Mistakes IMGs make in Step 2 CS

The USMLE Step 2 has historically been a difficult exam for international medical graduates (IMGs) to pass. There are a number reasons for that: differences in medical training, unfamiliarity with the American way of performing an exam, cultural nuances, etc.

I’ve helped a lot of foreign medical graduates pass their USMLE Step 2 CS. In my experience, when IMGs fail, it is typically not due to lack of knowledge, improper physical exam, or being a bad physician. Failure is purely a result of unfamiliarity with the American medical exam process, which is hard to learn from books or videos. And there is one consistent problem across-the-board as a result of this: the inability to do a complete, thorough, and concise review of systems. 

What is the review of systems:

The review of systems is information on other systems that are not included in the history of present illness. For example if the patient's main complaint is chest pain, included in the review systems are other problems like difficulty swallowing, problems urinating, or cough.

The inability to do a good, thorough and consistent review of systems is, by far, the most common reason why IMGs fail.
Here are some simple tips to help you master the review of systems:

1. Use a checklist. Having a checklist with yes/no answers for the review of systems will help tremendously. This is one of the few times where the standard open-ended questions to your patients will be detrimental. For example, use questions like “do you have chest pain” (yes/no); “do you have nausea” (yes/no); “do you have swelling in your legs” (yes/no). Make it rapid fire, yes/no questions.
2. Be as comprehensive as possible. It's important to hit every organ system within the body in a concise, yet thorough manner. Have a plan of attack and make it consistent with every case. For example always ask about shortness of breath, chest pain, or diarrhea for every patient that you see. Have a concise, consistent, yet comprehensive plan.
3. Don't feel rushed. It may seem like a lot of information to get through but you'd be surprised how quickly but thoroughly you can get a good review of systems. Have a couple of points for each system and make sure you are consistently hitting those same points.​
4. Practice, practice, practice. The review of systems should be second nature. Practice the same script for multiple patients when studying for the exam so that it becomes second nature to you.

By making these few changes, you will be able to improve your chances of passing the USMLE Step 2 CS examination. 

Sameer Islam, MD, is a board-certified Gastroenterologist and Hepatologist practicing in Texas. He has helped hundreds of students, residents, and fellows pass the MCAT and USMLE Step examinations. You can get more information at www.scutworkefficiency.com or his personal webpage (www.sameerislam.com).

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