Post by Admin on May 2, 2014 3:00:43 GMT -5
OUTLINE. Part I is an introduction. Part II discusses the outline of the exam, and how it's scored. Part III discusses the "History and Physical" component. Part IV discusses the patient note, and Part V discusses the communication skills.
I. Introduction.
Please refer to section I of the document, On Step 1 for all paperwork necessary for Step 2 CS. The paperwork is essentially the same.
Only major difference is in the eligibility period (1 YEAR after acceptance of your credentials), and the mechanism of scheduling for the exam (A centralized online database, where you can choose ANY DAY in ANY of the centers)
And as a side note, CS is a standardized exam. All test centers have the same level of difficulty and approachability. Moreover, the regional differences are also taken into account, and are balanced across the centers. (eg. African American accent and diseases are more prevalent in Philadelphia, compared to southern accent in Georgia,..)
THUS, it's meaningless to ask, which test center is the best. Essentially, they're all the same. Still, logistics will definitely differ from person to person. A flight to LA is much more expensive than a flight to NYC then a BoltBus to Phiily. And if someone in THI/Northwestern for elective, Houston/Chicago is a definite choice.
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II. Before you start your Study
II. 1. What is CS?
a.The exam is composed of 10 to 12 clinical cases, each is given 25 minutes to finish. Of which, 15 minutes are spent with the patient, and 10 minutes are spent typing your provisional patient note. There are 30 seconds between each case and the next one.
b. These clinical encounters are composed of a Standardized Patient (SP), who is going to imitate a specific disease and/or complaint. He/she usually answers only in response to certain questions or exam maneuvers you ask or perform.
c. CS exam thus, by using "non-real" patients, DOES NOT want us to "diagnose" any disease. In fact, Diagnosis is not required, nor necessary, for ANY case at all. This is simply because there are NO diseases to diagnose. The patients are all actors.
d. However, ECFMG DO want the examinee to perform a certain chain of reasoning (History -> Physical -> Discussion with patient -> Note writing) that indicates his familiarity with the typical out-patient (3eyadat) interview in general.
II. 2. OK. So what IS a typical "out-patient" clinic encounter in a US Hospital/Private Clinic?
a. The patient usually calls the Clinic well in advance to reserve his appointment. He fills up some biographic data (name, sex, age, Ht., Wt., Main Complaint, and of course Insurance type), and schedules the date. The appointments generally are of TWO BROAD TYPES: A NEW Patient visit/encounter (NPE) or a RETURNING Patient visit/encounter (RPE)
b. The NPE is when a patient is referred by his primary care physician to you, a specialist, for an expert opinion. When an MD is faced with an NPE, he typically sits with the patient from 30 to 60 minutes, re-asking ALL important and screening questions, performs FULL physical, orders a COMPLETE lab check up, have a PROLONGED discussion with the patient on management plan, write INITIAL prescription, and finally RESCHEDULE him for another visit, usually a month later, to observe his progress, and refill his drugs. The next appointments for this patient are now called RPEs.
c. Hence, MOST of the patients seen at the clinics are RPEs. The major point is that an RPE is short, around 10 to 15 minutes. It usually involves asking about any major changes (improvement or worsening) since last encounter, performing a specific exam, refilling prescriptions, and adding any new dug for a recent onset complain.
During the exam room itself, the setting is usually friendly. The patient is usually fully-clothed, and even accompanied by his/her spouse. The encounter itself can involve a lot of patient's personal details, as well as off topic discussions. Hence, some data are irrelevant to actual therapy, and only directed at strong Doctor-Patient relationship.
d. On the day of the encounter, and before entering the exam room, the nurse usually is the one who measures the patient's vitals (HR, ABP, RR and Temp.), along with Ht., Wt., and other vital information, and enter them in the PC system.
e. Right after ANY encounter, the doctor sits for writing/dictating a detailed Patient Note. In it, the doctor writes a brief History, documents all the positive findings and relevant patient social history, writes any lab values or imaging results, write down the management plan, and most importantly reminds HIMSELF of why he chose such a therapy or procedure for the patient. This is very important as it helps immensely when resuming the dialogue in a RPE.
f. While, after the encounter, the social worker will handle all the financial aspects of the visit (where to send the bills, Insurance notice,..)
II. 3. But in the CS exam, MANY things are different from the typical scenario...
a. EACH patient is to be considered a NPE.
The patient's biographic data are listed on the door of the room he is in, along with his name and his MAIN COMPLAINT. These are called Doorway Information.
b. During the encounter itself, when you enter the room, the SP, pretending to be NP, will be waiting for you ALONE, wearing ONLY his gown. You have to be very careful to "tying/untying" the gown in certain exam parts.
c. Most of the data you elicited from the patient are very important, since he only replies to certain questions pertinent to his case. Hence, you need to memorize, or write down, most of what was said during the encounter.
d. The discussion will be strictly formal. No room for any side talks. It actually can lead to Irregular Behavior.
e. After the discussion, you must explain ALL the next steps in your management to the patient. You can't postpone the discussion to the "next encounter".
f. After the encounter, you'll write type the patient note directly, and within 10 minutes.
II. 4. Thus, in a typical CS clinical encounter, you're expected to,
a. You'll check the SP Last name, main complaints, and vitals from the doorway information.
b. Knock on the door, introduce yourself, close the door, and start your encounter.
c. Ask your "data gathering" questions, perform your "physical".
d. Summarize all your POSITIVE RELEVANT findings to the patient.
e. Counsel the patient on next steps of management, and other relevant health issues of impact.
f. Address any concerns the patient might have, including his "challenging question".
g. Thank the patient, close the Encounter, and exit the room to start your Patient Note.
II. 5. Exam scoring.
a. To pass the exam, you need to pass the three components of CS. The scoring is derived form 10 cases you encountered. If you had more than 10, then the excess are "trials" and won't be scored. Note, however, that no one knows which case is graded, and which is a trial.
b. Note that scoring in a single component depends on the specific performance of the component across the entire set of cases, and thus the PASS of a certain component depends on you doing it acceptably (PASS) in the entire exam sessions, versus doing it poorly across ALL the cases. In other words, not doing ANYTHING in a single case or two is much "better" than not doing one specific item across ALL of the cases. The former will lower the score across the three components slightly, while the latter will seriously harm the score of a single component.
c. The first of these three components is the "Integrated Clinical Encounter" or ICE, which is the ability to gather pertinent History and perform pertinent Physical exam, both collectively known as "Data Gathering or DG", and write a concise patient note "PN". For "DG", The History and Physical are scored off the checklist that each SP has. Everything you do that's in that Checklist, you'll get a mark for it. What you fail to do, or what you do which is NOT on the list, will not get you any marks. Again to reiterate, the component scoring depends on your performance across the entire set of cases. One very bad case is less worse that 5 so-so cases. For example, forgetting to ask a "bloody sputum" case about TB and lung cancer in one case is much better than forgetting to address quality of pain in three cases.
The PN is scored by US physicians using predefined standards.
d. The second component is "Communications and Interpersonal Skills", or CIS. This one is very difficult to master for us, as IMGs mainly and Egyptians specifically, due to the absolute lack of proper Doctor-Patient relationship from our everyday encounter with patients. It's also scored off a checklist, and involves a wide range of topics and activities that I'll discuss later.
e. The last one is "Spoken English Proficiency" or SEP. This one is all about you understanding the patient, and him understanding you. This component is very difficult for someone who never practiced TALKING in English for an extended period of time. Moreover, generally, it's assumed that ICS and CIS are very easy to pass for IMGs, and thus ANY FAILURE IN STEP 2CS IS AUTOMATICALLY ATTRIBUTED BY PROGRAM DIRECTORS TO BE due to SEP failure, i.e. lack of proper English communication. Thus, CS failure is very bad, as it usually means that the applicant, regardless of how brilliant he maybe, can't speak English properly.
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III. How to prepare for ICE - Data Gathering?
III. 1. What is ICE - DG?
a. ICE has two components. Data gathering (DG) which includes both History and Physical, and the Patient Note (PN). I'll talk on DG first.
b. In order to pass in ICE - DG, you must collect enough points in the SP checklist, across all checklists. Thus your performance in all the cases is added up, and the final score determines your PASS/FAIL verdict. And although this part is the most bulky, and the one we all tend to focus on, it's actually quite easy to master, and therefore it's not the main focus point in the CS exam.
c. FA for CS is the text of choice of course. KAPLAN CS, and CS Checklist are similar but in no way superior to FA. Other sources like CES videos, and UW CS are only supplementary AFTER FINISHING FA... Now, the question is, how to use FA properly to study for ICE -DG?
d. Since the entry point for data gathering is "Main Complaint", this will be the starting point during the study. Section III of FA covers 40 of the most commonly tested "main Complaint" scenarios. Most of us just blindly start practicing over and over in those 40 cases, without really understanding the concept of "Data Gathering", and thus they limit themselves to those long cases, and become very distracted when faced with a new unknown case, not mentioned in FA.
e. The information we need to collect during Data Gathering from an SP fall within FIVE broad categories of questions. BEFORE you do ANYTHING with FA, bring a notebook, and identify each new MAIN COMPLAINT in a new page. All the 5 categories of questions you'll need to ask about this complaint should be arranged as you would write them in the exam day before entering the patient room. Fill the notebook as you practice cases for the CS, and return to it after finishing the 40 Long cases.
III. 2. Category I. Questions for Analysis of Present Complaint.
a. These are the questions we start the encounter with. They MUST be asked in each case.
b. They include the mnemonic OPDFC - AAA for Onset of symptoms, Progression (Is it getting worse?), Duration (How long does it last?), Frequency (Does it come and go? How often?), Context of start (What were you doing when symptoms started?), Alleviating (Anything makes it better?), Aggravating (Anything makes it worse?), and Association (Any other symptoms happen along with this one?).
c. However, some complaints may need further analysis beyond the OPDFC. Examples include Cough (Productive? With Blood? Color of Sputum?), and Pain ( Location? Intensity on a 1-to-10 scale? Quality? Radiation? )
d. In general, you can use questions on page 45 (FA CS 3rd Ed.) to generate questions on each complaint. Although it's better to write them down in the Notebook as you practice the long cases.
III. 3. Category II. Questions on Differential Diagnosis.
a. Just like the idea of "Concepts" in Step 1, here we're talking about "Main Complaint". Each complaint in Step 2CS can be caused by multiple diseases. The cases are actually constructed to give multiple possible etiologies for the symptoms. And since the main task of ICE in general is to reach a plausible diagnosis, it follows that each question addressed to the patient should serve in eliciting a differential, thus questions must be targeted towards differentials of the case...
THUS, each complaint will be broken down to "possible etiological diseases", and each of these diseases will have its own "disease questions"
b. This approach is unique in the regard that it will enable us, from the second we see the "Main Complaint" in the Doorway information, to rapidly construct a list of differentials and their associated questions. Thus, the most important items of the checklist, and the ones easily forgotten, will be within our hands. Moreover, it can also enable us to tailor the Physical exam, investigations, and even counseling, in advance (according to the differentials listed)
c. In other words, the main complaint should trigger a family of diseases once heard. For example, a 25 year old female with palpitations should trigger a set of 4 different etiologies : A Fib, Hyperthyroid, Drugs, and Anxiety.
After listing the differentials, mentally revise the associated questions. So, questions on Hyperthyroid (sweating, Heat Intolerance,..), A Fib (sudden onset, previous episodes, low CO), Drugs (Cocaine, recently prescribed asthma medication), and Anxiety (Stress at work, agoraphobia) should all be readily available to you, without much mental recall.
d. But how can we build this list of differentials and their associated questions? Fortunately, after each Long case, the case discussion lists the differential list, and a short paragraph on each one. The differentials, and their associated questions from the Long Case question list, should go into the notebook.
III. 4. Category III. Questions on Review of Systems (RoS).
a. These questions are best asked directly following Category II questions. They rarely give any new insight, but they constitute one point that's worth to have.
b. In general, you need to ask IN FULL about the part of the body the main complaint is likely related to. Thus if cough -> Chest, if Headache -> Head, if back pain -> Abdomen.
c. Otherwise, You'll be asking about common symptoms present in the other non-involved parts of the body. SP will usually answer with a brief NO. Thus, you too should ask them fast and concise.
d. Start with Head (Headache, Blurred Vision, ), Chest (Pain, Cough, Troubles breathing), Heart (Pain on exertion, Feeling one's heart beats), Abdomen (Pain, Swelling, Defecation or Urination changes),...
III. 5. Category IV. Questions on Patient Demography.
a. This is the famous PAM G FOSS WA. They ask for Past Medical and Surgical History, Allergies, Medications currently used, Gynecological (Date of LMP?, regualr in duration?, Normal in amount? ), Family (Similar symptoms in a family member), Occupation, Social (Stress, Sleep, Smoking, Alcohol, CAGE, Illicit Drugs), Sexual (Active? With who? Protection? STDs? HIV Status? ), and finally recent Weight and Appetite changes.
b. Although these questions are rarely beneficial, they are VERY important as they constitute a LARGE portion off the checklist, and can be asked in most of Data Gathering cases.
Pages 45 to 53 in FA have all the question categories I mentioned above. They start with simple questions on complaints (category I), then questions targeted to differentials for etiologies of these complaints (II), then general system questions (III), and finally demographic and social questions (IV). You DO NOT need to memorize those. You will build these questions as you practice the long cases they have...
III. 6. Category V. Pertinent Physical Examination.
a. In a typical clinic setting, the physical exam is rarely done, and if done rarely indicates anything new. However, many still do a "quick" physical, just to comfort the patient that he got a "check up". Hence, in CS, the physical exam is rarely useful. This is especially true since patients are actually SPs, with no real disease. Still, you must perform pertinent exam to the patient.
b. Pertinent exam means to focus your exam on the part of the body most likely involved with this specific symptom. Thus a main complaint of "Bright blood per stool" will have in its differential Rectal Cancer, thus abdominal exam is important.
c. Some cases might involve extensive physical, like those with "toe numbness" with Lumbar disc as one differential, and the "follow-up" cases in patients with chronic DM an HTN. In general, do NOT spend long time on physical. Limit yourself to a 3 : 5 minutes.
d. As a routine, Chest and Heart auscultation are always done. DO NOT FAKE THE EXAM. place the stethoscope on its appropriate locations, and give yourself reasonable time before moving on. Always ask the patient to (take a breath in and out, slowly, and through his mouth)
The physical you need to do is in FA 55.. Also, use CES and UW CS videos to strengthen yourself. AGAIN, no more than 3 minutes per physical exam, unless the case really needs it.
III. 7. In summary to ICE.
a. As is obvious, ICE depends entirely on your knowledge with both Differential Diagnosis of main complaints, and on questions to ask to diagnose a certain disorder. These questions can be memorized off FA Long Cases checklist by brute force. However, it's far better to organize them into categories, and try to link the questions with differentials, then link sets of differentials to main complaints.
b. While practicing the long cases, each complaint is followed by "case discussion" where they list the differential per this specific complain. As said before, your notebook should have these differentials and their related questions per each main symptom.
c. Once the 40 long cases are done, you should have a good idea on how to proceed when faced by a relatively new "Main Complaint". You'll first ask the OPDFC-AAA, RoS and PAMGFOSSWA, then you put 3 to 4 differentials, and ask questions about them, as well as perform pertinent exam specific for them.
d. After you master these 40 cases, move to Section III of FA CS. There, you'll find that the book is already divided into a minicase, representing a "Main Complaint" with some analysis of the main complaint (Category I), as well as a list of Differentials for the "Main Complaint". Hence, any minicase can be turned into long case by simply creating questions specific for the list of Differentials provided (creating category II questions).
e. It's still better to re-write the minicases in your notebook, and create the 5 categories of questions for each of them. This way, you'll be prepared even if a minicase come up in the actual exam.
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IV. What about ICE - Patient Note?
IV. 1. A simple paradigm is to jot down all positive history the patient tells you in simple abbreviations, and then type it once outside. Just practice the 40 cases in FA. Try to time yourself accurately when typing to know exactly how many words per minute (wpm) you are.
Before starting any encounter, make a standardized Microsoft Word Patient Note, and always practice typing in it.
IV. 2. You need to MASTER touch typing (with your ten fingers). This app is a perfect learning tool for such a task. Typing Master PRO. (Use this torrent file: www.demonoid.me/files/download/2382165/7365495)
IV. 3. A list of acceptable abbreviations can be found here (http://www.ecfmg.org/acculturation/medical-medicalese.html), as well as in FA itself.
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V. The real problem in the CS exam is the CIS.
V. 1. CIS involves all the Doctor-Patient communications, that lie outside data gathering. Hence, they involve;
Mannerism (Door knocking, introducing oneself by name, handshake, maintaining eye contact, extending bed feet, using facilitative comments and transitional sentences, and helping the patient in cumbersome tasks)
Professionalism (Handling tough patients, answering challenging questions, proper sanitation, and maintaining practical yet empathic demeanor)
Clarity (Summarizing patient's complaint to him, asking patient's permission for exam, explaining all exam maneuvers, closure and agreeing with him on the management plan, and counsel him on any other related health problem)
V. 2. Both Mannerism and Professionalism are handled effectively in FA.
YOU MUST, AND I REPEAT MUST, HAVE A STUDY PARTNER TO OBSERVE YOU DOING THESE POINTS IN THE ENCOUNTER WHILE YOU PRACTICE WITH HIM. You can NEVER EVER recognize your own problems. We've been practicing non-professional medicine since day 1 in our med schools. What we think is normal, like performing an abdominal exam without mentioning what OR WHY it is to the patient, CAN CAUSE SERIOUS HARM TO THE SCORE. This is especially true considering that one will tend to repeat the same error over and over in all cases.
V. 3. How to be clear with the patient?
a. SUMMARY. At the end of the your history taking, you should summarize the patient's data. Go for the RELEVANT data only. It can go like: "So, Mr. x, just to recap all the important details you've told me; You said you woke up yesterday, 4 am, with chest pain that was more like burning. You had a big meal the night before, and that this pain happened many times in the last year. You have no problems with exercise, and you're taking your Blood pressure medication regularly. Am I correct? "
b. EXAM. ALWAYS ASK PERMISSION for doing the physical exam. Try to be focused on the regions to be examined, exposing these regions only. More importantly, explain EVERYTHING you do in your exam, while you're doing it. Maybe something as "So, Mr. x, I'd like now to examine your belly. Is that OK with you? Great. I'll first listen to your stomach (Auscultate). Hmm. Good. Now I'll gently press on your belly (palpate). Perfect. Now I'll just tab on your belly to know where the pain is exactly (Percuss). Perfect. Thank you."
c. CLOSURE. This is the MOST essential part in the encounter. Simply put. It's the "take home" message for the patient. The thing that the patient will later on tell to his/her spouse, children, and family. Hence, it can't be emphasized enough. Let's just say that missing closure in around 3 to 4 cases is usually enough for a nice FAIL in CS.
Closure in its basic form tells the patient the probable diagnosis for his symptoms, and then discusses the plan of management - further physical exam, labs, imaging, biopsy, medications, and surgeries - in depth with the patient, always offering an honest view regarding benefits, and risks, of each step in management.
Although it might sound simple, many people FAIL in CIS although they did FULL closure in each case. To understand why this might be the case, consider these two closures regarding a patient presenting with hempotysis.
Closure #1. So, Mr. X. Based on the history you gave me, and the exam I just did, it seems that the problem you're having can be explained by many different causes. Many of them are treatable. At this point, it's too early to know which is causing your problem for sure. So now, we must run some tests, maybe even get an imaging, and some other tests. And I'll see you after the results are here to further discuss your treatment options. Goodbye.
Closure #2. So, Mr. X, Based on the history you gave me, and the exam I just did, it seems that the bloody cough you're having is due to many reasons. Most likely, the long term irritation to your airways and all morning coughing is the culprit. However, it could also be Tuberculosis, since you have traveled recently. Or even some serious lung problems. At this point, it's too early to tell. I'll order a complete blood count, also a sputum sample, to make sure there's no infection going on. I'll also need to take a Chest X ray - a painless imaging of your chest - to see if any fluids are in your lung. I'll schedule you for an appointment next week to discuss the results of the tests and imaging. Any questions?
It's very clear that closure No.1 is not closure. It can be applied to both Hemoptysis and painful urination, as well as tinnitus. It's SO GENERIC, it WON'T BE COUNTED AS A CLOSURE AT ALL.
And just to be honest, MANY people do closure #1 because of multiple reasons (ran out of time, became distracted, didn't make any differential for the main complaint.
I. Introduction.
Please refer to section I of the document, On Step 1 for all paperwork necessary for Step 2 CS. The paperwork is essentially the same.
Only major difference is in the eligibility period (1 YEAR after acceptance of your credentials), and the mechanism of scheduling for the exam (A centralized online database, where you can choose ANY DAY in ANY of the centers)
And as a side note, CS is a standardized exam. All test centers have the same level of difficulty and approachability. Moreover, the regional differences are also taken into account, and are balanced across the centers. (eg. African American accent and diseases are more prevalent in Philadelphia, compared to southern accent in Georgia,..)
THUS, it's meaningless to ask, which test center is the best. Essentially, they're all the same. Still, logistics will definitely differ from person to person. A flight to LA is much more expensive than a flight to NYC then a BoltBus to Phiily. And if someone in THI/Northwestern for elective, Houston/Chicago is a definite choice.
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II. Before you start your Study
II. 1. What is CS?
a.The exam is composed of 10 to 12 clinical cases, each is given 25 minutes to finish. Of which, 15 minutes are spent with the patient, and 10 minutes are spent typing your provisional patient note. There are 30 seconds between each case and the next one.
b. These clinical encounters are composed of a Standardized Patient (SP), who is going to imitate a specific disease and/or complaint. He/she usually answers only in response to certain questions or exam maneuvers you ask or perform.
c. CS exam thus, by using "non-real" patients, DOES NOT want us to "diagnose" any disease. In fact, Diagnosis is not required, nor necessary, for ANY case at all. This is simply because there are NO diseases to diagnose. The patients are all actors.
d. However, ECFMG DO want the examinee to perform a certain chain of reasoning (History -> Physical -> Discussion with patient -> Note writing) that indicates his familiarity with the typical out-patient (3eyadat) interview in general.
II. 2. OK. So what IS a typical "out-patient" clinic encounter in a US Hospital/Private Clinic?
a. The patient usually calls the Clinic well in advance to reserve his appointment. He fills up some biographic data (name, sex, age, Ht., Wt., Main Complaint, and of course Insurance type), and schedules the date. The appointments generally are of TWO BROAD TYPES: A NEW Patient visit/encounter (NPE) or a RETURNING Patient visit/encounter (RPE)
b. The NPE is when a patient is referred by his primary care physician to you, a specialist, for an expert opinion. When an MD is faced with an NPE, he typically sits with the patient from 30 to 60 minutes, re-asking ALL important and screening questions, performs FULL physical, orders a COMPLETE lab check up, have a PROLONGED discussion with the patient on management plan, write INITIAL prescription, and finally RESCHEDULE him for another visit, usually a month later, to observe his progress, and refill his drugs. The next appointments for this patient are now called RPEs.
c. Hence, MOST of the patients seen at the clinics are RPEs. The major point is that an RPE is short, around 10 to 15 minutes. It usually involves asking about any major changes (improvement or worsening) since last encounter, performing a specific exam, refilling prescriptions, and adding any new dug for a recent onset complain.
During the exam room itself, the setting is usually friendly. The patient is usually fully-clothed, and even accompanied by his/her spouse. The encounter itself can involve a lot of patient's personal details, as well as off topic discussions. Hence, some data are irrelevant to actual therapy, and only directed at strong Doctor-Patient relationship.
d. On the day of the encounter, and before entering the exam room, the nurse usually is the one who measures the patient's vitals (HR, ABP, RR and Temp.), along with Ht., Wt., and other vital information, and enter them in the PC system.
e. Right after ANY encounter, the doctor sits for writing/dictating a detailed Patient Note. In it, the doctor writes a brief History, documents all the positive findings and relevant patient social history, writes any lab values or imaging results, write down the management plan, and most importantly reminds HIMSELF of why he chose such a therapy or procedure for the patient. This is very important as it helps immensely when resuming the dialogue in a RPE.
f. While, after the encounter, the social worker will handle all the financial aspects of the visit (where to send the bills, Insurance notice,..)
II. 3. But in the CS exam, MANY things are different from the typical scenario...
a. EACH patient is to be considered a NPE.
The patient's biographic data are listed on the door of the room he is in, along with his name and his MAIN COMPLAINT. These are called Doorway Information.
b. During the encounter itself, when you enter the room, the SP, pretending to be NP, will be waiting for you ALONE, wearing ONLY his gown. You have to be very careful to "tying/untying" the gown in certain exam parts.
c. Most of the data you elicited from the patient are very important, since he only replies to certain questions pertinent to his case. Hence, you need to memorize, or write down, most of what was said during the encounter.
d. The discussion will be strictly formal. No room for any side talks. It actually can lead to Irregular Behavior.
e. After the discussion, you must explain ALL the next steps in your management to the patient. You can't postpone the discussion to the "next encounter".
f. After the encounter, you'll write type the patient note directly, and within 10 minutes.
II. 4. Thus, in a typical CS clinical encounter, you're expected to,
a. You'll check the SP Last name, main complaints, and vitals from the doorway information.
b. Knock on the door, introduce yourself, close the door, and start your encounter.
c. Ask your "data gathering" questions, perform your "physical".
d. Summarize all your POSITIVE RELEVANT findings to the patient.
e. Counsel the patient on next steps of management, and other relevant health issues of impact.
f. Address any concerns the patient might have, including his "challenging question".
g. Thank the patient, close the Encounter, and exit the room to start your Patient Note.
II. 5. Exam scoring.
a. To pass the exam, you need to pass the three components of CS. The scoring is derived form 10 cases you encountered. If you had more than 10, then the excess are "trials" and won't be scored. Note, however, that no one knows which case is graded, and which is a trial.
b. Note that scoring in a single component depends on the specific performance of the component across the entire set of cases, and thus the PASS of a certain component depends on you doing it acceptably (PASS) in the entire exam sessions, versus doing it poorly across ALL the cases. In other words, not doing ANYTHING in a single case or two is much "better" than not doing one specific item across ALL of the cases. The former will lower the score across the three components slightly, while the latter will seriously harm the score of a single component.
c. The first of these three components is the "Integrated Clinical Encounter" or ICE, which is the ability to gather pertinent History and perform pertinent Physical exam, both collectively known as "Data Gathering or DG", and write a concise patient note "PN". For "DG", The History and Physical are scored off the checklist that each SP has. Everything you do that's in that Checklist, you'll get a mark for it. What you fail to do, or what you do which is NOT on the list, will not get you any marks. Again to reiterate, the component scoring depends on your performance across the entire set of cases. One very bad case is less worse that 5 so-so cases. For example, forgetting to ask a "bloody sputum" case about TB and lung cancer in one case is much better than forgetting to address quality of pain in three cases.
The PN is scored by US physicians using predefined standards.
d. The second component is "Communications and Interpersonal Skills", or CIS. This one is very difficult to master for us, as IMGs mainly and Egyptians specifically, due to the absolute lack of proper Doctor-Patient relationship from our everyday encounter with patients. It's also scored off a checklist, and involves a wide range of topics and activities that I'll discuss later.
e. The last one is "Spoken English Proficiency" or SEP. This one is all about you understanding the patient, and him understanding you. This component is very difficult for someone who never practiced TALKING in English for an extended period of time. Moreover, generally, it's assumed that ICS and CIS are very easy to pass for IMGs, and thus ANY FAILURE IN STEP 2CS IS AUTOMATICALLY ATTRIBUTED BY PROGRAM DIRECTORS TO BE due to SEP failure, i.e. lack of proper English communication. Thus, CS failure is very bad, as it usually means that the applicant, regardless of how brilliant he maybe, can't speak English properly.
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III. How to prepare for ICE - Data Gathering?
III. 1. What is ICE - DG?
a. ICE has two components. Data gathering (DG) which includes both History and Physical, and the Patient Note (PN). I'll talk on DG first.
b. In order to pass in ICE - DG, you must collect enough points in the SP checklist, across all checklists. Thus your performance in all the cases is added up, and the final score determines your PASS/FAIL verdict. And although this part is the most bulky, and the one we all tend to focus on, it's actually quite easy to master, and therefore it's not the main focus point in the CS exam.
c. FA for CS is the text of choice of course. KAPLAN CS, and CS Checklist are similar but in no way superior to FA. Other sources like CES videos, and UW CS are only supplementary AFTER FINISHING FA... Now, the question is, how to use FA properly to study for ICE -DG?
d. Since the entry point for data gathering is "Main Complaint", this will be the starting point during the study. Section III of FA covers 40 of the most commonly tested "main Complaint" scenarios. Most of us just blindly start practicing over and over in those 40 cases, without really understanding the concept of "Data Gathering", and thus they limit themselves to those long cases, and become very distracted when faced with a new unknown case, not mentioned in FA.
e. The information we need to collect during Data Gathering from an SP fall within FIVE broad categories of questions. BEFORE you do ANYTHING with FA, bring a notebook, and identify each new MAIN COMPLAINT in a new page. All the 5 categories of questions you'll need to ask about this complaint should be arranged as you would write them in the exam day before entering the patient room. Fill the notebook as you practice cases for the CS, and return to it after finishing the 40 Long cases.
III. 2. Category I. Questions for Analysis of Present Complaint.
a. These are the questions we start the encounter with. They MUST be asked in each case.
b. They include the mnemonic OPDFC - AAA for Onset of symptoms, Progression (Is it getting worse?), Duration (How long does it last?), Frequency (Does it come and go? How often?), Context of start (What were you doing when symptoms started?), Alleviating (Anything makes it better?), Aggravating (Anything makes it worse?), and Association (Any other symptoms happen along with this one?).
c. However, some complaints may need further analysis beyond the OPDFC. Examples include Cough (Productive? With Blood? Color of Sputum?), and Pain ( Location? Intensity on a 1-to-10 scale? Quality? Radiation? )
d. In general, you can use questions on page 45 (FA CS 3rd Ed.) to generate questions on each complaint. Although it's better to write them down in the Notebook as you practice the long cases.
III. 3. Category II. Questions on Differential Diagnosis.
a. Just like the idea of "Concepts" in Step 1, here we're talking about "Main Complaint". Each complaint in Step 2CS can be caused by multiple diseases. The cases are actually constructed to give multiple possible etiologies for the symptoms. And since the main task of ICE in general is to reach a plausible diagnosis, it follows that each question addressed to the patient should serve in eliciting a differential, thus questions must be targeted towards differentials of the case...
THUS, each complaint will be broken down to "possible etiological diseases", and each of these diseases will have its own "disease questions"
b. This approach is unique in the regard that it will enable us, from the second we see the "Main Complaint" in the Doorway information, to rapidly construct a list of differentials and their associated questions. Thus, the most important items of the checklist, and the ones easily forgotten, will be within our hands. Moreover, it can also enable us to tailor the Physical exam, investigations, and even counseling, in advance (according to the differentials listed)
c. In other words, the main complaint should trigger a family of diseases once heard. For example, a 25 year old female with palpitations should trigger a set of 4 different etiologies : A Fib, Hyperthyroid, Drugs, and Anxiety.
After listing the differentials, mentally revise the associated questions. So, questions on Hyperthyroid (sweating, Heat Intolerance,..), A Fib (sudden onset, previous episodes, low CO), Drugs (Cocaine, recently prescribed asthma medication), and Anxiety (Stress at work, agoraphobia) should all be readily available to you, without much mental recall.
d. But how can we build this list of differentials and their associated questions? Fortunately, after each Long case, the case discussion lists the differential list, and a short paragraph on each one. The differentials, and their associated questions from the Long Case question list, should go into the notebook.
III. 4. Category III. Questions on Review of Systems (RoS).
a. These questions are best asked directly following Category II questions. They rarely give any new insight, but they constitute one point that's worth to have.
b. In general, you need to ask IN FULL about the part of the body the main complaint is likely related to. Thus if cough -> Chest, if Headache -> Head, if back pain -> Abdomen.
c. Otherwise, You'll be asking about common symptoms present in the other non-involved parts of the body. SP will usually answer with a brief NO. Thus, you too should ask them fast and concise.
d. Start with Head (Headache, Blurred Vision, ), Chest (Pain, Cough, Troubles breathing), Heart (Pain on exertion, Feeling one's heart beats), Abdomen (Pain, Swelling, Defecation or Urination changes),...
III. 5. Category IV. Questions on Patient Demography.
a. This is the famous PAM G FOSS WA. They ask for Past Medical and Surgical History, Allergies, Medications currently used, Gynecological (Date of LMP?, regualr in duration?, Normal in amount? ), Family (Similar symptoms in a family member), Occupation, Social (Stress, Sleep, Smoking, Alcohol, CAGE, Illicit Drugs), Sexual (Active? With who? Protection? STDs? HIV Status? ), and finally recent Weight and Appetite changes.
b. Although these questions are rarely beneficial, they are VERY important as they constitute a LARGE portion off the checklist, and can be asked in most of Data Gathering cases.
Pages 45 to 53 in FA have all the question categories I mentioned above. They start with simple questions on complaints (category I), then questions targeted to differentials for etiologies of these complaints (II), then general system questions (III), and finally demographic and social questions (IV). You DO NOT need to memorize those. You will build these questions as you practice the long cases they have...
III. 6. Category V. Pertinent Physical Examination.
a. In a typical clinic setting, the physical exam is rarely done, and if done rarely indicates anything new. However, many still do a "quick" physical, just to comfort the patient that he got a "check up". Hence, in CS, the physical exam is rarely useful. This is especially true since patients are actually SPs, with no real disease. Still, you must perform pertinent exam to the patient.
b. Pertinent exam means to focus your exam on the part of the body most likely involved with this specific symptom. Thus a main complaint of "Bright blood per stool" will have in its differential Rectal Cancer, thus abdominal exam is important.
c. Some cases might involve extensive physical, like those with "toe numbness" with Lumbar disc as one differential, and the "follow-up" cases in patients with chronic DM an HTN. In general, do NOT spend long time on physical. Limit yourself to a 3 : 5 minutes.
d. As a routine, Chest and Heart auscultation are always done. DO NOT FAKE THE EXAM. place the stethoscope on its appropriate locations, and give yourself reasonable time before moving on. Always ask the patient to (take a breath in and out, slowly, and through his mouth)
The physical you need to do is in FA 55.. Also, use CES and UW CS videos to strengthen yourself. AGAIN, no more than 3 minutes per physical exam, unless the case really needs it.
III. 7. In summary to ICE.
a. As is obvious, ICE depends entirely on your knowledge with both Differential Diagnosis of main complaints, and on questions to ask to diagnose a certain disorder. These questions can be memorized off FA Long Cases checklist by brute force. However, it's far better to organize them into categories, and try to link the questions with differentials, then link sets of differentials to main complaints.
b. While practicing the long cases, each complaint is followed by "case discussion" where they list the differential per this specific complain. As said before, your notebook should have these differentials and their related questions per each main symptom.
c. Once the 40 long cases are done, you should have a good idea on how to proceed when faced by a relatively new "Main Complaint". You'll first ask the OPDFC-AAA, RoS and PAMGFOSSWA, then you put 3 to 4 differentials, and ask questions about them, as well as perform pertinent exam specific for them.
d. After you master these 40 cases, move to Section III of FA CS. There, you'll find that the book is already divided into a minicase, representing a "Main Complaint" with some analysis of the main complaint (Category I), as well as a list of Differentials for the "Main Complaint". Hence, any minicase can be turned into long case by simply creating questions specific for the list of Differentials provided (creating category II questions).
e. It's still better to re-write the minicases in your notebook, and create the 5 categories of questions for each of them. This way, you'll be prepared even if a minicase come up in the actual exam.
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IV. What about ICE - Patient Note?
IV. 1. A simple paradigm is to jot down all positive history the patient tells you in simple abbreviations, and then type it once outside. Just practice the 40 cases in FA. Try to time yourself accurately when typing to know exactly how many words per minute (wpm) you are.
Before starting any encounter, make a standardized Microsoft Word Patient Note, and always practice typing in it.
IV. 2. You need to MASTER touch typing (with your ten fingers). This app is a perfect learning tool for such a task. Typing Master PRO. (Use this torrent file: www.demonoid.me/files/download/2382165/7365495)
IV. 3. A list of acceptable abbreviations can be found here (http://www.ecfmg.org/acculturation/medical-medicalese.html), as well as in FA itself.
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V. The real problem in the CS exam is the CIS.
V. 1. CIS involves all the Doctor-Patient communications, that lie outside data gathering. Hence, they involve;
Mannerism (Door knocking, introducing oneself by name, handshake, maintaining eye contact, extending bed feet, using facilitative comments and transitional sentences, and helping the patient in cumbersome tasks)
Professionalism (Handling tough patients, answering challenging questions, proper sanitation, and maintaining practical yet empathic demeanor)
Clarity (Summarizing patient's complaint to him, asking patient's permission for exam, explaining all exam maneuvers, closure and agreeing with him on the management plan, and counsel him on any other related health problem)
V. 2. Both Mannerism and Professionalism are handled effectively in FA.
YOU MUST, AND I REPEAT MUST, HAVE A STUDY PARTNER TO OBSERVE YOU DOING THESE POINTS IN THE ENCOUNTER WHILE YOU PRACTICE WITH HIM. You can NEVER EVER recognize your own problems. We've been practicing non-professional medicine since day 1 in our med schools. What we think is normal, like performing an abdominal exam without mentioning what OR WHY it is to the patient, CAN CAUSE SERIOUS HARM TO THE SCORE. This is especially true considering that one will tend to repeat the same error over and over in all cases.
V. 3. How to be clear with the patient?
a. SUMMARY. At the end of the your history taking, you should summarize the patient's data. Go for the RELEVANT data only. It can go like: "So, Mr. x, just to recap all the important details you've told me; You said you woke up yesterday, 4 am, with chest pain that was more like burning. You had a big meal the night before, and that this pain happened many times in the last year. You have no problems with exercise, and you're taking your Blood pressure medication regularly. Am I correct? "
b. EXAM. ALWAYS ASK PERMISSION for doing the physical exam. Try to be focused on the regions to be examined, exposing these regions only. More importantly, explain EVERYTHING you do in your exam, while you're doing it. Maybe something as "So, Mr. x, I'd like now to examine your belly. Is that OK with you? Great. I'll first listen to your stomach (Auscultate). Hmm. Good. Now I'll gently press on your belly (palpate). Perfect. Now I'll just tab on your belly to know where the pain is exactly (Percuss). Perfect. Thank you."
c. CLOSURE. This is the MOST essential part in the encounter. Simply put. It's the "take home" message for the patient. The thing that the patient will later on tell to his/her spouse, children, and family. Hence, it can't be emphasized enough. Let's just say that missing closure in around 3 to 4 cases is usually enough for a nice FAIL in CS.
Closure in its basic form tells the patient the probable diagnosis for his symptoms, and then discusses the plan of management - further physical exam, labs, imaging, biopsy, medications, and surgeries - in depth with the patient, always offering an honest view regarding benefits, and risks, of each step in management.
Although it might sound simple, many people FAIL in CIS although they did FULL closure in each case. To understand why this might be the case, consider these two closures regarding a patient presenting with hempotysis.
Closure #1. So, Mr. X. Based on the history you gave me, and the exam I just did, it seems that the problem you're having can be explained by many different causes. Many of them are treatable. At this point, it's too early to know which is causing your problem for sure. So now, we must run some tests, maybe even get an imaging, and some other tests. And I'll see you after the results are here to further discuss your treatment options. Goodbye.
Closure #2. So, Mr. X, Based on the history you gave me, and the exam I just did, it seems that the bloody cough you're having is due to many reasons. Most likely, the long term irritation to your airways and all morning coughing is the culprit. However, it could also be Tuberculosis, since you have traveled recently. Or even some serious lung problems. At this point, it's too early to tell. I'll order a complete blood count, also a sputum sample, to make sure there's no infection going on. I'll also need to take a Chest X ray - a painless imaging of your chest - to see if any fluids are in your lung. I'll schedule you for an appointment next week to discuss the results of the tests and imaging. Any questions?
It's very clear that closure No.1 is not closure. It can be applied to both Hemoptysis and painful urination, as well as tinnitus. It's SO GENERIC, it WON'T BE COUNTED AS A CLOSURE AT ALL.
And just to be honest, MANY people do closure #1 because of multiple reasons (ran out of time, became distracted, didn't make any differential for the main complaint.