First Aid for the USMLE Step 2 CS

Section 2. The Patient Encounter

Introduction

As described in Section 1, the Step 2 Clinical Skills (CS) exam consists of 12 clinical encounters with trained “standardized patients” (SPs). These encounters are designed to replicate situations commonly seen in clinics, doctors’ offices, and emergency departments.

Each encounter in the Step 2 CS lasts 15 minutes. You will be given a warning when five minutes remain in the session. The 15-minute period allotted for each of your interviews includes meeting the patient, taking the history, performing the physical exam, discussing your findings and plans, and answering any questions the patient might have. After that, you will have 10 minutes to summarize the patient history and physical exam and to formulate your differential diagnosis and workup plan. All this may seem overwhelming, but it need not be. This chapter will guide you through the process step by step.

Fifteen minutes should be adequate for each patient encounter as long as you budget your time wisely. The most common reasons for running out of time are as follows:

 Taking an overly detailed history

 Conducting an unnecessarily detailed physical exam

 Carrying out the encounter in a slow or disorganized fashion

 Allowing the patient to stray away from relevant topics

 Failing to adapt to or redirect challenging (eg, unresponsive, angry, crying) patients

To best manage your encounter, it is recommended that you distribute your time judiciously. A recommended timetable is as follows:

 Doorway information (assessing preliminary information posted on the door of each room): 10-20 seconds

 History: 7-8 minutes

 Physical exam: 3-5 minutes

 Closure: 2-3 minutes

Of course, this is only an approximation. In reality, each encounter is different, so some encounters will require more time for taking the history or doing the physical exam, while others will necessitate that more time be spent on closure and patient counseling. You should thus tailor your time to the demands of each case. Here are some additional time management tips:

 Do not waste valuable time looking at the clock on the wall. Use the official announcement that five minutes remain in the encounter as your only time indicator. If you have not begun to perform the physical exam by that point, you should do so.

 An organized and well-planned history is key. Stay focused on asking questions that are pertinent to the chief complaint.

 A brief and focused physical exam is also critical. There is no need to conduct a comprehensive physical exam during encounters. Remember that points may be deducted for omitting critical exam findings, but no bonus points will be given for performing low-yield maneuvers.

 One of the principal objectives of the Step CS is to evaluate your ability to communicate with patients. Make sure you leave time to discuss your management plan, and never try to save time by ignoring the patient’s questions, requests, or emotional status.

 Practice is the best way to improve your performance, efficiency, and sense of timing.

Figure 2-1 illustrates the key components and desired outcomes of the clinical encounter. The following sections will guide you through each.

FIGURE 2-1. Overview of the Clinical Encounter



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