Step 2 CS and CSA Tips

Pam Shaw MD

January 10, 2013

Don’t panic. You are well-prepared

You have had lots of SP experiences that have prepared you for the test

CSA is a good trial run-dates for CSA in KC are May 29, 31, and June 3, 5, 7, 10, 12, 14, 18, 25

Residency program directors rate our students’ skills highly

We have a high pass rate for CS

BUT……

CS changes for 2013 One of the recommendations emerging from the Comprehensive

Review of USMLE (CRU) process is that USMLE consider ways to further enhance the testing methods used in the Step 2 Clinical Skills (CS) examination. these enhancements were implemented in mid-2012.

The Step 2 Committee decided to increase the performance levels required to receive a passing outcome on two of the three Step 2 CS subcomponents:  Communication and Interpersonal Skills (CIS) and Integrated Clinical Encounter (ICE).  There will be no change to minimum passing requirements for the Spoken English Proficiency (SEP) subcomponent of Step 2 CS at this time.

The change means that the passing rate would be changed by 3% based on last years results

What is CS? Step 2 of the USMLE assesses the ability of

examinees to apply medical knowledge, skills, and understanding of clinical science essential for the provision of patient care under supervision, and includes emphasis on health promotion and disease prevention. Step 2 ensures that due attention is devoted to the principles of clinical sciences and basic patient- centered skills that provide the foundation for the safe and effective practice of medicine.

What is CS?

Step 2 CS uses standardized patients to test medical students and graduates on their ability to gather information from patients, perform physical examinations, and communicate their findings to patients and colleagues.

Step 2 CS: 3 components Integrated Clinical Encounter

Data gathering (with SP) scored by checklistDocumentation (or note)scored by physicians-this

changed last yearCommunication and Interpersonal Skills (SP

scored)This also changed last year

Spoken English Proficiency (SP scored)Must pass all three to pass exam

Step 2 CS Test Sites

ChicagoLos AngelesAtlantaPhiladelphiaHouston

Step 2 CS

12 patients—15 min encountersKnock in room after 10 min—you

have 5 left5 pts-30 min lunch break-4 pts-15

min break-3 ptsOnce you leave the room, you are

donePost-encounter note after each patient

—10 minApproximately 8 hours

Step 2 CS

No PDAs or phonesOnly white coat and stethoscope and

blank paperExam is confidential so sharing of

information is tabooYou must be on time to be able to sit for

the exam

Step 2 CS: Possible types of encounters

Acute, chronic casesCounseling vs. PE casesFollow up lab resultsTelephone casePeds cases with child out of roomCases with a simulator

Changes to the assessment of Communication and Interpersonal Skills

(CIS)

The CIS subcomponent of Step 2 CS has been redesigned to assess a fuller range of competencies. 

Beginning June 17, 2012, the Communication and Interpersonal Skills (CIS) scale will focus on five functions:1. Fostering the relationship2. Gathering information3. Providing information4. Making decisions: basic5. Supporting emotions: basic  

Fostering the Relationship

Expressed interest in the patient as a person

Treated the patient with respectListened and paid attention to the patient

Gathering Information andProviding Information

Encouraged the patient to tell his/her story

Explored the patients reaction to the illness or problem

Provided information related to the working diagnosis

Provided information on next steps

Making Decisions-Basic

Elicited the patient’s perspective on the diagnosis and next steps

Finalized plans for the next steps

Advanced skills are still being developed

Supporting Emotions-Basic

Facilitated the expression of an implied or stated emotion or something important to him/her

Advanced skills to be determined

And lastly, helping patients with behavior change

Communication and Interpersonal Skills

Questioning skills – examples include:use of open-ended questions, transitional

statements, facilitating remarks avoidance of

- leading or multiple questions, repeat questions unless for clarification, medical terms/jargon unless immediately defined, interruptions when the patient is talking

accurately summarizing information from the patient

Communication and Interpersonal Skills

Information-sharing skills – examples include: acknowledging patient issues/concerns and

clearly responding with information avoidance of medical terms/jargon unless

immediately defined clearly providing

- counseling when appropriate - closure, including statements about what happens next

Communication and Interpersonal Skills

Professional manner and rapport – examples include: asking about expectations, feelings, and concerns of the

patient; support systems and impact of illness, with attempts to explore these areas

showing consideration for patient comfort during the physical examination; attention to cleanliness through hand washing or use of gloves

providing opportunity for the patient to express feelings/concerns

encouraging additional questions or discussion making empathetic remarks concerning patient

issues/concerns; patient feels comfortable and respected during the encounter

Communication and Interpersonal Skills tips

Introduce yourself every timeCall pt. Ms. or Mr. or ask!Open-ended questionsTransition statementsDon’t interrupt your patient!Don’t use jargon (eg. Say high blood

pressure, not hypertension)Empathize

Communication and Interpersonal Skills tips

Partner with the patientAsk the pt what they think/want to doAsk the pt if they have questions (and answer

them)Explain what you think and want to do. Make

sure your pt is ok with the plan!Counsel pt if appropriateClosure

Provide hope, follow-up plan

Spoken English Proficiency

For most, should not be an issue, if you are concerned, please touch base in student counseling or with Student Affairs

Integrated Clinical Encounter Components

History takingFull history

Physical examFocused exam

Post-exam discussion with patientPost-encounter note

Integrated Clinical Encountertips: History

Focus on the processKeep diagnostic possibilities wide open

Don’t focus on an obvious dx early

Open-ended questions first, second and third. You can be specific later.

One question at a timeGet all the concerns on the table

early--“Anything else?”

Integrated Clinical Encountertips: History

Ask ALL appropriate attributes of a symptom: LOCATESLocationOther symptomsChronology/TimingAlleviating factorsThings that make it worseExperience of the symptom/QualitySeverity

Integrated Clinical Encountertips: History

ALWAYS ASKPast Medical HistoryMedicationsAllergiesSocial History

Occupation, Smoking, Alcohol, Drugs, Sex

Family HistoryReview of Systems

Integrated Clinical Encountertips: Physical exam

Focused examsThink about your differential before you

do your examWash hands every timeTechnique matters

Keep your patients modestly drapedIf you have questions, review before

Step 2CS

Integrated Clinical Encountertips: Physical exam

ALWAYS listen with stethoscope on the skinVitals given, but you may want to repeatNo GU/breast/corneal exams—goes in write

up—do talk to your pt about theseThere may be abnormalities!

May be real or simulatedIf you observe something abnormal, it is

supposed to be that way

Integrated Clinical Encountertips: Post-exam discussion with

patientDon’t just leave the room!Discuss differential dx with patientDiscuss your diagnostic plans with

patient (GU exam for example)Be prepared for difficult questions

Eg. “Am I going to die?” “Did I do something to cause this?”

Don’t let these sidetrack you from your task

Integrated Clinical Encountertips: Post-encounter note

10 min per noteCharacter limit in each area of 250

charactersAbbreviations must be acceptable to

USMLETyping is required this year

You will only be handwriting anything if computer glitch

Patient Note Entry Form

Post-encounter noteHistory and Physical

History: Describe the history you just obtained from this patient. Include only information (pertinent positives and negatives relevant to this patient’s problem(s).

Physical examination: Describe any positive and negative findings relevant to this patient’s problem(s). Be careful to include only those parts of examination you performed in this encounter.

Post-encounter noteData Interpretation

Based on what you have learned from the history and physical examination, list up to 3 diagnoses that might explain this patient’s complaint(s). List your diagnoses from most to least likely. For some cases, fewer than 3 diagnoses will be appropriate. Then, enter the positive or negative findings from the history and physical examination (if present) that support each diagnosis. Lastly, list initial diagnostic studies (if any) you would order for each listed diagnosis (eg restricted physical exam maneuvers, laboratory tests, imaging, ECG, etc.)

Quick word on telephone casesTreat as if the patient were in the roomTake your timeAsk all your usual questions Usually a pediatric case

Feedback before taking the examIf you plan on taking CSA in June or July,

you need to meet with Dr. Shaw before taking the exam

Everyone who scores in the bottom 15% of the class will have to meet with Dr. Shaw

CSA will be scored like the CS so it is good feedback

ResourcesMore info:

USMLE® : Test Content & Practice Materials http://www.usmle.org/examinations/step2/step2cs.html Use your clerkships/faculty!Recommended resources