Everything I need to know about OSCE and Step 2 CS Exams Paul Mendez MD, FACP Monica Broome MD, FACP, FAACH, FAMWA May 2018

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

OSCE Exam - Setup Be on time – anticipate problems Clinical Dress / ID / Stethoscope 11 stations – 15 minutes per station (2:45) Standardized Patient / Faculty Evaluator Student Instruction Sheet on the door Specific Task – Hx, PE, Diagnosis, Counseling, … Progress Note Feedback

OSCE - Scoring Components Scoring History Taking Physical Examination Clinical Reasoning Communication Skills Counseling Scoring Thoroughness High Impact Core – 80% overall General Overall Impression

Tips Hx – Thorough / Pertinent +/-’s PE – Review CS Videos Think of Illness Scripts PE – Review CS Videos Clinical Reasoning Avoid Premature Closure Think of your DDx’s at the door Communication Skills Dr. Broome / List of Communication Skills

Step 2 CS Exam - Setup 12 Patient Encounters – 15 min / 10 min 8 hrs with three breaks Standardized Patients Evaluate you Communication and Interpersonal Skills Evaluate your Physical Exam Faculty grade your write-up Documentation of findings, Diagnostic Reasoning Expectations – Intern with primary responsibility for care of the patient Do not defer decision making to others Introduce yourself as student or doctor 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 Exam - Setup Focused pertinent Hx and PE Discuss Diagnoses and Plans Respond to questions, emotions, challenge If no PE required – street clothes – may leave PE section of note blank Assisting the patient with making decisions and/or with disease or problem management A PE will not be required, and the data interpretation section of the patient note will not need to be completed. 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 Images will be included

Step 2 CS – Setup - Note Write only information solicited Include VS if pertinent Be as specific as possible – avoid “normal” List up to three diagnoses in order of likelihood List Hx andPE findings supporting dx List Diagnostic studies – not Tx/Mgmnt, Consultations, Referrals, Admission May be “No studies indicated” May be “Perform a Rectal Exam” Approved Abbreviations Auto submit after 25 mins

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 (SEP) 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 - use of terms the patient can understand, and by providing reasons that the patient can accept. These statements need to be clear and understandable and the words need to be those in common usage. The amount of information provided needs to be matched to the patient’s need, preference, and ability. The patient should be encouraged to develop and demonstrate 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 - Scheduling Schedule by Dec 31 to have it available by Rank time in February

Step 2 CS Score Reporting Testing Period Reporting Start Date Reporting End Date January 1 – January 27 March 7 March 28 January 28 – March 24 April 25 May 23 March 25 – May 19 June 20 July 18 May 20 – July 14 August 15 September 12 July 15 – September 8 October 10 November 7 September 9 – November 3 December 12 Juanuary 9, 2019 November 4 – December 31 January 30, 2019 February 20, 2019

Step 2 CS - Stats Failure Rates (MD / 1st Takers) Pass Rates per Section (2015-2016 / 2016-2017) Changed after Sept 10, 2017 2014-2015 2015-2016 2016-2017 US grads 4% 3% IMGs 20% 18% CIS ICE SEP US grads 99% / 99% 98% / 97% >99% / >99% IMGs 93% / 95% 87% / 85% 98% / 99%

UMMSM Failures Class of OSCE Step 2 CS 2014 16** Miami 14 Miami 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) 2017 14 MD 1 MDMPH 9 MD (7 CIS / 3 ICE) 1 MDMPH (1 CIS) 2018 9 MD 2 MDMPH 22 MD (14 CIS / 10 ICE) 4 MDMPH (3 CIS / 1 ICE)

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” Not so much this year New this year – no recent generalist clinical rotation shortly prior to the exam

End Step 2 CS movement Cost Redundancy High Pass Rate Feedback provided is nonspecific to student and to school

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

And now… Dr. Broome

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 are concerned 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) Safe sex * 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”