In mid 2012, the pattern of the patient note writing for the USMLE Step 2 CS exam changed. Though the general theme and subheadings remain the same, the new format is challenging to the examinee because he/she has to pay attention to details in history and P/E. In the old system, you just had to enlist your possible diagnosis for the case with no explanation as to why you picked the DD. For example if it is a case of chest pain, you could just rattle away with Angina, MI, Costochondritis, Rib Fracture, Pleurisy but now you got to lay it down-Why you think it is MI? Why you think it is Rib fracture? Chest pain on exertion, associated sweating, location on the precordial region probably radiating to left arm would probably be the basis why you picked Angina/MI. I think the CIS component gets tested here as well because ‘listening effort’ will play a big role in getting to the basis of your diagnosis. If you are focused on just asking questions and not listening and recording the information mentally, you may find it difficult to list the reasons for your DD. The Data Gathering component is also important. What if you don’t ask for chest trauma during the encounter and list Rib Fracture as a DD in your patient notes for Chest Pain? Bottomline, it is challenging isn’t it? But that’s what we go to do in everyday practice as well. Right? Hence it is just a better system to evaluate you if you are good at what you call yourself to be – a doctor! That’s what your patient wants from you as a doctor as well – “to LISTEN “. So be a good one! P.S. In Target’s 7 Easy Steps 2 CS , STEP 4 has an interactive Differential Diagnosis module which will help you guide along the thinking process of pinning down the Diagnosis for various symtoms. Don’t miss to check it out!