Step 2 CS and CSA Tips

1. Step 2 CS and CSA Tips Pam Shaw MD January 6, 2011

2. 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 June 1, 3, 10, 13, 15, 17, 21, 23, 24 and 28th Residency program directors rate our students� skills highly We have a high pass rate for CS

3. Feedback before taking the exam If you plan on taking CSA in July, you need to meet with Dr. Shaw before taking the exam Everyone who scores in the bottom 15% of the class will have a meeting with Dr. Shaw CSA is scored like the CS so it is good feedback

4. 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 One you leave the room, you are done Post-encounter note after each patient�10 min Approximately 8 hours

5. Step 2 CS Test Sites Chicago Los Angeles Atlanta Philadelphia Houston

6. 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

7. 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

8. Step 2 CS: 3 components Integrated Clinical Encounter Data gathering (with SP) scored by checklist Documentation scored by physicians Communication and Interpersonal Skills (SP scored) Questioning skills Information sharing skills Professional manner and rapport Spoken English Proficiency (SP scored) Must pass all three to pass exam

9. Integrated Clinical Encounter Components History taking Full history Physical exam Focused exam Post-exam discussion with patient Post-encounter note Focused H and P

10. Integrated Clinical Encountertips: 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?�

11. Integrated Clinical Encountertips: 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

12. Integrated Clinical Encountertips: HistoryALWAYS ASK Past Medical History Medications Allergies Social History Occupation, Smoking, Alcohol, Drugs, Sex Family History Review of Systems

13. Integrated Clinical Encountertips: 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

14. Integrated Clinical Encountertips: 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

15. Integrated Clinical Encountertips: 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

16. Integrated Clinical Encountertips: Post-encounter note Think of this as a short H and P rather than a SOAP note 10 min per note Write everything (relevant) you learned or did down Pertinent negatives as well as positives in HPI (no separate ROS needed) Typing is required this year You will only be handwriting anything if computer glitch

17. Integrated Clinical Encountertips: Post-encounter note Instead of A/P do Diff Dx and Diagnostic Work-up GU/breast/corneal reflex exams belong in diagnostic work-up section NO treatments, consultations or referrals Do NOT include things you forgot to do in the pt encounter Examples and practice available on USMLE website including abbreviations

18. Integrated Clinical Encountertips: Post-encounter note HISTORY: Include significant positives and negatives from history of present illness, past medical history, review of system(s), social history, and family history. PHYSICAL EXAMINATION: Indicate only pertinent positive and negative findings related to the patient's chief complaint. DIFFERENTIAL DIAGNOSES: In order of likelihood (with 1 being the most likely), list up to 5 potential or possible diagnoses for this patient's presentation (in many cases, fewer than 5 diagnoses are likely) DIAGNOSTIC WORKUP: List immediate plans (up to 5) for further diagnostic workup:

19. 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

20. 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

21. 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 feel comfortable and respected during the encounter

22. 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

23. 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

24. Spoken English Proficiency For most, should not be an issue, if you are concerned, please touch base in student counseling or with Student Affairs

25. 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

26. Resources Mastering the USMLE Step 2 CS by Reteguiz First Aid for the USMLE Step 2 CS by Bhushan et. al. More info: USMLE� : Test Content & Practice Materials http://www.usmle.org/examinations/step2/step2cs.html Use your clerkships/faculty!