’re asking the patient if they

have any questions or concerns, you should always assume that at least one question will

be asked. If there is a question, take a deep breath and answer it to the best of your ability.

If you follow all of the advice contained within this book, you should have all of the tools

needed to properly and confidently answer any question that gets thrown your way.

Once you’ve fully answered the SP’s question, be sure to ask if they have any more

questions. Technically, the SP can ask as many questions as they like so you want to
always make sure that they’ve asked everything that they wanted or needed to ask. Once

they confirm that they have no further questions, it’s time to begin your exit.

THE EXIT:

This is the last chance that you have to leave a lasting impression on the SP. The

advice I give to my students is to always consider what the majority of the students are

doing at this point in the encounter and to improve upon it. The advice I’m about to give

you is something that I came up with when I was preparing for my own CS exam many,

many years ago. I wanted to ensure that I was the most memorable medical student of

the day, and so I developed my exit strategy and I’m going to share it with you right now.

The first step to a marvelous exit is to tell the SP that it has been wonderful meeting

them; then you should shake their hand. Whether you shake their hand sitting or

standing is not all that important, I’d say do whatever feels more natural to you. Now,

after you shake their hand you should say “Have a nice day”. It is at this point that you

should implement your exit statement, which is going to do two things: 1) It is going to

show the SP one last time just how much you do care about them, and 2) It is going to

leave the SP with a great final impression. Let’s set the stage for this final exit statement:

You’ve shaken their hand and you have said ‘have a nice day’, as you begin walking

towards the door, pause for a second, turn around, and say the following: “Mr. Jones, if at

any time after I’ve left the room any questions or concerns come to mind, please don’t hesitate to

let the nurse know and I’ll come back and answer any questions you might have”. The reason

why this is so powerful is because nobody else is going to do it. I’ve never once put a

student through an initial patient encounter assessment and seen them do anything like

this, which tells me that it is still something that will help you stand out from the pack as

well as leave a positive and lasting impression on the SP.

 At this point, you’ve impressed the SP throughout the encounter and now you’re

showing them one last time just how impressive you are. What happens next is you leave

the room and your SP heads over to grade your performance. As long as you’ve done

your job, the SP should have a very easy time doing theirs.

That brings our discussion of the ‘Anatomy of the Encounter’ to an end. In order

to truly master this chapter, you should go over it several times. You should draw out

the ‘Anatomy of the Encounter’ chart from the beginning of this chapter and ensure that

you can go through it and know what to do at each different step. You’ll know you’ve

got this mastered once you can walk yourself through the entire chart and can explain

aloud, without hesitation, exactly what needs to be done at each step.

 8
Mastering
Challenging Questions
& Scenarios
You probably wouldn’t be surprised to learn that the thought of a challenging

question or scenario on the CS exam leads to anxiety in most medical students. The reason

for this is fairly straightforward, which is that there’s no real training around how to

tackle these situations. Luckily, I’ve developed a few strategies for my students over the

years that help with answering challenging questions and tackling challenging scenarios,

and we’re going to go over those right now.

The first step in mastering the approach to answering challenging questions or

diffusing challenging scenarios is to understand why they’re asked and what is expected

of us.

A challenging question or challenging scenario is difficult for students because it

forces them outside of their comfort zone. It takes them from going through the routine

they’ve practiced dozens of times and forces them to move in a completely different

direction. But this is the point of the challenging question or scenario – to make you

uncomfortable. As physicians, you’ll be faced with challenges each and every day, so it

only makes sense that the USMLE would include at least one challenge into each case.
You’ve got an advantage, however, because as you read this book you start to realize the

ins-and-outs of the challenging questions and scenarios, and the more you know and the

better prepared you are to tackle them, the less scary they should be. Shortly we’ll go

through a step-by-step strategy for tackling challenging questions so that by the time you

finish this chapter, you shouldn’t fear them at all.

Why are challenging questions asked?

Throughout ninety-nine percent of the encounter, the student has control and asks

the questions, so this gives the SP an opportunity to take charge and put the student on

the spot. If a student is ill-prepared or not prepared to answer a challenging question

when it comes (and it will come), then it could be a huge blow to the overall score of the

encounter. It is extremely important that as a student preparing for the CS exam you

recognize that challenging questions will be asked, and that learning how to answer

challenging questions must be worked on. Not only does the challenging question give

the SP a chance to take charge, it gives the SP a chance to really challenge the student to

see if they can handle something that they may not have been expecting. If a student is

doing exceptionally well thus far in the case, a challenging question may simply be a way

to reaffirm that the student is on top of their game. On the other hand, if a student is

doing poorly thus far in the encounter, a challenging question may be asked to see if it

will further negatively affect the student’s ability to perform under pressure. No matter

the reason for the challenging question, realize that you will be asked a challenging

question on most cases and that you do need to prepare yourself for when it comes.
What is our primary goal in answering the challenging questions?

The primary goal of the challenging question is to provide the SP with an answer,

however it is important to realize that many of the challenging questions that you’re

asked may not actually have a definitive answer, in which case your job will be to provide

the SP with the best possible answer that you can with the information you’ve got at the

time. Thus, you may be asked a question that you can answer right away, in which case

you will answer it. You may also be asked a question that is impossible to answer at the

time, which is where things tend to get trickier for students. You see, it’s easy to answer

a simple question such as ‘Will this take long?’ But answering a question such as ‘Do you

think I have cancer?’, poses a much bigger challenge. At this point in time, the thought of

having to answer the question ‘Do you think I have cancer?’ may lead to some anxiety.

But as you’ll see shortly, answering this type of question is actually quite easy once

you’ve got a strategy in place.

How the SP responds to a poorly vs. well-answered question:

One of the biggest mistakes a student can make when answering a challenging

question is to answer the question and then move on immediately. Once you answer a

question, you’ll likely get some sort of feedback from the SP, be it verbal or non-verbal,

but you will get some sort of cue and it is extremely important that you can read these

cues and respond appropriately. The easiest way to determine whether or not the SP likes

your answer is to ask them. So many students fear asking the SP/patient if what they’re

going to do or what they’ve said is to their satisfaction, but when done correctly it can

provide you with some really valuable information. For example, let’s say that you just

answered a challenging question whereby the patient asked about their odds of having

cancer. Whether you think you answered sufficiently or not can be confirmed by asking
the patient a simple question: “Are you ok with that plan?” If they’re happy with your

answer, they’ll let you know. If on the other hand they’re not happy with your answer,

you’ll likely be met with hesitation, confusion, or some other indicator that what you just

said wasn’t all that great.

The most important lesson here is that you can in fact tell based on the SP’s

response to your answers if you did a good job or not. You can also use that valuable

feedback to course-correct in the case that you didn’t do a good job the first time. Imagine

how much better you’ll do overall if you understand how to properly answer a

challenging question, then use the feedback given by the SP to either move forward

confidently or try again. Either way, as with so much of what goes on during the

encounter, it is the tone and delivery of your responses that is almost as important as the

content of those responses.

THE STRATEGY FOR ANSWERING CHALLENGING QUESTIONS:

This next section is going to be one of the most valuable of this entire book, simply

because most students never learn how to do this properly, and because so much depends

on your ability to properly handle challenging questions and scenarios. If you know how

to handle anything that is thrown your way, not only will you be able to handle it with

grace, but you’ll have more confidence overall, which will be evident to the SP.
You’ll get one of two types of questions

You’re going to only get one of two types of questions as part of the challenging

questions that come your way on the exam: #1. A question with an immediate and specific

response, or #2. A question that cannot be answered completely.

It is #2 that tends to stump most students because they get caught off-guard and

because there is no response to give, they tend to freeze and either stare off into space or

answer in a way that doesn’t come close to providing the SP with a quality answer.

Because of this, what we’re going to do now is use a 4-step approach to answering

challenging questions that will provide you with a strategy to answer absolutely

anything. No matter how odd, absurd, or challenging the question may be, you’ll be able

to provide an answer based on this 4-step process to almost any challenging question.

The Strategy

As I said above, you’re going to get one of two types of questions; one that can be

answered immediately and one that can’t. I want you to take a look at the following

flowchart and try to get a sense for how you’ll approach a question given to you on the

exam.
 As I mentioned previously, if the question is straightforward, you can simply

provide an answer, but chances are that it won’t be that simple, which is why we have

our 4-step strategy.

The 4-step strategy:

There’s nothing overly complicated about this strategy, but you do have to

understand how to execute each one of these steps if you hope to get the most out of it.

Let’s now take a look at the steps and look at an example of how each one is executed.

For example’s sake, let’s assume that the question posed by the SP Mr. Jones was this:

“Doc, do you think I have cancer?”

#1. Acknowledge the concern: This means repeating the patient’s question in a statement

that essentially lets them know that you understand what they’re asking and that you

recognize their concern.

How this looks: “Mr. Jones, I can understand why you might be concerned that you could

have cancer”.

#2. Let them know that more information is needed to properly answer their question:

This means that because the question isn’t a ‘yes’ or ‘no’ type of question, that you need

to explain this fact to the SP. By properly executing this step, we begin the process of

explaining to the SP that their question cannot be answered at this moment; this sets us

up for step #3.

How this looks starting from step #1: “Mr. Jones, I can understand why you might be

concerned that you could have cancer. At this time, I simply don’t have enough

information to give you an accurate answer”.

#3. Give them a quick breakdown of what you’ll do to get to a point where their

question will be answered: This is a very crucial step because it outlines what you will

have to do in order to come to a definitive answer to their question. In step #2 we told the

SP that we simply cannot answer their question with the information we have, which if

we stopped there, would be a terrible way to answer the question. Perfectly executing

step #3 is the key to ensuring that you get top points for your response to the challenging

question.

How this looks starting from step #1: “Mr. Jones, I can understand why you might be

concerned that you could have cancer. At this time, I simply don’t have enough

information to give you an accurate answer. What I’d like to do is finish asking you a few

questions, do a focused physical exam, and then run some tests that will give me all of

the information I need to better answer your question. Once I’ve gathered everything I

need, I’ll be able to give you a definitive answer to your question”.

#4. Ask if they’re ok with your response: This is the final step and arguably one of the

most important because this step will let you know if you did a good job or not. It is very

simple to execute; simply ask the SP if they’re ok with your plan. If they agree, then you’re

in good shape. If they act confused or tell you that they don’t quite understand what you

mean, then you have a second chance to clarify your response. If done properly, this will

ensure that you’ve done a good job.

How this looks starting from step #1: “Mr. Jones, I can understand why you might be

concerned that you could have cancer. At this time, I simply don’t have enough

information to give you an accurate answer. What I’d like to do is finish asking you a few

questions, do a focused physical exam, and then run some tests that will give me all of

the information I need to better answer your question. Once I’ve gathered everything I

need, I’ll be able to give you a definitive answer to your question. Does that sound like a

good plan to you?”

And that’s all there is to it.

By following this simple 4-step approach, you’ll be able to tackle most challenging

questions that don’t have an ‘on-the-spot’ answer. As I said earlier, this isn’t going to

work for every single possible question that you could be asked; there’s no one-size-fits-

all approach to anything, but this should allow you to answer almost anything that gets

thrown your way on the CS exam

THE STRATEGY FOR HANDLING CHALLENGING SCENARIOS:

Challenging situations or scenarios are manufactured by the SP and are designed

to elicit stress and cause you to falter. These types of scenarios are going to present

themselves throughout your entire exam, so it is important that you realize this and are

well-prepared to handle anything coming your way. The easiest ways to ensure that a

challenging scenario or situation doesn’t cause you any undue stress is to remember that:

1) It is a manufactured scenario created by the SP at the request of the USMLE; these

aren’t real and so you’re not in any real danger, and 2) They will be coming; if you realize

that it is going to happen and more importantly, you’re actually prepared for it, then

there’s really nothing to be stressed out or anxious about.

Some of the more common types of ‘challenges’ that you could experience include any of

the following:

ü An angry patient

ü A rude patient

ü A flirtatious patient

ü A ‘tired’ patient who can’t stay awake

ü A patient with memory impairments

In truth, you could experience almost anything, however these are some of the

most well-known and common types of patients you’ll experience in reality and therefore

they’d make for a great challenging scenario as well.

Something that you need to remember up-front is that you cannot apply a ‘one-

size-fits-all’ type of approach to the challenging patient, simply because a rigidly

structured response won’t work the same with every type of issue. There is however a

relatively simple formula that you can use for most situations that will at least give you

a framework for working through the challenging scenario and help you to achieve your

goal. The basic strategy that you can apply to your challenging scenarios/patients is as

follows:

1) Remember that the SP/patient is only acting

2) Tell them that you can see that they’re [angry, sad, tired]

3) Ask if they’d like to tell you why they’re feeling that way

4) Offer an apology and/or offer to listen

Let’s take a look at some of the common scenarios and how our simple 4-step strategy

will work to diffuse the situation.

Challenging Scenario #1 - The Angry Patient

While the angry patient may be the most intimidating of them all, the first step in

our 4-step strategy is to remember that they’re simply acting angry, they’re not truly

angry at you. This should immediately help you to remain calm, cool, and collected.

Here’s a look at the dialogue of the 4-step process in action for this type of patient (step 1

is not included below):

You: “Mr. Smith, I can see that you’re angry, would you mind telling me why?”

Mr. Smith: “I’m mad because you kept me sitting in the lobby for over forty-five minutes

and now I’m late for a lunch meeting”.

You: “Mr. Smith, I’m truly sorry that you were kept waiting for so long. We had an

emergency here that we had to deal with and I’m truly sorry that we kept you waiting.
I’m here now and you have one-hundred-percent of my attention, would it be ok if we

moved forward and you let me do what I can to best help you?”

As you can see, all that really needs to be done in this type of scenario is to

acknowledge that you see the patient’s emotions and inquire as to why they’re feeling

that way. If you or your staff are the cause, you can offer them an apology and then

simply ask if you can proceed with the encounter. The goal here is to wait for feedback

from the SP after you offer an apology. For the most part, if you offer an angry patient a

sincere apology, they will accept it and move on. There is of course a chance that the

angry SP doesn’t move on this easily, at which point you could ask if there’s anything

that you could do to rectify the situation. Since there probably isn’t much that you can

actually do to make it up to them, you’ll likely repeat to them how sorry you are and that

they’ve got your full attention. As long as you approach this with respect for their feelings

and sincerity in your apology, you’ve done your job.

Challenging Scenario #2 - The Sad Patient

The sad patient poses a bit more of a challenge because it isn’t as easy to snap

someone out of sadness as it is out of anger. Now, the sad patient challenge assumes that

the case is not in fact a mood-related encounter. What this means is that the ‘sad patient’

may show up for a headache or stomach ache, but also appear to be sad. In this instance,

your goal will be to address the issue and offer a solution to show that you’re concerned

and want to give that problem the attention it deserves. Let’s assume for the sake of this

example that Mr. Smith is seeing you for chronic headaches. Here is how this

conversation might look between you and the SP (remember that this is a headache case

first and foremost):

You: “Mr. Smith, it seems that you’re feeling a bit down, am I reading that right?”

Mr. Smith: “Yes, I’ve been feeling pretty down for the last little while and I don’t know

why”

You: “Ok, I’m really sorry to hear that. This is a concern for me and I want to give this

my full attention so that we can figure out what’s going on and get you feeling better as

soon as possible. Since we don’t have time right this second to dive into it, what I’d like

to do is schedule you for a follow-up visit and during that time we can discuss your

sadness and try to figure out what’s going on. Does that sound like a plan to you?”

Mr. Smith: “Yes, it does. Thank you so much for your help!”

And that’s all you need to do in a scenario such as this. As you can see, the main

features of the strategy, no matter what the challenge, include recognizing the problem

and directly asking the SP about it. Then, offering a solution based on the reason for their

problem. If it’s something you can fix with an apology, then apologize. If it’s something

that needs to be addressed on a deeper level, tell the SP that you’d like to see them again

so that you can give the problem one-hundred-percent of your attention.

Challenging Scenario #3 – The Flirtatious Patient

The flirtatious patient poses a significant challenge because you have to ensure

that your response doesn’t come across as being dismissive or offensive. If you’re not

ready for this type of challenge, it could pose a huge problem. Luckily, we’re going to

explore how to handle two different types of ‘flirtatious’ patients so that in case you come

across this during your CS exam, you’ve been exposed to it and have an idea of how to

delicately handle the situation.

We have two common scenarios that we should recognize: 1) A patient who asks you out

socially, and 2) A patient who wants to set you up with their

son/daughter/niece/nephew/etc. So, let’s take a look at how we can handle each of these

different, yet equally challenging scenarios:

#1 – The Patient who asks you out socially:

The biggest challenge here is not necessarily in answering the question, but it is

doing so in a way that will not cause the patient to feel embarrassed or insulted. In my

experience, the single best way to deal with this type of scenario is to let the SP know that

you’re flattered but married. In that type of response, you acknowledge that you

appreciate the fact that they are interested in your company, however being married

means that it is one-hundred-percent off-the-table. Here’s how this might look during an

encounter:

Ms. Jones: “Would you possibly be free today after work to grab a coffee with me?”

You: “Ms. Jones, I’m flattered that you would ask me out for coffee, but I am married and

that just wouldn’t be appropriate”

Ms. Jones: “Ok, I understand”

The reason why I would suggest this approach versus saying that you’re not

allowed to date patients is because if you use that approach, the SP might simply tell you

that they’ll find another doctor, which puts you into an even worse situation because now

you have to deny the request a second time. In reality, yes, we are not allowed to have an

intimate relationship with our patients, but our goal on the CS is to meet challenges such

as this with as much grace and as little friction as possible. If your goal is to accomplish
this, then the response laid out above will accomplish these goals with a very small

chance that the SP keeps pushing back.

#2 – The Patient who wants to set you up with a family member:

I would suggest that you follow the exact same approach with this type of patient

as you would with one who asks you out themselves. For the sake of an example, let’s

say your patient is Mrs. Johnson and she thinks that you would be perfect for her

daughter. This might look something like this:

Mrs. Johnson: “I think that you would be perfect for my daughter. Here’s a picture of her,

would you be interested in meeting her for a coffee or a drink sometime this week?”

You: “Mrs. Johnson, I’m flattered that you would consider me worthy enough for your

daughter, but unfortunately I’m married and unavailable”

Mrs. Johnson: “Oh, that’s too bad, you two would have been perfect together”

You: “I bet. Would you mind if we continued and I asked you a few more questions about

your current visit?”

That’s all that you really need to do in this scenario. You’re taking the same

approach with the ‘set up’ question as you are with being asked out directly. The goal

with both is the same: To be respectful and prevent the patient from being embarrassed

or offended. By using this type of response, you will easily achieve both of those

objectives.
Challenging Scenario #4 – The Patient with Altered Mental Status

This challenge is a bit different from the previous three scenarios because in this

instance we’re likely having trouble effectively communicating with our SP. This scenario

requires that you maintain composure, respect, and patience more than it does being able

to ask the right questions.

This patient may consistently lose focus and veer off into space, or they may

repeatedly ask who you are or where they are. No matter how this patient challenges

you, your goal should be to demonstrate your patience, which is the main objective in

this type of challenging scenario. If they stand up and start walking around in the middle

of your discussion, simply get their attention by saying their name and asking them if

you can resume your interview. If the SP asks you over and over again what your name

is, simply repeat your name and continue asking your questions. If they continue to ask

you where they are, simply remind them where they’re at and then continue with your

questions.

All that you really need to remember here is that the SP may challenge you to the

point of annoyance, but your job is to keep smiling and to be respectful and patient. As

long as you maintain patience and respect, you will earn full points for your handling of

this challenging scenario.

Let’s finish this section by reviewing the important information that you need to keep

in mind for any type of challenging scenario:

ü Always be prepared (When you expect it and you’re ready for it, it is easier to

deal with)
 ü Practice with a partner and on your own (You want to use a partner for feedback

on your performance and you want to repeat how you’ll handle this in your head

so that you build ‘muscle memory’ into your responses, which ensures that you

can handle anything, despite how stressful the scenario)

ü Always demonstrate extreme patience (This is a test, and if you lose your patience

you can expect to lose points; no matter how bad it might get, stay calm,

composed, and respectful)

ü Always be respectful of the patient (This cannot be stressed enough)

ü Think about the patient first (If you were the patient, how would you want to be

treated? Keep this in mind during your cases and it should make your job a bit

easier)

WHAT TO DO WHEN YOU’RE RUNNING OUT OF TIME:

Running out of time during the CS encounter might be one of the biggest fears that

students face. The thought of running out of time might be scary, but even scarier is the

fact that most students don’t know why it keeps happening or how to avoid it. In order

to avoid running out of time and messing up your entire encounter, let’s take a look at

some of the most common reasons why students run out of time, what not to do if you

run out of time, and how you can prevent this from ever happening to you in the first

place.

Most common reasons why you might run out of time

It isn’t a surprise that so many students can’t navigate their way through a CS

encounter in a timely manner; we’re never taught how to do it. We’re taught how to
perform the physical exam in medical school and we’re taught how to interact with

patients during our clinical years, but nobody ever takes us aside and shows us how to

do a full interview and physical exam in under fifteen minutes, let alone one that includes

rapport-building, empathy, and a variety of other requirements. So, if you’re running out

of time during your CS encounters, it really isn’t your fault. Now, the key to avoiding

unfortunate scenarios such as running out of time is by knowing why it happens. So, let’s

take a look at some of the most common reasons why students are running out of time

and I’ll give you some information so that you fully and completely understand what is

meant by each.

Reason #1 – Not following the mnemonic properly

We’ve discussed the importance of using mnemonics many times throughout this

book already, and by now you should have a solid understanding of their benefits and

why using them is so important and beneficial to your overall exam strategy. Mnemonics

help to keep you focused on the important questions during the interview, and they allow

you to quickly and rapidly transfer that information onto your patient note. If you’re not

using mnemonics during your encounter, you’re likely losing one to two minutes. Those

one or two minutes would be useful to properly close the encounter, but if they’re lost

then you might find yourself running out of time just as you sit down to close the

encounter.

Another issue that occurs commonly is that students start out by following the

mnemonic, but they end up abandoning it halfway through the interview, which ends up

costing them time. It can be difficult and challenging at first to stick with the mnemonic

throughout the entire encounter, but that’s where practice and repetition will help ensure

that this never becomes an issue. One of the common reasons why students stray from
the mnemonic occurs when the SP mentions something that takes them to a different area

of the mnemonic. If that happens, students might end up staying there and not returning

back to where they were at in the course of the interview, so be aware of this problem

and make sure that if you catch yourself doing it, that you correct it as you continue to

practice.

Reason #2 – You’re doing a review of the facts before your PE

I’ve seen this one throughout the years and it always puzzles me why students

feel the need to repeat the entire history to their patient; the patient just gave it to you

and you took notes, why are you repeating the entire thing all over again? This is a huge

waste of time and should be avoided. Now, you might be thinking that by reviewing

everything that you’ll confirm that nothing was missed, but if you used the mnemonics

and you demonstrated to the SP that you were documenting things as you asked the

questions, there’s a very slim chance that they’re questioning your ability to gather the

right information. Most students seem to be doing this to remind the SP that they got the

information they needed. Remember that the SP is present with you in the room and they

know whether you did things correctly or not, so there’s no need to repeat everything.

Reason #3 – Not writing in shorthand

I’ve seen so many students write out words like ‘headache’ or ‘nausea and

vomiting’, when they could have easily written ‘HA’ and ‘N/V’ and saved fifteen to

twenty seconds of their time. If you’re writing out words in full when they can easily be

shortened, then you’re doing a lot of harm to your overall encounter. Imagine that each

full word you write out could be written in shorthand; you could possibly save five

seconds per word, which will end up being several additional minutes of time you’ll have
at the end of your encounter to close properly. So be sure that you don’t make the mistake

of writing every word in its full form. Use shorthand whenever possible and you’ll find

yourself with a lot of additional time to focus on other areas of the encounter.

Reason #4 – Speaking too slowly or in excess

Often times students think that they need to speak very slowly in order to cater to

the SP, but speaking either too slowly or too quickly will probably do more harm than

good. You should aim to speak as you normally would, paying special attention to ensure

that you aren’t going too slowly or too fast as a result of exam-day nerves.

Students often times believe that they need to keep the conversation going for as

long as possible, often to the detriment of the entire encounter. If you follow all of the

advice you’ve come across thus far in the book, you know exactly what you need to be

saying and when. You also have strategies and scripts to use throughout the more

challenging parts of the encounter, which means you shouldn’t end up making this

mistake. If you’re running out of time near the end of your encounter, meaning as you’re

going through the closure, you should ask yourself if you’re running out of time because

you made a mistake earlier that cost you some time now, or if you’re speaking excessively

during the closure and it’s costing you time. If you’ve covered the entire closure script

already but you keep speaking for the sake of filling the time, make sure that you

recognize this and stop right away. If you’ve completed the encounter but you end up

running out of time as a result of speaking in excess, you’re going to lose points.
Reason #5 – Asking more questions than the mnemonic requires

The mnemonics are designed specifically to ensure that the vast majority of the

necessary questions are asked during the interview. It is important of course that you

include all of the pertinent mnemonics into the interview based on the chief complaint,

otherwise you will miss some important questions. On the rare occasion that an

additional question or two may be needed outside of the mnemonic, it will likely be very

obvious. As an example, if the chief complaint is chest pain and the patient demonstrates

pain-relief when leaning forward, that is indicative of pericarditis and yet that specific

question is not part of the mnemonic. As I’ve said, mnemonics are designed to get you

the overwhelming majority of the needed information, but there will be times when you

have to count on your intellect to extract additional information.

So, if there’s an obvious question that needs to be asked outside of the mnemonic,

you of course want to go ahead and ask it. However, don’t sit in silence searching for

extra questions to ask just for the purpose of asking more questions. If you do a good job

and ask what needs to be asked, have confidence in yourself and keep moving forward.

What ‘not’ to do if you end up running out of time

Even the most well-prepared student might find themselves tight on time, or

worse yet running out of time before finishing the encounter. The first thing to keep in

mind is that if this happens once, it doesn’t equal failure. If it happens consistently on the

other hand, you do run the risk of failing. If you are ever faced with the unfortunate

circumstance of running out of time, you need to be prepared to deal with it. Before we

get into that, however, here’s a few “don’ts” that I want you to keep in mind should you
find yourself in the unfortunate scenario where the encounter has ended but you’re not

quite done yet:

ü Don’t act surprised and freeze

ü Don’t stand up and walk out of the room without saying anything

ü Don’t just say goodbye and leave

ü Don’t keep going as though you didn’t hear the announcement

Before I give you a scripted plan that you can implement should you find yourself

in this type of scenario, let me expand a bit on these four “Don’ts” so that you fully

understand what many students do and why they are bad ideas.

Don’t act surprised and freeze:

Believe it or not, I’ve seen this happen. This is almost always the case when a

student hasn’t considered what they’d do if the time was to run out, and as a result they

were rendered frozen. This is probably the worst thing that you could possibly do

because it shows the SP that in the case of a surprise, you’re not someone who knows

how to handle themselves. Remember, this shouldn’t happen to you because I’m giving

you some insight into this problem and ‘acting surprised and freezing’ is typically

reserved for someone who has never considered how they would handle this scenario.

Don’t stand up and walk out of the room without saying anything:

This comes in at a close second behind freezing on the spot. Never should you exit

the room during a CS case without first saying goodbye to the SP, at the very least. Even

if you’re forced to exit the room abruptly, there’s no excuse for not taking two or three
seconds to say ‘goodbye’ and ‘have a nice day’. Not only is exiting the room without

saying anything rude, it also makes things very awkward and doesn’t make you look

good.

Don’t just say goodbye and leave:

What I mean by this is to not just literally say ‘goodbye’ and then walk out. It takes

an extra two seconds to also shake the SP’s hand and tell them to ‘have a nice day’. If

you’re forced to exit the room early, the very least you should try to do is leave the SP

with a good final impression.

Don’t keep going as if you didn’t hear the announcement:

This is a very bad idea, simply because the act of ignoring the announcement and

continuing will not only show the SP that you don’t respect the rules, it could lead to

some serious penalties from the exam moderators. You should absolutely wrap-up the

case within five to ten seconds, which I’ll explain how to do shortly, but you simply

cannot keep going as though the announcer didn’t tell you to leave the room. This might

seem like you’re going above and beyond to show the SP how dedicated you are, but this

is going to backfire and lead to a significant drop in your score.

What to do when you run out of time

How well you handle running out of time in an encounter will depend entirely on

how well you planned for it during your preparation. This means you need to have a

strategy in place for if and when this occurs, and you need to practice it to the point of
mastery; if you take this approach and go into the exam well-prepared for the worst, it

won’t affect you negatively if it happens.

The way by which I’m going to ensure your preparedness for this scenario is by

providing you with a script that you can use as a template for your early exit. The

following script is the one I recommend for my own students since it does a couple of

things very well:

I. It ensures that you wrap up the encounter as nicely as possible given the

circumstances

II. It makes you look prepared and well-equipped to handle a tricky scenario

Use the following script as a template for formulating your own exit-strategy. Or

if you like, use it as is. The following is an example script of what you could say to your

SP as soon as the announcement comes from the PA system telling you to exit the room:

“Mr. Jones, I’m so sorry but I’m being paged and I need to end our interview a bit early.

I will run some tests and get in touch with you once the results are in. If you have any questions

in the meantime, please let the nurse know and I’ll get in touch with you as soon as I can. It was

great meeting you and I’ll speak with you soon. Have a great day”.

This script wraps things up quickly yet still covers some important pieces of

information that you should share with your patient prior to exiting the room. I

encourage you to practice this until you can recite it convincingly and within no more

than ten seconds. It is also important to remember that there is no time to answer

questions once you’re told to leave the room, so don’t end this statement by asking the

SP if there’s anything you can answer for them. Remember, this is not at all an ideal
scenario to find yourself in, however what we’re doing here is simply trying to do our

best to turn a bad situation into a slightly less bad situation. There’s no way around the

fact that an incomplete encounter is not what you want, however it is in your best interest

to always be prepared for the worst-case scenario so that you can at least minimize the

potential damage.
 9
The
Physical
Exam
Now it’s time to get into the physical exam portion of our encounter. We’ve

discussed the details of the interview at great length and by now you should have a very

good idea of everything you should be doing throughout the encounter in order to ensure

that you get as many points as possible, both on the CIS and ICE components of the exam.

The goal of the physical exam is of course to gather even more information about

the patient’s current status and should be based on the chief complaint. Remember that

for the sake of this exam, there is most likely going to be one main system that needs to

be examined. Something very important to keep in mind however is the fact that you

should also perform a very basic heart and lung exam for each encounter, assuming that

neither the heart nor the lungs is the system requiring a more thorough examination. If

the lungs require a thorough examination, then stick to a basic heart exam and a thorough

lung exam. If the heart requires a thorough exam, then stick to a basic lung and a

thorough heart exam.

Proper draping during the physical exam

Ensuring that the patient is properly draped and has a lap towel is extremely

important, so when you walk into the room this needs to be one of your initial

observations. Check to ensure that the patient is wearing the gown, and check to see that

they have a small towel or blanket on their lap. If either of these is missing and/or not in

place, you should get to them right away.

Properly exposing the area to be examined

It’s important to remember that the area you’re examining, whether it is the chest,

back, or abdomen, should be exposed during and only during the time of examination.

Of course, it is also important that you do not overexpose the patient and make them feel

uncomfortable, so keep that in mind at all times. For example, if you’re examining the

heart of a female patient, she will be wearing a bra or other supportive device to cover

her breasts; you don’t want to remove this item of clothing. Additionally, when

examining the heart of a female patient, if you need to listen to the mitral valve, it is in

your best interest to ask the patient to lift her left breast, not to try and move it yourself.

This is typically common sense however I want to be sure that this mistake isn’t made

during your exam.

One of my favorite physical exam tips to share with students has to do with

exposing the chest during the exam. When you are ready to examine that anterior chest,

which you will do during almost all cases, you are required to expose the patient’s chest.

Most students tell the SP they need to access the chest and then they move the gown

down themselves. Instead of doing this yourself and risking potentially making the SP

feel uncomfortable, make your life easier and let the patient know that you’d like them
to lower the gown themselves. This would sound something like this: “Mrs. Smith, I need

to listen to your heart now, would you mind lowering your gown as far as you’re

comfortable so I can access your heart?”. And when you do this, it does a couple of very

important things: 1) It shows the SP that you’re concerned for their comfort, and 2) It

lowers the risk that you’ll accidentally touch them in an inappropriate way.

As soon as you’re finished with an exposed area, you must cover it back up. This

is something that I’ve seen so many students forget time and time again. Therefore, make

it a habit to ask the patient to cover back up immediately after you’ve finished the

examination of that particular area. If you’ve finished the cardiovascular examination

and you need to now examine the abdomen, you want to cover up the chest before

moving onto the abdomen (i.e. Cover up each area as soon as you’re done with that

particular exam, don’t wait until the end of the entire exam to cover everything up).

Knowing what physical exams need to be performed

This is by far one of the most common issues students have when it comes to the

physical exam component of the exam. Students are often times lost when it comes to

figuring out which areas need to be examined based on the chief complaint. The real

problem here is that there’s nothing out there that teaches students the theory of the CS

exam in a way that simplifies things and makes it super easy to navigate. Therefore, I’m

going to give you a very simple strategy that you can use in order to ensure that you

never screw up the physical exam portion of the exam, as well as ensure that you have

confidence in yourself to make the right decisions.

The first step is remembering to always do a basic heart and lung exam, meaning

a quick auscultation of the four valves of the heart and four quadrants of the upper back
when listening to the lungs. This is of course assuming that your case doesn’t involve

either the heart or the lungs. If you’re dealing with a cardiovascular case, then you’d do

a basic lung exam and a thorough heart exam. If you’re dealing with a pulmonary case,

you’d do a basic heart exam and a thorough pulmonary exam. The basic heart and lung

exams are done when neither of these systems is the main system requiring your

attention. I also recommend doing this at the very beginning of your physical exam so

that you can take those twenty to thirty seconds to think about what you need to do as

part of your thorough exam.

Breakdown strategy for the physical exam

As with every other area of the exam we’ve discussed thus far, we can also apply

a strategy to our physical exam in order to make things as simple as possible. The

following is a step-by-step strategy that you can put in place to ensure that you navigate

these four to six minutes as efficiently and perfectly as possible:

1) Ask the SP permission to begin the PE

2) Wash your hands (use this time for rapport-building)

3) Tell the SP exactly what you’re going to do and be sure that you have their

permission prior to starting

4) With each different part of the exam, explain what you’re doing so that they feel

comfortable the entire time

5) Once finished, thank the SP for allowing you to perform the exam

The overwhelming majority of the time you’re only going to have to focus on one

system, however there are some instances when you’ll need to do a bit more. For example,

if you’re examining a patient that you believe to have hypothyroidism, you need to
examine the thyroid, which is part of the HEENT exam, but you also need to check

reflexes since hypothyroidism can present with decreased DTRs, which can be used to

support your differential. In this instance, you don’t need to do a thorough neurological

exam when checking the DTRs, you simply need to use your knowledge to recognize

what exams should be done in order to get you as much information as possible. When

more than one system comes into play, such as in the hypothyroidism example, make

sure that your main exam focuses on the primary issue, which is the thyroid, and

recognize which system that belongs to; in this case it is the HEENT system, and thus the

HEENT exam should be your primary focus. The secondary system to examine is the

neurological system however remember that you only need to do specific maneuvers that

will get you the information you need for your support. This strategy should apply to

any case whereby more than one system needs to be examined. Remember, the primary

goal is to perform the system-specific exam that is causing the issue, and the secondary

exam will be done if another system can provide you with important additional

information.

Next, I’m going to outline the maneuvers that I’ve been teaching my students for years

as part the ‘system-specific’ exams. This means that for the sake of the CS exam, if you

know all of these maneuvers when performing each system’s exam, you should get the

points and the information that you need. One thing to keep in mind is that there’s not a

specific list of maneuvers that they’re looking for; simply a thorough exam. This means

that even if you have additional maneuvers that you’ve been using, that’s not a problem.

Simply keep in mind that ‘thorough’ is the most important component of the focused

exam.
The Cardiovascular exam:

Performing a thorough cardiovascular exam requires that each of the following

maneuvers is performed:

o Inspect & palpate

o Auscultation of the heart

o Auscultation of the carotids

o Check pulses in all extremities

o Check PMI (in left lateral decubitus position)

o Check for JVD in supine position

The Pulmonary exam:

Performing a thorough pulmonary exam requires that each of the following maneuvers

is performed:

o Inspect & palpate

o Auscultation of the lungs (posteriorly)

o Check lung expansion

o Percussion

o Fremitus (say ‘99’)

o Egophony
The HEENT exam:

Performing a thorough HEENT exam requires that each of the following maneuvers is

performed:

o Inspect the head

o Palpate the lymph nodes

o Palpate the sinuses

o Look into the eyes, ears, and nose

o Look into the mouth

o Look at the throat

o Palpate the thyroid gland

The Neurology exam:

Performing a thorough neurology exam requires that each of the following maneuvers is

performed:

o Mini mental status exam (if LOC or AMS is present)

o Cranial nerves 2-12

o Sensory in upper & lower extremities

o Motor strength in upper & lower extremities

o Deep tendon reflexes in upper & lower extremities

o Alternating hand test

o Romberg test (for balance assessment)

o Gait test
The Abdominal exam (GI, GU, OBGYN)

Performing a thorough abdominal exam requires that each of the following maneuvers

is performed:

o Inspect (do this 1st)

o Auscultate (do this 2nd)

o Percuss (do this 3rd)

o Palpate (do this 4th)

o Rovsing test

o Psoas test

o Obturator test

o Murphy’s test

The Musculoskeletal exam:

Performing a thorough musculoskeletal exam requires that each of the following

maneuvers is performed:

o Inspect & palpate

o Range of motion (compare affected side to unaffected side)

o Ensure an understanding of the MSK ‘special tests’ (Knee, shoulder, back,

wrist all have special tests)

The Special tests:

Several systems have ‘special tests’ that we must perform in order to get the

necessary information from the patient, as well as ensure that we get full points. Below

you will find a list of the common special tests that should be performed during the CS

exam.

HEENT: Weber & Rinne test, Brudzinski & Kernig tests

KNEE: Ballottement, McMurray, Anterior/Posterior drawer tests, Varus/Valgus stress

tests

WRIST: Phalen, Tinel tests

SHOULDER: Drop arm test, open-can test

BACK: Straight leg test

How to properly document your PE findings

The PE findings are an area that most students don’t realize is a potential time-

saving section of the patient note. The reason why this is the case is because the physical

exam findings are for the most part going to be the same each time. Therefore, by

recognizing this and more importantly learning how to properly and quickly document

these findings in your patient notes, you can free up some time that can be directed

towards more challenging sections of the note, such as the HPI or the differential

diagnoses. My suggestion to you would be to practice typing all of the following physical

exam findings as many times as is needed to ensure that you can type them quickly and

without much thought. The faster you can type out your physical exam findings, the more

time you’ll free up for other parts of the patient note. Below you will find a list of all

physical exam findings that you should document when each of these types of cases

present themselves on the exam.

Documenting the HEENT findings:

Head: NC/AT

Eyes: EOMI, PERRLA, normal eye fundus

Ears: TM intact, no discharge, no tinnitus, no redness, no fullness

Nose: Nasal turbinates not congested

Mouth: No tonsillar erythema, exudates, or enlargement, good dentition

Neck: No JVD, normal thyroid, no lymphadenopathy, no carotid bruit

Documenting the Neurology findings:

CN 2-12 grossly intact, motor strength 5/5 in all muscle groups, DTRs are 2+ intact and

symmetric, sensation intact to sharp and dull, rapid alternating movement intact,

cerebellum intact

* If MMSE is done: AAOx3, good concentration

Documenting the Respiratory findings:

Inspection: No bruises, cuts, or scars

CTAB/L, no rales, rhonchi, wheezing, or rubs

Normal to palpation, no tactile fremitus, no dullness, whispered pectoriloquy negative,

egophony negative

Documenting the CVS findings:

+S1/S2, RRR, no MRG, no JVD, no pedal edema, pulses 2+ in all extremities

Documenting the Abdominal findings:

Soft, non-tender, non-distended, Murphy’s sign +/-, rebound tenderness +/-, Psoas sign

+/-, Rovsing sign +/-, Obturator sign +/-

Documenting the MSK findings:

ROM increased/decreased, sensation intact, motor strength intact, [special maneuver] +/-

Documenting the Extremities findings:

No deformity or trauma, +/- tenderness, ROM increased/decreased, muscle strength 5/5

in all groups, DTRs 2+ bilaterally, sensation intact to sharp/dull, no cyanosis, clubbing, or

edema
 10
The
Phone
Case
The phone case is the most unique part of the entire CS exam because it is the only

case whereby you won’t be required to see a patient face-to-face. Even though you don’t

have to see a patient and perform a physical exam, the phone case still presents some

unique challenges that you need to be aware of prior to taking the exam. If you

understand how to tackle the phone case, it shouldn’t pose much of a problem. If you

don’t take the time to understand the intricacies of the phone case or you don’t put in

enough practice, you’re going to find that this seemingly simple case can become a

nightmare fairly quickly. In the following pages, we’re going to discuss a strategy for

handling the phone case, then I’m going to outline some of the common challenges

experienced on the phone case and how they can be overcome.

How to Handle the Phone Case

Before we dive into the challenges that we’re likely to face during the Step 2 CS

exam’s phone case, we need to know what to expect and how to navigate a basic

encounter. If you’re not familiar with the phone case, simply put, it is a case that you will
do over the telephone, speaking to someone on the other end. Overwhelmingly, this is

going to be someone calling on behalf of their child; be it a parent, caregiver, etc. Your job

during the phone case will be to collect the necessary information as you would any other

case, however the main difference is that you will not be performing a physical exam. At

the end of your encounter, however, you should request that the caregiver bring the child

into your clinic for a physical exam.

In order to efficiently navigate the questions of the phone case, we need to

understand which mnemonics we should be using (this is of course a recommendation

but not a necessity). The following mnemonics can be used to collect information about

the chief complain and the medical history, respectively.

Chief Complaint: Medical History:

C: Colds (runny nose, etc.) P: PMH/Surgical/Hosp history
U: Urinary problems A: Allergies
B: Bowel changes M: Medications
F: Fever I: Ill contacts
E: Ear pulling F: Family history
V: Vomiting
E: Ear/eye discharge B: Birth history
R: Rash I: Immunization history
S: Seizure/jerky movement G: Growth & Development

D: Daycare attendance
E: Eating habits, feeding habits
A: Appetite
L: Look of the child
S: Sleep

Just as with our regular case, we should be taking care to introduce each new line

of questioning so that the SP understands when we are switching gears. It is also

important to remember that parents are very sensitive when it comes to their children, so

you should approach this case with an empathetic, non-judgmental tone, no matter what

they may say.

We’ve discussed the way by which you should behave in great detail many times

throughout this book, so we’re not going to revisit everything once again here. Remember

that the same principles that guide your regular cases should also guide your phone case.

This means you should be patient, kind, and empathetic, and you must do your absolute

best to make the person on the other end of the phone feel as comfortable talking with

you as possible.

We can break the phone case down into three main sections: 1) Introduction, 2)

Interview, and 3) Closure. Let’s take a look at some tips & tricks that you should

implement throughout each main section of the phone case to ensure that you maximize

your CIS & ICE points at each point:

During the introduction:

ü Say hello

ü Provide your name

ü Ask the SP’s name

ü Ask why they’re calling

ü Get the name of the child

ü Ask the relationship to the child

ü Show empathy when you’re given the reason for the call
During the interview:

ü Get information based on the chief complaint (CUB FEVERS)

ü Get information based on medical history (PAM IF BIG DEALS)

ü Try to build some rapport if possible

During the closure:

ü Give your impressions and outline potential differentials

ü Ask the SP to bring their child into the office for a physical exam ASAP

ü Discuss potential management plans

ü Field any challenging questions (if transportation is an issue, use social

services)

ü Ask the SP if they have questions or concerns

ü End the call by saying: “I look forward to seeing you in my office shortly”

The phone case can be a challenge if you’re not sure what to do, but everything

I’ve just outlined for you should give you the bulk of what you actually need to do. The

quality of your delivery will depend on how much you practice and how comfortable

you are speaking with someone over the phone. One trick that I’d like to recommend that

you use when doing the phone case is to smile. Even though the person on the phone

cannot see you, when you smile as you speak over the phone, it changes your overall

demeanor and the tone of your voice in positive ways.

Common Phone Case Challenges:

The phone case isn’t likely to trouble you with as many challenges as a face-to-face

encounter however it will definitely challenge you and you have to be ready for those

challenges. Below I’ve outlined some of the most common challenges, as well as some

strategies to help you tackle each one should they come your way on the exam:
 § Showing empathy

§ Building rapport

§ Challenging questions

§ Closure over the phone

§ Lack of transportation

The way you’re going to approach these challenges is fairly similar to how you would

approach them in a face-to-face encounter, however since you’re speaking over the phone

you have to rely on verbal cues as opposed to a combination of verbal and non-verbal

cues. Verbal cues may come in the form of a shift in the tone of voice, or they may come

in the form of what is actually said. Either way, be sure to follow the advice below and

you’ll be well-equipped to handle these common challenges should they arise.

Showing empathy:

This is often times difficult for students because they simply don’t understand

how and when to be empathetic during a phone call. For the sake of simplicity, let’s

assume that every phone call is going to begin with someone on the phone explaining to

you exactly what’s wrong and why they’re calling. In the overwhelming majority of

phone cases, a parent or guardian is calling about their child. As a way to ensure that you

get your CIS points for empathy, you should take the time after the parent or guardian

explains to you why they’re calling to demonstrate empathy. For example, if a mother

calls you about her one-year-old son who has diarrhea and she seems very concerned,

you should take that opportunity to explain to her that you can understand her concern

and that you’re going to get some information so that you can try and help the child feel

better as soon as possible; that’s how you show empathy right from the start.
 Now, while you can almost always guarantee that the opportunity to be

empathetic will come at the onset of the phone call, you can’t always be sure when the

next opportunity is going to come. Thus, as a general rule, I like to recommend that

students wait for the parent or guardian to ask a question based out of fear or concern

until you show your next display of empathy, which ensures that you don’t come across

as being fake. As an example, if you’re having a conversation with a child’s mother and

she begins to cry because she’s worried about her son, it’s at this time that you should

explain that you understand her concern, but that you’re going to do everything in your

power to help her son feel better as soon as possible.

Those are typically the two most likely instances on the phone when you’re going

to have a chance to show your empathy, so as you move through your practice, be sure

to pay close attention to these two instances and be sure to take advantage of them once

they arise. If for some reason you get a very simple and straightforward case whereby

the parent or guardian doesn’t show any excessive concern, then be sure to use the very

beginning of the phone call to display your ability to be empathetic.

Building Rapport:

Building rapport on the phone case is a major challenge. Some of the main reasons

for this challenge include the fact that the case is not done face-to-face, as well as the fact

that the call is usually about a child’s illness, which makes the opportunities to build

rapport very minimal. Nonetheless, it is in your best interest to do your best and try to at

least be very friendly and demonstrate an interest in trying to build rapport. Remember,

a mother who is in hysterics about her sick child probably has no interest in discussing

anything other than her child’s welfare, so the way you approach this has to be well

planned out before you even start your exam. Since it is not likely to come across very

well if you ask the person on the other end of the line what they like to do for fun or how
old their other kids are (in the context of making light conversation), you should try to

predetermine when and where you can ask a rapport-building question during your

interview questions.

In my experience, a few simple yet highly effective ways to do this include during the

following times:

o When asking about the child’s siblings (if he/she has siblings, you can and should

ask about their gender and age; you could use this time to tell the SP that you too

have a three-year-old and that you can understand the handful they might be; or

some other variation of this approach)

o When inquiring about diet (if the child is a picky eater, perhaps you can relay that

you too have a young child and that you completely understand how difficult it

can be to try and get a three-year-old to eat his vegetables)

o When inquiring about the parents’ work schedules (although this should only be

done if the situation is not dire, it could be an opportunity to inquire as to the

parents’ job; if it’s interesting it could be a talking point)

Ultimately, you have to be very cautious about when you try to build rapport in this

type of case and you have to determine based on the chief complaint whether or not you

should try to insert some light rapport-building banter into the conversation or not. For

example, if the child has a one-day history of constipation, the situation isn’t dire, and it

opens you up to being able to be a bit friendlier over the phone and asking a few lighter

rapport-building questions. On the other hand, if the reason for the call is a febrile seizure,

then the parent or guardian on the phone is most likely not going to respond too well to

your attempt at making small-talk about their job or the names of her other children.
 So, my recommendation here would be to have a few places in the interview where

you might want to ask questions to build some rapport, but to use your best judgement

and discretion when asking them and base how much or how little you’ll ask on the

severity of the problem at hand.

Challenging Questions:

Challenging questions on the phone case can be approached similarly to those in

a real face-to-face encounter. The only difference between the phone case and the regular

cases is that the parent or guardian on the other end of the line is more likely to be

excessively worried and irrational than someone sitting in your office; although that isn’t

a guarantee. If you remember back to our section about how to handle challenging

questions, we used one of two answering options and then based on which was needed,

we either answered the question directly or implemented our 4-step challenging question

answer strategy. As a reminder, this is the approach we took with our standard face-to-

face challenging questions:

 Luckily for us, the way we’re going to answer a challenging question over the

phone is essentially the exact same as we’d do in a face-to-face setting. You’re going to

acknowledge the parent or guardian’s concern, let them know that you don’t yet have

enough information to properly answer their question, let them know exactly how you

intend to get the information to be able to answer their question, then ask them if they

are in agreement with your plan. As long as you have the skills needed to answer a

challenging question in a regular clinical scenario, then you should be just fine when it

comes to the phone case’s challenging question.

Closure over the phone:

You might recall from our regular encounters that we can use our closure script to

close each and every face-to-face encounter, but over the phone we have to do things a

little bit differently because we don’t have any physical exam information. Thus, you

shouldn’t use the standard closure, but instead your closure should be aimed at getting

the patient into your office as soon as possible.

This typically looks something like this:

“Mrs. Smith, thank you for answering all of my questions about your son John. At this

point, the next step is for me to perform a physical exam on John so that I can gather more

information that will help me to determine exactly what’s going on and so that I can determine the

most appropriate course of treatment. How soon do you think you can bring him in?”

Now, you might get lucky and the parent or guardian might tell you that they’ll

bring the child in right away, or you might face a tough challenging scenario in the form

of ‘I don’t have transportation’, or some derivative of that answer. This is right at the end

of the encounter and so you have to ensure that you’re well-equipped to answer it,
because how well you answer this challenging question can either put a great ending to

a great encounter, or it could completely ruin an otherwise solid phone case. Since this is

such a common area for a challenging question or scenario, let’s take a closer look at how

it should be handled.

Lack of transportation:

Whether the person on the other end of the phone doesn’t have a car, can’t take

time away from work, or doesn’t have enough money to get to the hospital using public

transportation, you can approach the way you handle it the same. The best way to handle

any situation like this is to tell the person you’re speaking with that you’d like to put

them in touch with social services so that they can help them to arrange transportation to

the hospital. Nine times out of ten, if you offer social services as a way to help them get

their child the help they need, they are going to cooperate. If for some reason they push

back, it is then your job to express the importance of seeing their child as soon as possible.

For the overwhelming majority of people, this communication from a physician will get

them to take action, but for the sake of the CS exam, you never know what type of strange

pushback you might get from the parent or guardian. But either way you cut it, you need

to tell the parent or guardian that the next step is to bring the child into the office, and

then to ask them how soon they can come. If they have transportation challenges, offer to

help them with social services. As long as you keep these strategies in your back pocket

when you come to the end of the phone case, you should be able to effectively navigate

any situation that comes your way.

Final words about the phone case:

People usually feel one of two ways about the phone case: They either love it

because it’s a break from the typical face-to-face case, or they absolutely hate it because

they see it as a bigger challenge than it needs to be. Whichever of these two buckets you

fall into will likely depend on how well you understand the process of navigating the

phone case and how much effort you put into your phone case mastery. Most students

who I’ve had the pleasure of meeting over the years despise the first phone case we go

through, but by the end of our time together they love them. What changed? Nothing

more than their perception of the case’s difficulty. We slowly walked our way through a

case, took a look at the different components, understood how to get your CIS and ICE

points along the way, and recognized and developed strategies for tackling the most

common challenges. When you know what to expect, the scariness of something often

fades away, and that’s what I hope I was able to help you accomplish with this section of

the book. Take your time going through this section two or three more times and really

think about the encounter. Break it down into the different sections and do a few dry runs

as though you’re on the phone with the SP. In a unique situation such as this, knowing

what to expect and how to tackle the challenges that come up will be the key to a

successful phone case encounter.

 11
The
Consultation
Case
The consultation case is very new to the USMLE Step 2 CS exam at the time of

writing the first version of this book in 2019, so the information we have on these cases is

still very minimal. My team of Step 2 CS experts and I have discussed these cases at great

length and we have been advising our students based on the limited amount of

information provided by the USMLE organization. As we learn more, this section of the

book will be updated. Although what we know about these cases is very limited, we do

know a little bit. Below I will outline some general pieces of information that we do know

about these cases and provide you with some general guidelines that will help you to

better understand what to expect on exam day.

The cases you may see on your exam vary greatly, but we do know that they are

‘counseling’ cases, which usually means you’re going to have a discussion with the

patient about one thing or another. Common topics of discussion could include:

§ Smoking cessation

§ Alcohol cessation

§ Safe sexual practices

 § Diagnostic results

§ Therapeutic discussions/decisions

Please note that these aren’t guaranteed cases, they are simply examples of

common scenarios that would warrant a discussion instead of an interview and physical

exam. Since these cases can vary greatly based on the topic that needs to be discussed, it

is quite possible that the doorway instructions are different based on the case, so it is

extremely important that you take the time to read and fully understand exactly what

they’re asking of you on the case. My suggestion would actually be to jot down the

specific instructions you’re given from the doorway information so that you don’t do

anything that is not asked of you and/or is unnecessary.

As I’ve said, we still don’t know too much about this type of case, but here are

some general instructions that I give my students based on what we know so far from the

USMLE’s instructions:

ü Carefully read and follow the given instructions as they may differ case-by-

case

ü If instructed to simply ‘document the conversation’, type out the main topics

that were discussed and input the information discussed within each topic in

the note

ü Use all ten minutes of your patient note time to complete this note; since you’re

likely to finish the case early, you must ensure that your note is as robust and

detailed as possible, especially since there is no physical exam or differential

diagnosis section to be completed

 You’re likely to encounter one of these newer cases on your exam, but since these

cases are brand new, there’s also a good chance that since we don’t know too much about

them yet that they may be used as a ‘pilot case’ and may not even count. That’s not a

guarantee, but don’t let it bother you too much if you felt overly challenged or lost during

this case. Follow the instructions provided above and do your best. The most important

thing to keep in mind is that you need to document as much of the conversation as

possible, so take your time during the conversation, take detailed notes, and ensure that

everything you discuss ends up on your patient note.

 Final Words

The Step 2 CS exam is thought of as the ‘easiest’ USMLE exam, but if you’re not

accustomed to North American culture and language nuances, this exam might be the

most challenging of them all. Regardless of whether you grew up in North America or

somewhere else, you can do well and be successful on this exam, it simply takes knowing

what to expect and putting in the work to ensure your readiness.

If you understand everything in this book and put it into practice, you will develop

the skills and have the tools needed to excel on the exam. As with any USMLE exam, it is

always a good idea to take a diagnostic exam before taking the real test. This will ensure

that you get feedback prior to your exam so that you can fix any issues that may be

present. Be sure that you don’t underestimate this exam like so many students tend to

do. If you assume the worst and over-prepare, you’ll put yourself in the best possible

position to succeed.

I truly hope that you found this book to be helpful. If you did, please leave me

some feedback using one of the links below; my goal is to get this book into the hands of

each and every medical student in the world who plans on taking the Step 2 CS exam. If

you want to work with me directly or want me to speak to a group or at an event, reach

out to me on social media.

Best of luck on your exam and in your career!

Paul Ciurysek, MD; President of Step2CSPrep.com

Did you love the book? If so, please send your feedback or testimonial to
paul@step2csprep.com and let me know what you thought!
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