Did you know that, on the USMLE Step 2 CS exam (formed called Clinical Skills Assessment), having a standard protocol saves times and prevents memory lapses ? Read on...
This simple pattern can be used for almost all cases - except of course for telephone encounters and patients for lab results counselling...I used the following protocol myself!
First Sight...
Knock 3 times with confidence , a smile , walk in and say, "Good morning Mr. Smith, I am Dr. Digitaldoc and am here to see you today as your physician." Shake hands with the patient, look around the room and say "Is everything in the room alright for you ?" - SP says yes - Then you say "Let me make you a little more comfortable".....and while saying so, drape the patients legs up to his belly (applies to a sitting or a reclining SP) . Then, "So Mr. Smith, how may I help you today?"
Warning: A friend of mine who took his exam before me, told me about an incidence where a student asked the SP - "What brings you here today ?" and the SP replied "A bus !!" - to avoid such nasty mishaps, ask "How may I help you ?" or use a new style being discussed these days - "Mr. Smith, it seems you have come in today for a racing heart - could you tell me more about it?" ( Chief complain is already stated on the door before you enter !
After the patient tells you the chief complaints and stops, first express sympathy - say, "Oh I am sorry to hear that, I shall try my best to help you. Hope you dont mind if I make a few notes as you speak" This makes you free to write or pretend to write as you try to recall what to ask without showing ur nervousness - actually a good time to write ur mnemonics !! If the setting is appropriate - you may sit on a stool and bend forwards as if listening - I did so because it created a feeling of showing humility and friendliness.
After finishing off with data collection, i.e. "PAM HUGS", before you move on to "FOSS", it is good to say, "Mr. Smith, the way clinical medicine works, there could be some clues hidden in a few personal questions I need to ask you - is that OK with you ? " and then move on to FOSS.
If you think you have finished or can't recollect what else needs to be asked, do give the patient a final chance by saying " Is there anything else you want to tell me ?" then move on to washing hands and examination. Warning : Dont ever express explicitly that you have concluded your questioning, because you might remember something during physical examination and it is ok to ask then !
Transitioning to a hand wash:
There have been quite a few concerns about how to handle a change from history mode to a hand wash mode ...A sample transcript :
You = "I shall now need to perform a quick general examination and then look at your heart - is that fine ?" (No need to say Head, Neck, Eyes, Feet, etc and waste seconds ! - you're gonna be graded for doing it , not for u saying it in detail !)
SP = "Sure, doctor"
You = "Arrite ! Before we begin Mr. Smith , excuse me for a moment here to wash my hands" (smile)
I had reserved the time to wash my hands to enquire about occupation and say "thats interesting, my uncle used to do something similar" or something like that.Transitioning to a Physical exam:
Before you begin physical examination say "I will now need to perform a quick general examination and then we shall have a look at your chest [or abdomen - wutever the chief complaint is]" and do keep talking during each thing your examine - like "lets start with your eyes, could you look up for me" while examining pallor. By the way , a good mnemonic of quickly completing general examination is "PICKLE" - Pallor, icterus, Cyanosis, Clubbing, Koilonychia, Lymphadenopathy and Edema Feet" along with Jugular veins, carotid bruit if a CVS case.
At the end of the entire general + systemic examination, summarise : "Based on what you told me and your physical exam, there are certain diagnostic possibilities like 1._____, 2. ________ or 3. _______ and others. But to be more certain, let us order a few tests - like blood tests, chest x-ray , an EKG , and then discuss further management. "
The last minutes...
While concluding, keep this 4-stage pattern in mind to cover everything and to be courteous:
a. First, Counsel !!! For example - for a case of diabetes, it is good to say a few words on foot care ! if the patient smokes or drinks alcohol - say "are you aware of the harmful effects of smoking / alcohol ? Have you ever considered quitting - if you wish to , we have a good support team that is willing to help you quit the habit" thats it - dont get personal about it .
b. Then say " Have you understood everything we have discussed today ?"
c. Then "Are there any special concerns you have ?"
d. Finally " Thankyou very much Mr. Smith . I shall leave my contact information with my nurse - feel free to contact me anytime if you have any questions"
A Trick, in case Time falls short...
If you have to leave, dont make it abrupt and embarrasing. Rather it is good to pretend looking at your beeper and say "Oh ! Mr. Smith, We have an emergency and I have to leave - I will see you as soon as I get free" and leave with a smile. ( ...Speaking of showing those SPs that you are no less when it comes to some fine acting ;-)... )
Hope this helps guys....
Q. What if I miss out on some clinical test due to lack of time ?
A. Mention that as an investigation on your Patient Note ! (Some may argue that since the PN is graded by physicians separately later, while the actual encounter by the SPs on the spot, it may be ok to bluff on the PN ... I am not sure if that's how grading is done but nevertheless mentioning missed physical exams on the PN should be safe too)
Q. Should we auscultate in ALL cases ?
A. Yeah - make it a part of the routine ! Except, of course, for Lab result explanation cases.
Q. Carotid Bruit auscultation : Bell or Diaphragm ?
A. Use the Bell !
Joke: Heard this one ? : Doctor to patient: "Well, Mrs. Cole, I'm afraid you're not quite as sick as we'd hoped." :-) :-) :-)
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