USMLE STEP2 CLINICAL SKILLS : HOWTO APPROACH ?DR.ALAA KHALAFALLAHTA,FACULTY OF MEDICINE,UNIVERSITY OF KHARTOUM
OBJECTIVES OF THIS SESSION : Familiarize candidates  with the USMLE –  Clinical skills exam Identify its components  and...
FACTS: A very important exam. Why? Both easy and difficult to pass . How? The key to pass is : PRACTICE ,PRACTICE  AND ...
COMPONENTS OF THE EXAM: Spoken English proficiency Interactive clinical encounter Communication skills You gotta pass ...
WHERE TO BEGIN ? You gotta divide your efforts equally! Identify your weakness points and work on  them . Know your ene...
WHAT ARE THEY TESTING YOU FOR ? ICE : Data gathering: history + physical  examination Patient notes : History +physica...
DATA GATHERING The easiest to pass ! Use first aid for step 2 CS +  Neeraj notes Use mnemonics … Develop your own set ...
DATA GATHERING You have to be focused ,,,why ? And systematic ,,,,why ? Famous mnemonics : Last name /age /sex/CC/abno...
DATA GATHERING : Physical examination: If you have to scarify  something ,,,,, go with this  one =) You gotta be really...
DATA GATHERING:   Physical examination:   Neuro :   Practice neuro in less than 2 minutes ,,,YEP 2    minutes =)   Fun...
DATA GATHERING: Physical examination : Auscultate the heart only in 1 or 2 areas! Musculoskeletal: Always compare with...
DATA GATHERING: Always auscultate the chest -2 areas and the  heart 2 areas ,,if you have time ! Pay attention to the co...
PATIENT NOTES : Summarize your findings+DDs+initial  workup(including genital,pelvic,revtal and breat  exam). Practice y...
COMMUNICATION SKILLS :   Questioning skills :   Very tricky part ,,,make sure to    master!   Use :   Open ended quest...
COMMUNICATION SKILLS : Questioning skills : Avoid : Leading Q Multiple Q Repeating questions ,,what if ? O_o using m...
COMMUNICATION SKILLS : Information sharing skills: Acknowledge sp concerns  .how ? Respond clearly ? How Challenging q...
COMMUNICATION SKILLS : Acknowledge : I understand your concern I appreciate your  apprehension I know this must be  wo...
COMMUNICATION SKILLS :   Challenging questions :   Don’t be taken by surprise !   Pause for a second   Be empathetic ...
COMMUNICATION SKILLS : Challenging questions : Practice from the first aid section Keep the rules in mind Always asses...
COMMUNICATION SKILLS:
COMMUNICATION SKILLS: Challenging questions : A 32 y/o F presented with amenorrhoea   My mother had menopause at my age...
COMMUNICATION SKILLS :   A 53 y/o M presented with blood in stool    suggestive of colorectal cancer   Doctor I think th...
COMMUNICATION SKILLS:   A 24 y/o F presented with right lower    abdominal pain for 2 hours,,,   Doctor ,,,do you think ...
COMMUNICATION SKILLS :   A 28 y/o M presented with obstructive    pneumonia ,,,he has a hx of Hodgkin    lymphoma!!   Th...
COMMUNICATION SKILLS: A 46 y/o F presented with knee  pain..suggestive of Rheumatoid arthritis! I did not know that one ...
COMMUNICATION SKILLS: A 55 y/o M presented with one time  generalized seizures Do you have any Q ? Do you have any conc...
COMMUNICATION SKILLS : Counsel: What for ? When? How ? How much time ? What if the patient  was reluctant or  refuse...
COMMUNICATION SKILLS : Closure : 6 points or more =) Use the case to close ! Save enough time for closure 2 DDs+2 Inv...
COMMUNICATION SKILLS: Professional manner and rapport : Always explore patient`s  :feelings,expectations,concerns,suppor...
COMMUNICATION SKILLS : Before and during physical: Wash hands Face the patient while washing hands Use soap and dry we...
COMMUNICATION SKILLS: Help the patient lie down, get up, use foot rest,  bed head if a cardiac case,drape,tie/untie  gown...
COMMUNICATION SKILLS : Dress in a professional manner KNOCK THE DOOR THRICE ! Address the sp with his last name ! If y...
COMMUNICATION SKILLS : Do not forget to introduce your self in a phone  encounter ! Empathize with the patient, how? Whe...
SPOKEN ENGLISH PROFICIENCY: Practice ,,, speak with Americans Do observerships prior to the exam if possible  to break t...
TIME MANAGEMENT SP encounter – 15 minutes 5 minutes notice ,,,where  should I be by then ? History taking-less than 8  ...
TIME MANAGEMENT: Practice in a timed mode Download the online stop watch Difficult start….smooth end ;))) Invest at th...
DIFFICULT PATIENTS: SP=standardized  patients Trained for all accents  ,,yet try to avoid heavy  accent! Trained, every...
DIFFICULT PATIENTS: How to tackle? Never mind SP SP with heavy accent SP in severe pain SP with severe headache SP w...
DIFFICULT PATIENTS :   NEVER MIND PATIENTS ?   COOPERATIVE PATIENT?
DIFFICULT PATIENTS:   SP with heavy accent?
DIFFICULT PATIENTS:   SP in severe pain?
DIFFICULT PATIENTS:   SP with severe headache?
DIFFICULT PATIENTS:   SP with cough?
DIFFICULT PATIENTS:   Talkative SP?
DIFFICULT PATIENTS An assaulted SP SP with dementia SP with depression SP with hallucinations-distracted SP Worried c...
DIFFICULT PATIENT:   Assaulted SP?   SP with hallucinations –distractible?
DIFFICULT PATIENT:   SP with dementia ?
DIFFICULT PATIENTS :   SP with depression?
DIFFICULT PATIENTS:   SP on a phone encounter ?
DIFFICULT PATIENTS:   Angry SP-waiting ?
DIFFICULT PATIENTS:   Adolescent SP?
DIFFICULT PATIENTS:   Worried care giver –mother ?
EXAM BIGGEST CHALLENGES: Anxiety Calmness counts towards professionalism  score ! Taking SP behavior personally ! Time...
AFTER THE EXAM: JUST FORGET IT ! LONG WAIT Anxiety over results is totally understandable You will only remember mistak...
EXAM LOGISTICS: Visa Which center? Hotels Transportation  during the day of  the exam?
USEFUL RESOURCES : FA-step2 CS Neeraj notes Csprotocol blog !!! BRILLIANT CSE videos Practice with a live partner ,,,...
MESSAGE TO TAKE HOME: It is never about the cases! It is about how you carry yourself with the  SPs! It is all about th...
Step 2 CS How to Approach?
Step 2 CS How to Approach?
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Step 2 CS How to Approach?

  1. 1. USMLE STEP2 CLINICAL SKILLS : HOWTO APPROACH ?DR.ALAA KHALAFALLAHTA,FACULTY OF MEDICINE,UNIVERSITY OF KHARTOUM
  2. 2. OBJECTIVES OF THIS SESSION : Familiarize candidates with the USMLE – Clinical skills exam Identify its components and how to tackle each one Put candidates on the right path to help improve the quality of their practice!
  3. 3. FACTS: A very important exam. Why? Both easy and difficult to pass . How? The key to pass is : PRACTICE ,PRACTICE AND PRACTICE It is never about the amount of practice !!
  4. 4. COMPONENTS OF THE EXAM: Spoken English proficiency Interactive clinical encounter Communication skills You gotta pass each component separately to pass the whole exam! You gotta get a minimum passing score across all of these components !
  5. 5. WHERE TO BEGIN ? You gotta divide your efforts equally! Identify your weakness points and work on them . Know your enemy !
  6. 6. WHAT ARE THEY TESTING YOU FOR ? ICE : Data gathering: history + physical examination Patient notes : History +physical findings +diagnostic impression +initial workup
  7. 7. DATA GATHERING The easiest to pass ! Use first aid for step 2 CS + Neeraj notes Use mnemonics … Develop your own set of mnemonics and practice with them from the beginning ! Have a scheme before going into the SP room,,,why ?
  8. 8. DATA GATHERING You have to be focused ,,,why ? And systematic ,,,,why ? Famous mnemonics : Last name /age /sex/CC/abnormal vitals OPDF C AAA/LIQORAAA/PAMHUGFOSS/COUSEL/ 2DD/2 INVESTIGATIONS/SPECIAL WORKUP E.G. RECTAL/PELVIC /BREAST
  9. 9. DATA GATHERING : Physical examination: If you have to scarify something ,,,,, go with this one =) You gotta be really systematic !!! Start from head to toe ,,,,be focused though! Start with general look! PICKLE
  10. 10. DATA GATHERING: Physical examination: Neuro : Practice neuro in less than 2 minutes ,,,YEP 2 minutes =) Fundoscopy Otoscopy –throw the speculum ! Gait : Always support the sp,,,should never fall! Cardiac case : elevate the bed head/carotid bruits/Thyroid gland/auscultate the chest –only 4 area (2 areas each side) Chest case : General examination of upper airways
  11. 11. DATA GATHERING: Physical examination : Auscultate the heart only in 1 or 2 areas! Musculoskeletal: Always compare with the other side! Look ,,,feel and move . Abdomen : Again be systematic ,,,remember pelvic and rectal exam !
  12. 12. DATA GATHERING: Always auscultate the chest -2 areas and the heart 2 areas ,,if you have time ! Pay attention to the communication skills part during data gathering ! Pay attention to the time management factor during data gathering! And pay attention to your spoken English proficiency !
  13. 13. PATIENT NOTES : Summarize your findings+DDs+initial workup(including genital,pelvic,revtal and breat exam). Practice your typing ! 25 wpm 10 minutes ,,,when does it start? Follow the FA template-patient notes template Use acceptable abbreviations, check grammar and spelling! Practice patient notes along with cases!
  14. 14. COMMUNICATION SKILLS : Questioning skills : Very tricky part ,,,make sure to master! Use : Open ended questions/facilitating remarks/transitions/paraphrasing Use them thrice ! Fix them, how ? How may I help you today? Do you have anything else that you would like to add? Do you have any questions or concerns( pause between the two =)
  15. 15. COMMUNICATION SKILLS : Questioning skills : Avoid : Leading Q Multiple Q Repeating questions ,,what if ? O_o using medical jargon,,,,unless ? Interrupting the patient!!!...again unless ? Summarize ,,,when? How ? ACCURATELY
  16. 16. COMMUNICATION SKILLS : Information sharing skills: Acknowledge sp concerns .how ? Respond clearly ? How Challenging questions ?? Counsel Close
  17. 17. COMMUNICATION SKILLS : Acknowledge : I understand your concern I appreciate your apprehension I know this must be worrying I can imagine this must be of concern to you ! Use different phrases !amongst the same and different SPs
  18. 18. COMMUNICATION SKILLS : Challenging questions : Don’t be taken by surprise ! Pause for a second Be empathetic Yet professional and firm Reassure but Never give false hopes Tell the patient what you think but without being too direct or mean about it Always let the patient know it is a possibility but you need further workup and you will let him know !or
  19. 19. COMMUNICATION SKILLS : Challenging questions : Practice from the first aid section Keep the rules in mind Always assess your initial response ! Compare with the FA and modify accordingly ,,however there are no model answers ,,but there are appropriate responses! Worse comes to the worst ? =) USE the template!
  20. 20. COMMUNICATION SKILLS:
  21. 21. COMMUNICATION SKILLS: Challenging questions : A 32 y/o F presented with amenorrhoea My mother had menopause at my age ,,,,is the same going to happen to me ?
  22. 22. COMMUNICATION SKILLS : A 53 y/o M presented with blood in stool suggestive of colorectal cancer Doctor I think this is just hemorrhoids ,,,give me something to stop the bleeding and I will go back home ?
  23. 23. COMMUNICATION SKILLS: A 24 y/o F presented with right lower abdominal pain for 2 hours,,, Doctor ,,,do you think this is something awful?
  24. 24. COMMUNICATION SKILLS : A 28 y/o M presented with obstructive pneumonia ,,,he has a hx of Hodgkin lymphoma!! The SP is murmuring with something you can not apprehend!!
  25. 25. COMMUNICATION SKILLS: A 46 y/o F presented with knee pain..suggestive of Rheumatoid arthritis! I did not know that one can get rheumatoid arthritis at such a young age ! Can you write me something for my employer so I can wear sneakers to work !
  26. 26. COMMUNICATION SKILLS: A 55 y/o M presented with one time generalized seizures Do you have any Q ? Do you have any concern? I am just worried that my employer might delay my pay cheque because I am off work today!
  27. 27. COMMUNICATION SKILLS : Counsel: What for ? When? How ? How much time ? What if the patient was reluctant or refuses help ?
  28. 28. COMMUNICATION SKILLS : Closure : 6 points or more =) Use the case to close ! Save enough time for closure 2 DDs+2 Investigations lay man language+workup+show availability +ask about any questions OR concerns –again pause between the two ! Again worse comes to the worst –Use the template !
  29. 29. COMMUNICATION SKILLS: Professional manner and rapport : Always explore patient`s :feelings,expectations,concerns,support,impact of the illness When relevant ! And Attempt to provide help! Examples : depression,dementia,chronic disabling disease,chronic pain ,,etc Establish confidentiality in all cases ,,from the start if confidentiality especially if sexual assault, Sexually transmitted disease, Contraceptive use !!!
  30. 30. COMMUNICATION SKILLS : Before and during physical: Wash hands Face the patient while washing hands Use soap and dry well Make sure your stethoscope is warm, ask the sp if uncomfortable! Take permission Keep the patient informed through running commentary
  31. 31. COMMUNICATION SKILLS: Help the patient lie down, get up, use foot rest, bed head if a cardiac case,drape,tie/untie gown Never repeat painful maneuvers! What if ? Be gentle ,,,especially with abdominal palpation and percussion! You are not allowed to do : pelvic/rectal/or breast exams,,,however you should write them down on patient notes! Workup section and you should tell the patient that you wanna do them!
  32. 32. COMMUNICATION SKILLS : Dress in a professional manner KNOCK THE DOOR THRICE ! Address the sp with his last name ! If you think you are pronouncing the name wrongly ask the sp Introduce yourself with your last name ! Smile when entering the room, maintain a strong comfortable eye contact, how ? While gathering data O_o
  33. 33. COMMUNICATION SKILLS : Do not forget to introduce your self in a phone encounter ! Empathize with the patient, how? When ? Interact with the patient ,,,in a spontaneous way ,,without acting fake! The trick is PRACTICE UNTIL IT FLOWS ALL NATURALLY from u ;)))) At the end thank the patient, smile and say good bye,,,
  34. 34. SPOKEN ENGLISH PROFICIENCY: Practice ,,, speak with Americans Do observerships prior to the exam if possible to break the cultural and language barrier Speak slowly and clearly and focus on annotations What if the patient can not understand you ? Use simple sentences and as short and as to the point as possible
  35. 35. TIME MANAGEMENT SP encounter – 15 minutes 5 minutes notice ,,,where should I be by then ? History taking-less than 8 minutes Physical examination-3 minutes Closure -2 minutes Introduction –challenging questions –washing hands-2
  36. 36. TIME MANAGEMENT: Practice in a timed mode Download the online stop watch Difficult start….smooth end ;))) Invest at the beginning and at the end! Closure ,,,what if no enough time ?
  37. 37. DIFFICULT PATIENTS: SP=standardized patients Trained for all accents ,,yet try to avoid heavy accent! Trained, every thing is purposeful ! Respond accordingly! Structured behavior to simulate real practice
  38. 38. DIFFICULT PATIENTS: How to tackle? Never mind SP SP with heavy accent SP in severe pain SP with severe headache SP with cough Cooperative SP Talkative SP
  39. 39. DIFFICULT PATIENTS : NEVER MIND PATIENTS ? COOPERATIVE PATIENT?
  40. 40. DIFFICULT PATIENTS: SP with heavy accent?
  41. 41. DIFFICULT PATIENTS: SP in severe pain?
  42. 42. DIFFICULT PATIENTS: SP with severe headache?
  43. 43. DIFFICULT PATIENTS: SP with cough?
  44. 44. DIFFICULT PATIENTS: Talkative SP?
  45. 45. DIFFICULT PATIENTS An assaulted SP SP with dementia SP with depression SP with hallucinations-distracted SP Worried care giver –mother Adolescent SP SP in a phone encounter An angry SP –waiting !
  46. 46. DIFFICULT PATIENT: Assaulted SP? SP with hallucinations –distractible?
  47. 47. DIFFICULT PATIENT: SP with dementia ?
  48. 48. DIFFICULT PATIENTS : SP with depression?
  49. 49. DIFFICULT PATIENTS: SP on a phone encounter ?
  50. 50. DIFFICULT PATIENTS: Angry SP-waiting ?
  51. 51. DIFFICULT PATIENTS: Adolescent SP?
  52. 52. DIFFICULT PATIENTS: Worried care giver –mother ?
  53. 53. EXAM BIGGEST CHALLENGES: Anxiety Calmness counts towards professionalism score ! Taking SP behavior personally ! Time management Getting over poorly performed cases
  54. 54. AFTER THE EXAM: JUST FORGET IT ! LONG WAIT Anxiety over results is totally understandable You will only remember mistakes ! You will never remember what you did right ! My mistakes!!!! O_o Refer to this forum : www.usmleforum.com-thread: my step2cs mistakes =)
  55. 55. EXAM LOGISTICS: Visa Which center? Hotels Transportation during the day of the exam?
  56. 56. USEFUL RESOURCES : FA-step2 CS Neeraj notes Csprotocol blog !!! BRILLIANT CSE videos Practice with a live partner ,,,worse come to the worst –skype study partner!
  57. 57. MESSAGE TO TAKE HOME: It is never about the cases! It is about how you carry yourself with the SPs! It is all about the patient The key is to practice as long as you know what you are practicing for ! Act like a doctor ! And you are good to pass with flying colors =)))

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