step 2 cs and csa tips pam shaw md january 10, 2013
TRANSCRIPT
Step 2 CS and CSA Tips
Pam Shaw MD
January 10, 2013
Don’t panic. You are well-prepared
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 checklistDocumentation (or note)scored by physicians-this
changed last yearCommunication 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
ChicagoLos AngelesAtlantaPhiladelphiaHouston
Step 2 CS
12 patients—15 min encountersKnock in room after 10 min—you
have 5 left5 pts-30 min lunch break-4 pts-15
min break-3 ptsOnce you leave the room, you are
donePost-encounter note after each patient
—10 minApproximately 8 hours
Step 2 CS
No PDAs or phonesOnly white coat and stethoscope and
blank paperExam is confidential so sharing of
information is tabooYou must be on time to be able to sit for
the exam
Step 2 CS: Possible types of encounters
Acute, chronic casesCounseling vs. PE casesFollow up lab resultsTelephone casePeds cases with child out of roomCases 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 relationship2. Gathering information3. Providing information4. Making decisions: basic5. Supporting emotions: basic
Fostering the Relationship
Expressed interest in the patient as a person
Treated the patient with respectListened and paid attention to the patient
Gathering Information andProviding 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 timeCall pt. Ms. or Mr. or ask!Open-ended questionsTransition statementsDon’t interrupt your patient!Don’t use jargon (eg. Say high blood
pressure, not hypertension)Empathize
Communication and Interpersonal Skills tips
Partner with the patientAsk the pt what they think/want to doAsk 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 appropriateClosure
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 takingFull history
Physical examFocused exam
Post-exam discussion with patientPost-encounter note
Integrated Clinical Encountertips: History
Focus on the processKeep 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 timeGet all the concerns on the table
early--“Anything else?”
Integrated Clinical Encountertips: History
Ask ALL appropriate attributes of a symptom: LOCATESLocationOther symptomsChronology/TimingAlleviating factorsThings that make it worseExperience of the symptom/QualitySeverity
Integrated Clinical Encountertips: History
ALWAYS ASKPast Medical HistoryMedicationsAllergiesSocial History
Occupation, Smoking, Alcohol, Drugs, Sex
Family HistoryReview of Systems
Integrated Clinical Encountertips: Physical exam
Focused examsThink about your differential before you
do your examWash hands every timeTechnique matters
Keep your patients modestly drapedIf you have questions, review before
Step 2CS
Integrated Clinical Encountertips: Physical exam
ALWAYS listen with stethoscope on the skinVitals given, but you may want to repeatNo GU/breast/corneal exams—goes in write
up—do talk to your pt about theseThere may be abnormalities!
May be real or simulatedIf you observe something abnormal, it is
supposed to be that way
Integrated Clinical Encountertips: Post-exam discussion with
patientDon’t just leave the room!Discuss differential dx with patientDiscuss 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 Encountertips: Post-encounter note
10 min per noteCharacter limit in each area of 250
charactersAbbreviations must be acceptable to
USMLETyping is required this year
You will only be handwriting anything if computer glitch
Patient Note Entry Form
Post-encounter noteHistory 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 noteData 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 casesTreat as if the patient were in the roomTake your timeAsk all your usual questions Usually a pediatric case
Feedback before taking the examIf 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
ResourcesMore info:
USMLE® : Test Content & Practice Materials http://www.usmle.org/examinations/step2/step2cs.html Use your clerkships/faculty!Recommended resources