M4 Comprehensive Clinical Assessment

(CCA)

Practical Advice2008

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)

Warning

Any information from past CCA exams may

be misleading.

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 (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.

History Taking and Physical Exam Details

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 INFORMATION

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 Exercise

Information

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 STATION FAILURES and

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 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

GOOD LUCK!