M2 Clinical Comprehensive Assessment (CCA)

Michael Lukela, M.D.Director, M2 CCA

October 25, 2011

Exam Composition

• Practical Exam– Physical Exam– History Taking– History Presentation

• Written Exam

Exam Composition (Practical)

• Physical Exam– Abdominal– Cardiac– Musculoskeletal– Neurology– Pulmonary

• History Taking– History Taking– History Presentation– Communication Skills

Physical Exam

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

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)

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

M2 CCA Website

Example Teaching (CFM) Checklist

History Taking

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

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

Preparation and Resources

• Review CFM teaching videos, interviews (portal)– 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

Exam Format

BLOCK 1: 45 minutesHistory Taking

Abdominal ExamVerbal presentation

BLOCK 2: 45 minutesHistory TakingCardiac Exam

Pulmonary Exam

BLOCK 3: 45 minutesNeurology Exam

Musculoskeletal Exam

Current plan is to have groups rotate between sections every 45 minutes. Blocks 1 and 2 are integrated stations following the sequence of History Physical Exam Presentation (BLOCK 1 only).

Written Exam

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

Example Question #1

Which of the following is the ideal order in which to perform the abdominal exam?

a. Auscultation, inspection, percussion, palpationb. Inspection, auscultation, percussion, palpationc. Inspection, palpation, auscultation, percussiond. Inspection, palpation, percussion, auscultation

Example Question #2

A 17-year-old football player is seen in clinic for his sports physical. Initial blood pressure is 150/90 with a pulse of 68 and repeat blood pressure measurement in the exam room is 126/84 with a pulse of 65. Previous blood pressure measurements have been normal and he is otherwise healthy. The most likely explanation for this finding is:

a. Development of essential hypertensionb. He ate a Super size meal at McDonald’s just prior to

the visitc. He is nervous he may be withdrawn from practiced. Use of a cuff that is too small for the patient

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

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

Exam Logistics

Exam Dates

Clinical Exam

– Friday, January 20, 2012– Saturday, January 21, 2012– Monday, January 23, 2012– Tuesday, January 24, 2012

Make-Up Exam

– Wednesday, March 14, 2012 (tentative)

Written Exam

The M2 CCA Written Exam opens on Thursday, January 19, 2012 at 8:00 a.m. through Wednesday, January 25, 2012 at 12:00 a.m. (24h, midnight).

Sign up for the exam will open following the holiday break

Make-Up Exam

• Make Up Exam– Wednesday, March 14, 2012

• Remediation– Tentatively scheduled between March 1 through March 9,

2012

Note: Students who are unable to take the exam during January must obtain approval to take the exam on March 14 from the M2 CCA Committee and Director

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.

Contact Information

• Michael Lukela, MD– Director, M2 CCA– E-mail: mlukela@umich.edu

• Amy Page– Lead Administrator, M2 CCA– E-mail: amypage@umich.edu