BCM Clinical Performance Examination

1. BCM Clinical Performance Examination Tyson Pillow, M.D., M.Ed. Anita Kusnoor, M.D.

2. BCM CPX Goals • Assess the clinical skills performance of medical students after the completion of their third year of medical school. • Serve as a competence benchmark for clinical performance (history taking, physical exam, communication, clinical reasoning) at this stage of training.

3. Competence “The habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and community being served.” -Epstein and Hundert. JAMA. 2002;287:226

4. BCM CPX Objectives • Based on BCM standards, the students will: • Perform a focused history in a SP environment. • Perform an appropriate physical exam given the SP case. • Communicate effectively in a SP encounter. • Demonstrate fundamental patient-centered skills that constitute the basis of safe and effective patient care • Synthesize and construct a differential diagnosis, diagnostic plan & treatment plan based on the SP scenario provided.

5. Framework Basic Clinical Skills Physical Examination Communication Context in Healing Problem Solving 5 Clinical Cases

6. Framework 5 Clinical Cases • 15 minutes each • Outpatient, time-limited cases • Checklists to assess clinical skills • 10 minutes for interstation exercises to evaluate clinical reasoning

7. New This Year • Pilot stations (you won’t know which ones) • No invasive exams (breast, rectal, pelvic, GU). If you need to do one, notify the patient as part of your plan • New communication scale (details to follow) • Interpretation of labs and studies • Post-encounter note in the USMLE Step 2 CS Format

8. Basic Clinical Skills Draw upon experiences from core clerkships, LACE, and special sessions • History based on complaint and patient setting • Physical exam items evaluated according to BCM standards (available on CPX website)

9. Communication Opening the Interview • Addresses the patient by name • Introduces self by name AND title • Involves patient when discussing the reason for the visit • Maintains appropriate eye contact • Uses effective body language

10. Communication Responding to the Patient • Legitimizes patient’s emotions • Reinforces positive behaviors

11. Communication Conducting the Interview • Encourages questions or concerns • Elicits patient perspective • Avoids interrupting • Avoids leading questions • Avoids multiple questions • Conducts the interactions in an organized manner • Uses open- and close-ended questions effectively • Checks for accuracy during the interview

12. Communication Educating, Negotiating, Collaborating • Summarizes the interview (history and exam, if applicable) • Avoids inappropriate language • Reviews next steps • Verifies patient’s understanding

13. Cases Problem solving tasks related to type of visit • New problem • Chronic illness • Psychosocial

14. New Problem Visit Assess Presenting Complaint • Information gathering and differential diagnosis • HPI questions • Associated symptoms • Relevant review of systems • Thoroughness associated with accuracy • Major error is “premature closure”

15. Chronic Visit History • Assess severity and control of condition • Signs and symptoms of condition • Home monitoring • Target organ damage from condition • Evaluate adherence and treatment side effects • Review status of other risk factors

16. Psychosocial Visit History • Assess emotional needs of patient • Background, Affect, Trouble, Handling, Empathy (BATHE) • Evaluate for diagnosable mental illness • Evaluate for suicide risk

17. Areas of Weakness HPI • Open-ended questions • OLD CARTS/OPQRST • Alleviating/aggravating factors • Associated symptoms • Pertinent review of systems

18. Areas of Weakness Differential diagnosis • Vascular • Infectious • Traumatic • Autoimmune • Metabolic • Idiopathic/iatrogenic • Neoplastic • Congential • Vascular • Inflammatory/Infectious • Neoplastic • Degenerative/Deficiency/Drugs • Idiopathic/iatrogenic/intoxication • Congential • Autoimmune/Allergic/Anatomic • Traumatic • Endocrine/Environmental • Metabolic

19. Areas of Weakness Chronic illness • Level of control • Adherence to treatment plan • Signs/symptoms of end-organ damage • Other related risk factors

20. Areas of Weakness Psychosocial • Effect on functioning • Emotional reaction • Social support

21. Areas of Weakness Physical Exam Thoroughness Lung Cardiovascular Neurologic Technique • Lymph nodes • Thyroid • Abdomen • Neurologic Thoroughly test any organ system associated with the chief complaint. Don’t forget to look for complications of the disease. PE should be focused but thorough (should take longer than 30 sec). Drape patients appropriately. Don’t listen over gown/sports bra. Don’t abbreviate the heart/lung exam (e.g., don’t just listen to one valve). Don’t be overly aggressive with palpation.

22. The Neurologic Exam Clarification of wording • Focused - specific components of neurologic exam relating to the patient’s complaints • Screening - the 36 item checklist taught in PPS and the neurology clerkship • Full - a complete, head-to-toe neurologic examination with adjunct testing tools included Any patient with a primary neurologic complaint should get a screening examination!

23. The Neurologic Exam Pitfalls and Tips • Memorize the components – be sure to address all of them (CN, motor, sensation, reflexes, coordination, mental status) • Full MMSE is not required, but you should ask ALL orientation questions • Pay attention to details specified in BCM Physical Exam Standards document (available on website) • Time management is crucial on this station • Practice the screening neuro exam. Time yourself!

24. Post-Encounter Note HISTORY: Describe the history you just obtained from this patient. Include only information (pertinent positives and negatives) relevant to this patient’s problem(s).

25. Post-Encounter Note 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.

26. Post-Encounter Note DATA INTERPRETATION: Based on what you have learned from the H&P, 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 the physical examination (if present) that support each diagnosis. Lastly, list initial diagnostic studies (if any) you would order for each listed diagnosis (e.g., restricted physical exam maneuvers, laboratory tests, imaging, ECG, etc.)

27. Performance Information Available online after review and release of grades Passing the BCM CPX is a graduation requirement

28. Professionalism It is our expectation that you will show up ON TIME* and PREPARED for the exam *Please refer to the tardiness/late policy

29. Professionalism Professional dress + white coat enhances the standardized patient’s perception of your competence

30. Professionalism DO NOT share exam content with your colleagues

31. Scheduling • Exam administration: March 28 – April 7 • Online signup was completed in February • Refer to the website for specific scheduling questions • Dates for testing, remediation, and retesting will be posted in a timely fashion

32. Website

33. Website

34. Further Information https://www.bcm.edu/education/schools/medical-school/programs/standardized-patient-program

35. BCM Clinical Performance Examination Tyson Pillow, M.D., M.Ed. Anita Kusnoor, M.D.