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Step 2 CS How to Approach?

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  • 1. USMLE STEP2 CLINICAL SKILLS : HOWTO APPROACH ?DR.ALAA KHALAFALLAHTA,FACULTY OF MEDICINE,UNIVERSITY OF KHARTOUM
  • 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. 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. 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. WHERE TO BEGIN ? You gotta divide your efforts equally! Identify your weakness points and work on them . Know your enemy !
  • 6. WHAT ARE THEY TESTING YOU FOR ? ICE : Data gathering: history + physical examination Patient notes : History +physical findings +diagnostic impression +initial workup
  • 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. 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. 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. 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. 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. 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. 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. 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. 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. COMMUNICATION SKILLS : Information sharing skills: Acknowledge sp concerns .how ? Respond clearly ? How Challenging questions ?? Counsel Close
  • 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. 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. 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. COMMUNICATION SKILLS:
  • 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. 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. 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. 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. 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. 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. COMMUNICATION SKILLS : Counsel: What for ? When? How ? How much time ? What if the patient was reluctant or refuses help ?
  • 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. DIFFICULT PATIENTS : NEVER MIND PATIENTS ? COOPERATIVE PATIENT?
  • 40. DIFFICULT PATIENTS: SP with heavy accent?
  • 41. DIFFICULT PATIENTS: SP in severe pain?
  • 42. DIFFICULT PATIENTS: SP with severe headache?
  • 43. DIFFICULT PATIENTS: SP with cough?
  • 44. DIFFICULT PATIENTS: Talkative SP?
  • 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. DIFFICULT PATIENT: Assaulted SP? SP with hallucinations –distractible?
  • 47. DIFFICULT PATIENT: SP with dementia ?
  • 48. DIFFICULT PATIENTS : SP with depression?
  • 49. DIFFICULT PATIENTS: SP on a phone encounter ?
  • 50. DIFFICULT PATIENTS: Angry SP-waiting ?
  • 51. DIFFICULT PATIENTS: Adolescent SP?
  • 52. DIFFICULT PATIENTS: Worried care giver –mother ?
  • 53. EXAM BIGGEST CHALLENGES: Anxiety Calmness counts towards professionalism score ! Taking SP behavior personally ! Time management Getting over poorly performed cases
  • 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. EXAM LOGISTICS: Visa Which center? Hotels Transportation during the day of the exam?
  • 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. 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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