M4 Comprehensive Clinical Assessment (CCA) : Practical Advice 2009

M4 Comprehensive
Clinical Assessment
(CCA)
Practical Advice
2009
M4 CCA
The mission of the M4 CCA is to
ensure that students are
competent in the fundamental
clinical skills necessary to
provide excellent, effective, and
safe patient care as a PGY1
trainee.
Goals:
M4 CCA vs. USMLE Step 2 CS
• The M4 CCA is designed to measure
student competency across U of M
specific intended learning
outcomes.
• Therefore the M4 CCA is similar to

but differs from the Step 2 CS
Exam in several ways.
Continued:
M4 CCA vs. USMLE Step 2 CS
• The M4 CCA includes radiographic
studies, EKGs, and EBM.
• Each station on the M4 CCA may or

may not be followed by post-
encounter note or exercise.
• Similar to the Step 2 CS, you may

need to interview parents.
Content of M4 CCA:
Part 1 - Computer Based Exam
Content includes:
• EBM
• EKG
• Imaging
•There may be “pilot” components
to the computer based exam
Content of M4 CCA:
Part 2 - Clinical Exam
• Cases are drawn from a blueprint and
include important symptoms and
diagnoses, presenting complaints, and
conditions – balanced by age and gender.
• Settings include in-patient unit, urgent care
and outpatient clinic sites.
• Approximately 10 -12 stations.
• There may be “pilot” stations – which
you will not be graded on.
Tasks
• Many stations include a focused
history and/or physical exam.
• There may or may not be a post-

encounter note or exercise following
the patient encounter.
• Be sure to read the instructions on

the door and understand the tasks at
each station before entering the room.
Standardized Patient Scoring
Specific checklists and rating scales
are used to record examinee’s
performance in the following areas:
1. Content:
– Important history items and/or physical exam
items
– Personal Manner (e.g. hand washing and
draping)
2. Communication Skills:
– Open the interview (appropriate
introductions, identification of cc, agenda
setting)
SP Scoring: Communication Skills
Continued:
– Assess the patient’s problem (accurate
and efficient data collection, and
understanding of the pt)
– Verbal and Non-verbal relationship
building skills (empathy, support,
partnership, respect, and appropriate eye
contact, and body language)
– Manage the patient’s problems
(achievement of pt understanding,
involvement of pt in treatment process,
affirmation of intent)
Warning
Any information from
past CCA exams may
be misleading.
Overall Station
Details
Content of Door Instructions
For each patient encounter, there will be
door instructions that include:
– Pt name, age, chief complaint and the site
where the patient is being seen (e.g. in-patient
unit, urgent care or outpatient clinic.)
– Pt’s vital signs (can be trusted, do not need to
re-take)
– List of specific tasks to be completed (hx,
physical exam, etc.)
– Time allotted for the station
- Notice if a post-encounter exercise will
follow or not.
At the Door
• Read instructions and understand
the tasks
• Review patient’s name, CC, vital sx
• Quickly formulate your checklist
• Knock, enter room, and introduce
yourself as you would in the hospital
setting, i.e. student doctor _______
• Address patient by his or her full name
(first AND last name)
Timing of Patient Encounters:
History AND Physical Exam
Stations
• Door instructions: 10-20 sec.
• History taking: 7-8 minutes
• Physical exam: 4-5 minutes
• Discuss plan with pt/closure: 1-2
min.
TOTAL = 15 minutes
Timing of Patient Encounters:
History taking only Stations
• Door instructions: 10-20 sec.
• History taking: 12-13 minutes
• Discuss plan with pt/closure: 2-3 minutes
TOTAL = 15 minutes
*Remember that you will not be doing pelvic
or rectal exams on the M4 CCA or Step 2
CS. However, if indicated you should let the
patient know that “you will return” to do this
part of the exam.
History Taking,
Communication
and Physical
Exam Details
Some Components of HPI
• Chronology
• Symptoms
• Pertinent negatives
• Relevant:
– PMH (include tx, hospitalizations)
–Medications (include OTC,
supplements, herbs, etc.)
• Risk factors
• Relevant ROS
HPI: Symptoms
• Timing – onset, duration, frequency
• Location
• Quality
• Severity/Intensity
• Aggravating factors
• Alleviating factors
• Associated symptoms
Assessing pediatric
patients
PMH:
–Birth hx
–Feeding hx
–Growth and development
–Immunizations and screening
–Childhood illnesses (acute or
chronic)
–Social development
Past Medical Hx (PMH)
• Past medical illnesses
• Past surgical illnesses
• Psychiatric illnesses
• Medications (include OTC,
supplements, herbs, etc.)
• Allergies
Communication
Review of the CS Step 2 web-site re: the
scoring of Communication subcomponents
may be helpful in preparation for the M4
CCA and Step 2 CS:
Subcomponents:
1.Questioning skills
2.Information sharing
3.Professional manner and rapport
Click here for USMLE Step 2 CS Information
NOTE: Go to page 10 for a more detailed
description of subcomponents.
Physical Exams
• Perform relevant physical exam
• May need to perform a breast exam
• Do not need to perform pelvic or rectal
but if indicated, you need to inform the
patient that it will be done later
• Also can indicate any further physical
exam needed in the post-encounter note.
Other Useful
Topics/Tools to
Review
Assessing Possible Depression
• Affect
• Two-Question Depression Screen:
1. “Have you often been bothered by feeling
down, depressed, or hopeless?”
2. “Have you often been bothered by little
interest or pleasure in doing things?”
• “SIGECAPS” mnemonic
Assessing Geriatric Patients
http://www.med.umich.edu/i/geriatrics_center/UMGeriatricsCare
• ADLs (Activities of Daily Living)

• IADLS (Instrumental Activities of Daily
Living)
• Social supports
• Living environment
• Medications
• Incontinence
• Falls
• Cognition
• Affect
Assessing Geriatric patients:
Geriatric Physical Assessment
http://www.med.umich.edu/i/geriatrics_center/UMGeriatricsCare
• Mobility:
– Observed Gait
– Timed up & Go Test
• Cognition:
– Mini-Cog Exam
– Mini Mental Status Exam (MMSE)
• Affect:
– Two-Question Depression Screen
– -SIGECAPS
– Geriatric Depression Screen (GDS), use if handout is
available
Coma and Mental Status
Changes
Review materials suggested:
1. Coma examination video (Dr. Selwa in
LRC)
2. Gelb lecture syllabus from M2 year,
lectures on Toxic metabolic
disorders, Acute mental status
changes.
3. Gelb Introduction to Clinical
Neurology Chapter 11
Post-Encounter
Exercise
Information
Post-Encounter Exercises
Post-encounter exercises occur at six
stations and may include one of the
following:
– A post-encounter Note (PEN)
or
– A brief post-encounter assessment that asks
you to make a decision and justify your
conclusion (PEA)
or
– A post-encounter verbal presentation (PEP)
Post-Encounter Note (PEN)
• Timing: after clinical encounter with
Standardized Patient
• Time allotted: 15 minutes
• Standard SOAP format:
– Subjective component
– Objective
– Assessment
– Plan
• Assessment based on inclusion of
relevant details, accuracy, and
judgment
Post-Encounter Assessment
(PEA)
• Timing: after clinical encounter with
Standardized Patient
• Time allotted: 10 minutes
• Goal: to understand your assessment of

the patient based on the patient encounter
and the justification for your assessment
and plan. Be as complete as you can.
Post-Encounter Presentation
(PEP)
• Timing: after clinical encounter with Standardized
Patient
• Time allotted: 15 minutes, includes:
– Preparation time
– Presentation time
• Goal: a 5 minute concise, relevant oral
presentation to faculty member
• Assessment based on:
– Content: relevance, accuracy, and judgment
– Communication
PEP: Components
3 components (PE is provided;
not obtained from standardized
patient):
1. History
2. Assessment
3. Plan
PEP: History
• Standard components:
–HPI (CC, associated relevant
symptoms)
–Past Medical History
–Family History (if relevant)
–Social History
–Medications
PEP: Assessment and Plan
• Assessment:
–Differential Diagnosis, along
with rationale
• Plan:
–Further testing, with rationale
–Initial therapy, with justification
Common Reasons
for Station Failures
Common Reasons for Failure:
History Taking
Incomplete history :
– **Failure to consider broad
differential - premature closure.
– Failure to ask about PMH including

medications, allergies.
– Failure to obtain FH, SH

Physical Exam
• Not focused – too diffuse
• Incomplete – omit important
elements
• Exam must be focused, i.e., cannot
do the whole physical, but must be
thorough within that focused area
• Example: If a pt has chest pain,
need to do elements of pulmonary,
abdominal, musculoskeletal exam,
etc.
Communication
• Patient Communication (evaluated
across all stations). The student:
– Interrupts the patient or uses medical
terminology or jargon.
– Fails to follow up on patient concerns
or response.
– Fails to wash hands, extend table,
drape, and interact with the
standardized patient as the student
would interact with a real patient.
Post Encounter Notes,
Assessments, and Presentations:
–Illogical
–Omitting critical elements such as
pertinent positives and negatives
–Premature closure re: diagnosis
–Poorly written with non-standard
abbreviations
Remediation
& Retake
Information
Remediation
In preparation for retaking a station(s),
you will be required to:
1. Review Educational Resources
(electronically).
2. Complete a written electronic Self-
Assessment of your performance by
watching a reference video and
comparing it to your own video.
*Some students may be required to attend
a small group session or meet with a
faculty member.
Retakes
Two retake exams will be offered and
you will be given the opportunity to
select one of the following:
– Wednesday, July 15
– Wednesday, August 19
**Be sure that you are available for one

of these dates as generally >50% of
students need to re-take at least one
station
GOOD LUCK!

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M4 Comprehensive

• Therefore the M4 CCA is similar to

• Each station on the M4 CCA may or

• Similar to the Step 2 CS, you may

• There may or may not be a post-

• Be sure to read the instructions on

• ADLs (Activities of Daily Living)

• Time allotted: 10 minutes

• Goal: to understand your assessment of

– Failure to ask about PMH including

– Failure to obtain FH, SH

**Be sure that you are available for one

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