1. M4 Comprehensive Clinical Assessment (CCA) Practical Advice 2009

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: Part 1 - Computer Based Exam Content includes: EBM EKG Imaging There may be “pilot” components to the computer based exam

6. Content of M4 CCA: Part 2 - Clinical Exam Cases are drawn from a blueprint and include important symptoms and diagnoses, presenting complaints, and conditions – balanced by age and gender. Settings include in-patient unit, urgent care and outpatient clinic sites. Approximately 10 -12 stations. There may be “pilot” stations – which you will not be graded on.

7. 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.

8. Standardized Patient Scoring Specific checklists and rating scales are used to record examinee’s performance in the following areas: 1.Content: –Important history items and/or physical exam items –Personal Manner (e.g. hand washing and draping) 2.Communication Skills: –Open the interview (appropriate introductions, identification of cc, agenda setting)

9. SP Scoring: Communication Skills Continued: –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)

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

11. Overall Station Details

12. Content of Door Instructions For each patient encounter, there will be door instructions that include: –Pt name, age, chief complaint and the site where the patient is being seen (e.g. in-patient unit, 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.

13. 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 as you would in the hospital setting, i.e. student doctor _______ Address patient by his or her full name (first AND last name)

14. 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

15. 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.

16. History Taking, Communication and Physical Exam Details

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

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

19. Assessing pediatric patients PMH: –Birth hx –Feeding hx –Growth and development –Immunizations and screening –Childhood illnesses (acute or chronic) –Social development

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

21. Communication Review of the CS Step 2 web-site re: the scoring of Communication subcomponents may be helpful in preparation for the M4 CCA and Step 2 CS: Subcomponents: 1.Questioning skills 2.Information sharing 3.Professional manner and rapport Click here for USMLE Step 2 CS Information NOTE: Go to page 10 for a more detailed description of subcomponents.

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

23. Other Useful Topics/Tools to Review

24. Assessing Possible Depression Affect Two-Question Depression Screen: 1.“Have you often been bothered by feeling down, depressed, or hopeless?” 2.“Have you often been bothered by little interest or pleasure in doing things?” “SIGECAPS” mnemonic

25. Assessing Geriatric Patients 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

26. Assessing Geriatric patients: 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 –-SIGECAPS –Geriatric Depression Screen (GDS), use if handout is available

27. Coma and Mental Status Changes Review materials suggested: 1.Coma examination video (Dr. Selwa in LRC) 2.Gelb lecture syllabus from M2 year, lectures on Toxic metabolic disorders, Acute mental status changes. 3.Gelb Introduction to Clinical Neurology Chapter 11

28. Post-Encounter Exercise Information

29. Post-Encounter Exercises Post-encounter exercises occur at six 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)

30. 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

31. 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. Be as complete as you can.

32. 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

33. PEP: Components 3 components (PE is provided; not obtained from standardized patient): 1. History 2. Assessment 3. Plan

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

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

36. Common Reasons for Station Failures

37. 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

38. 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.

39. 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.

40. Common Reasons for Failure: 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

41. Remediation & Retake Information

42. 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.

43. Retakes Two retake exams will be offered and you will be given the opportunity to select one of the following: – Wednesday, July 15 – Wednesday, August 19 **Be sure that you are available for one of these dates as generally >50% of students need to re-take at least one station

44. GOOD LUCK!