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 how to tackle each one Put candidates on the right path to help improve the quality of their practice!
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 !!
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 !
WHERE TO BEGIN ? You gotta divide your efforts equally! Identify your weakness points and work on them . Know your enemy !
WHAT ARE THEY TESTING YOU FOR ? ICE : Data gathering: history + physical examination Patient notes : History +physical findings +diagnostic impression +initial workup
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 ?
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
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
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
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 !
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 !
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!
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 =)
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
COMMUNICATION SKILLS : Information sharing skills: Acknowledge sp concerns .how ? Respond clearly ? How Challenging questions ?? Counsel Close
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
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
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!
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 ?
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 ?
COMMUNICATION SKILLS: A 24 y/o F presented with right lower abdominal pain for 2 hours,,, Doctor ,,,do you think this is something awful?
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!!
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 !
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!
COMMUNICATION SKILLS : Counsel: What for ? When? How ? How much time ? What if the patient was reluctant or refuses help ?
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 !
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 !!!
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
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!
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
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,,,
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
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
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 ?
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
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
DIFFICULT PATIENTS : NEVER MIND PATIENTS ? COOPERATIVE PATIENT?
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 !
DIFFICULT PATIENT: Assaulted SP? SP with hallucinations –distractible?
DIFFICULT PATIENTS: Worried care giver –mother ?
EXAM BIGGEST CHALLENGES: Anxiety Calmness counts towards professionalism score ! Taking SP behavior personally ! Time management Getting over poorly performed cases
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 =)
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 ,,,worse come to the worst –skype study 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 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 =)))