Date post: | 20-Dec-2015 |
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M4 CCAThe 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.
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.
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.
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 andoutpatient clinic sites.
• Approximately 10 -12 stations.
• Some stations are computer based: – EBM, EKG, and Imaging.
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.
Standardized Patient ScoringSpecific 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)
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.
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)
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
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
minutesTOTAL = 15 minutes
*Remember that you will not be doing pelvicor rectal exams on the M4 CCA or Step 2CS. However, if indicated you should let thepatient know that “you will return” to do thispart of the exam.
Some Components of HPI• Chronology• Symptoms• Pertinent negatives• Relevant:
–PMH (include tx, hospitalizations)–Medications (include OTC,
supplements, herbs, etc.)• Risk factors• Relevant ROS
HPI: Symptoms• Timing – onset, duration, frequency
• Location
• Quality
• Severity/Intensity
• Aggravating factors
• Alleviating factors
• Associated symptoms
Past Medical Hx (PMH)• Past medical illnesses
• Past surgical illnesses
• Psychiatric illnesses• Medications (include OTC,
supplements, herbs, etc.)
• Allergies
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.
Special cases: Pediatric History
PMH:–Birth hx–Feeding hx–Growth and development–Immunizations and screening–Childhood illnesses (acute or
chronic)–Social development
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)– “ABC Stamp Locker” (pdf)– OPE Form (word doc.)
• Cognitive exam should be focused and only as detailed as needed for the clinical situation.
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
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)
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)
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
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.
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
PEP: Components
• 3 components (PE not obtained from standardized patient):
–History
–Assessment
–Plan
PEP: History• Standard components:
–HPI (CC, associated relevant symptoms)
–Past Medical History–Family History (if relevant)–Social History–Medications
PEP: Assessment and Plan• Assessment:
–Differential Diagnosis, along with rationale
• Plan:
–Further testing, with rationale
–Initial therapy, with justification
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
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.
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.
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
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.
Retakes
• Two retake exams will be offered and you will be given the opportunity to select one of the following:
–Wednesday, August 6th
–Friday, September 5th