Explanations for the 2017-2018 Official Step 2 CK Practice Questions

The updated 2017-18 official “USMLE Step 2 CK Sample Test Questions” PDF, released in May and available here.

The PDF set is completely unchanged from last year. You can read the complete explanations for last year’s set here.


As for the updated multimedia questions found only in the online version:

Block 1

7. A – Classic Moro reflex, entirely expected and normal until it disappears around age 4 months. If you have never seen a newborn before, also note that the mom is concerned about delayed milestones at two weeks of age, which is a red flag for BS: babies aren’t even smiling socially yet by two weeks.

Block 2

3. D – Pill-rolling resting tremor of Parkinson’s disease secondary to loss of dopamine neurons in the substantia nigra.

18. A – I’m going to point out that a normal healthy kid with no cardiac history or symptoms and no family history of sudden cardiac death for a pre-sports physical is probably going to have a benign exam no matter what you think you hear. HOCM is what you want to exclude theoretically, but here we don’t have a real systolic murmur, just a little vibratory flow murmur at LLSB.

33. E – This one is a bit silly. The lung exam is normal outside of the super common basilar crackles. Everything except for PE you would expect to hear a more impressive auscultation abnormality. But for this question: B and C take longer than 3 days. D we would expect fever, productive cough etc. Bronchitis would be possible, but still more often to have at least productive cough if not fever. PE, on the other hand, classically has a nonproductive cough, hypoxemia, and tachycardia. All three are present. And then they mention her med: OCPs, which are an important predisposing factor for PE in young women for whom it is otherwise a rare entity. Young lady on OCPs is a classic set-up for an STD question (who needs condoms?) or a PE question, one of the two.

Block 3

12.1 D – Statistical significance (a low p-value) does not equal clinical significance. A favorite teaching point when it comes to interpreting literature.

12.2 C –A & D are conjectures: the kind of statements people drop inappropriately in the conclusion of a weak paper to make it sound important. E is an exclusion criterion. B is the opposite: including 0 is equivalent to something not being significantly different.

Your ERAS application photo

You may not have thought about it, but a lot of people are going to be looking at your glamour shot. The program director and any application reader will see it before you’re chosen for an interview.

  • Your interviewers will see it.
  • It’ll probably make it into a big interview day composite along everyone else visiting that day.
  • The residency selection committee will usually blow it up and put it up on the big screen when they discuss you.

So, for better or worse, people are basically going to see it whenever they think about you. While the people who meet you may form additional images, not everyone who has a role in your selection is going to meet you in person.

Once you land a residency, the photo will almost certainly make more appearances in the “meet our new interns” flyer, get plastered around the department, and may even be accessible online. Rarely, it could even be on your badge.

This is all to say, it might as well not be a terrible photo.

And, like your personal statement, it’s also probably best for you to not stand out.

Not that you can’t be incredibly good looking, of course, but rather that the format of your photo should be the usual bland applicant kind where you’re wearing something you’d wear to the interview while sitting angled slightly in front of a miscellaneous grayish or bluish pseudo-cloud background. Please don’t wear your white coat; you’ll look like a tool.

Stands out in a bad way? How about in front of a random white wall in your apartment under harsh lighting taken by your roommate with your phone where you’re too far away like a B-grade passport photo. The instagram-worthy pic of you in a park with your hair in the breeze and a beautiful bokeh background—while better to look at—also doesn’t scream, “I will answer pages promptly at 3 am and like it.”

Just google something like “residency photo ERAS” and see which examples spark joy for you.

Every interview day we’ll get a big pdf emailed to all the residents and faculty with a composite of everyone who’s visiting. Inevitably, there will be one person who stands out with a blurry poorly lit photo. Does it really matter? I very much doubt it (unless it dovetails with other more serious mistakes/poor judgment calls), but I can’t think of any meaningful benefit to choosing this moment to pinch pennies.

If you have the option of paying an extra 20 or 30 bucks to have the photo professionally retouched, frankly, I encourage you to do so. While this is an irritating expense, again, this photo is used everywhere. Even if you do have it retouched, I still recommend taking steps personally to improve it if you have the skills and desire. Photoshop, its free alternative GIMP, or one of the many free or paid photo retouching apps (including the very nice and very free Adobe Photoshop Fix for iOS) will all do the trick to remove stray hairs, razor burn, leftover blemishes or even whiten teeth. In other words, you want to take reasonable steps to ensure that the photo is a good one.

And, of course, #NoFilter.

Stealth/Health Battles

The stealth battle between hospitals and insurers over bills for each hospitalization, office visit, test, piece of equipment and procedure is costly for us all. Twenty-five percent of United States hospital spending — the single most expensive sector in our health care system — is related to administrative costs, “including salaries for staff who handle coding and billing,” according to a study by the Commonwealth Fund. That compares with 16 percent in England and 12 percent in Canada.

NYTime’s Those Indecipherable Medical Bills? They’re One Reason Health Care Costs So Much.

ACGME pays increased lip service to physician wellness

Because actually changing how young doctors are trained or medicine is practiced is a big hairy potentially expensive and undoubtedly difficult problem, the ACGME has opted to abandon doubling down on actual rules governing work hours and instead focused on broad and largely unenforceable mandates on “wellness.” You can read the track changes version of the new ACGME Common Program Requirements here.

I’ve attempted to translate key portions of Wellness section for clarity:

In the current health care environment, residents and faculty members are at increased risk for burnout and depression. Psychological, emotional, and physical well-being are critical in the development of the competent, caring, and resilient physician. Self-care is an important component of professionalism; it is also a skill that must be learned and nurtured in the context of other aspects of residency training. Programs, in partnership with their Sponsoring Institutions, have the same responsibility to address well-being as they do to evaluate other aspects of resident competence.

Guys, be nice.

This responsibility must include:

a) efforts to enhance the meaning that each resident finds in the experience of being a physician, including protecting time with patients, minimizing non-physician obligations, providing administrative support, promoting progressive autonomy and flexibility, and enhancing professional relationships; b) attention to scheduling, work intensity, and work compression that impacts resident well-being; c) evaluating workplace safety data and addressing the safety of residents and faculty members;

Please attend to the degree of suffering you impose on trainees. There are no guidelines to help you determine what that might entail, so please use your best judgment. We trust you.

d) policies and programs that encourage optimal resident and faculty member well-being; and, d)(1) Residents must be given the opportunity to attend medical, mental health, and dental care appointments, including those scheduled during their working hours.

You must let doctors see other doctors for personal reasons. You can make them use vacation days. You can also remind them that they’ll be letting their peers down who will now have to cover twice the work.

The program, in partnership with its Sponsoring Institution, must educate faculty members and residents in identification of the symptoms of burnout, depression, and substance abuse, including means to assist those who experience these conditions. Residents and faculty members must also be educated to recognize those symptoms in themselves and how to seek appropriate care.

Please single out residents who look especially miserable.

There are circumstances in which residents may be unable to attend work, including but not limited to fatigue, illness, and family emergencies. Each program must have policies and procedures in place that ensure coverage of patient care in the event that a resident may be unable to perform their patient care responsibilities. These policies must be implemented without fear of negative consequences for the resident who is unable to provide the clinical work.


Also, please remember burnout is a problem with an individual trainee and not indicative of a systemic failure.

Clinical and educational work hours must be limited to no more than 80 hours per week, averaged over a four-week period, inclusive of all in-house call clinical and educational activities, clinical work done from home, and all moonlighting.

Please make sure your residents understand that they do not document work more than 80 hours per week.

Residents should have eight hours off between scheduled clinical work and education periods. There may be circumstances when residents choose to stay to care for their patients or return to the hospital with fewer than eight hours free of clinical experience and education.

We used to say 10, but 8 is easier to comply with so we changed it back. Also, it’s okay to help residents choose to stay when particularly useful. In fact, we’re continually surprised at how selfless residents are, particularly in general surgery.

Clinical and educational work periods for residents must not exceed 24 hours of continuous scheduled clinical assignments.

When we say 24, we mean 28. Just don’t put it on the official schedule like that.

In unusual rare circumstances, after handing off all other responsibilities, a resident, on their own initiative, may elect to remain beyond their scheduled period of duty or return to the clinical site…

Physician, heal thyself (during brief bathroom breaks).

These additional hours of care or education will be counted toward the 80-hour weekly limit.

Please make sure your residents are honest. Really. Even though residents breaking duty hours is always due to a resident’s inefficiencies and not related to over-reliance on cheap labor by your healthcare system, we still want to know.

The program director must review each submission of additional service, and track both individual resident and program-wide episodes of additional duty.

This was too tedious, sorry about that.

A Review Committee may grant rotation-specific exceptions for up to 10 percent or a maximum of 88 clinical and educational work hours to individual programs based on a sound educational rationale.

Don’t forget to mentally tack on the uncounted additional 10% for up to 97 hours per week.


Incoming interns, I hope this was helpful to make sense of the new changes.



16 hours is a nice start to the shift

Changes to the 2017 ACGME program requirements:

Maximum Duty Clinical Work and Education Period Length

Duty periods of PGY-1 residents must not exceed 16 hours in duration.
Duty periods of PGY-2 residents and above may be 547 scheduled to a maximum of 24 hours of continuous duty in the hospital.
Clinical and educational work periods for residents must not exceed 24 hours of continuous scheduled clinical assignments.

The first chapter in the experiment in trying to make residents lives better is coming to a close. The 16-hour rule is going away. That’s because:

The requirements were revised to reflect that residency/fellowship education must occur in a learning and working environment that fosters excellence in the safety and quality of patient care. With that priority as their foundation, highlights of the changes include:

— greater emphasis on patient safety and quality improvement
— a dedicated section addressing the critical importance of physician well-being to graduate medical education and patient care
— more explicit requirements regarding team-based care a framework for clinical and educational work hours that allow for flexibility with a maximum toward the ultimate goals of physician education and patient care

Now, the 16-hour rule has always been controversial. As I’ve discussed before, its implementation within the current training paradigm of high work density shifts and a long (80+) workweek leaves a lot to be desired. There’s no doubt, for example, that interns doing less work on some services automatically leads to upper levels doing more. Likewise, because of the coveted post-call day off, it is for many services better to work a few long shifts than a bunch of shorter ones. I would argue that all things being equal, working a short shift would be nicer than working a long shift. The problem is that all things are not equal, and working a long shift and then coming right back to work the next morning sucks.

This change is supposedly evidence-based on the back of the FIRST trial. If you haven’t heard of it, I discussed it here. Frankly, believing that the take home message of the FIRST trial is that working longer hours is better is a very generous reading of its data.

As a general rule, an arbitrary shift length limitation by itself can do almost nothing to combat physician burnout or its effects on patient safety, because those effects are predominately related to chronic fatigue, which comes from indefinitely working an unsustainable schedule and juggling too many patient care tasks at once while often being treated like a subhuman. A shift length of 16 hours at a time just means that it partially prevents a very particular variant of acute fatigue, during which inexperienced interns might be more susceptible to doing stupid things. And that assumes you can get home, eat, get a good amount of sleep, and make it back during that 8-10 hour break.

But the idea that abdicating the reins and momentum on top-down measures to control resident work-hours is concordant with both “a greater emphasis on patient safety” and “the critical importance of physician well-being” is sadly only true in the parallel universe the ACGME occupies. Even the FIRST trial showed that “Residents working longer shifts indicated that their educational experience improved, but at the expense of time with friends and family, extracurricular activities, rest, and health.”

Of course, between working 16 hours for 80 hours or 24 hour shifts up to 60 hours, which would you choose? A long shift can be a good shift, but it’s hard to have a work life balance or avoid “work compression” if you’re always at work.

The 16-hour rule only made sense in a world where as a country we’ve decided to take a proactive centralized approach to ensuring doctors are trained in a way that is compatible with the values we want, not just the self-destructive values we’ve had.

16-hours for an individual shift without addressing 1) how much work must get done per shift and 2) how many hours are worked over time is meaningless. As a component of a sustainable training regiment, it may have actually had a chance to improve patient care. Certainly, the public thinks so. But in a world where 80 hours is the ideal but unforced limit, we’re not there yet.

I think there are valid arguments that an arbitrary universal shift max that short may be unproductive and that it is possible to mitigate some fatigue effects during a longer shift in the appropriate work environment. Certainly scrubbing out of a surgery at the critical moment because you hit a limit is probably stupid. But so is working 80 hours a week for months or years at a time. So is having a job where you’re forbidden from using your vacation or are shunned for getting sick.

We’re in trouble when residents don’t tell the truth about how long they work, how hard they work, or how independently they work for fear of censure or—worse—getting their program in trouble. But that’s how basically every program where residents truly suffer works.