Transcript USMLE Step2 CS - University of Michigan Health System

M4 CCA
Important Orientation and
Preparation Information
2010
M4 CCA
The mission of the M4 CCA is to
ensure that students are
competent in the fundamental
clinical skills necessary to
provide excellent, effective, and
safe patient care as a PGY1
trainee.
Goals:
M4 CCA vs. USMLE Step 2 CS
• The M4 CCA is designed to measure
student competency across U of M
specific intended learning
outcomes.
• The M4 CCA is similar to but differs
from the Step 2 CS Exam.
Continued:
M4 CCA vs. USMLE Step 2 CS
• The M4 CCA includes Radiographic studies,
EKGs, Critical Values, and EBM.
• Each station on the M4 CCA may or may
not be followed by post-patient encounter
note or exercise.
• Similar to the Step 2 CS, you may need to
interview a parent but not by phone.
Content of M4 CCA
Part I: Clinical Exam
• Cases are drawn from a blueprint and
include important symptoms and
diagnoses, presenting complaints, and
conditions – balanced by age and gender.
• Settings include urgent care and
outpatient clinic sites.
• Approximately 10 -12 stations
• The exam may include pilot station/s or
components
Tasks: Clinical Exam
• Most stations include a focused
history and/or physical exam.
• After you complete the patient
encounter, you may need to write a
note or answer questions relating to
the case.
• Be sure to read the instructions on
the door and understand the tasks at
each station before entering the
room.
Communication Skills
• Assessed across all patient encounter
stations; they are categorized and
scored in similar ways to the USMLE
scheme of (Questioning, Information
sharing, and Professionalism).
– Resource: See p. 10 of 2010 Step 2 CS
document: Content description and
General Information.
– Warning: Pay particular attention to the
Information Sharing Domain.
Communication Skills
• You must demonstrate your Ability to:
–
–
–
–
–
–
Open the interview appropriately
Establish and maintain rapport
Elicit a relevant history
Demonstrate active listening skills
Close the interview appropriately
Be attentive and empathetic throughout the
interaction
– Be aware and sensitive to the patient’s health
concerns
• Resource: Patient Doctor Communication
(M4 CCA web-site)
Content of M4 CCA
Part II: Computer Based Exam
1. EBM*
2. EKG*
3. Critical Values (see next slide)
4. Imaging*: includes mainly chest and
abdominal plain films. No ultrasound or MRI.
*For Prep materials: See clinical resources
on M4 CCA web-site.
Critical Values
•
•
Questions that center on decisions that Program Directors expect
an intern to be able to make independently on day 1.
Content may include:
–
–
–
–
–
–
–
–
–
–
–
–
–
–
Issues Associated With Basic Life Support
Use of Beta Blockers in Acute Coronary Syndrome
Medical Treatment of Acute Coronary Syndrome
Recognition and Treatment of Urinary Tract Infections
Differentiation of Upper vs. Lower UTI
The Treatment, Recognition and Electrolyte and Glucose Abnormalities
in Seizure Disorders
Recognition of Trauma Related Injuries and their initial management
The Recognition and Treatment of Common Electrolyte Abnormalities
Calculations and the Sources of Free Water
Patient Safety Interventions
Acid Based Disorders - interpretation of blood gases and management
Recognition and management of respiratory failure
Recognition and initial treatment of common toxidromes
Calculations and the Sources of Free Water
Warning
Any information from past
CCA exams may be
misleading – especially
for 2010!
Overall Station
Details
Content of Door Instructions
• For each patient encounter, there will
be door instructions that include:
– Pt name, age, chief complaint and where the
patient is presenting (e.g. urgent care or
outpatient clinic)
– Pt’s vital signs (these can be trusted, do not
need to re-take)
– List of specific tasks to be completed (hx,
physical exam, etc.)
– Time allotted for the station
– Notification of whether you will need to write a
note or answer questions after you complete
the patient encounter.
At the Door
• Read instructions and understand the
tasks and time allotted
• Formulate your checklist
• Review patient’s name, cc, vital sx
• Knock and introduce yourself as
Student Doctor ________
• Address patient by his or her full
name (first AND last name)
Advice re time allocation:
History AND Physical Exam
Stations
• Door instructions: 10-20 sec.
• History taking: 7-8 minutes
• Physical exam: 4-5 minutes
• Discuss plan with pt/closure: 1-2
minutes
TOTAL = 15 minutes
Advice re time allocation:
History taking only Stations
• Door instructions: 10-20 sec.
• History taking: 12-13 minutes
• Discuss plan with pt/closure: 2-3 minutes
TOTAL = 15 minutes
*Remember that you will not be doing pelvic
or rectal exams on the M4 CCA or Step 2
CS. However, if indicated you should let the
patient know that “you will return” to do this
part of the exam.
History: Review of
important points
History
• The cases are designed to suggest a
broad differential.
• Based on the patient’s chief complaint,
you should consider a number of possible
diagnoses.
Components of the HPI
•
•
•
•
Chronology
Symptoms
Pertinent negatives
Relevant:
– PMH
– Medications ( include OTC,
supplements, herbs, etc.)
• Risk factors
• Relevant ROS
HPI: PQRST
P = Provoking:
Aggravating factors
Alleviating factors
Q = Quality
R = Radiating, location
S= Severity/Intensity
T= Timing – onset, duration, frequency
Remember to ask about Associated
symptoms
HPI: Past Medical Hx
• Past medical illnesses
• Past surgical illnesses
• Psychiatric illnesses
HPI: Medications/Allergies
• Medications (include OTC,
supplements, herbs, etc. Include
dosage and frequency)
• Allergies
Physical Exam
• Perform relevant physical exam
based on the patient’s history
• Patients may present with
positive simulated findings
Physical Exam
• You will not need to perform pelvic or
rectal exams but, if indicated, let the
patient know that this is the case.
• You must make note of the need for
any additional physical exam (e.g.,
rectal, pelvic) in the
“Management/Treatment” section of
your note.
Oral Case Presentation
• http://depts.washington.edu/medclerk/student/presentati
on.html
• Caution on above link: not everything is the 'Michigan
Way'. For example, the site suggests using 'normal' to
save time while presenting the physical. We actively
discourage this. Please follow the Michigan protocol
• "'Normal' will not suffice. You must state the findings.”
SPECIAL CASES
INFORMATION
Special Cases
• Remember that you need to modify your
history to include pertinent questions
appropriate to age, gender, and other
factors.
• For example, a pediatric history should
include specific questions. Refer to Dr.
Schmidt’s power point for more details.
•
•
•
•
Special cases:
Psychiatric history
Past psych hx
Family psych hx
Social hx/support system
PSYCHIATRIC mental status exam
(appearance, behavior, speech, emotions,
thoughts, cognition)
– “MSE Outline” (pdf)
• Cognitive exam should be focused and
only as detailed as needed for the clinical
situation.
Special cases:
Geriatric History
http://www.med.umich.edu/i/geriatrics_center/UMGeriatricsCare
• ADLs (Activities of Daily Living)
• IADLS (Instrumental Activities of Daily
Living)
• Social supports
• Living environment
• Medications
• Incontinence
• Falls
• Cognition
• Affect
Special case continued:
Geriatric Physical Assessment
http://www.med.umich.edu/i/geriatrics_center/UMGeriatricsCare
• Mobility:
– Observed Gait
OR
– Timed up & Go Test
• Cognition:
– Mini Mental State Exam (MMSE)
• Mood symptoms:
– Two-Question Depression Screen
(If positive, do full depression screen)
Acute Mental Status Changes
•Dr. Selwa Coma Examination Video:
Click Here
•Gelb lecture syllabus from M2 year,
lectures on Toxic metabolic disorders,
Acute mental status changes.
Post-Patient
encounter
components of the
exam
Post-Patient Encounter
Exercises
After seeing the patient you may be asked
to either:
• Write a note,
• Answer questions that probe your
rationale or justification for the differential
diagnosis or management plan of the
patient you have just seen, or
• Do a verbal presentation.
Post- Patient Encounter Note
• Time: 10 minutes, enter into computer, cannot
be handwritten
• Format (similar to Step 2 CS) but for the M4
CCA, you must give a rationale for the top 2
diagnoses in your differential
• Note format:
–
–
–
–
History
Physical Exam
Differential diagnosis (with rationale)
Plan
Post- Patient Encounter Note:
Components
History:
Include significant positives and
negatives from the history of present
illness, past medical history, review of
systems, social history, and family history
pertinent to this patient’s chief
complaint. Also include medications
(dosage and frequency) and allergies.
Post- Patient Encounter Note
• Physical Examination:
– Include only pertinent positive and
negative findings related to the patient’s
chief complaint.
– Remember to include Vital signs!
Post- Patient Encounter Note
• Differential diagnoses:
– In descending order of likelihood (with 1
being the most likely), list up to 5 potential or
possible diagnoses for this patient’s
presentation (in some cases, fewer than 5
diagnoses are likely).
– Provide the rationale for your top 2
diagnoses.
Post- Patient Encounter Note
• Plan:
– List next steps in the management of this
patient (up to 5). Include diagnostic tests and
/or treatments (if applicable).
Post-Encounter Questions
• Instead of writing a note after you see the
patient, you may be asked to answer
questions that center on key elements of
the diagnosis or plan for the patient you
have just seen.
• Time allotted: 10 minutes
Post- Patient Encounter
Presentation
• Timing: after clinical encounter with
Standardized Patient
• Time allotted: 15 minutes, includes:
– Preparation time
– Presentation time
• Goal: a 5 minute concise, relevant oral
presentation to faculty member
• Assessment based on:
– Content: relevance, accuracy, and judgment
– Communication
Components of the Oral
Presentation
– History
– Physical exam (this will be
given to you since you will not
have examined this patient)
– Assessment
– Plan
Oral Presentation: History
• Standard components:
–HPI (CC, associated relevant
symptoms)
–Past Medical History
–Family History (if relevant)
–Social History
–Medications
Oral Presentation: Physical
Exam
• You will not have examined this patient
but the physical exam findings will be
provided to you.
• Do not forget to include this information in
your presentation
Oral Presentation:
Assessment and Plan
• Assessment:
–Differential Diagnosis, along
with rationale
• Plan:
–Further testing, with rationale
–Initial therapy, with justification
COMMON REASONS
FOR FAILURE,
REMEDIAITON &
RETAKE
INFORMATION
Common Reasons for Failure:
History Taking
• Incomplete history :
–**Failure to consider broad
differential - premature closure.
–Failure to ask about PMH
including medications, allergies.
–Failure to obtain pertinent FH, SH
Common Reasons for Failure:
Physical Exam
• Not focused – too diffuse
• Incomplete – omit important elements
• Exam must be focused, i.e., cannot do
the whole physical, but you must be
thorough within that focused area
• Example: If a pt has chest pain, need to
do elements of pulmonary, abdominal,
musculoskeletal exam, but would not
need to do cranial nerves, etc.
Common Reasons for Failure:
Communication
• The student:
– Interrupts the patient or uses medical
terminology or jargon.
– Fails to follow up on patient
concerns or response.
– Fails to wash hands, extend table,
drape, and interact with the
standardized patient as the student
would interact with a real patient.
Reasons for Failure: Notes
• Omitting critical elements:
pertinent positives and negatives
in the H & P that are consistent
with your differential.
• Premature closure re the
diagnosis
• Failure to consider a lifethreatening or serious diagnosis
Common Reasons for Failure:
Notes
• Plan is not consistent with the
differential diagnosis or is
dangerous
• Note is poorly written
Grading*
• If you fail the exam overall, you must
re-take the entire CCA exam after
completing a remediation process.
• If you fail one or more stations but
pass the exam overall, you must retake the station/s you failed after
completing a remediation process
• * (See grading policy on the M4 CCA website)
Make-Up Exams
• Approximately 50 % of students
will need to re-take at least one
M4 CCA station
• Two retake exams will be offered
and you will be given the
opportunity to select one of the
following:
Marginal Grades
• You may receive a grade of “Marginal” for one
or more stations.
• If you have a marginal grade, the remediation
for that station (a web-based self-assessment)
must be completed but you will NOT have to retake the station unless your self- assessment
exercise is deemed inadequate by the faculty
reviewer.
Remediation
If you fail or receive a “marginal” on a
station:
- You will need to complete a
remediation process.
- Generally, this process may be
completed on-line.
- Remember that if you failed the exam
or a station, you will need to re-take
the exam/station at one of the 2 make
–up dates noted.
GOOD LUCK
• Any questions??
• Content, grading: e-mail Dr. Hernandez
[email protected]
• Scheduling and other concerns:
[email protected]