University of Texas Medical Branch Year 3 Mid-Year Formative Clinical Skills Exercise

School of Medicine Orientation Instructions 2016-17 12/1/16

Student Objectives For the Year 3 Mid-Year Clinical Skills Exercise

1. Perform properly organized problem-focused medical interviews and physical examinations, and
conduct appropriate counseling for patients with problems representative of the clerkships they have
completed

2. Complete initial post-encounter notes summarizing patient data, initial diagnoses and management
plans, oral presentations, or other relevant skills after patient encounters

3. Demonstrate professional interactions and communication with patients

Student Participation and Scheduling

Students are scheduled for the Mid-Year Clinical Skills Exercise in December each year if they (a) plan to
complete at least one Year 3 required clerkship by December, and (b) have not yet taken the Integrated
Curriculum Evaluation exercise (ICEE).

Exercise Format
The format of the exercise is a multi-station clinical examination consisting of three 15-minute standardized
patient encounters, and three 10-minute post-encounter stations, including a written patient note, oral
presentation, and other clinical skill task(s).

The three patient evaluations will be representative of patients or problems typically encountered on each of
three clerkships (Surgery-Family Medicine-Pediatrics, or Internal Medicine-OB/Gyn-Psychiatry, depending on
the student’s schedule). Students will participate in the entire 3-patient exercise even if they have not yet
completed all three clerkships represented in the exercise.

How Performance Will be Rated

Student performance on the exercise will be evaluated in three areas:
1. Patient encounter skills, which will be rated by the standardized patients, using faculty-developed
checklists of actions determined to be important for each encounter.
2. Communication/Interpersonal skills, which will be rated by the standardized patients, using the
performance checklist below.

Communication/Interpersonal Skills
Appropriate greeting and encounter initiation Appropriately demonstrating respect towards patient
Appropriate questioning style Appropriate visit closure and time management
Appropriate language Appropriate physical appearance
Appropriate facilitating phrases/gestures Appropriate attitude toward patient
Appropriately addressing patient concerns/counseling Overall performance

3. Written note, oral presentation or other clinical skills, which will be rated by standardized patients or
faculty.

What are the Consequences of Student Performance

Participation in the exercise is required, but performance does not result in a transcript grade. Negative
consequences are limited to students who
(a) do not appear on-time, as scheduled for the exercise; or
(b) demonstrate inadequate professional behavior
The consequences for either of these behaviors is
(a) submission of an Early Concern Note; and
(b) requirement that the student participate in Phase 1 and pass Phase 2 of the Year 4 ICEE after
completion of Year 3. This requirement applies to all students who do not complete the Year 3
exercise for any reason, including absences due to travel, illness, schedule conflicts, and reasons
outside the student’s control.

What Feedback Will Students Receive

Students will receive general written feedback in January on their performance in each case based on their
interview, physical examination, communication/interpersonal skills, written note and oral presentation
skills. Students with substantial performance deficiencies will be offered the opportunity to review their
performance with faculty.
University of Texas Medical Branch Year 3 Mid-Year Formative Clinical Skills Exercise
School of Medicine Orientation Instructions 2016-17 12/1/16

Typical Format of the Year 3 Mid-Year Clinical Skills Exercise

Patient Encounter Stations

You will interview, examine, and/or counsel three patients during the exercise, which will be video-recorded
for feedback and quality-control purposes. You must arrive to the test orientation room on-time and dressed
appropriately for a patient encounter. Long or artificial nails are prohibited and strong fragrances are
discouraged. You will not be allowed to use references or study aids of any kind during the exercise. You will
be provided a clipboard, schedule, and blank notepaper. You will be provided basic patient information (e.g.;
name, age, gender, chief complaint) prior to entering an examination room. You must bring a stethoscope for
use in the exam. Other examination instruments, such as sphygmomanometer, reflex hammer, and oto-
ophthalmoscope, along with other items that may be appropriate for each encounter, will be available.

In each case you have 15 minutes, are functioning as a medical student, not a physician, and the patient will
be visiting you for the first time. You will be serving as a primary care provider. From the moment you enter
the room you are expected to behave as you would on a genuine patient encounter. You should direct your
attention to the problem(s) for which the patient presents. Specific instructions will be available outside each
examination room. The instructions will direct you to perform a medical interview, physical examination,
patient counseling, or a combination of these activities. In all cases, you should explain your diagnostic
impressions and management plan to the patient, as well as respond to patients’ concerns or questions.

Upon entering the examination room, you should introduce yourself, explain your purpose for the visit, and
begin your interview. You should wash your hands in the patient’s presence at the beginning of the encounter.
Patients for whom a physical examination is expected will be gowned appropriately. Your interviews should
always explore the chief complaint by means of a thorough history of present illness. You must decide the
detail in which other interview items (Past Medical History, Family History, Social History, Review of Systems)
should be pursued with each patient.

Examples
A detailed cardiovascular ROS is indicated for a patient with chest pain
A GI ROS is not necessary for a focused encounter of a patient with headache
Quantifying ethanol use is indicated in a patient with suspected liver disease
It is a mistake to omit a FH of ASCVD complications in a patient with ischemic chest pain

In some of the cases you will need to perform a limited physical examination appropriate to the patient's
problem(s). You should be as sensitive to eliciting pain on examination as you would be on a genuine patient
encounter, but as in a genuine patient encounter, some examinations will inevitably cause discomfort, such as
eliciting rebound tenderness. You must decide how comprehensive your physical examination should be. You
will not perform a breast, genital, rectal, or pelvic examination. If you believe one or more of these
examinations are indicated, you should include these tests as part of your plan in your written note, or inform
the patient him/herself that this is part of your plan.

Examples
A detailed cardiovascular exam is indicated for a patient with chest pain
A lung exam is not necessary for a focused encounter of a patient with headache
In a patient with chest pain, most of the time should be spent on a CV exam, not a detailed neurologic exam
It is a mistake to omit a lung exam in a patient with cough, or to examine lungs through the patient’s gown

The most common avoidable errors on physical exam are (a) errors in draping that lead to inadequate or
excessive patient exposure, or examining a body part through/over/under the gown; and (b) failure to use
proper PE technique as demonstrated in the Bates textbook and video series.

In all cases, you should explain your diagnostic impressions and management plan to the patients, as well
as respond to patient concerns or questions. If the patient asks you questions during the encounter, you
should answer them to the extent you can. Upon completing your patient encounter, thank the patient for
his/her time and indicate that you are going to review the case with your faculty supervisor. Then excuse
yourself, and exit the room. You may leave the room early if you finish before the end of the 15-minute
period, but once you exit the patient room, you may not re-enter for any reason.
University of Texas Medical Branch Year 3 Mid-Year Formative Clinical Skills Exercise
School of Medicine Orientation Instructions 2016-17 12/1/16
Post-encounter stations

After completing each 15-minute patient encounter, you will have 10 minutes to complete a post-encounter
station. Post-encounter stations will direct you to complete the following types of activities.

1. SOAP Note
After one of your patient encounters, you will be directed to type a post-encounter “SOAP” note at a computer
station. Except in the case of technical problems, you do not have the option of hand-writing your note. This
note will include

History and Physical Examination

Record your findings on interview and PE in either narrative or bullet form, including all pertinent
positive and negative findings. For example, in a patient with chest pain, it is just as important to
record that a patient DID NOT have relevant findings such as shortness of breath, as it is to record
pathologic symptoms/findings the patient DID have. Be certain that your written note reflects only
those questions you asked and exam maneuvers you performed. Documenting actions that did not
occur may be interpreted as falsifications, which are considered unprofessional behavior. Also avoid
“overdocumentation” (e.g., CN II-XII intact, when only selected nerves were tested).

Differential Diagnosis for the most important problem(s)

List a rank-ordered differential diagnosis for the highest priority problem(s) on interview and/or
physical examination. These diagnoses should follow logically from the interview/exam findings you
document. For example, a diagnosis of “hyperthyroidism” is not credible if you fail to ask questions
related to that diagnosis, or fail to perform and document a thyroid gland exam.

Supportive Data
List items from your history and/or physical examination that support the diagnosis you listed FIRST,
as the most likely, in your differential diagnosis. For example, history findings of weight loss and
palpitations, and physical exam findings (or absence) of tremor and tachycardia would support (or
refute) a diagnosis of hyperthyroidism.

Initial Diagnostic Management Plan

Provide your initial recommendations for initial diagnostic interventions, such as laboratory tests, X-
rays, and consultations with other health care providers. Initial tests are those you would order now
as a group, not those dependent on the results of each other. This is also where you would list
genital, rectal, or pelvic examinations, if you believe such examinations are indicated. It is not
necessary to include therapeutic interventions, such as medications.

2. Abbreviated Note
After one of your patient encounters, you will be directed to write an abbreviated note focusing on formulating a
problem list, differential diagnoses and a treatment and plan.

3. Oral Presentation
After one of your patient encounters you will be directed to make an oral presentation of that patient. That
patient will have been clearly identified as the subject of your oral presentation as part of your exam
instructions at the time of the encounter. You may use any patient notes you made during that patient
encounter, and you will be rated using the standard clerkship oral presentation checklist.

Completion of Exercise Evaluation Forms

You will be asked to complete a brief evaluation of the exercise, after which you are excused from the
exercise.