M2 Clinical Comprehensive Assessment (CCA)

1. M2 Clinical Comprehensive Assessment (CCA) Michael Lukela, M.D. Director, M2 CCA October 30, 2012

2. Exam Composition • Practical Exam • Physical Exam • History Taking • History Presentation • Case Write-up • Written Exam

3. Physical Exam Abdominal Cardiac Musculoskeletal Neurology Pulmonary History Taking History Taking History Presentation Communication Skills Exam Composition (Practical)

4. Physical Exam

5. General Principles • The patients are SPs • Grading is performed by SPs and faculty proctors • Targeted, but complete physical exam • Expectation is NOT to elicit abnormalities • No checklists, notes, or aides allowed • Required equipment will be posted on CCA website Safety tip: Practice talking through your exam aloud

6. Musculoskeletal • Split into two components (A & B) • During the exam you will perform only either A or B, but are responsible for content of both • Musculoskeletal A • Hands • Wrists • Elbows • Shoulders • Spine (cervical) • Musculoskeletal B • Hips • Knees • Ankle/Foot • Spine (thoracolumbar)

7. Resources and Helpful Hints • Clinical Foundations of Medicine (CFM) checklists are your friends • Refer to course syllabus, M2 CCA website • Practice the exam in “sections” • e.g. Cardiac, Neurology, Musculoskeletal • Become familiar with equipment (e.g. safety pins for sensory testing) • Practice talking aloud while you are performing the exam • Resources under development to assist in your preparation • “Modified” CFM checklists to guide preparation • Exam FAQ’s drawn from prior exams/student questions to be posted on M2 CCA website

8. M2 CCA Website

9. Example Teaching (CFM) Checklist

10. History Taking

11. History Taking • General Principles • History of Present Illness focusing on key elements that lead to the visit and to address the patient’s specific concern(s) • Assessment of relevant risk factors based on the problem(s) identified • Exploration of other relevant history based on understanding of problem(s) • Knowing the patient’s PMH, Meds, Allergies • Exploration of relevant family and social history • Application of targeted and relevant review of systems to include, exclude other relevant diagnoses • History Taking Station Notes • Goal is to elicit a focused, but complete history based on patient’s chief complaint • Patients are “standardized” • Communication skills will be assessed as a component of the history taking sessions • Content of interview drawn from CFM curriculum and CEP experiences • Time allocation is up to the student Standard templates and ROS sheets will be provided at each station; no other notes may be used

12. History Presentation • History presentation will occur as part of the an integrated station lasting 45 minutes during which students perform a history, targeted physical exam, and verbal presentation in sequence • During the station block students are expected to: • Organize a verbal presentation • Present his/her observations to a faculty physician/observer Notes may be taken during history taking station and you may use these notes to present to the faculty/observer

13. Preparation and Resources • Review CFM teaching videos, interviews • Practical history taking • Patient interview • Review prior interview topics covered during the M1/M2 year • Review and practice ROS in a targeted manner • Recognize that every clinical history is a story- not everything is PQRST • Practice, practice, practice

14. Exam Format Groups rotate between sections every 50minutes. Blocks 1 and 2 are integrated stations following the sequence of History Physical Exam Presentation or Case Write-Up. BLOCK 1: 50minutes History Taking Abdominal Exam Verbal presentation BLOCK 2: 50minutes History Taking Cardiac Exam Pulmonary Exam Case Write-Up BLOCK 3: 50minutes Neurology Exam Musculoskeletal Exam

15. Written Exam

16. Exam Composition • Written examination • Closed-book, web-based exam • Approximately 120-140 questions covering principles of physical exam and basic pathophysiology • Topic areas include: abdominal, cardiac, musculoskeletal, neurologic, pulmonary, ENT, ophthalmology • Content from exam covered in CFM lectures, course syllabus, exam checklists • Administered during CCA exam weekend Note: You may take the written examination either before or after the clinical portion of the CCA

17. Example Question #1 Which of the following is the ideal order in which to perform the abdominal exam? • Auscultation, inspection, percussion, palpation • Inspection, auscultation, percussion, palpation • Inspection, palpation, auscultation, percussion • Inspection, palpation, percussion, auscultation

18. Example Question #2 A 17-year-old football player is seen in clinic for his sports physical. Initial blood pressure is 160/90 with a pulse of 68 and repeat blood pressure measurement in the exam room is 170/84 with a pulse of 65. Previous blood pressure measurements have been normal and he is otherwise healthy and asymptomatic. The most likely explanation for this finding is: a. Development of essential hypertension b. He ate a Super size meal at McDonald’s just prior to the visit c. He is nervous he may be withdrawn from practice d. Use of a cuff that is too small for the patient

19. Preparation and Resources • Review content specifications (M2 CCA website) • CFM written exam • Review physical exam outlines • Review physical exam checklists • Swartz: Textbook of Physical Diagnosis

20. Example: Content Specifications Outline • Knowledge (Written Exam): Abdominal • Know the anatomic location of intra-abdominal organs • Know the physical exam findings in patients with ascites • Know how to assess liver span • Know the physical exam findings in patients with abdominal aortic aneurysms • Know the physical exam findings in patients with diverticulitis • Know the technique for examination of the spleen • Know the physical exam findings in patients with peritonitis • Know the correct sequence of performing the abdominal exam • Know the physical exam findings in patients with pyelonephritis • Know the technique for auscultation of abdominal and renal bruits • Know the physical exam findings in patients with appendicitis • Know the terminology for associated physical exam findings in patients with cirrhosis • Know the anatomic location for referred pain from intra-abdominal organs

21. Exam Logistics

22. Exam Dates Clinical Exam • Friday, February 2, 2013 • Saturday, February 2, 2013 • Monday, February 4, 2013 • Tuesday, February 5, 2013 Make-Up Exam • Wednesday, March 13, 2013 (tentative) Written Exam The M2 CCA Written Exam opens on Thursday, January 31, 2013 at 8:00 a.m. through Wednesday, February 6, 2013 at 12:00 a.m. (24h, midnight). Sign up for the exam will open following the holiday break

23. Make-Up Exam • Make Up Exam • Wednesday, March 13, 2013 • Remediation • Tentatively scheduled between March 1 through March 8, 2013 Note: Students who are unable to take the exam during February mustobtain approval to take the exam on March 13 from the M2 CCA Committee and Director

24. Myths and Misconceptions About the CCA • Myth: The faculty get enjoyment by inflicting physical and emotional pain on the medical students by making them take the M2 CCA. • Fact: The faculty REALLY experience great joy inflicting physical and emotional pain on the medical students by making them take the M2 CCA. • Myth: Each year, many students FAIL the exam and do not begin their M3 year on time. • Fact: Although there are a handful of individual station failures each year, the majority of the students pass each section on the first attempt. We have NEVER had a student receive a failing grade for the CCA recorded on his/her transcript. We have NEVER had a student’s matriculation to the M3 year delayed because of his/her performance on the M2 CCA. • Myth: Students are graded on/expected to perform tasks that are not on the teaching checklists. • Fact: The exam is not designed to “trip up” students. The tasks to be completed at a given physical exam station is based on what is taught during the CFM course using the teaching checklists. • Myth: There is no way that I will be able to complete these tasks during the allotted time. • Fact: The overwhelming majority of students complete the exam/history taking stations without difficulty and often have time to spare. Many times, students who run into time pressure have not followed the door instructions and spend time completing tasks not required/expected at the station. Practice, practice, practice.

25. Contact Information • Michael Lukela, MD • Director, M2 CCA • E-mail: mlukela@umich.edu • Amy Page • Lead Administrator, M2 CCA • E-mail: amypage@umich.edu