M4 CCAImportant Orientation and Preparation Information

2010

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.

• The M4 CCA is similar to but differs from the Step 2 CS Exam.

Continued: M4 CCA vs. USMLE Step 2

CS• The M4 CCA includes Radiographic studies, EKGs, Critical Values, and EBM.

• Each station on the M4 CCA may or may not be followed by post-patient encounter note or exercise.

• Similar to the Step 2 CS, you may need to interview a parent but not by phone.

Content of M4 CCA Part I: 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 urgent care andoutpatient clinic sites.

• Approximately 10 -12 stations • The exam may include pilot station/s

or components

Tasks: Clinical Exam• Most stations include a focused

history and/or physical exam.• After you complete the patient

encounter, you may need to write a note or answer questions relating to the case.

• Be sure to read the instructions on the door and understand the tasks at each station before entering the room.

Communication Skills

• Assessed across all patient encounter stations; they are categorized and scored in similar ways to the USMLE scheme of (Questioning, Information sharing, and Professionalism).– Resource: See p. 10 of 2010 Step 2

CS document: Content description and General Information.

– Warning: Pay particular attention to the Information Sharing Domain.

Communication Skills

• You must demonstrate your Ability to:– Open the interview appropriately– Establish and maintain rapport– Elicit a relevant history– Demonstrate active listening skills– Close the interview appropriately– Be attentive and empathetic throughout the

interaction– Be aware and sensitive to the patient’s health

concerns• Resource: Patient Doctor

Communication (M4 CCA web-site)

Content of M4 CCAPart II: Computer Based Exam

1. EBM* 2. EKG* 3. Critical Values (see next slide) 4. Imaging*: includes mainly chest and

abdominal plain films. No ultrasound or MRI.

*For Prep materials: See clinical resources on M4 CCA web-site.

Critical Values• Questions that center on decisions that Program Directors

expect an intern to be able to make independently on day 1.

• Content may include:– Issues Associated With Basic Life Support– Use of Beta Blockers in Acute Coronary Syndrome– Medical Treatment of Acute Coronary Syndrome– Recognition and Treatment of Urinary Tract Infections – Differentiation of Upper vs. Lower UTI– The Treatment, Recognition and Electrolyte and Glucose

Abnormalities in Seizure Disorders– Recognition of Trauma Related Injuries and their initial

management– The Recognition and Treatment of Common Electrolyte

Abnormalities – Calculations and the Sources of Free Water– Patient Safety Interventions– Acid Based Disorders - interpretation of blood gases and

management– Recognition and management of respiratory failure– Recognition and initial treatment of common toxidromes– Calculations and the Sources of Free Water

Warning

Any information from past CCA exams may be

misleading – especially for 2010!

Overall Station Details

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 (these 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 – Notification of whether you will need to

write a note or answer questions after you complete the patient encounter.

At the Door• Read instructions and

understand the tasks and time allotted

• Formulate your checklist • Review patient’s name, cc, vital

sx • Knock and introduce yourself as

Student Doctor ________• Address patient by his or her full

name (first AND last name)

Advice re time allocation: 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 minutesTOTAL = 15 minutes

Advice re time allocation: 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.

History: Review of important points

History

• The cases are designed to suggest a broad differential.

• Based on the patient’s chief complaint, you should consider a number of possible diagnoses.

Components of the HPI• Chronology• Symptoms• Pertinent negatives• Relevant:

–PMH–Medications ( include OTC,

supplements, herbs, etc.)• Risk factors• Relevant ROS

HPI: PQRSTP = Provoking:

Aggravating factors Alleviating factors

Q = QualityR = Radiating, locationS= Severity/IntensityT= Timing – onset, duration,

frequencyRemember to ask about

Associated symptoms

HPI: Past Medical Hx• Past medical illnesses• Past surgical illnesses• Psychiatric illnesses

HPI: Medications/Allergies

• Medications (include OTC, supplements, herbs, etc. Include dosage and frequency)

• Allergies

Physical Exam

• Perform relevant physical exam based on the patient’s history

• Patients may present with positive simulated findings

Physical Exam• You will not need to perform

pelvic or rectal exams but, if indicated, let the patient know that this is the case.

• You must make note of the need for any additional physical exam (e.g., rectal, pelvic) in the “Management/Treatment” section of your note.

Oral Case Presentation

• http://depts.washington.edu/medclerk/student/presentation.html

• Caution on above link: not everything is the 'Michigan Way'. For example, the site suggests using 'normal' to save time while presenting the physical. We actively discourage this. Please follow the Michigan protocol

• "'Normal' will not suffice. You must state the findings.”

SPECIAL CASES INFORMATION

Special Cases

• Remember that you need to modify your history to include pertinent questions appropriate to age, gender, and other factors.

• For example, a pediatric history should include specific questions. Refer to Dr. Schmidt’s power point for more details.

Special cases: Psychiatric history

• Past psych hx• Family psych hx• Social hx/support system• PSYCHIATRIC mental status exam

(appearance, behavior, speech, emotions, thoughts, cognition) – “MSE Outline” (pdf)

• 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 OR–Timed up & Go Test

• Cognition:–Mini Mental State Exam (MMSE)

• Mood symptoms:–Two-Question Depression Screen (If positive, do full depression screen)

Acute Mental Status Changes

•Dr. Selwa Coma Examination Video: Click Here

•Gelb lecture syllabus from M2 year, lectures on Toxic metabolic disorders,

Acute mental status changes.

Post-Patient encounter

components of the exam

Post-Patient Encounter Exercises

After seeing the patient you may be asked to either: • Write a note,• Answer questions that probe your

rationale or justification for the differential diagnosis or management plan of the patient you have just seen, or

• Do a verbal presentation.

Post- Patient Encounter Note

• Time: 10 minutes, enter into computer, cannot be handwritten

• Format (similar to Step 2 CS) but for the M4 CCA, you must give a rationale for the top 2 diagnoses in your differential

• Note format:– History– Physical Exam– Differential diagnosis (with rationale)– Plan

Post- Patient Encounter Note: Components

History: Include significant positives and

negatives from the history of present illness, past medical history, review of systems, social history, and family history pertinent to this patient’s chief complaint. Also include medications (dosage and frequency) and allergies.

Post- Patient Encounter Note

• Physical Examination:– Include only pertinent positive and

negative findings related to the patient’s chief complaint.

– Remember to include Vital signs!

Post- Patient Encounter Note

• Differential diagnoses:– In descending order of likelihood

(with 1 being the most likely), list up to 5 potential or possible diagnoses for this patient’s presentation (in some cases, fewer than 5 diagnoses are likely).

– Provide the rationale for your top 2 diagnoses.

Post- Patient Encounter Note

• Plan:– List next steps in the management of

this patient (up to 5). Include diagnostic tests and /or treatments (if applicable).

Post-Encounter Questions

• Instead of writing a note after you see the patient, you may be asked to answer questions that center on key elements of the diagnosis or plan for the patient you have just seen.

• Time allotted: 10 minutes

Post- Patient Encounter Presentation

• 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

Components of the Oral Presentation

– History– Physical exam (this will be given to you since you will not have examined this patient)

– Assessment– Plan

Oral Presentation: History• Standard components:

–HPI (CC, associated relevant symptoms)

–Past Medical History –Family History (if relevant)–Social History–Medications

Oral Presentation: Physical Exam

• You will not have examined this patient but the physical exam findings will be provided to you.

• Do not forget to include this information in your presentation

Oral Presentation: Assessment and Plan

• Assessment:–Differential Diagnosis, along with rationale

• Plan:–Further testing, with rationale

–Initial therapy, with justification

COMMON REASONS FOR FAILURE,

REMEDIAITON & RETAKE

INFORMATION

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 pertinent 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 you must be thorough within that focused area

• Example: If a pt has chest pain, need to do elements of pulmonary, abdominal, musculoskeletal exam, but would not need to do cranial nerves, etc.

Common Reasons for Failure: Communication

• 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.

Reasons for Failure: Notes• Omitting critical elements:

pertinent positives and negatives in the H & P that are consistent with your differential.

• Premature closure re the diagnosis

• Failure to consider a life-threatening or serious diagnosis

Common Reasons for Failure: Notes

• Plan is not consistent with the differential diagnosis or is dangerous

• Note is poorly written

Grading*

• If you fail the exam overall, you must re-take the entire CCA exam after completing a remediation process.

• If you fail one or more stations but pass the exam overall, you must re-take the station/s you failed after completing a remediation process

• * (See grading policy on the M4 CCA web-site)

Make-Up Exams• Approximately 50 % of

students will need to re-take at least one M4 CCA station

• Two retake exams will be offered and you will be given the opportunity to select one of the following:

Marginal Grades

• You may receive a grade of “Marginal” for one or more stations.

• If you have a marginal grade, the remediation for that station (a web-based self-assessment) must be completed but you will NOT have to re-take the station unless your self- assessment exercise is deemed inadequate by the faculty reviewer.

Remediation

If you fail or receive a “marginal” on a station:- You will need to complete a remediation process. - Generally, this process may be completed on-line. - Remember that if you failed the exam or a station, you will need to re-take the exam/station at one of the 2 make –up dates noted.

GOOD LUCK• Any questions??

• Content, grading: e-mail Dr. Hernandez

maryeb@med.umich.edu • Scheduling and other concerns:

kellypos@med.umich.edu