Usmle Smasher: A Smart Guide to Smash Usmle Clinical Skills

Copyright © 2008 by K.G. Paul MD.

ISBN:

   HARDCOVER   978-1-4363-516 1-4

   SOFTCOVER    978-1-4363-5 160-7

All rights reserved. No part of this book may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the copyright owner.

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CONTENTS

1   Introducing Usmle Smasher

2   Check List

3   Things To Remember

4   Success Tips

5   Patient Encounters

6   Writing Patient Note

7   Formulating The Differential Diagnosis

8   Ordering The Diagnostic Work Up

9   Frequently Asked Questions

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Our Father’s God! To Thee,

Author Of Liberty,

To Thee We Sing;

Long May Our Land Be Bright

With Freedom’s Holy Light;

Protect Us By Thy Might,

Great God, Our King!

Dedicated to my wife Dr. Nini Thomas and all other physicians, residents, and future residents serving the people of the United States of America

1

Introducing USMLE SMASHER

In common usage, a SMASHER has many meanings. But two particular definitions caught my attention before I chose it as the title of this book. In physical sciences, the atomic smasher has two functions. First it increases the kinetic energy of the charged particles. As I write these words, scientists at CERN, the European Organization for Nuclear Research, are building Large Hadron Collider. LHC will be the world’s largest atomic smasher as it uses an unprecedented peak energy of 14 trillion electron volts to smash two beams of protons together, and in the process, to discover new types of smaller particles, known as quarks.

When I heard about Large Hadron Collider, I was bemused by the importance of understanding the microstructures of the atom in order to decipher the macrostructure of our universe. I think similar principle holds importance even in the health care: it starts with laying the foundation with basic principles of physician-patient communication and then building the edifice of patient care on the top of it. That is where this book starts. Patient Encounters are intended to make all the bricks of patient communication available to the physician to work upon.

Second, that atomic smasher breaks the atom into small pieces. This book is written with the same purpose in mind. It dissects the USMLE Clinical Skills Examination into small components and explain the basic principles to score high in each component.

My second definition of Smasher comes from the world of sports. In sports, to smash means to hit a ball in a forceful stroke. I think the first principle to achieve success is to unleash your best shot at the target with all the force you can muster in the given time. Perhaps the greatest baseball player in history, Babe Ruth once described how he hit home runs, How to hit home runs: I swing as hard as I can… . I swing big, with everything I’ve got. I hit big or I miss big. I like to live as big as I can

I hope this book will help you deliver your best shot at USMLE Clinical Skills, to smash it and then to realize your dreams in medical profession.

Please send me your comments, corrections and criticisms to [email protected]

I wish you all the best,

K.G.Paul MD

2

Check List

I have filled the application form on the website: NBME or ECFMG 21835.jpg

I have a government-issued photo identification to present at the test center for identification (If you do not have one, start now to get one, it takes time) 21839.jpg

I have a white lab coat and a stethoscope 21841.jpg

I have received the notification of registration 21843.jpg

I have scheduled my test date 21845.jpg

I have prepared a study plan for this test 21847.jpg

I have learned the history taking techniques 21849.jpg

I have mastered all basic physical examination methods 21852.jpg

I know how to counsel patients for common clinical problems 21854.jpg

I have practised doing my patient encounters within time limit 21856.jpg

I have memorized the important mnemonics 21858.jpg

I am aware of the test procedure, regulations and requirements 21861.jpg

I have planned my travel to the test center 21863.jpg

I have reserved my flight ticket, bus ticket or train ticket (whatever necessary) 21865.jpg

I have reserved my room in the nearby hotel (if necessary) 21868.jpg

Before leaving home:

I have packed my admission permit and government issued photo identification 21870.jpg

I have packed my white lab coat and stethoscope before leaving for the test center 21873.jpg

3

Things To Remember

DOS

21876.jpg    Read the doorway information carefully along with the specific instructions regarding the tasks you are supposed to perform

21879.jpg    Knock on the door before you enter the examination room

21881.jpg    Introduce yourself to the patient

21883.jpg    Always look into the patient's eyes when you speak to them

21886.jpg    Always start your patient interview with open-ended questions

21888.jpg    Use simple, clear words in framing your questions

21891.jpg    Use transitional questions while moving from one topic to the other

21894.jpg    Always drape the patient before starting your physical examination

21896.jpg    Always wash your hands before examining the patient

21898.jpg    Always answer the patient's questions, if you do not know the answer, say, 'I don't know'.

21900.jpg    In your physical examination, explain to the patient what you are going to do before doing it

21902.jpg    After your physical examination, help the patient put their gown back on

21904.jpg    Explain your findings and tentative diagnosis to the patient

21906.jpg    Explain to the patient about the investigations and laboratory tests you are going to order

21909.jpg    Give a brief conclusion/counseling at the end of your patient encounter

21911.jpg    Ask the patient whether they have any questions for you

21913.jpg    Thank the patient for their cooperation, once you finish the encounter and about to leave

21915.jpg    Do a fundus examination in all diabetic patients

21918.jpg    Carefully look for the abnormal signs in your physical examination

21920.jpg    Remember to examine the abdomen in the correct order: inspection, auscultation, percussion, and palpation

21922.jpg    Be a good listener and pay attention to the patient while they are talking with you

21924.jpg    Do complement the patient if it is sincere

DON’Ts

21932.jpg    Do not try to cram new material on the day of or the day before the test.

21935.jpg    Do not use medical terminology in your conversation with the patient

21938.jpg    Do not examine the patient through the gown

21941.jpg    Do not rush or compel the patient

21943.jpg    Do not give false reassurance about the outcome of the disease

21945.jpg    Do not perform a pelvic, genital, rectal, female breast and corneal reflex tests

21947.jpg    Do not get perplexed even if you feel you have 'messed up' two or three cases

21949.jpg    Do not talk too fast that your patient cannot understand you

21951.jpg    Do not jabber

21953.jpg    Do not talk down

21955.jpg    Do not make fun of the patient's questions, answers, behavior etc.

21957.jpg    Do not contradict the patient

21960.jpg    Do not ask embarrassing personal questions

21962.jpg    Do not make tactless comments

21964.jpg    Do not use Mr before your name in your introduction to the patient

21966.jpg    Do not repeat painful maneuvers.

21968.jpg    Do not give the patient more information than they can handle

21970.jpg    Do not reenter the examination room, once you go outside, to ask 'forgotten' questions in history or to perform 'missed' tests in physical examination. Before you leave the patient examination room make sure that you have finished everything relevant to that case

21972.jpg    Do not waste your time with rechecking the vital signs given on the doorway information sheet, unless you are specifically asked to do so.

21974.jpg    Do not perform a 'head to toe' pattern of physical examination. You should be able to do a focused physical examination within 5 to 6 minutes.

21976.jpg    Do not mark on the patient's body during your physical examination.

21978.jpg    Do not make twitchy mannerisms—pulling at your hair, pursing your mouth, wrinkling your brow etc.

21981.jpg    Do not interrupt the patient while they are doing the talking

21983.jpg    Do not show your nervousness or anxiety in front of the patient

21985.jpg    Do not look at the big clock on the wall in the examination room, repeatedly.

21987.jpg    Do not hesitate to say such gracious words like 'please' and 'thank you' to the SP

21989.jpg    Do not link positive remark with a negative one (e.g. You are taking good care of your diabetes, but you neglected.)

21991.jpg    Do not ask multiple choice questions, ask one question at a time

21995.jpg    Do not ask leading questions

21997.jpg    Do not close your open-ended questions with another closed-ended question (e.g. Tell me about your pain? Is it severe?)

21999.jpg    Do not leave the examination room without saying goodbye to the patient

22001.jpg    Do not linger at the door after your conclusion

22004.jpg    Do not show off your medical knowledge to the SP using medical knowledge. Translate your medical vocabulary into lay terminology before conveying to the patient

22007.jpg    Do not keep your hands on patient's head while doing the ophthalmoscopic examination.

22009.jpg    Do not write less familiar abbreviations in your patient note.

22011.jpg    Do not write treatment plans, referrals, and management plans in your diagnostic work up

4

Success Tips

An old Chinese proverb says, "Tell me, I’ll forget. Show me, I may remember. But involve me, I’ll understand and master. USMLE Step-2 Clinical Skills is a unique test with its own characteristics and keeping them in your perspective while preparing for this examination is the key to success. This chapter focuses on the main components of an effective preparation to succeed in this test. Synchronizing various parts of your preparation according to a few time-tested guide lines help you habituate yourself to perform and pass this test with an imperturbable demeanor. Try to apply the following principles to your preparation.

1.    Practice! Practice! Practice!

   Remember that USMLE Clinical Skills Examination is not as easy as it would seem. Your absolute key to success in this test is practicing with patients in a real clinical setting or, at least, with someone who can portray as your standardized patient. All your study material tell you what to ask in history, what to look for in physical examination and where to look, but they can never replace practice. Find a study partner or friend, who can portray patients in a realistic way and every day, practice at least one case with them: history taking and physical examination, always being aware of time limit. However, the best preparation is to see the actual patients in a real clinical setting such as a medical clinic or hospital, under the supervision of a competent physician, who can critique your performance.

      Since USMLE Step-2 CS is designed to simulate an actual clinical experience, the more clinical experience and practice you have, the more comfortable you will feel during the patient encounter in this test. If you do not have a helpmate around you, try for a phone study partner. Following a fixed time frame, discuss the cases everyday over the phone, while you are acting as the physician and your conversant acting as the standardized patient. Studying with another person or with a small group, enhances your learning a lot. But do not join a group, which rises your anxiety level or is not serious about Step-2 CS. For instance, do not take a student preparing for USMLE Step-3 or Step-1 or Step-2 CK as your study partner. USMLE Step-2 CS is a lot different examination from other USMLE examinations. Again, what you need is practice, especially if you are out of touch with the patients recently.

2.   Develop a study plan and stick to it

   Allow plenty of time for the study and revision of important material. Many students preparing for this test are bewildered with a question, How many days do I need to study for this test? Though this is a subjective decision, for a medical student or graduate, who is adequately trained in his or her medical school, approximately thirty days are sufficient for a confident preparation for this test. However, this decision must be made carefully by the student himself/herself individually lest they endanger their preparation and outcome of this test.

      Stick to your study plan with a steady pace. Plan what you will need to study and when and over how many days you are trying to learn the required tasks. Do not rush, but study chapter after chapter, form the fundamental clinical knowledge base, develop the basic clinical skills and review the common diseases, their symptoms and signs, and the relevant physical examination. While it is important to learn the topics essential to pass this examination, one tends to forget the most vital points as the days of preparation progresses toward the day of examination. That is why you need a strategy to remember what you’ve learned. It is also extremely important to analyze how your daily study is relevant to your examination and to maintain the coherence between the topics of study and the things tested in the examination

3.   Organize your material for a parallel study.

   Allot the greatest amount of your time to the most important topics of the test. Rather than studying history taking, physical examination, and patient note writing sequentially, follow a parallel study plan. For instance, study the history taking of a particular system in the morning, the physical examination of that system in the afternoon, and then it’s patient note writing in the evening. This mode of study help you concrete your thinking in the mode of the actual examination.

4.   Take breaks

   Anxiety is your most ruthless enemy in this test. It is usual that you experience some level of nervousness before this test because of the cost of failure in terms of the fee, impact on the residency interviews, and loss of time, sometimes, a full resident year. But, remember nervousness actually devastates your preparation and minimizes your chances of success. Therefore, do not allow your anxiety to run the show. Take charge of the preparation with an attitude of self-confidence. Take breaks for relaxation. Taking deep breaths, remembering your past academic victories, rotating your shoulders are some of the well known techniques to relax yourself and boost your confidence level.

5.   Face the test with confidence

   As mentioned earlier, anxiety and nervousness destroy everything you planned for. Anxiety is like a double-edged sword. A little anxiety is a good thing. Some level of anxiety, which is usual for all of us, can be channeled into a motivating force that help us energize, focus, and prepare well, but too much of tension will paralyze and incapacitate us, for the bad results. Therefore, it is important to face this test with confidence. After all, you have been exposed to the components of this examination—history taking, physical examination and patient note writing—ever since you entered into the medical school. Beside you have finished the United States Medical Licensing Examination Step-1 in order to get the eligibility to sit for this test. Taking your medical school experience and the Step-1 success into the context, with good preparation, passing Step-2 Clinical Skills should not be a difficult task to overcome. The pass in Step-1 is an attestation that you have enough cognitive skills to appear for this examination. However, on the other hand, it is equally important to recognize the fact that your score in Step-1 is not a card of assurance that you are going to pass this test. To say that using an example, a student with 96 percentile score in Step-1 might fail in clinical skills examination due to lack of preparation and practice, which, sometimes, is bred by over-confidence generated from a high score in Steps. Succinctly, it is your practice and preparation for this test—not your scores in other Steps—which determine your success. Completion of USMLE Step-2 Clinical Knowledge in not required to perform well in Step-2 Clinical Skills either. Above all, avoid thinking of yourself in a negative sense.

6.   Learn the mnemonics

   Completing history taking, physical examination and counseling the patient within 15 minutes is an awesome task. Time flies away very quickly during patient encounters. To barrage yourself against the tides of anxiety related to the tasks, learn the essential mnemonics given in this book. They enhance your memory and speed of performance in the real test.

7.   Improve your English proficiency

   One of the components of this test is proficiency in English language, which will be assessed by the standardized patients. Excellence in clinical skills does not compensate a poor English language proficiency. It is also important to recognize that having English as mother language or the language of one’s upbringing is not a guarantee that he or she has English proficiency. For example, even an American-born student may fail to communicate his or her ideas effectively to the patient while a student from a non-English background may have troubles with pronunciations. Thus, regardless of one’s upbringing, it is important to improve their English language skills: Transforming thoughts into meaningful sentences using accurate grammar, identifying words that clearly communicate one’s point of view, feelings and ideas, learning to pronounce those words clearly and confidently, spelling the words correctly and writing legibly if you are planning to write your patient note rather typing on the computer. If you are uncertain of your English language proficiency, consider taking TOEFL or/and TSE (Test of Spoken English) as screening tests prior to applying for the USMLE Step 2 CS.

8.   Revise your previously studied material as frequently as possible

   It is important to recognize the truth that human beings forget 46% of what they read after one day, 79% after 14 days, and 81% after 28 days. Thus, if you start your one-month study plan today, you will have forgotten 81% of what you have studied today by the end of your study plan. Thus, it is essential to review your previous study regularly to get the maximum benefits from your study plan.

9.   Familiarize with the test procedure

   Lastly, familiarization with the test procedures is as essential as the studying for the test. Many students fail because of their non-acquaintance with the testing procedures and regulations. Please read the orientation material often and watch the videos in the CD to get familiarized with the testing procedure. Synchronize your preparation with hoarding essential information about the testing procedures and regulations.

10.   Make preparations in advance

   Finally make preparations for your test well in advance, at least 6 months on hand, because there is an year-round demand for test dates, test centers, flight tickets, hotel rooms, car rentals etc

THE DAY BEFORE THE TEST

1.   Relax yourself!: On the day before the test, you must relax yourself from all anxiety. Avoid cramming new material at this time. Trying to learn new techniques, maneuvers, formulas, mnemonics on the day before the test can easily produce anxiety.

2.   If you are traveling a long distance, consider arriving in the test-town at least a day before the test. For example, do not plan to take a morning flight to Philadelphia on the day of the test. Also, do not plan to arrive at the test center through a long-hour driving, which might exhaust you. Amtrak, Greyhound and some airlines are becoming synonymous with delay and disruptions. Therefore, do not plan to travel on the day of the test. Get the information about restaurants, motels, and weather conditions of the city of your test center.

3.   Review major concepts of history taking, physical examination and doctor-patient communication. This should be limited to the material you have already studied during your preparation. Again, attempting to crash learn new material at this pivotal time may interfere with your recall of material you have already mastered.

4.   If you completed your study plan, do something relaxing that refreshes your mind. This does not affect your performance in the test.

5.   Avoid calling any friends you know to be ‘tension creators’. They might ask you whether