Everything I need to know about OSCE and Step 2 CS Exams Paul Mendez MD, FACP Monica Broome MD, FACP, FAACH May 2016

Goals OSCE Clinical competency in History-Taking, PhysExam, Clinical Reasoning, Communication Skills, and Counseling Skills Effectiveness of the UMMSM Clinical Curriculum Preparation for the USMLE Step 2 CS Exam Step 2 CS Taking a Relevant Medical History Performing an Appropriate Physical Examination Communicating Effectively with a Patient Clearly and Accurately Documenting the Findings And Diagnostic Hypothesis from the Clinical Encounter Ordering Appropriate Initial Diagnostic Studies

UMMSM Failures Class of OSCE Step 2 CS 2013 --- 11 Miami 0 RMC 2014 2015 4 MD 3 MDMPH 8 MD 1 MDMPH 2016 4 MD 0 MDMPH 6 MD (3 CIS / 3 ICE) 3 MDMPH (1 CIS / 2 ICE)

OSCE Exam - Setup 11 stations – 15 minutes per station Standardized Patient / Faculty Evaluator Student Instruction Sheet Focused Pertinent Hx and PE Progress Note Feedback

OSCE - Scoring Components Passing vs Remediation History Taking Physical Examination Clinical Reasoning Communication Skills Counseling Passing vs Remediation Thoroughness High Impact Core

Tips Be on time – anticipate problems Clinical Dress / ID / Stethoscope Hx – Thorough / Pertinent +/-’s Avoid Premature Closure PE – Review CS Videos Clinical Reasoning & Communication Skills

Step 2 CS Exam - Setup 12 Patient Encounters – 15 min / 10 min 8 hrs with two breaks Standardized Patients – consider them real Expectations – Intern with primary responsibility for care of the patient Do not defer decision making to others Introduce yourself as student or doctor If no PE required – street clothes Focused pertinent Hx and PE Respond to questions, mention Dx’s and Plans If you leave the room early, you may use the additional time for the note Assume you are working in a setting where you are the only provider present If no PE required, leave PE section of note blank

Step 2 CS – Setup - PE Wash hands or use gloves Ask to loosen or move bra No – Rectal, Pelvic, Genital incl Inguinal hernia exam, female Breast, Corneal reflex Yes – Femoral pulses, Inguinal nodes, Axillary exams Patient comfort Consider simulated findings as real Starting May 2016 – Images will be included

Step 2 CS – Setup - Note Write only information solicited Be as specific as possible – avoid “normal” List up to three diagnoses in order of likelihood List Hx and PE findings supporting dx List Diagnostic studies – not Tx/Mgmnt, Consultations, Referrals, Admission May be “No studies indicated” Approved Abbreviations

Step 2 CS - Categories Communication & Interpersonal Skills (CIS) Fostering the Relationship Gathering Information Providing Information Helping Patients Make Decisions Supporting Emotions Integrated Clinical Encounter (ICE) Data Gathering Skills Data Interpreting Skills Spoken English Proficiency Communication & Interpersonal Skills (CIS) Fostering the Relationship - Listening attentively, showing interest, demonstrating genuineness, caring, concern, and respect Gathering Information - Use of open-ended techniques that encourage the patient to explain in their own words and in a manner relevant to the situation at hand, develop understanding of expectations and priorities of the patient and how the health issue has affected the patient Providing Information - Explaining what is likely occurring in terms patient can understand, providing reasons that patient can accept, clear understandable statements with words commonly used words, matching amt of info provided to pt’s ned, preference, and ability, have patient demonstrated a full and accurate understanding of key messages Helping Patients Make Decisions - Outlining what happens next, linked to a rationale, assessing a patient’s level of agreement, willingness, and ability to carry out the next step. Supporting Emotions - Seeking clarification or elaboration of the patient’s feelings, using statements of understanding and support. Integrated Clinical Encounter (ICE) Data Gathering Skills Data Interpreting Skills Spoken English Proficiency – pronunciation, word choice

Tips for Higher Scores Use correct medical terminology, & be as specific as you can Arthritis vs Gouty Arthritis vs Acute Gouty Arthritis Do not use inexact, nonmedical terminology, such as “pulled muscle” Provide detailed documentation of pertinent Hx & PE findings “pharynx without exudate or erythema” is preferable to “pharynx is clear” Do not document something that was not done !!!

Tips for Higher Scores List only Dx’s supported by the Hx & PE findings (even if this is fewer than three) Support Dx’s with pertinent findings obtained from the Hx & PE Do not list an appropriate Dx without including supporting evidence List Dx’s in the order of likelihood, with the most likely Dx first Do not list improbable or unsupported Dx’s

SAMPLES

Step 2 CS - Stats Failure Rates (MD / 1st Takers) Pass Rates per Section (2013-2014 / 2014-2015) 2013-2014 2014-2015 US grads 4% IMGs 26% 20% CIS ICE SEP US grads 97% / 98% 98% / 98% >99% / >99% IMGs 89% / 91% 81% / 86%

Step 2 CS - Scheduling Slots all full after Aug, 80% full Jan-Apr School Policy: Schedule by Jan 15 / Take by Feb 15 Recommenation: Schedule by Dec 31 to have it available by Rank time in February

Survey Step 2 CS Failures Corey Hiti / Rest / Feel well Practice with a partner Write all your findings Practice Timing of writing the note Need to focus on both – Communication Skills and Getting the Right Diagnosis Pretend it’s real, o/w hard to display empathy Passed OSCE – “false sense of security”

End Step 2 CS movement Cost Redundancy High Pass Rate Feedback provided is nonspecific to student and to school Michigan & Mass. Medical Societies AMA to vote in June

End Step 2 CS movement Social Compact with the Public Robust Clinical Skills programs did not exist until Institution of CS Exam Variability between Schools / Lack of reliability Students who have failed multiple times have a higher rate of problems with State Medical Boards USMLE looking to increase feedback

References to Review http://www.usmle.org/step-2-cs/ http://www.usmle.org/practice-materials/ First Aid Practice, Practice, Practice

Important Premise Communication on the job is different from ordinary conversation The medical interview is considered a procedure As with any procedure, there is a set format with standard elements that are considered core and essential Medical communication is intended to be Diagnostic AND Therapeutic

Standardized Examinations Standardized Examinations look for specific core elements The Calgary Cambridge Guide to the Medical Interview is a globally accepted tool Several sections with specific elements Core elements in each section Review the attachment/sections

Communication Skills Tips Entering the Room – Invest in the Opening KNOCK / Wash Hands 5 things in 3 seconds Patient Name (formal – last name) Your Name Hand Shake Eye Contact Opening Remarks (“nice to meet you” / “glad you came in”)

Take Home Points Gather data: Remember 2 different agendas: Dr. agenda = biomedical, Find it / Fix it Pt. agenda = the story of their illness includes emotions/fear/anger/anxiety* Included in HPI is the PPI – Patient’s Perspective of Illness – Two Parts: “I’m interested in hearing what you think is causing your symptoms, Mr. Smith.” “What is your greatest concern, is there something you’re worried about?”

Take Home Points Attention to: Open ended questions Nonverbal communication Tone of voice Active listening (um, okay, nod head, look interested)

Take Home Points Respond to emotions – Two Parts: 2-3 empathic opportunities are usually built into the case Listen for cues, respond & check for coping* “Sorry to hear that Mr. Smith, how are you coping with that?” Or “Sorry that you’re going through that/went through that, how are you doing/do you have support/someone to help you?”

Take Home Points Discussion and Closing: Ask-Tell-Ask core communication tool Ask=establish baseline knowledge “What do you already know about X/what have other doctors already told you?” Tell=concise/short Ask=check for understanding “To make sure I’ve explained things correctly, can you tell me what the plan is/what you’re going to do when you get home/etc?”

Take Home Points Screening and counseling incorporated into the cases: Depression SA – substance abuse, tob, etoh, drugs IPV – intimate partner violence (formerly DV) ASK and offer counseling*

Take Home Points Remember when you’re closing: NEXT STEPS- “will that work for you?” “What questions do you have for me?” “Is there anything else you think I should know/you would like me to know?” Shake hands Partnering / hopeful remark “It was nice talking with you/nice to meet you/take care/etc”