How to Survive Medical School: Step 2 CK and CS

Over the past couple of months, I’ve received a flurry of emails and Instagram messages about USMLE 2. These messages have one common question: “how do I study for USMLE 2 CK?” These questions, by my interpretation, are sent by medical students who are a bit more flustered than the medical students who send inquiries about USMLE 1. There are probably a couple of reasons for this. For one, there is insane pressure to receive a higher score on USMLE 2 than USMLE 1. If you crushed USMLE 1, you’re left kind of wondering…how can I reasonably do better? And, understandably, if USMLE 1 did not go the way you wanted…the pressure to do extremely well on USMLE 2 is high.

The awesome thing about USMLE 2 is that you’ve been studying for this exam since you started your clerkship year. The manner in which you prepared for your shelf examinations is honestly the way you should prepare for USMLE 2. I won’t address in this post how I approached each particular subjective given that there are three posts that address my approach to OB/GYN, Internal Medicine, Family Medicine, Surgery, Pediatrics, Psychiatry, and Neurology.

You figured out the kinks of studying for standardized examinations when you studied for USMLE 1. Aspects that I addressed in my USMLE 1 post such as registration, study schedules, and etc. aren’t worth revisiting in this post. Give yourself some credit. You already know how many hours you can study a day, how many days off per week you need to feel like a normal human, and what examination snacks are gonna carry you through test day. I say all of this to reassure you: you are going to be great. I say all of this because I am still extremely aware of how panicked I was before USMLE 2 and I was legitimately more stressed for USMLE 2 CK than USMLE 1.

Why? Well, I think people downplay USMLE 2. I asked quite a few people the year above me for their advice for Step 2. The advice I received was minimal: “you don’t need more than two weeks or so. It’s easy.” You guys are going to do well on this exam, I have faith in you, but it is by no means easy. Like all standardized examinations, USMLE 2 CK can be tricky. There are questions that are you almost guaranteed to look at…skip…come back to…look at…shed tears…say a prayer…make an educated guess. That’s fine and honestly to be expected.

In this blog post, I’ll share my approach to receiving a 250+ score on USMLE 2 CK and share a little bit about how I prepared for USMLE 2 CS.

step 2

 


USMLE 2 CK: This nine-hour examination is the hardest part of MS4. Once you tackle this exam, you can focus on everything else (e.g. applying to residency – I plan to share a detailed account of how to apply to residency and what I learned on the trail). I’ll share how I approached this examination. I’ll reiterate a point I made earlier: you worked out the kinks of USMLE examinations when you took USMLE 1. You studied throughout the year in preparation for shelf examinations. In regard to mental preparedness, the USMLE 2 CK experience is easier than USMLE 1. In regard to content, this examination is challenging. Don’t let the mantra of “2 months of preparation for USMLE 1, 2 weeks for USMLE 2 CK, and 2 days for USMLE 3” lull you into complacency.

  • Approach: Think carefully about your clerkship year.
    • Identify weaknesses: Which core clerkship was the most challenging? What was your last clerkship? I started with internal medicine. This gave me a great foundation prior to my other rotations, but my knowledge of internal medicine staples and algorithms/approaches was beyond rusty. Given the emphasis of internal medicine on USMLE 2 CK I knew that I needed to spend the majority of my time reviewing internal medicine (due to the importance and also my distance from the rotation). I ended on OBGYN and felt comfortable enough with the material that I knew I would need a cursory review.
    • Evaluate resources: What resources did you utilize during your clerkships? I made a list of every book/resource I utilized over the year and (don’t judge me too hard) assigned a score to each resource. The score correlated with how useful I found the text/flashcard set/question set. The short-list of resources were included in my study schedule. I made the decision to not include new resources during my dedicated period of study. The most stressful part of USMLE 1 dedicated season was becoming acquainted with UWORLD (I’m very confused why we tell MS1s and early MS2s to save it until dedicated, I don’t think that makes any academic sense although there is a financial argument for this). I definitely did not want to repeat that issue.
  • Timing: There are quite a few factors to consider before you select your test date.
    • Do you really need a strong USMLE 2 CK?  If your USMLE 1 score is not competitive for your specialty of choice, USMLE 2 CK can be a chance at redemption. A strong USMLE 2 CK score can demonstrate to programs that they have no reason to be concerned about your academic performance (assuming that rotations went well) or your future test-taking boards-passing capabilities. Shoot for a test date with score release prior to ERAS submission (middle of September) so that residency programs can see your score prior to interview invites.
    • Are you worried that your USMLE 2 CK score will pale in comparison to your USMLE 1 score? If this is the case, you may want to take USMLE CK after ERAS submission but with scores released prior to rank list submission (so that the program knows you passed USMLE 2 CK). At that point, they’ve already met you. So a slight dip in USMLE 2 CK is not likely to really impact your place on the rank list. Failing, of course, is a different story.
    • Definitely ask individuals at your school the year above you (who matched in your specialty of interest), to see how they approached timing of USMLE 2 CK.
  • Schedule: They key to success is a schedule.
    • Time: I think most individuals do well if they have four weeks of dedicated time to study. You may need less time if you ended your clerkship year on internal medicine or family medicine. You may need more time if you ended on a clerkship that is low-yield for USMLE 2 CK (e.g. OBGYN). I underestimated how much time I needed and scheduled USMLE 2 CK three weeks out from the end of the OBGYN clerkship. Two weeks of that time was during a radiology rotation (if you study best in the morning, even a low-key rotation can derail your productivity) and family things led to unexpected traveling which also impacted my schedule. I kept my CS date (scheduled four weeks out from the end of the OBGYN clerkship) and pushed CK to the week after I completed my PICU sub-internship. Clearly a time-consuming rotation, but the extra time allowed me to adequately prepare for the examination.
    • Be realistic: It is extremely hard to study all day like you did when you prepared for USMLE 1. Build a schedule assuming that you can put in about 6 hours per day.
  • Resources: The resources I utilized are not all that important but since you guys ask for specifics, I’ll share. Like I mentioned above, I did not introduce new resources.
    • Practice Questions
      • UWORLD: As always, UWORLD is the cornerstone of USMLE preparation. I decided to go through UWORLD by organ system rather than by specialty. I started with cardiology because that is the material that leads to major eye-rolling. It took me 2.5 weeks to go through UWORLD. I made an Anki deck on the material I forgot / never knew / will never know.
        • My approach to UWORLD is atypical. I always work through UWORLD on tutor mode because I never have run into the problem of running out of time on examinations. This allowed me to make Anki cards as I went through the questions.
        • I am not the type who benefits a ton from questions. I planned to only make one pass through UWORLD and multiple passes through my Anki deck.
        • If you want to take a look at my Anki deck, feel free to do so here. I wish that I made a more organized Anki deck as I went through each clerkship so that I would not have needed as much time for my final pass through UWORLD.
        • Like last year, I didn’t do the UWORLD diagnostic tests. I really dislike the UWORLD interface. I just could not bring myself to do them. Ask your friends how they liked them!
      • Lippincott Q&A Medicine: I fell in love with the Shelf Life series early in the clerkship year. Lippincott Q&A is similar to Shelf Life (available for Pediatrics, OBGYN, and Surgery) and I stumbled upon it after I finished my internal medicine rotation. I did not make an effort to review the entire book during my dedicated study period. I did make sure to review the cardiology section because I felt as though I needed additional practice.
      • Shelf-Life Obstetrics and Gynecology: I am sure that I mentioned how much I appreciated this book in my recap of the OBGYN rotation. There were a few chapters I wanted to review (e.g. STIs) because I felt like more detail was provided as compared to UWORLD.
      • NBMEs: I reviewed the notes I took on the NBME exams. I thought this was worthwhile only to identify trends. I did identify some similar questions on my actual examination but there is definitely no need to feel like you have to go through the NBMEs if you never found them particularly useful.
    • Books:
      • Step Up to Medicine: This book is the go-to for internal medicine. There was absolutely no way that I was going to go through every single chapter of this textbook. Let’s be real: I didn’t even read this entire thing when I was on internal medicine. I made sure to read the three chapters that I thought were high-yield or were personal weak points: cardiology, pulmonary, and dermatology.
        • If I needed additional information or an explanation of UWORLD was unsatisfactory, I supplemented the UWORLD explanation with Step Up to Medicine.
      • Crush Step 2: A lot of people are a huge fan of Master the Boards. I think in content it is similar to Crush Step 2. However, Master the Boards is more paragraph form whereas Crush Step 2 is bullet-form and honestly worked better for my attention span. This is almost like the Robbins versus Golijan situation. Crush Step 2 reminds me more of Golijan and that’s probably why I utilized this source throughout clerkship year. This is a book I read cover-to-cover multiple times. This book served as my “First Aid” although there is truly no text that is as comprehensive for USMLE 2 CK as First Aid was for USMLE 1.
    • Flashcards: My attention span is shot. Seriously, I don’t know how I was so productive during USMLE 1 dedicated period. The flashcard sets I used throughout clerkship year were used to break up my study day. I had: 1) medicine, 2) OBGYN, 3) pediatrics, and 4) pharmacology cards. These were really easy to breeze through if I had downtime at work.

USMLE CS: People describe this examination as a waste of time. I will not disagree but I will state that the examination is expensive. It’s worthwhile to take it seriously. It’s a long day and if the examination is not offered in your city, you have to put a lot of resources into this examination. You certainly do not want to take this examination again. Not every scenario has an obvious answer. Don’t be thrown off by that. Just be as thorough as you can be within the time frame. Remember, you have been practicing for this examination every single day of your clerkship year. Try to stay calm!

  • Approach: Think about previous standardized patient encounters. If you have had the opportunity to have standardized patient encounters as part of your medical school curriculum, you have received feedback. What are some concerns that have been raised? Do you have an issue with time management? Do your notes require more work?
  • Schedule: There are few testing sites in the country and so test dates fill up quickly. Start to look for a date 4-5 months prior to when you intend to take the examination.
  • Timing: I was told that pediatrics residency programs favor applicants who have passed CS prior to ERAS submission. I have no evidence for this but I did that anyway. If you can knock out CS early in the year – go for it. Motivation wanes throughout MS4 and you don’t want to take CS too late in the year. If you fail CS between rank list submission and match day, your situation becomes…dire. There is very little time to re-take the examination prior to graduation and a “pass” is required to receive your M.D. degree. I strongly recommend taking CS prior to December of your MS4 year.
  • Resources: There is a consensus: read First Aid for USMLE Step 2 CS. To start: read the introduction so you have a clear understanding of how the examination works. There is also a list of hotels that offer discounted rates for individuals in town for the examination. Take a look at the cases and focus on: chief complaint, physical examination maneuvers, and differential. Have a good working differential (at least 5 diagnoses) for common complaints (e.g. fatigue, abdominal pain, chest pain, syncope, dizziness, rash, shortness of breath, etc.). I also paid for the UWORLD Step 2 CS material. This is by no means necessary. I just appreciated how each case was explained and that there was a video component. Again, by no means necessary. It wasn’t particularly expensive and so I decided to go for it!
  • Practice: Don’t underestimate the need to practice. Practice physical examination maneuvers. Practice your neurological examination so that you can knock it out in 3-5 minutes at most. Practice writing notes on the official website provided by the USMLE. It gives you a feel for the character and line limits.
  • Tips: Here are some quick tips to make things less stressful.
    • Routine: Become a creature of habit. Read the vignette, knock on the door, introduce yourself, shake hands, explain your aim, sit down, ask questions (in the same order – this prevents you from forgetting anything important), ask “is there anything else you think is important that you would like to tell me?,” transition to the physical examination, wash hands & clean stethoscope, perform a brief heart & lung examination on each individual, perform other examination maneuvers if indicated, explain why you are conducting the examination maneuvers, conclude, ask for questions, share differential and potential tests, ask them to wait in the room for you to “discuss with supervising physician,” and close the encounter.
    • Interviewing: Be thorough in every single case. Ask a complete review of systems (this should take 1-2 minutes at most; start with: fever, chills, weight changes and then go top to bottom. Don’t forget to ask about skin changes!). Make sure to obtain a gynecological history for all women (especially if they have a complaint of abdominal pain). Make sure to obtain a family history, past medical and surgical history, and social history (living situation & substances & sexual activity) from every single patient. Ask about psychiatric history if you think it is necessary (also perform a mini mental examination if that is the case).
    • Physical Examination: There is no way you can do a head-to-toe physical examination. Don’t feel as though you have to. Touch on every organ system that is on your differential. For the top two organ systems, do a complete examination.
    • Timing: I aimed for 9 minutes of interviewing and 6 minutes of physical examination. Maybe I talk faster than I thought…but I finished each room with 3-5 minutes to spare (this gave me extra time to write my note). Don’t feel pressured to stay in the room if you have asked all the questions you have. If you are organized about how you approach each patient, you will have plenty of time.
    • Oddball Case: There may be 1-2 cases where you are completely confused. Don’t let this throw you off. Take a complete history. If you are super confused, throw in a mental status examination. Try to pull yourself together when you wash your hands. Perform heart and lung examinations and throw in anything else if it pertains to your differential. Remind yourself you can completely fail two rooms and still pass. Don’t beat yourself up!

I hope this post was helpful to some degree. If you have more questions, feel free to comment below to get in touch over email or instagram! Rooting for you guys!

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3 thoughts on “How to Survive Medical School: Step 2 CK and CS

  1. Pingback: Match Series: Aji, Pediatrics | Yang's Wear Abouts

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