The USMLE Step 2 CK is a relatively easier exam than the USMLE Step 1 and yet a lot of people still fail or do poorly because of mistakes in their prep. For the past 5 years, since I originally wrote this article, I have had many students who have passed Step 2 CK with very good scores and went on to finish their residency. I have compiled the most common mistakes I have found in their prep that we had to correct before they went on to pass Step 2 CK. First, Not Studying Enough Detail. The purpose of the USMLE Step 2 CK is to test your readiness to apply clinical science in medical practice and you need to know a lot of medical facts in order to do that. IT is not an OPEN BOOK test, so you need those facts in your head. And yet too many people make the mistake of studying only very little. The fact that you see so many popular reviewers in the market that purport you can ace the exam by studying the little material it contains reinforces this serious misconception. That is a lot of bull. Medicine is a very broad subject and Step 2 CK covers all the most common and even some rare cases. Those little reviewer just does not give you enough detail to do well in this exam. The problem with those mini-reviewers is that they presume you have just finished or are in the middle of your clinical rotation when you will sit for Step 2 CK. They also presume you did a lot of deep reading during those clinical rotations, which any medical student know is almost impossible unless you decide that you do not need to sleep. Do yourself a favor and actually read and study for the USMLE Step 2 CK in detail. In most cases using Kaplan Notes supplemented by Step Up for Medicine is good enough to get a decent score although you need to do more if you want to score high. For old IMG, you may need to supplement your reading with more detail, especially for IM and Ob-gyne. Second, Not Preparing for Next Best Step in Management Type of Questions Next best step in management type of questions account for about 20% of Step 2 CK. This type of questions involve cases that describes the management done on the patient so far and asks what you think is the next best step in dealing with this particular patient. Normally, when we read clinical science books we are taught how to diagnose and treat patient. But in clinical practice, we need to work up patients, not just diagnose them and we need to manage patients, not just treat them Diagnosing a patient requires knowledge of signs and symptoms and what examinations and test to be done to elicit these signs and symptoms. Working up a patient involves knowing implications of positive and negative results of previous tests and physical examinations and what lab or diagnostic test should be ordered next as well as further diagnostic maneuvers that needs to be performed. Treating a patient involves knowing what drugs and treatments to use. Managing a patient takes into consideration patient response, adverse reactions and other factors and altering the treatment accordingly. Most people study for Step 2 CK by reading textbooks and reviewers. That is of course the appropriate way to study the clinical content for the Step 2 CK exam. However, most textbooks present diagnosis and management combined with detailed discussion of pathophysiology and other clinical details. This tends to obscure what is the next best step in your head. Come exam time, you will spend valuable time trying to remember the exact step by step by recalling all the other details when you just need the next best step. For example, you have a case of a patient who came in with chest pain and you suspect it to be a case of Acute Myocardial Infarction. In a next best step questions, all 5 choices are correct choices in the diagnosis and management of AMI but you need to decide which of the five is the next best step. Give streptokinase, hook up to a cardiac monitor, extract blood for cardiac enzymes, give nitrates, etc. Unless you know the exact step-by step diagnosis and management of Acute MI, you will be lost as to the best answer. The best way to study next best step in management type of question is to construct algorithms that outline the diagnostic and management steps you need to take for any particular type of clinical situation. You can answer the next best step in management type of question without using algorithms but it will take longer and more analysis to be able to answer them. And as we all know, in the USMLE time is what you lack. Third, Knowing too little Pathophysiology or Mechanisms of Diseases. Pathophysiology, better known as mechanisms of disease in Step 2 CK comprises about 20% of Step 2 CK. That is the biggest reason why I emphasize studying pathology and pathophysiology really well when prepping for Step 1 as it is not only the biggest subject in Step 1, it covers significant portions of Step 2 CK and Step 3. While Step 1 primarily covers General Pathology, Step 2 CK covers primarily Systems Pathology. Also in Step 2 CK, the pathophysiology tested are more clinical in nature, i.e. how they account for various signs and symptoms and complications of diseases. You will also encounter cases which I call “applied pathophysiology”. If you did algorithms for diagnostic workups and patient management, you may know the next best step in management, but applied pathophysiology helps explain the reason why. Why this test, not that. Why they may look the same but actually are not. This is usually a problem for old IMG’s who decide to take Step 2 CK first instead of Step 1. If you really have to take Step 2 CK first, then make sure to cover this well. Even if you took Step 1 first, this becomes a problem if you did not study pathology we and did poorly. The solution is therefore to make sure that you are solid in pathophysiology. Goljan’s Rapid Review for Pathology is a short but good book to brush up on pathophysiology, although it covers general pathology as well which is not needed in Step 2 CK. Reading Harrison’s Principles of Internal Medicine or Cecil’s Textbook of Medicine also covers the topic pretty well. Fourth, Failure to Recognize Atypical Presentation of Common Diseases. According to Cecil’s Textbook of Medicine, there are four types of cases you normally encounter in clinical practice. In order of frequency, they are (1) common diseases with typical presentation, (2) common diseases with atypical presentation, (3) rare disease with typical presentation and (4) rare diseases with atypical presentation. They also occur roughly in the same number in Step 2 CK with slightly more type 2 cases than normal. In Step 1, most of the cases you will encounter are presented classically. But in real life you rarely see classical cases where all the key signs and symptoms are present. Even in Type 1 cases, not all the signs and symptoms will be there. However, enough will be present so diagnosis is not so difficult. The big problem in Step 2 CK for most people is type 2 cases where common diseases presents atypically. For example, although sarcoidosis is most common in young, black female. They do occur in males, older people and other races. So in Step 2CK a sarcoidosis patient may be an old, white male instead. You need to be able to diagnoses the case even with atypical presentation or you won’t be able to answer the questions. This is usually a problem with medical students with limited clinical experience and old grads who have not practiced medicine for some time. Other ways clinical cases are tougher in Step 2 CK is the addition of both relevant and irrelevant normal findings and the addition of irrelevant abnormal findings that will not change the diagnosis. You need to be able to discern what facts are important and what are not. Remember in an actual live patient, they may present with symptoms that is irrelevant to their main complaint and you need to decide what is relevant and what is not. The best way to correct this problem is to study classical cases and know what symptoms and signs are absolutely essential in making a diagnosis. When doing qbanks and you misdiagnose a case, it may make sense to find out where you got it wrong and write down the minimum symptoms and signs you need to make the diagnose, so you don’t make the same mistake again. Source
