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YOUR FIRST CLERKSHIP: Internal Medicine Foundations (IMF)

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YOUR FIRST CLERKSHIP: Internal Medicine Foundations (IMF) OSCE Orientation CLINICAL TEACHING FELLOWS OSCE| 1 What does OSCE mean? .Objective Checklists assess most of performance .Structured Controlled timed conditions Specific skills tested by structured tasks .Clinical Clinical skills assessed against professional competencies (core ACGME competencies & EPAs) .Examination Examination Clinical skills are tested in two ways: . Formative (with feedback) 10 practice SP OSCE’s 2 practice PE sessions 3 practice OSCE notes . Summative (no feedback) = 30% of IMF Grade OSCE Exam during week 6 . 2 cases with SP’s . 1 procedural skill (IV, pelvic, airway) PE Examination during week 3 Graded OSCE notes during week 4 & 5 Why do we have OSCE? Competency Gaps . Differential diagnoses and critical thinking . Written and oral communication . Essential clinical procedures . Step 2 CS readiness Several OSCE sessions in IMF . 10 SP OSCE’s . 13 Simulation OSCE’s (SimMan 3G) . 4 Procedural Skill OSCE’s OSCE Door Signs Instructions . Take a focused history. Perform a focused physical examination (DO NOT PERFORM: throat swab, rectal, genitourinary, or female breast exam). Explain your clinical expression and work up plan to the patient. Write your patient note after leaving the room. OSCE Pointers Sample Opening Scenario: Jason Morris, a 21-year-old male, has come to the student health clinic because he recently passed out while playing basketball. Vital Signs: . Temperature 98.8⁰F (37.1⁰C) . Blood Pressure 120/76 mm Hg . Heart Rate 78/min . Respirations 15/min Once you open the door… . You have 15 minutes to: Obtain a focused history Performed focused physical Close the encounter . You have 10 minutes to: Write a patient note What does OSCE evaluate? ▪ Can you apply medical knowledge and principles in a clinical setting? ▪ Can you provide patient-centered care and treat the patient as a person? ▪ Can you use appropriate communication and interpersonal skills? ▪ Can you efficiently gather relevant clinical data? ▪ Can you properly document the encounter? ▪ Can you formulate likely diagnoses with sound reasoning? ▪ Can you choose appropriate diagnostic studies? Components of OSCE . Integrated Clinical Encounter (ICE) . Communication and Interpersonal Skills (CIS) . Spoken English Proficiency (SEP) Evaluation of ICE ICE is evaluated twice: ▪ Patient Note ▪ History & Physical ▪ Diagnostic Impressions: DDx ▪ Justification of potential diagnoses ▪ Initial patient diagnostic studies ▪ Physical Exam with SP ▪ Must fit differentials ▪ SPs can fake it Evaluation of CIS . Fostering a doctor-patient relationship . Gathering information . Providing information . Helping the patient make decisions . Supporting emotions . Helping patient with behavioral change Evaluation of SEP . Assessment of clarity of spoken English communication, including: Pronunciation Word choice Minimizing the need to repeat questions, statements, or instructions . Assessed by the standardized patients only IMF OSCE Final Exam . Two 25-minute cases . 117 points per case divided among the following objective structured TASKS History: 8 to 10 minutes Physical: 3 to 5 minutes Closure: 2 to 4 minutes Patient Note: 10 minutes . One 10-minute skills station worth 26 points . Two graded notes worth 10 points each . One PE exam during week 3 worth 20 points OSCE Final Exam Grading . ICE 60% . CIS 25% . SEP 5% . Skills 10% Tasks performed are rated as “poor to excellent” based on objective checklist-based rubrics ICE Grading . SP Graded Physical Exam 15% Based on IMF PE Checklist . Physician Graded Note 45% (Total) History & Physical 25% 2+ DDx w/ supporting evidence 15% Diagnostic testing 5% Patient Note . History HPI, Associated signs & symptoms, PMH, Allergies, Medications, Family Hx, Social Hx Keep it relevant to the chief complaint . Physical Exam Vital signs and general appearance Record pertinent positives and negatives Forbidden exams can be listed as diagnostic studies . Differential Diagnoses & Diagnostic Studies DDx most likely to least likely with supporting info What studies can help confirm your diagnoses? CIS Grading . Fostering the Relationship ▪ Expressed interest in patient as a person ▪ Treated patient with respect ▪ Listened and paid attention to patient ▪ Being genuine and caring . Gathering Information ▪ Used open-ended techniques to have patient explain situation in his/her own words ▪ Established chronology of primary problem CIS Grading . Providing Information Gives an explanation of what is likely occurring and next steps using understandable statements Matches the amount of information to a patient’s preference Encourages questions, while checking for patient understanding Encourages patient to demonstrate a full and accurate understanding of key messages CIS Grading . Supporting Emotions Facilitated the expression of an implied or stated emotion or something important to him/her Acknowledges patient affect, mood, and behaviors – and address them directly Seeks clarification or elaboration of the patient’s feelings and by using statements of understanding and support . Helped with Behavior Change Counseled patient on lifestyle modifications Gave patient autonomy to make change for self SEP Grading . Pronunciation – clarity of speech . Word Choice – keeping it in layman’s terms . Understanding student without needing to repeat statement Physical Exam Tips . Do not repeat vital signs. Keep it focused on the system involved in the chief complaint, but make sure it is complete! . Not every case will have a heart and lung exam. Multisystem cases require specific examinations . Chronic fever, weight loss, and fatigue cases require a good hematological and lymphoid system examination. Do not repeat painful maneuvers. Images during OSCE . USMLE Step 2 CS examinees may see a case in which the standardized patient provides a digital image (for example, a photograph, x-ray, MRI, or CT) on a tablet computer. Examinees will see a maximum of one case with an image per examination. You must incorporate that image into supportive findings when it supports your diagnosis. Tips on Writing Notes (General) . Write note as either paragraph or bullet points; it does not matter. Cover all required sections. Include important pertinent positives and negatives . Avoid URI, UTI, back pain as a differential. Use terms like rhinitis, pharyngitis, cystitis, pyelonephritis, musculoskeletal strain, etc. Chronic PMH is not a differential diagnosis, but the exacerbation of the PMH can be. Tips on Writing History . HPI is key section – write it like a narrative in complete sentences or bullet points. Practice writing it in both to see what works best for you. In the history section, include HPI, PMH, surgical history, family history, social history (alcohol, illicit drugs, cigarettes, sexual activity), medication, allergies, over the counter medications, OB/GYN Hx (if applicable) Tips on Writing Physical Exam . Write out the vitals and comment on the general appearance of the patient. Inspection is an important part of documentation. Avoid words like “normal” or “clear to auscultation B/L.” Instead use “bronchovesciular breath sounds heard throughout, no wheezes or crackles.” . Don’t be afraid of the ophthalmoscope, especially if it’s headache or diabetes. Document on light AND deep palpation. Data Interpretation ▪ The diagnoses should be listed in order of likelihood. ▪ You must also indicate the pertinent positive and negative findings obtained from the history and physical examination to support each potential diagnosis. Creating Differentials . If the case has one straightforward diagnosis – write that as your number one – don’t second guess, e.g. pancreatitis, pyelonephritis, etc. Most cases have at least two diagnoses. A non-specific chief complaint usually can have three diagnoses, e.g. weight loss, fever, or fatigue. Malingering, drug seeking is not a diagnosis. Random and rare diagnoses without supporting documents in DI section bring your score down on that case. Chronic problems are not a diagnosis (hyperlipidemia, hypertension), but an exacerbation of a chronic problem could be a diagnosis. Tips on Workup . Think of two or three immediate tests that can help you establish the diagnosis. Do not use a shotgun approach. The forbidden exams can be ordered in your diagnostic workup. It should be specific and cost-effective. Costly and high-risk procedures can bring your score down, unless it is standard of care (e.g., doing CT angiogram for pulmonary embolism) Suggested Study Materials . IMF PE Video and checklist . First Aid for the USMLE Step 2 CS . USMLE World STEP 2 CS Practice materials . The Ultimate Guide and Review for the USMLE Step 2 Clinical Skills Exam By Mark H. Swartz . Med-U Cases USMLE Step 2 CS| 2 USMLE Step 2 CS . A Licensing OSCE . 12 SP OSCE Cases: 25 minutes each H&P + “closure” + patient note Same timing as IMF OSCE . Designed to assess minimal clinical skills competency for a 4th year medical student . http://www.usmle.org/step-2-cs/ to see a sample video as to how Step 2 CS runs . http://www.usmle.org/pdfs/step-2-cs/cs-info-manual.pdf for the most up- to-date information on Step 2 CS Be sure to check out the appendices for sample notes! Before You Take 2 CS . You must take one or more of the following: Becker CSA RUSM Mock CS Ambulatory Care Competencies Elective . It is recommended that you complete at least 4 core clerkships, including internal medicine. When to Take Step 2 CS . Ideally take CS by July of the year you are applying to have the results ready for ERAS residency
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