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Wednesday, May 27, 2015

Step 2 CS, All You Need to Know

      The Step 2 CS (Clinical Skills) is the examination that was formerly known as the CSA. To put it as simply as possible, it is just an OSCE with loads of frills. Nothing difficult, I assure you. AKU graduates rarely fail the exam. However, you have to pass it in order to secure ECFMG certification (and hence any chance of matching). So, I would strongly advise that you do not take it too lightly, regardless of what anyone says. Imagine how embarrassing it would be to get a pre-match at the place of your dreams… and having to call them to tell them that you will not be able to join their program because you flunked the Step 2 CS…

Earlier, the TOEFL examination was also a requirement for ECFMG certification. However, since the transition from CSA to Step 2 CS, the TOEFL examination is no longer required. The Step 2 CS itself will be used to check your ability to communicate.

The examination is available to be given throughout the entire year, however, it must be given before a certain deadline. In the Match of 2005, this deadline was December 31st 2004. In the Match of 2004, the deadline was January 31st 2003. So, it keeps changing. You’ll have to check the ECFMG website ( for the latest information. (Note that the deadline for the Match of 2006 is December 31st again).

There are some recommended times that one should give this exam. The vast majority of applicants are going to visit the USA on a three month visit visa. In this period, it would be highly desirable to give the Step 2 CS, interview at a dozen programs, and perhaps even sit for the Step 3 examination, if you have time. The biggest constraint is the fact that the interview season lasts from November to January – itself being a three month period. So, in order to maximize your chances of getting everything done before your visa expires, schedule the Step 2 CS somewhere in early November. You’ll get it out of the way before you start interviewing. Also, since you’ll land in the USA in early November, you can continue to stay till early February, potentially enabling you to sit for the Step 3 examination.

Of course, the earlier you give the Step 2 CS, the better. It’ll speed up the process of ECFMG certification and enable you to get an earlier date for the Step 3. This, in turn, will allow an earlier processing of an H1B visa (if that’s what you’re going for). So, you see, everything is connected. Another fact is that program directors will be more keen on interviewing you and ranking you when you have passed more examinations. If you can secure a six month stay in the USA, sit for the Step 2 CS in, say, mid-October. Some people flew to the USA specifically for the purpose of giving the Step 2 CS early. However, to do this, you’d have to have a long term visa to start off with (e.g. five year multiple) and plenty of funding.

Being the fortunate ones you are, another opportunity has opened up for you lot – one which was not available to us. Earlier, passing the USMLE Step 1 examination was a prerequisite for application for Step 2 CS. That rule has been abolished. All you need now are two years of medical school. Consequently, my advice would be that one should sit for the Step 2 CS during one’s final year electives (if one is doing these in the USA). Any earlier would probably result in insufficient clinical and OSCE experience.

There are five centers in the USA where the Step 2 CS examination can be given:

·    Philadelphia, Pennsylvania
·    Atlanta, Georgia
·    Los Angeles, California
·    Chicago, Illinois
·    Houston, Texas

Where you sit for the exam should not really make a difference. It did make a difference when the centers first sprung up in 2004 (earlier established centers dispatched results earlier).  However, since they have been functioning for more than a year now, I don’t think it will affect anybody anymore.

As for the fine print regarding the examination, I have quoted an extract (slightly edited in order to update), written by Zainab Samad, from Road to Residency. Updates have been written in non-italicized bold text. A couple of comments before I attach her material:

There is a new book in the market called “First Aid for the USMLE Step 2 CS (Clinical Skills Exam),” written by Vikas Bhushan and others. I would recommend this book for everyone. If one reads this and nothing else, it is more than sufficient. After familiarizing yourself with this book, if you feel you need more practice, then, go ahead and attempt the dozens of cases available in the Kaplan photocopy. More practice is always good. I spent a week of relaxed studying on this exam. However, one can get away with less. People pass the exam with a day or two of preparation (not that I would advise it!). The exam is all about being able to deal with the patient as a reflex. Therefore, grab a friend and practice, practice, practice. As far as Bates is concerned, one does not need to go over it if one is comfortable with physical examinations.

The Step 2 CS has three components (on the basis of which you’re marked):
o    Integrated Clinical Encounter (ICE) Subcomponent (Data gathering, Documentation)
o    Communication and Interpersonal Skills (CIS) Subcomponent (Questioning Skills, Information-sharing skills, Professional manner and rapport)
o    Spoken English Proficiency (SEP) Subcomponent

(Extract commences here…)


Before going for the exam, watch the video and the Candidate Orientation manual that they provide (the candidate orientation manual is now available online - If you are feeling very apprehensive, then read up the 47 cases given in the Kaplan CD photocopy. That gives a fair idea of what is tested in the exam. You can even go through the basic history and physical examination from Bates. The cases that generally come are very common complaints like chest pain, headache, backache, etc.  These have been time and again tested in our OSCEs and therefore do not pose a problem. And when you take the history, you’ll find that there is a wide differential. The history usually does not point to one specific diagnosis because they want to check whether you know the ‘right’ questions for those common complaints.
During the physical exam, check the relevant systems e.g. in a patient with chest pain, you would want to check the pulse, JVP, listen for crepitations in the lungs, feel the cardiac impulse, percuss the heart borders (or pretend to), listen to heart sounds, check for sternocostal tenderness, palpate the abdomen for any epigastric tenderness, and check for pedal edema. Most patients do not have physical findings. But in some cases, the patient may have real signs - crepitations with a COPD lung, an inflamed joint, etc. The patient may even mimic signs - loss of sensation or paralysis. So bottom line - keep your eyes and ears open.

During the patient encounter, you might get a ‘mean’ and ‘un-co-operative’ patient. Don’t worry. They are being deliberately mean. The trick is to be firm. Remain polite and try not to lose your temper.

There are 10-11 patient encounters (the 11th is usually not graded but you will not know which one is the 11th patient). One gets 15 minutes with each patient and then 10 minutes to write the patient note.  SO that makes 25 minutes for each patient encounter.
The actual encounter is marked on a checklist by the patient. The checklist is for communication skills, the questions in the history that you asked and the maneuvers you performed in the physical exam. The patient fills this out once you leave the room. So what matters is not how you percussed the patient but whether you did it at all or not. This makes it much easier than our regular OSCEs. There are also points for knocking before entering, washing hands, draping the patient etc., so one needs to remember those.

The Basic Format (that my friend Sultana came up with and that I found very useful), one should follow so that you don’t forget anything:

(Editor’s Note: Before you even knock at the door, pay attention to the case introduction written on the door. Read it carefully and jot down points on the clipboard. It is imperative to have your thoughts organized at this stage in order to avoid awkward pauses during the actual encounter. Write the name, age and any abnormal vital signs. You may even list your differential diagnoses. Write whatever mnemonic you use for history taking. Take your time at this stage and you will save time further on.)
1. Knock
2. Enter and address the patient by Mr. / Mrs. Surname
3. Introduce yourself as Dr. Surname
4. Walk to the sink, wash your hands and while you are at it, explain that you will  be doing a brief history and physical exam and will be discussing your impression with the patient.
5. Walk back to the patient and drape the legs (they are usually uncovered)
6. Sit or stand; whatever you find comfortable. Spend 5 minutes taking the history. Avoid using medical jargon. Ask both open ended and close-ended questions.
7. While taking the personal history, if the person smokes or drinks, counsel there and then...or one tends to forget near the end.
8. Spend 5 minutes on doing a focused and relevant physical exam.
9. Spend 5 minutes summarizing/reconfirming the history that you got, explaining to the patient what you think, he or she has, what investigations you think he/she should get. Remember to ask if he/she has any questions. (Editor’s Note: - Also ask the patient if there is anything else that he/she would like you to know. This provides the patient to guide you if you have been misled. Remember, the simulated patient is not out to get you).
10. Tell the patient when you would like to see him or her next. Say that it was nice meeting them. Walk out.
11. If you are done before time…then walk out and start on the note.
12. The patient note has to be written in legible clear handwriting. Practice on the sample sheet that they provide in the information booklet. Since there is less space on the paper, put only relevant points and important negatives down.

Avoid speaking to anyone inside or outside the exam center about the exam. You are not going to do any better by sharing your case histories or exams. But you might certainly end up paying for it if you do!!

Only people with serious problems in communication fail the exam (those who don’t know how to speak English) and since you are not in that category, you don’t need to worry.

Things to take with you to the exam center:

1) White Coat
2) Stethoscope
3) The CSA permit
4) Passport
5) They provide a pen
6) Dress professionally but comfortably (the way one dresses for a viva)
7) Panadol, lunch (if you think that the salad, fruit and chips that they provide will not whet your appetite. They have turkey sandwiches for those who are not too particular about halal food), and Chocolate if you want to. Coffee, soft drinks and water is provided.

Travel and Places to stay:

You can search yahoo for making a reservation at a hotel. Usually, the rates are lower if you book on the Internet.

Regarding the Philadephia center, the Marriott and the Divine Tracy are right opposite each other and 3-minute walk from the center. There are plenty of other places to stay. You can find them on the net.

Try and make it to the city at least a day prior. It is important to keep room for contingencies. Remember to put all the things that you are going to take to the exam center in a hand bag as one runs the risk of losing checked-in luggage.

For more detailed information, use the following link - “

(Extract ends here…)

Another thing which may prove useful… After giving the Step 2 CS, one tends to wait impatiently for the result, because one can only apply for the Step 3 after passing it (along with all the other exams, of course). At that point in time, even the wait between the dispatch (as told by OASIS) and the actual receipt of the result (by mail) seems long. A simple way of finding out if you have passed is by trying to apply for the Step 2 CS again (don’t worry, you will not be charged for trying!) After inputting your information, the website will tell you that you cannot apply for this examination because you have already cleared it. If this happens, you have passed! Apply away for your Step 3! If not, well, better luck next time!

Congestive Heart Failure, what I needed to learn

So if we all know the basic management of CHF, diagnosed clinically based on history and exam supported by some labs like BNP and echocardiogram and managed mainly with diuresis. Beyond the basic management, these were the aspects of CHF diagnosis and management that I wasn't clear about and decided to research them.

Does Obesity affect BNP interpretations? What are the things to consider when interpreting BNP?

What are natriuretic peptides? So in summary, we have BNP (brain Natriuretic Peptide), which is derived from the cleavage of pro-BNP (released primarily by the heart, but initially found in the brain), resulting in production of BNP the active form and the N-terminal-Pro-BNP (NT-BNP) which is inactive. There is also Atrial Natriuretic Peptide. Both are released in heart failure in response to increased ventricular filling pressure. Both ANP and BNP have diuretic, natriuretic, and hypotensive effects. They also inhibit the renin-angiotensin system, endothelin secretion, and systemic and renal sympathetic activity.
Things to consider when interpreting levels:
  • In a normal healthy person: both BNP and NT pro BNP levels are the same.
  • In heart failure: NT pro BNP> BNP, as per uptodate, NT pro BNP 900~100BNP
  • Both levels lower in obese patients, so a normal or low BNP does NOT exclude heart failure in obese patients.
  • Both levels are higher in patients with renal disease and it is not recommended to use it as a diagnostic tools in such patients.
  • NT pro BNP levels higher in women and elderly.
  • Value may also be elevated in coronary heart disease, valvular heart disease, pulmonary hypertension, and sepsis.
  • Diastolic vs systolic: number will go up in both, but cannot differentiate one from another based on BNP.
  • Should NOT be measured during Niseritide therapy.
  • As per AHA recommendations, BNP is used when diagnosis is not clear and should not be used solely to include or exclude the diagnosis of heart failure.

How do you decide what dose of Lasix to give? What factors to consider before or during treatment with Lasix?
  • No single dose has been recommended, varies from patient to patient. But consider the following factors:
  • In acute exacerbation, always start with IV Lasix because there may be impaired absorption orally because of intestinal edema.
  • Instead of increasing frequency, increase the dose of Lasix as response is threshold based.
  • If diuresis does not increase after a certain dose, then increasing the dose further won’t make a difference, consider adding eplerenone or spironolactone to Lasix (aldosterone antagonists).
  • If creatinine goes up or BP goes down, do NOT stop diuresis, just lower the dose to slow the rate of fluid removal. 
  • Goal is to achieve dry weight and then find the right oral dose to maintain dry weight.
(to be continued)

Now that I'm a resident physician in internal medicine.....

Gone are the days when I used to sit on the computer reading posts on forums and blogs about how to get into residency in the USA. I'm 2 years into my residency now and it sure has been a bumpy ride. Since day 1 of my residency it has been a struggle to find the time and motivation (well mostly motivation, time is no longer that much of an issue) to study. And trust me, you do need to study! I decided to dedicate this blog to cases I come across during my daily routine at the hospital and address different clinical issues. This will help me study myself and hopefully help others along the way.

The first post is going to be about heart failure management and hopefully should be ready soon!

Tuesday, June 11, 2013

USMLE Step 1, the working formula!

This is my experience of USMLE Step 1 that I am sharing with you guys hoping some of you might find something useful in it. I will try to keep it to the point. :)

Kaplan except for pathology for which I used Goljan and Microbiology for which I read Made Ridiculously Simple once and then First Aid +uworld notes. The Kaplan's Microbiology notes are too detailed so decided not to study that. I had used MRS in my third year as well so it was an easy choice. One thing we usually tend to ignore is the ethics part of the exam. For that, I studied this small book by Conrad Fischer called "100 cases you're most likely to see in your exam". Very useful book, helped in all USMLE exams.

Video Lectures
Personally I am not a great fan of the videos, but they DO help a lot. They are not our typical class lectures. Specially with subjects like neuroanatomy, genetics and behavioral sciences, they were really helpful. I skipped the video lectures for pathology and microbiology. Some of the lecturers talk very slowly, for that I would speed up the video to 1.5x, would save up some time and make it less boring. I watched the videos with my first read. I would give a quick read to a few pages in the book, then watch the video and write down stuff on the book.

Kaplan Qbank:
Personally I don't think its that high yield. Yes it helps but I felt that I could have done without it. If you want to save up money than do this one offline. I did it along with my second read of Kaplan.

USMLE world:
This is the real deal!!! Some questions are actually tougher than the real exam. The interface is EXACTLY the same as the exam so when I was taking the exam, I felt very comfortable. I did all questions once, used the notes utility that comes within the interface as I am really good at typing which saved alot of time. Then I got those notes printed and read them again and again. I got two months subscription and did two blocks a day, which would hardly leave anytime for reading any other material. These days most people do it offline from the books. You can do that, but even after that I think one should use the online version to get familiar with the exam's interface. Plus you get to see the slides, radio images and scenarios based on heart sounds.

First Aid
Very useful! I did it after uworld along with uworld notes. I reserved it for the last month and this along with the uworld notes was the only material I studied in the last few weeks.

Self Assesment:
Once you are done with studying the books and uworld, its time to test yourself. I took NBME twice. One immediately after I finished uworld and second after revising uworld notes and First Aid. These days uworld has a self assessment exam as well which, if bought along with the qbank, costs just 10 dollars. NBME is pretty accurate in predicting your score. Uworld self assessment generally overestimates your score by 10-20 points.

Actual exam:
Honestly speaking I found it easier than I was expecting. Very few recall questions. Some concepts were repeated. Micro and Pharma, very straight forward and easy! Physiology very tricky, specially graphs and all those isolated preparations questions. Loads of questions from anatomy, specially upper limb's nerve supply.

Kaplan +Video lectures
Kaplan + Kaplan Qbank
Usmle world
USMLE World + First Aid

Best of luck to all you test takers!!! Have faith in yourself! Its very doable. Feel free to ask any questions, I'll be happy to answer.

Sunday, June 9, 2013

Medical Mnemonics? Yes please!

Medicine is a series of never ending recall material. Specially subjects like pharmacology and microbiology, where there are probably more recalls than concepts. Most medical students find mnemonics very handy for such circumstances. Considering almost everyone has a smartphone these days, its good to have a mnemonics app installed and here is our recommendation for Androiders.

           The app has a database of more than 1500 hundred mnemonics! The design is simple and smooth. There is a quick search on the main screen which makes it pretty convenient to find what you are looking for. You start typing and the list is modified accordingly.

           You can also add your own mnemonic. You mnemonics are saved with the "by User" tag so next time you want to see all your own mnemonics, just type "by user" in the quick search box. Other than that, you can edit or delete mnemonics as well, so basically you have full control, all for free!

           Another feature worth mentioning feature is the "Mark" option. While viewing a mnemonic, if you feel you might want to review it later, you can just check the checkbox labeled "Mark" right below the mnemonic. You can then access all your marked mnemonics from the main menu.

          So basically its a very handy app for medical professionals and is totally free which no locked features unlike most other such app on the play store. Worth a try!

Friday, April 5, 2013

H1B visa application -Step by Step

So the time is here when IMGs go crazy runing around trying to figure out how to work their way through the complicated visa paperwork. Here is a simplified step by step application process for H1b visa.

1. Get the contract and contact the lawyer:

Once you have signed the contract, the next step is to get in touch with the lawyer. Usually most programs will recommend their own lawyer. But it doesn't really matter which lawyer you hire, as long as you know the one you are hiring is not a scam, to avoid which, go by recommendation. Its always a better idea to use a lawyer that has worked with the same program before, that will speed up things and he or she would know who to get in touch with. Typically the lawyer fee is around a thousand bucks. If the one your program recommends is too expensive, you can always use a cheaper one.

2. Send documents to your lawyer:

Initially the lawyer will ask for a copy of the contract only. Then he will send you a long list of documents. This list typically includes copies of your passport, your previous visa, I 94 if any, ECFMG certificate and copy of your medical degree.

3. The LCA:

Once the lawyer has all the documents in place, the first step in the application is filing the LCA. This step ensures that the employee is not violating any labor laws. The application is free and typically takes upto two weeks to complete. Once the LCA is approved, the lawyer then send the LCA and other documents to your program to get them signed by the PD.

4. State License:

Some states require you to have a state license before you can get an H1 visa. So be sure to sort that out with your program coordinator.

5. The H1B petition:

Once the lawyer receives the signed LCA from the program, its time to file for the H1B petition. The regular petition costs around 800 dollars and can take upto 3 months! But if you apply for the premium processing, they promise to give you an outcome in 15 days. If for any reason your case is not processed in 15 days, your fee will be refunded and your case will still be treated as a premium case! Usually its processed in less than a week! So if you are short of time, its always a good idea to go for the premium processing.

Legally, the employee cannot pay for the visa and the employer has to pay. In case your program is not covering the visa cost, you have to find a third party to pay it! This is called donation in legal terms. It can be anyone, your parents, your siblings or a friend, just not you yourself.

6. Approval and form I 797:

Once the petition is approved, the USCIS will send the approval notice/form I797 to your lawyer who will then send that along with a copy of your petition application to you. The lawyer might ask extra money for sending it via DHL or FedEx. Be ready to pay around a 100 bucks as the petition application is a huge bungle of papers! Upon receiving the documents, next step is to apply for the visa at the local embassy. You have to fill out the online form DS 160, the same as you did for your B1/B2 visa. Its pretty straight forward and take 15-20 minutes.

7. Interview at the US embassy:

The interview is pretty straight forward. The usual questions are:
Why did you apply for the H1b visa?
Which hospital is it?
What will be your job?
Did you take all the USMLEs? (Duh!)
What did you do in your previous trips to the US?
How long is your contract?

There might be a few weird questions like which medical school did you go to or what was your CK or step 1 score. I guess they do so to make sure its the same person or to cross check with the information on file. Usually they won't look at any documents but its good to be prepared. The usual set of documents would be:

Form i797
Copy of Petition application sent by the lawyer.
Educational documents
USMLE Score reports
Documents related to your previous trips to the US like LORs
Financial documents- though not really important but still, to prove you have enough cash to buy yourself tickets.

The good thing about H1B is that you don't have to prove strong ties to your home country, which is the most common reason for refusal of B1/B2 and F1 visa. So H1B for medical residents is almost always approved. 

8. The 10 days rule:

Legally, you are not allowed to enter the US more than 10 days before the start date of your contract. This creates an issue when the orientation starts earlier than the start date of the residency. For example, if your contract starts from the 1st of July, the earliest you can enter the US is the 21st of June. But if your orientation starts from the 23rd of June, you literally won't have time for anything! So make sure you discuss this with your program coordinator and request them to put the orientation start date as the start date of the residency.

Good luck everyone! I hope I didn't miss out much. :)

Friday, December 21, 2012

The flight

My mother's fear of the outside world resulted in me growing up in the corner of my room in our village house. I had never been in a plane! Never needed to since my parents were never big on traveling. So the first time I got on a plane was my flight to the US and boy was it a long flight! Be sure to pick the right airline for you. Some might be expensive than others but trust me, the cheaper ones are cheap for a reason. If your flight to the US is going to be more than ten hours, then better not think of saving that extra cash on the flight. I chose Qatar Airways because it has been awarded the best airline in the world by Skytrax. I did not regret choosing it. The plane was spacious and even though I was in the economy cabin, I had enough space around me to avoid those awkward physical contacts with the next passenger. Also the entertainment system was really good. The screen was of a decent size and had a good collection of movies and TV shows.

Do check the website of whatever airline you choose. Most of them come with the options of selecting your seats and meal preference. For long flights, do not make the mistake of choosing the window seat. You will need to go to the rest room and to the self service at the back. So if you get the isle seat, you won't be holding it just because you don't want to wake up the passenger sitting next to you. Besides, you won't be missing out much anyway since most of the flight will be above the clouds.

Also, do not forget to sign up for the airlines miles club. Do know that you will be making more than one trips to the US. All those miles piling up will help you fly like a smug executive in the business class some day! Of the things that you should carry on the plane with you, a neck pillow might help. It will help you head stay in one place and not swing like a pendulum unless you have a pretty person sitting next to you and you wanna end up on their shoulder. ;)