1. M4 Comprehensive Clinical Assessment (CCA) Practical Advice 2008

2. M4 CCA The mission of the M4 CCA is to ensure that students are competent in the fundamental clinical skills necessary to provide excellent, effective, and safe patient care as a PGY1 trainee.

3. Goals: M4 CCA vs. USMLE Step 2 CS The M4 CCA is designed to measure student competency across U of M specific intended learning outcomes. Therefore the M4 CCA is similar to but differs from the Step 2 CS Exam in several ways.

4. Continued: M4 CCA vs. USMLE Step 2 CS The M4 CCA includes radiographic studies, EKGs, and EBM. Each station on the M4 CCA may or may not be followed by post- encounter note or exercise. Similar to the Step 2 CS, you may need to interview parents.

5. Content of M4 CCA Cases are drawn from a blueprint and include important symptoms and diagnoses, presenting complaints, and conditions – balanced by age and gender. Settings include urgent care and outpatient clinic sites. Approximately 10 -12 stations. Some stations are computer based: –EBM, EKG, and Imaging.

6. Tasks Many stations include a focused history and/or physical exam. There may or may not be a post- encounter note or exercise following the patient encounter. Be sure to read the instructions on the door and understand the tasks at each station before entering the room.

7. Standardized Patient Scoring Specific checklists and rating scales are used to record examinee’s performance: 1.Content: –Important history items and/or physical exam items –Personal Manner (e.g. hand washing and draping) 2.Communication: –Open the interview (appropriate introductions, identification of cc, agenda setting) –Assess the patient’s problem (accurate and efficient data collection, and understanding of the pt) –Verbal and Non-verbal relationship building skills (empathy, support, partnership, respect, and appropriate eye contact, and body language) –Manage the patient’s problems (achievement of pt understanding, involvement of pt in treatment process, affirmation of intent)

8. Warning Any information from past CCA exams may be misleading.

9. Overall Station Details

10. Content of Door Instructions For each patient encounter, there will be door instructions that include: –Pt name, age, chief complaint and where the patient is presenting (e.g. urgent care or outpatient clinic.) –Pt’s vital signs (can be trusted, do not need to re-take) –List of specific tasks to be completed (hx, physical exam, etc.) –Time allotted for the station *Notice if a post-encounter exercise will follow or not.

11. At the Door Read instructions and understand the tasks. Review patient’s name, cc, vital sx Quickly formulate your checklist Knock, enter room, and introduce yourself Address patient by his or her full name (first AND last name)

12. Timing of Patient Encounters: History AND Physical Exam Stations Door instructions: 10-20 sec. History taking: 7-8 minutes Physical exam: 4-5 minutes Discuss plan with pt/closure: 1-2 min. TOTAL = 15 minutes

13. Timing of Patient Encounters: History taking only Stations Door instructions: 10-20 sec. History taking: 12-13 minutes Discuss plan with pt/closure: 2-3 minutes TOTAL = 15 minutes * Remember that you will not be doing pelvic or rectal exams on the M4 CCA or Step 2 CS. However, if indicated you should let the patient know that “you will return” to do this part of the exam.

14. History Taking and Physical Exam Details

15. Some Components of HPI Chronology Symptoms Pertinent negatives Relevant: –PMH (include tx, hospitalizations) –Medications (include OTC, supplements, herbs, etc.) Risk factors Relevant ROS

16. HPI: Symptoms Timing – onset, duration, frequency Location Quality Severity/Intensity Aggravating factors Alleviating factors Associated symptoms

17. Past Medical Hx (PMH) Past medical illnesses Past surgical illnesses Psychiatric illnesses Medications ( include OTC, supplements, herbs, etc.) Allergies

18. Physical Exams Perform relevant physical exam May need to perform a breast exam Do not need to perform pelvic or rectal but if indicated, need to inform the patient that it will be done later Also can indicate any further physical exam needed in the post-encounter note.

19. SPECIAL CASES INFORMATION

20. Special cases: Pediatric History PMH: –Birth hx –Feeding hx –Growth and development –Immunizations and screening –Childhood illnesses (acute or chronic) –Social development

21. Special cases: Psychiatric history Past psych hx Family psych hx Social hx/support system PSYCHIATRIC mental status exam (appearance, behavior, speech, emotions, thoughts, cognition) –MMSE Link (pdf)MMSE Link –“ABC Stamp Locker” (pdf)“ABC Stamp Locker” –OPE Form (word doc.)OPE Form Cognitive exam should be focused and only as detailed as needed for the clinical situation.

22. Special cases: Geriatric History http://www.med.umich.edu/i/geriatrics_center/UMGeriatricsCare ADLs (Activities of Daily Living) IADLS (Instrumental Activities of Daily Living) Social supports Living environment Medications Incontinence Falls Cognition Affect

23. Special case continued: Geriatric Physical Assessment http://www.med.umich.edu/i/geriatrics_center/UMGeriatricsCare Mobility: –Observed Gait –Timed up & Go Test Cognition: –Mini-Cog Exam –Mini Mental Status Exam (MMSE) Affect: –Two-Question Depression Screen –Geriatric Depression Screen (GDS)

24. Post-Encounter Exercise Information

25. Post-Encounter Exercises Post-encounter exercises occur at four stations and may include one of the following: –A post-encounter Note (PEN) or –A brief post-encounter assessment that asks you to make a decision and justify your conclusion (PEA) or –A post-encounter verbal presentation (PEP)

26. Post-Encounter Note (PEN) Timing: after clinical encounter with Standardized Patient Time allotted: 15 minutes Standard SOAP format: –Subjective component –Objective –Assessment –Plan Assessment based on inclusion of relevant details, accuracy, and judgment

27. Post-Encounter Assessment (PEA) Timing: after clinical encounter with Standardized Patient Time allotted: 10 minutes Goal: to understand your assessment of the patient based on the patient encounter and the justification for your assessment and plan.

28. Post-Encounter Presentation (PEP) Timing: after clinical encounter with Standardized Patient Time allotted: 15 minutes, includes: –Preparation time –Presentation time Goal: a 5 minute concise, relevant oral presentation to faculty member Assessment based on: –Content: relevance, accuracy, and judgment –Communication

29. PEP: Components 3 components (PE not obtained from standardized patient): –History –Assessment –Plan

30. PEP: History Standard components: –HPI (CC, associated relevant symptoms) –Past Medical History –Family History (if relevant) –Social History –Medications

31. PEP: Assessment and Plan Assessment: –Differential Diagnosis, along with rationale Plan: –Further testing, with rationale –Initial therapy, with justification

32. COMMON REASONS FOR STATION FAILURES and REMEDIAITON & RETAKE INFORMATION

33. Common Reasons for Failure: History Taking Incomplete history : –**Failure to consider broad differential - premature closure. –Failure to ask about PMH including medications, allergies. –Failure to obtain FH, SH

34. Common Reasons for Failure: Physical Exam Not focused – too diffuse Incomplete – omit important elements Exam must be focused, i.e., cannot do the whole physical, but must be thorough within that focused area Example: If a pt has chest pain, need to do elements of pulmonary, abdominal, musculoskeletal exam, etc.

35. Common Reasons for Failure: Communication Patient Communication (evaluated across all stations). The student: –Interrupts the patient or uses medical terminology or jargon. –Fails to follow up on patient concerns or response. –Fails to wash hands, extend table, drape, and interact with the standardized patient as the student would interact with a real patient.

36. Common Reasons for Failure: Notes Post Encounter Notes, Assessments, and Presentations: –Illogical –Omitting critical elements such as pertinent positives and negatives –Premature closure re: diagnosis –Poorly written with non-standard abbreviations

37. Remediation In preparation for retaking a station(s), you will be required to: 1.Review Educational Resources (electronically). 2.Complete a written electronic Self- Assessment of your performance by watching a reference video and comparing it to your own video. *Some students may be required to attend a small group session or meet with a faculty member.

38. Retakes Two retake exams will be offered and you will be given the opportunity to select one of the following: –Wednesday, August 6 th –Friday, September 5 th

39. GOOD LUCK!