M4 CCA Important Orientation and Preparation Information 2010

1. M4 CCAImportant Orientation and Preparation Information2010

2. 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.

3. 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.

4. 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.

5. 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

6. 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.

7. 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.

8. 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)

9. Content of M4 CCAPart 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.

10. 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

11. Warning Any information from past CCA exams may be misleading – especially for 2010!

12. Overall Station Details

13. 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.

14. 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)

15. 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

16. 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.

17. History: Review of important points

18. 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.

19. Components of the HPI • Chronology • Symptoms • Pertinent negatives • Relevant: • PMH • Medications ( include OTC, supplements, herbs, etc.) • Risk factors • Relevant ROS

20. 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

21. HPI: Past Medical Hx • Past medical illnesses • Past surgical illnesses • Psychiatric illnesses

22. HPI: Medications/Allergies • Medications (include OTC, supplements, herbs, etc. Include dosage and frequency) • Allergies

23. Physical Exam • Perform relevant physical exam based on the patient’s history • Patients may present with positive simulated findings

24. 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.

25. Oral Case Presentation • http://depts.washington.edu/medclerk/student/presentation.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.”

26. SPECIAL CASES INFORMATION

27. 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 historyshould include specific questions. Refer to Dr. Schmidt’s power point for more details.

28. 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.

29. 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

30. 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)

31. 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.

32. Post-Patient encounter components of the exam

33. 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.

34. 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

35. 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.

36. 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!

37. 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.

38. 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).

39. 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

40. Post- Patient Encounter Presentation • Timing: after clinical encounter with Standardized Patient • Time allotted: 15 minutes, includes: • Preparation time • Presentation time • Goal: a 5 minuteconcise, relevant oral presentation to faculty member • Assessment based on: • Content: relevance, accuracy, and judgment • Communication

41. Components of the Oral Presentation • History • Physical exam (this will be given to you since you will not have examined this patient) • Assessment • Plan

42. Oral Presentation: History • Standard components: • HPI (CC, associated relevant symptoms) • Past Medical History • Family History (if relevant) • Social History • Medications

43. 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

44. Oral Presentation: Assessment and Plan • Assessment: • Differential Diagnosis, along with rationale • Plan: • Further testing, with rationale • Initial therapy, with justification

45. COMMON REASONS FOR FAILURE, REMEDIAITON & RETAKE INFORMATION

46. 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

47. 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.

48. 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.

49. 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 life-threatening or serious diagnosis

50. Common Reasons for Failure:Notes • Plan is not consistent with the differential diagnosis or is dangerous • Note is poorly written