Step 2 CS Tips

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Step 2 CS Tips

• Pam Shaw, MD
• February 5, 2009

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Dont panic. You are well-prepared

• You have had plenty of SP experiences to help
  you prepare
• CSA is a good trial run
• Residency program directors rate our students
  skills highly

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Step 2 CS

• 12 patients15 min encounters
• Knock in room after 10 minyou 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 patient10 min
• Approximately 8 hours

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Step 2 CS Test Sites

• Chicago
• Los Angeles
• Atlanta
• Philadelphia
• Houston

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Step 2 CS

• No PDAs
• No watches
• Only white coat and stethoscope and blank paper

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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

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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

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Integrated Clinical Encounter Components

• History taking
• Full history
• Physical exam
• Focused exam
• Post-exam discussion with patient
• Post-encounter note
• Focused H and P

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Integrated Clinical Encountertips History

• Focus on the process
• Keep diagnostic possibilities wide open
• Dont 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?

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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

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Integrated Clinical Encountertips
HistoryALWAYS ASK

• Past Medical History
• Medications
• Allergies
• Social History
• Occupation, Smoking, Alcohol, Drugs, Sex
• Family History
• Review of Systems

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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

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Integrated Clinical Encountertips Physical exam

• ALWAYS listen with stethoscope on the skin
• Vitals given, but you may want to repeat
• No GU/breast/corneal examsgoes in write updo
  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

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Integrated Clinical Encountertips Post-exam
discussion with patient

• Dont 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?
• Dont let these sidetrack you from your task

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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 generally better
• If you hand-write, make it legible

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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

http//www.kumc.edu/ncsl/
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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

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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

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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

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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 should feel comfortable
  and respected during the encounter

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Communication and Interpersonal Skills tips

• Introduce yourself every time
• Call pt. Ms. or Mr. or ask!
• Open-ended questions
• Transition statements
• Dont interrupt your patient!
• Dont use jargon (eg. Say high blood pressure,
  not hypertension)
• Empathize

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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

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Spoken English Proficiency

• For most, should not be an issue, if you are
  concerned, please touch base in student
  counseling or with Student Affairs

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Quick word on telephone cases

• Treat as if the patient were in the room
• Take your time
• Ask all your usual questions

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Resources

• Mastering the USMLE Step 2 CS by Reteguiz
• First Aid for the USMLE Step 2 CS by Bhushan et.
  al.
• More info http//www.usmle.org/step2/Step2CS/Step
  2CS2007GI/description.asp
• Use your clerkships/faculty!

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Rock Chalk Jayhawk!