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

2. 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

3. 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)

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

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

6. 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

7. Step 2 CS Exam - Setup
12 Patient Encounters – 15 min / 10 min 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

8. 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

9. 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

10. 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

11. 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 !!!

12. 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

13. SAMPLES

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

15. 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

16. 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”

17. 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

18. 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

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

20. 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

21. 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

32. 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”)

33. 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?”

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

35. 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?”

36. 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?”

37. 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*

38. 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”