I eat Iron and Shhhhh!t chains.
That’s what one of my attendings taught me, and it’s a very helpful mantra to have walking into step 3. Step 3 messes with you psychologically.
For example 10-15% of the questions are “experimental” and not counted towards your grade. Wtf is that?!! So your cruising through your exam, and you come across one of these experimental questions, and it may even be something that you didn’t study for, and then you’re like omg, I have no clue, and then you guess, but then they are testing your grit, because on the next questions are you still thinking about that previous question thinking like, omg, im gonna fail, or are you thinking about the present question?
Then there’s the fingerprinting, waving a metal detector around your crotch, looking closely at my plastic see through glasses, all before returning from all breaktimes (wasting all my breaktime), and they have you on camera the entire time. I had my hands on my lap, and the one of the proctors tapped me on the shoulder and said “ keep your hands on the desk where we (the cameras) can see them.“
Ok, so you made it through the exam, now let’s make you wait 3 weeks for your results, come on, it doesn’t take 3 weeks to grade an electronic exam. Lol.
Then after the first 12ish hours of constant psychological pressure you still have to perform well on the CCS.
About a week or two ago I posted about failing step 3 the first time and having to sit in my car crippled with anxiety. Well a lot of people reached out to me specifically about the CCS portion of the exam.
The first time I took the exam I had totally bombed the first 4 ccs cases. One of them still sticks with me. It was a case about a 65 year old chronic smoker, with severe chest pains. Troponin was negative, EKG was normal, BP was like 95/65. Normal labs. Normal Xray, CT, pancreatic enzymes, everything was normal, but the chest pain just wouldn’t go away. I moved him from the ED into the floors, gave him everything I could think of like morphine, nitro, IV fluids, and I pretty much through every single thing at him, and still the chest pain was severe and unchanged. That was really messing with me. I think I sent him for a PCI because that was the only thing I could think of at that time.
After the exam was over, I realized I never ordered an abdominal ultrasound, and that this may have been AAA. This case dragged on the full 20 minutes, and I ran out of time.
Here's how I did things differently the second time I took the exam. I was much more prepared, and I had the shitting chains mantra going in the background. Just about all of my cases ended early, even a 20 minute case, ended in like 4 minutes. If a case ends early, its most likely a very good sign, that you figured out the key to their little game, after all this is truly a video game that leads to licensure.
One thing that kept messing me up was failing to forward time, and no training program effectively taught me this. So first its like are you in the Clinic/office, the ED, the floors, or the ICU? This matters because it sets the tone of how much you will be fowarding time.
For example its like if your in the clinic/office you have lots of time like many days or even weeks in some cases. If your in the ED you only have like 1-5 hours. If your on the floors you have 5-48 hours.
Lets say your in the clinic, you do your physical exam, and then you enter your standard orders like pulse ox, vitals, cmp, cbc, tsh, HCG if it’s a possible pregnancy, and then lets say you forward time for like 1 hour, but it tells you before the hour is up that the patient’s blood pressure is 85/45, you stop fowarding time, and then move them to the ED.
Now you have to stablilize them, right, so CCS is looking again for orders like NS IV fluids, again vitals, maybe telemetry, maybe oxygen depending upon pulse ox and respiratory rate, but in the ED on CCS you don’t want more than 2-5 hours going by without eithor admitting them to floors, shipping them off to the ICU or sending them home with clinic follow up if you stabilize them. Practice placing your orders and then fowarding time, waiting for the video game to give you confirmation of your diagnosis.
And when the case ends early, think “I eat Iron and Shhhhh!t chains,” because that’s exactly what happened, you beat them at their own game.
If you need help with CCS or anything else related to Step 3, feel free to message me, I’ve been helping a few people from my last post work through their study plans.