CLINICAL SKILLS ASSESSMENT (CSA) Part I

CLINICAL SKILLS ASSESSMENT (CSA?)
CANDIDATE ORIENTATION MANUAL PREFACE This Candidate Orientation Manual is intended as a guide for graduates of foreign medical schools who plan to take the Clinical Skills Assessment (CSA?) as part of their ECFMG? certification process. In the pages that follow, there is general information and a description of the CSA, its components and the method by which scores are derived. Also included are registration and scheduling procedures as well as practical information on preparing to take CSA. In addition, the most commonly asked questions about CSA are discussed. This manual will be periodically updated. Visit the ECFMG web site for the most current information. GENERAL INFORMATION Purpose of CSA The purpose of CSA is to ensure that graduates of foreign medical schools can demonstrate the ability to gather and interpret clinical patient data and communicate effectively in the English language at a level comparable to students graduating from United States medical schools accredited by the Liaison Committee on Medical Education (LCME). The CSA is still only one of the test elements leading to ECFMG certification. Prerequisites to CSA The ECFMG Information Booklet describes the prerequisites to CSA. Historical Perspective on CSA There are approximately 1,600 medical schools worldwide, each with varying educational standards and curricula. No universal system currently exists to compare the quality and characteristics of these medical schools with those of U.S. medical schools accredited by the LCME. The LCME requires that the assessment of clinical skills be a part of the overall evaluation of U.S. medical students. However, in the absence of any single set of international accreditation standards for medical schools throughout the world, the only viable alternative was to assess students graduating from those medical schools with a standardized assessment, the CSA. As early as 1980 ECFMG introduced the concept of testing the clinical skills of graduates of foreign medical schools as part of ECFMG certification requirements. ECFMG initiated an extensive program of planning and research to develop a CSA prototype that would provide an objective and consistent evaluation of the readiness of graduates of foreign medical schools to enter graduate medical education (GME) programs in the U.S. Pilot projects were conducted around the world, and as a result of those studies the current CSA prototype was developed. It integrates clinical encounters with standardized patients to assess history taking, physical examination, interviewing and interpersonal skills, as well as the ability to communicate effectively in written and spoken English. The current CSA prototype was tested in the United States and abroad to compile data and demonstrate its validity and reliability. Effective July 1, 1998, applicants who had not met all requirements for ECFMG certification by June 30, 1998 are required to pass CSA, as well as the basic medical and clinical science components of the medical science examination and the English language proficiency test. Applicants must also document the completion of all requirements for, and receipt of, the final medical diploma. The incorporation of CSA into the certification process helps to ensure that graduates of foreign medical schools achieving ECFMG certification possess the necessary basic clinical skills for entry into supervised GME training programs in the U.S. An Introduction to Taking CSA The CSA is designed to evaluate the basic clinical skills you will need to gain entry into a supervised GME training program in the U.S. The attributes of CSA, including the patients, medical presentations, and the CSA Center, simulate common medical practice in clinics, doctors? offices and emergency departments in the U.S. The CSA is used to assess your ability to consider reasonable diagnostic possibilities by presenting a set of common clinical scenarios. In addition, you must demonstrate an acceptable level of professionalism and rapport, as well as written and spoken English language skills. By gathering relevant medical history and performing a focused physical examination, you will be demonstrating your ability to collect information unique to the presentation of each patient. Taking a relevant medical history means that it relates specifically to the chief complaint of the patient. A focused physical examination consists of maneuvers that reveal information in direct relation to the same patient?s chief complaint, age and gender, and medical history. You will be required to write a legible patient note indicating the pertinent positive and negative historical and physical findings that relate to your potential diagnoses. Once you list the possible differential diagnoses that relate to the patient?s complaint, you will also list the diagnostic studies that you would use to pursue those diagnoses. A listing of treatment procedures or medications will not be required. When you take CSA, you will have the same opportunity as all other candidates to demonstrate your clinical skills proficiency. The assessment is standardized so that upon asking the same or similar questions, all candidates receive the same information from each patient. An on-going mechanism of quality control is employed to ensure that the assessment is fair to all. A videotape monitoring system documents each encounter and ensures the safety of the patients and candidates, and is an additional quality control procedure. The patients you will see are lay people trained to portray a clinical problem. This method of assessment is referred to as a standardized patient (SP) based examination. Ninety-five percent of LCME accredited medical schools in the U.S. and Canada use SPs for instruction. About 74% of these same institutions use them for evaluation. SPs are also incorporated into the Medical Council of Canada?s (MCC) medical licensure examination for Canadian and foreign medical graduates. The SP-based testing method was established more than 30 years ago, and its procedures were tested and validated in the United States and internationally. The CSA is designed as a standards-based (criterion referenced) examination, meaning that specific scores are set for passing performance. Committees of physicians review the case materials and determine the essential skills and behaviors that must be demonstrated by candidates for each case. You are evaluated only with reference to this standard, so there is no predetermined number or percentage of graduates of foreign medical schools who will pass. Pass rates for CSA candidates are solely a function of performance. Consequently, anyone can pass, depending on his or her level of proficiency relative to the standard. For purposes of entry into graduate medical education, a passing performance on the CSA will be valid for three years from the date passed. CSA is offered at a single site in Philadelphia, Pennsylvania, USA. The complex testing system involves a specially designed facility and trained personnel. Therefore, specific strategies for quality control were designed initially for only one site. In the future, consideration may be given to establishing another site outside of the United States. Back to Contents CSA Case Development Practicing physicians and medical educators write and review cases to ensure that they are fair and valid. These cases represent the kinds of patients and problems you would normally encounter while training in an accredited U.S. GME program. Cases are specially designed to elicit a process of history taking and physical examination in a clinical encounter that will demonstrate your ability to list and pursue various possible diagnoses. The eleven cases that make up each administration of CSA reflect a balance of presenting complaints as well as a diversity of patient age, sex, and ethnicity. There is also a mix of acute, subacute and chronic problems. On any assessment day, the set of cases will differ from the combination presented the day before or the following day, but each set of eleven cases will have comparable degrees of difficulty. CSA includes test cases representing the major clinical education programs encountered at medical schools accredited by the LCME in the United States. These disciplines include: Internal Medicine
Surgery
Obstetrics and Gynecology
Pediatrics
Psychiatry
Family Medicine
CSA Case Content Selection The CSA case content area is the universe of clinical symptoms (cases) that will be represented by standardized patients. The selection of eleven clinical cases from the larger pool of CSA content area is guided by the CSA assessment form specification that defines five main content areas: Cardiovascular/Respiratory
Digestive/Genitourinary
Neurologic/Psychiatric
General symptoms
Other (ear, eyes, nose, throat, musculoskeletal)
The selection of cases is also guided by specifications relating to acuity, age, gender, and type of physical findings presented in each case. Back to Contents DESCRIPTION OF THE CSA CSA Prototype In your CSA administration you will have eleven patient encounters, ten of which will be scored. Non-scoreable patient-encounter stations are added to the CSA rotation for research and other purposes, but those encounters are not counted in determining your score. Before you enter each examination room, you will have a few moments to review information that will be posted on the examination room door. This information gives you specific instructions, and tells you the patient?s name, age, gender, and reason for visiting the doctor. It will also indicate his or her vital signs, including pulse rate, blood pressure, temperature (Centigrade and Fahrenheit), and respiratory rate. You can accept these as accurate and do not need to repeat unless you believe the case specifically requires it. Upon entering each room, you will encounter an SP. By asking this patient the relevant questions and performing a focused physical examination, you will be able to gather enough information to develop preliminary differential diagnoses and a diagnostic work-up plan. You will also be expected to communicate in spoken English with the patients in a professional and empathetic manner. You are to answer any questions they have, tell them what diagnoses you are considering, and advise them on what tests and studies you will be ordering to clarify their diagnoses. The kinds of medical problems that your patients will be portraying are those you would commonly encounter in a clinic, doctor?s office or emergency department. There are no children presenting as SPs. However, there may be cases dealing with pediatric issues in which you may encounter a sick child?s parent or caretaker. In such cases, physical examination is obviously not possible and will not be expected. The elements of medical history you need to obtain in each case will be determined by the nature of the patient?s problems. Not every part of the history needs to be taken for every patient. Some patients may have acute problems, while others may have more chronic ones. You probably will not have time to do a complete physical examination on every patient, nor will it be necessary to do so. Pursue the relevant parts of the examination, based on the patient?s problems and other information you obtain during the history taking. The key to interacting with the SPs is to relate to them exactly as you would to any patients that you may see with similar problems. The only exception is that certain parts of the physical examination must not be done: rectal, pelvic, genitourinary, or female breast examinations. If you believe these are indicated, you may include them in your proposed diagnostic work-up. You will have fifteen minutes to spend with each patient. An announcement will tell you when to begin the encounter, when there are five minutes remaining, and when the encounter is over. In some cases you may complete the encounter in less than fifteen minutes. If so, you may leave the examination room early, but you are not permitted to re-enter. Be certain that you have obtained all of the necessary information before leaving the examination room. Immediately following each encounter you will have ten minutes to complete a patient note. You will be asked to write a patient note similar to the medical record you would compose after seeing a patient in a clinic, office or emergency department. You should record pertinent medical history and physical examination findings, as well as your initial differential diagnoses. Finally, you will list the diagnostic studies you would order next on that particular patient. If you think a rectal, pelvic, genitourinary, or female breast examination would have been indicated in the encounter, then list it as part of your diagnostic work-up. Treatment, consultations, or referrals should not be included in your work-up plan. Most cases are designed to present more than one diagnostic possibility. Based on the patient?s presenting complaint and the additional information you obtain as you begin taking the history, you should consider all possible diagnoses and explore the relevant ones as time permits. Perform physical examination maneuvers correctly and expect that there will be positive physical findings in some instances. Some may be simulated, but you should accept them as real and factor them into your evolving differential diagnosis. However, be considerate of the patients and always keep them comfortable and properly draped as you perform the physical examination. The testing area of the CSA Center consists of a series of examination rooms equipped with standard examination tables, commonly-used diagnostic instruments (blood pressure cuffs, otoscopes, and ophthalmoscopes), latex gloves, sinks, and paper towels. The orientation given immediately before you take CSA will include a brief demonstration of the instruments and equipment that you will be using in the actual patient encounters. Back to Contents Sample Opening Scenarios So that you have a better understanding of the typical mixture of case scenarios presented in one CSA administration, below are ten sample opening scenarios. This is the basic information that is posted on the doorway of each examination room prior to your seeing the patient. The scenarios listed below are representative of, but are not the exact cases you will see in your assessment session. 1. 50 year-old female complaining of chest pain
Blood pressure = 138/92 Pulse = 80 Respirations = 18 Temperature = 98.6 2. 35 year-old female complaining of abdominal pain
Blood pressure =146/88 Pulse = 92 Respirations = 20 Temperature = 99.1 3. 75 year-old male brought to see you because of a fall
Blood pressure =155/75 Pulse = 68 Respirations = 14 Temperature = 98.2 4. Mother of 1 year-old child with diarrhea
(child not available for physical examination) 5. 46 year-old male complaining that he has no energy for the past three months
Blood pressure = 122/70 Pulse = 70 Respirations = 12 Temperature = 98.7 6. 18 year-old female complaining of vaginal bleeding for two days
Blood pressure = 95/65 Pulse = 84 Respirations = 14 Temperature = 98.6 7. 63 year-old male with history of diabetes; new to your practice; here for medication refill
Blood pressure = 140/75 Pulse = 76 Respirations = 18 Temperature = 99.0 8. 24 year-old female brought in by colleagues because of a seizure at work
Blood pressure = 155/85 Pulse = 100 Respirations = 24 Temperature = 99.2 9. 59 year-old male complaining of blurry vision
Blood pressure = 138/82 Pulse = 88 Respirations = 14 Temperature = 98.6 10. 79 year-old female complaining of shortness of breath since last night
Blood pressure = 158/90 Pulse = 92 Respirations = 20 Temperature = 98.6 Sample Case Case Background Information The case excerpts you will see on the following pages were selected to familiarize you with the content and evaluative objectives that provide the basis for scoring. This information is used to train SPs. When you come to take the CSA, you will not have access to the information below. The background information presented here is simply an example of the materials on which a typical case is based. Most CSA cases incorporate patient history, physical examination, examinee communication skills (including spoken English proficiency), and a post-encounter patient note. You should become acquainted with the following examples of the doorway information, the checklists SPs use to document your actions during the encounter, the patient note format, and the evaluative tools used to derive communication skills ratings. Chief Complaint
Jolene Brown is a 48 year-old female complaining of chest pain. History of Present Illness
The patient is a 48 year-old female complaining of burning chest pain that began one and a half hours prior to presenting to the Emergency Department. The pain began 30 minutes after a heavy lunch. Nausea, slight sweating and dyspnea accompanied the pain. The pain passed spontaneously 20 minutes after its onset. She presently feels fine and wishes to be immediately discharged. She describes several similar episodes in the previous two to three months, especially after heavy meals or physical exertion, continuing for two to three minutes and passing spontaneously. Prior to this period Ms. Brown had no chest pain. She is not working harder nor experiencing any specific stress lately. She plays tennis once a week; no other physical activity. Lately, during matches, Ms. Brown complains of mild retrosternal burning sensation. Over the past two to three months, during the burning episodes, she used antacids, with partial relief of symptoms. For the past three to four years, the patient has had occasional heartburn after heavy meals and antacids gave partial relief. But now the pain is different. Her pain is not related to breathing or changes in body position. She has had no change in bowel movements, no melena. She has no symptoms of congestive heart failure or arrhythmias (no orthopnea, paroxysmal nocturnal dyspnea or palpitations). Past Medical History
Hyperlipidemia: Ms. Brown had cholesterol checked on routine blood tests done two years ago. She was told that her cholesterol was high, but does not remember any specific values. A low cholesterol diet was suggested at the time, but she did not follow this advice. Otherwise, the patient is completely healthy. She has not seen a physician in two years. Medication, Allergies, Diet, Immunization
Medications: The patient takes no prescribed medication. Occasional use of over the counter antacids. Allergies: Penicillin caused her to break out in a rash. Diet: Unremarkable. Immunization: Unremarkable. Family History
Older brother: Diagnosed with some sort of ?heart problem,? but never treated (patient does not know exact details). Father: Peptic ulcer disease. Mother: Non insulin-dependent diabetes mellitus (NIDDM) treated by diet alone. Social History and Habits
Smoking: She stopped smoking three years ago, and until then she smoked two packs a day for 15 years. Alcohol: Occasionally drinks socially, but takes in small amounts. Occupation: Executive Vice President of a not-for-profit charitable organization. Marital Status: Single heterosexual female. Sample Case Doorway Information Before entering the examination rooms, you will be given some basic information. This doorway information is posted on the examination room door and is similar to a triage note that a nurse normally gives a physician. Please read it carefully before seeing the patient because it will tell you his or her name, gender, age, presenting complaint, and the tasks you are to complete. You should accept the doorway information as accurate, though in some cases reexamination of vital signs may be appropriate. Most CSA stations will have the same types of tasks listed, but some may include specific, unique tasks. For your convenience, there will be an identical second copy of the doorway information in the examination room. Please do not remove the doorway information from the examination room. Doorway Information 1. Opening Scenario Jolene Brown, a 48 year-old female, comes to the Emergency Department complaining of chest pain. 2. Vital Signs BP: 160/80 Temp: 99.5? F (37.5? c) RR: 16/minute HR: 95/minute, regular. 3. Examinee Tasks Obtain a focused history.
Perform a relevant physical examination
(Do not perform rectal, pelvic, genitourinary, or female breast examinations).
Discuss your initial diagnostic impression and your work-up plan with the patient.
After leaving the room, complete your patient note on the given form. Sample Case History Taking and Physical Examination Checklists Standardized patients will document your actions during the encounter, and they are trained to do so in a fair and consistent manner. Each patient fills out checklists that document the inquiries you make and maneuvers you perform during the encounter. The history-taking checklist includes all of the key inquiries you are expected to make in the course of taking the patient?s history for a particular case. Patients also use a physical examination checklist that includes all of the key maneuvers you should perform during the course of doing a physical examination. Your technique in doing these maneuvers is also taken into account by the patient. He or she goes through the checklists and marks those items you asked or performed, for which you receive credit. Since the cases are broad, your history taking should consider multiple possible diagnoses. Do not prematurely close your history taking on a single diagnosis, and do not attempt a complete history. During your physical examination of the patient, you should attempt to elicit important positive and negative signs. The 15 minutes you have with the patient does not permit a complete history taking or physical examination, but only a gathering of relevant data. Make sure you discuss with the patient your initial diagnostic impression and work-up plan. The patients are instructed to ask very specific questions concerning their complaints. These inquiries are intended to challenge you, so you should address each patient?s concern as you would normally do in a clinical setting. All physical examination maneuvers, including exposing and draping the patient, should be done as you would normally do them in regular practice. Your score is based on what you look for in the encounter and the technique you employ while going about it. The sample checklist items on the following page are examples of examinee questions and physical examination maneuvers that might be expected in a particular case. However, the listed questions and maneuvers are not exact representations of complete history taking and physical examination checklists. Standardized Patient History Taking Checklist (Sample Items) KEY: Y, yes N, no Y N 1. What is the character of the pain? Y N 2. Does the pain radiate? Y N 3. Are there any precipitating factors? Y N 4. Nausea? OR Sweating? OR Dyspnea? Y N 5. Is there a history of smoking? Y N 6. Family history? Y N 7. Past medical history? Standardized Patient Physical Examination Checklist (Sample Items) KEY: Y, yes N, no Y N 1. Examinee auscultates lungs. Y N 2. Examinee auscultates precordium in at least 2 positions. Y N 3. Examinee palpates abdomen, at least epigastric or right upper quadrant. Sample Case Patient Note After leaving the encounter, you will have ten minutes to complete the patient note. In an actual practice setting, the patient note would be used to communicate with other health professionals. Keep in mind that once you leave the patient to complete your patient note, you cannot re-enter the examination room. Blank paper will be provided for note taking in the examination room, but all sheets must be returned with your completed patient notes. For security reasons, the sheets of blank paper are numbered. Refer to the example of a blank patient note, followed by two examples of completed notes. There are several styles of writing patient notes that are acceptable. The two examples are presented to demonstrate some of the variations in style. They are not meant to represent ideal or perfect patient notes, nor should they be assumed to be complete or accurate with respect to content. Both formats and styles, however, would be considered acceptable, despite their differences. HISTORY Make note of significant positives and negatives from the history taking. The following history categories may yield important information, although not all will necessarily be pertinent to every case: Chief complaint (CC)
History of present illness (HPI)
Past medical history (PMH)
Review of systems (ROS)
Social history (SH)
Family history (FH)
PHYSICAL EXAMINATION List pertinent positive and negative findings from the physical examination. DIFFERENTIAL DIAGNOSIS Consider a range of possible diagnoses, and list up to five of them. DIAGNOSTIC WORK UP Write your immediate plans for further diagnostic work-up. If you think rectal, pelvic, genitourinary, or female breast examinations should be done as part of the evaluation for that specific patient, you may include them in your diagnostic work-up plan on the patient note. Treatment (therapeutics) should not be included. Do not include hospitalization, consultations, or referrals. You should order fundamental first line tests that will help point you in a diagnostic direction. These requested tests must also be specific. For example, if you suspect hypothyroidism, you might order "T4 and TSH," but not "Thyroid studies" or "Thyroid panel." Do not order "SMA-20," "Chemistry panel," or "Liver profile," but rather, the specific component tests you are interested in, e.g., BUN, glucose, electrolytes. You may use abbreviations commonly used in the United States. If you are uncertain about the abbreviation, write out the full term. For the patient note to be scored, your handwriting must be legible. For your convenience in preparing for CSA, the glossary at the end of this manual lists some commonly recognized abbreviations and definitions. [Click for full-size image] Patient Note Example One The patient note below is written primarily in a narrative style. The History is written in full or near full sentences and the Physical Examination also has fairly complete phrases. Note that there are only four studies ordered under the Diagnostic Workup section; this is acceptable. There are some abbreviations not included in the glossary of terms and common abbreviations, but they are common enough to be recognizable by the practicing physicians rating the notes. The note is written in cursive script but it is legible. [Click for full-size image] Patient Note Example Two This patient note is written in more of a telegraphic or "bullet" style. There are no complete sentences, although there are some phrases where appropriate. However, in some parts of the History in particular, there are one or two words that stand alone. The writer of this note has chosen to transcribe the patient?s blood pressure from the doorway information. You may wish to include vital signs if they are particularly relevant to the case. In this note only four items are listed in both the Differential Diagnosis and in the Diagnostic Workup sections; again this is acceptable. This sample also has some abbreviations or symbols not included in the glossary of terms and common abbreviations but, as in Example One, they are generally recognizable. This note is printed throughout, although a mixture of cursive script and printing would also be acceptable provided both were legible. [Click for full-size image] Sample Case Communication Skills SPs undergo extensive and continuous training to rate your communication skills. This method of rating results in fair, valid, and reliable data. (See "References" at the back of this manual.) During all eleven encounters, each patient will evaluate your communication skills based on the following criteria: Skills in interviewing and collecting information
the clarity of your questions;
the effectiveness of your questioning techniques;
appropriate use of medical language;
your verification and summarization of information with the patients;
the effectiveness of your transitions between different parts of the interview. Skills in counseling and delivering information
the clarity of the information you give;
the effectiveness and sincerity of your counseling;
the thoroughness of the encounter closure;
the clarity and appropriateness of your speech;
the effectiveness of your summarization of information and how you link various information together. Rapport (connection between doctor and patient)
your attentiveness to the patients;
the appropriateness of your body language;
your confidence level and attitude;
the level of empathy and support you show the patients. Personal Manner
your manner of introducing yourself to the patients;
the appropriateness of how you expose and drape the patients;
your manner while conducting physical examinations;
the appropriateness of your demeanor. Spoken English Proficiency
your ability to communicate understandably;
your pronunciation and grammar;
your ability to correct or clarify your language when needed;
the amount of effort required by patients to understand you.