Step 2 CS and CSA Tips Pam Shaw MD
Transcription
Step 2 CS and CSA Tips Pam Shaw MD
Step 2 CS and CSA Tips Pam Shaw MD January 10, 2013 Don’t panic. You are wellprepared You have had lots of SP experiences that have prepared you for the test CSA is a good trial run-dates for CSA in KC are May 29, 31, and June 3, 5, 7, 10, 12, 14, 18, 25 Residency program directors rate our students’ skills highly We have a high pass rate for CS BUT…… CS changes for 2013 One of the recommendations emerging from the Comprehensive Review of USMLE (CRU) process is that USMLE consider ways to further enhance the testing methods used in the Step 2 Clinical Skills (CS) examination. these enhancements were implemented in mid-2012. The Step 2 Committee decided to increase the performance levels required to receive a passing outcome on two of the three Step 2 CS subcomponents: Communication and Interpersonal Skills (CIS) and Integrated Clinical Encounter (ICE). There will be no change to minimum passing requirements for the Spoken English Proficiency (SEP) subcomponent of Step 2 CS at this time. The change means that the passing rate would be changed by 3% based on last years results What is CS? Step 2 of the USMLE assesses the ability of examinees to apply medical knowledge, skills, and understanding of clinical science essential for the provision of patient care under supervision, and includes emphasis on health promotion and disease prevention. Step 2 ensures that due attention is devoted to the principles of clinical sciences and basic patient- centered skills that provide the foundation for the safe and effective practice of medicine. What is CS? Step 2 CS uses standardized patients to test medical students and graduates on their ability to gather information from patients, perform physical examinations, and communicate their findings to patients and colleagues. Step 2 CS: 3 components Integrated Clinical Encounter Data gathering (with SP) scored by checklist Documentation (or note)scored by physicians-this changed last year Communication and Interpersonal Skills (SP scored) This also changed last year Spoken English Proficiency (SP scored) Must pass all three to pass exam Step 2 CS Test Sites Chicago Los Angeles Atlanta Philadelphia Houston Step 2 CS 12 patients—15 min encounters Knock in room after 10 min—you have 5 left 5 pts-30 min lunch break-4 pts-15 min break-3 pts Once you leave the room, you are done Post-encounter note after each patient—10 min Approximately 8 hours Step 2 CS No PDAs or phones Only white coat and stethoscope and blank paper Exam is confidential so sharing of information is taboo You must be on time to be able to sit for the exam Step 2 CS: Possible types of encounters Acute, chronic cases Counseling vs. PE cases Follow up lab results Telephone case Peds cases with child out of room Cases with a simulator Changes to the assessment of Communication and Interpersonal Skills (CIS) The CIS subcomponent of Step 2 CS has been redesigned to assess a fuller range of competencies. Beginning June 17, 2012, the Communication and Interpersonal Skills (CIS) scale will focus on five functions: 1. Fostering the relationship 2. Gathering information 3. Providing information 4. Making decisions: basic 5. Supporting emotions: basic Fostering the Relationship Expressed interest in the patient as a person Treated the patient with respect Listened and paid attention to the patient Gathering Information and Providing Information Encouraged the patient to tell his/her story Explored the patients reaction to the illness or problem Provided information related to the working diagnosis Provided information on next steps Making Decisions-Basic Elicited the patient’s perspective on the diagnosis and next steps Finalized plans for the next steps Advanced skills are still being developed Supporting Emotions-Basic Facilitated the expression of an implied or stated emotion or something important to him/her Advanced skills to be determined And lastly, helping patients with behavior change Communication and Interpersonal Skills Questioning skills – examples include: use of open-ended questions, transitional statements, facilitating remarks avoidance of - leading or multiple questions, repeat questions unless for clarification, medical terms/jargon unless immediately defined, interruptions when the patient is talking accurately summarizing information from the patient Communication and Interpersonal Skills Information-sharing skills – examples include: acknowledging patient issues/concerns and clearly responding with information avoidance of medical terms/jargon unless immediately defined clearly providing - counseling when appropriate - closure, including statements about what happens next Communication and Interpersonal Skills Professional manner and rapport – examples include: asking about expectations, feelings, and concerns of the patient; support systems and impact of illness, with attempts to explore these areas showing consideration for patient comfort during the physical examination; attention to cleanliness through hand washing or use of gloves providing opportunity for the patient to express feelings/concerns encouraging additional questions or discussion making empathetic remarks concerning patient issues/concerns; patient feels comfortable and respected during the encounter Communication and Interpersonal Skills tips Introduce yourself every time Call pt. Ms. or Mr. or ask! Open-ended questions Transition statements Don’t interrupt your patient! Don’t use jargon (eg. Say high blood pressure, not hypertension) Empathize Communication and Interpersonal Skills tips Partner with the patient Ask the pt what they think/want to do Ask the pt if they have questions (and answer them) Explain what you think and want to do. Make sure your pt is ok with the plan! Counsel pt if appropriate Closure Provide hope, follow-up plan Spoken English Proficiency For most, should not be an issue, if you are concerned, please touch base in student counseling or with Student Affairs Integrated Clinical Encounter Components History taking Full history Physical exam Focused exam Post-exam discussion with patient Post-encounter note Integrated Clinical Encounter tips: History Focus on the process Keep diagnostic possibilities wide open Don’t focus on an obvious dx early Open-ended questions first, second and third. You can be specific later. One question at a time Get all the concerns on the table early-“Anything else?” Integrated Clinical Encounter tips: History Ask ALL appropriate attributes of a symptom: LOCATES Location Other symptoms Chronology/Timing Alleviating factors Things that make it worse Experience of the symptom/Quality Severity Integrated Clinical Encounter tips: History ALWAYS ASK Past Medical History Medications Allergies Social History Occupation, Smoking, Alcohol, Drugs, Sex Family History Review of Systems Integrated Clinical Encounter tips: Physical exam Focused exams Think about your differential before you do your exam Wash hands every time Technique matters Keep your patients modestly draped If you have questions, review before Step 2CS Integrated Clinical Encounter tips: Physical exam ALWAYS listen with stethoscope on the skin Vitals given, but you may want to repeat No GU/breast/corneal exams—goes in write up—do talk to your pt about these There may be abnormalities! May be real or simulated If you observe something abnormal, it is supposed to be that way Integrated Clinical Encounter tips: Post-exam discussion with patient Don’t just leave the room! Discuss differential dx with patient Discuss your diagnostic plans with patient (GU exam for example) Be prepared for difficult questions Eg. “Am I going to die?” “Did I do something to cause this?” Don’t let these sidetrack you from your task Integrated Clinical Encounter tips: Post-encounter note 10 min per note Character limit in each area of 250 characters Abbreviations must be acceptable to USMLE Typing is required this year You will only be handwriting anything if computer glitch Patient Note Entry Form Post-encounter note History and Physical History: Describe the history you just obtained from this patient. Include only information (pertinent positives and negatives relevant to this patient’s problem(s). Physical examination: Describe any positive and negative findings relevant to this patient’s problem(s). Be careful to include only those parts of examination you performed in this encounter. Post-encounter note Data Interpretation Based on what you have learned from the history and physical examination, list up to 3 diagnoses that might explain this patient’s complaint(s). List your diagnoses from most to least likely. For some cases, fewer than 3 diagnoses will be appropriate. Then, enter the positive or negative findings from the history and physical examination (if present) that support each diagnosis. Lastly, list initial diagnostic studies (if any) you would order for each listed diagnosis (eg restricted physical exam maneuvers, laboratory tests, imaging, ECG, etc.) Quick word on telephone cases Treat as if the patient were in the room Take your time Ask all your usual questions Usually a pediatric case Feedback before taking the exam If you plan on taking CSA in June or July, you need to meet with Dr. Shaw before taking the exam Everyone who scores in the bottom 15% of the class will have to meet with Dr. Shaw CSA will be scored like the CS so it is good feedback Resources More info: USMLE® : Test Content & Practice Materials http://www.usmle.org/examinations/step2/ step2cs.html Use your clerkships/faculty! Recommended resources
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