1. TIPS TO HELP YOU PREPARE FOR THE FAMILY MEDICINE OSCE

2. THE FORMAT There will be 5 stations total  2 patients with undifferentiated acute complaints from the list of 16 on the clerkship website under OSCE Preparation  1 patient with a chronic illness from the list of 8 on the clerkship website under OSCE Preparation  2 patients with a need for patient education only Do a focused physical exam for the chronic case and the 2 acute cases. Patient education cases do not need a physical exam. In order to standardize physical exam findings, you will be provided with the full physical exam during the post encounter portion of the exam. Use the physical exam results you are given after the encounter to create a differential and plan. If a sensitive exam is indicated (breast exam, rectal exam) please let the patient know you would like to do that exam and then the results will be outside the room. You will have 40 minutes for the chronic case and the 2 acute cases. This includes time in the room with the patient and time for follow up writing assignments. You will have only 17 minutes per patient education station because there is NO write- up for these stations  Bring a watch to help you better keep track of time You will be provided blank paper to take notes on. No other study aides allowed in room Bring your stethoscope and wear your white coat.  Other diagnostic equipment will be provided but you can bring your own if you wish

3. THE PATIENTS WITH ACUTE COMPLAINTS OVERVIEW Summary of task: This station focuses on your ability to develop a differential and management plan for an undifferentiated complaint based on your history and physical exam. Obtain a focused history and physical exam relevant to the patient’s acute complaint. Note that you are not expected to share your differential & management plan with patient. Leave sufficient time to do this during your written task. You have 40 minutes to complete the case. Suggested times given below are only a guide but leave enough time for the written portion after seeing patient. Student enters the room at signal. The following announcements will guide your time management: “15 minutes remaining, 10 minutes remaining, 5 minutes remaining, you must now leave the room. All students will be required to leave the patient room when there are 5 minutes left in the exam.

4. THE PATIENTS WITH ACUTE COMPLAINTS SUGGESTED TIME MANAGEMENT Review the patient's chart (Approximately 5 minutes) When you are ready, click “start encounter” on the computer screen and enter the room Time with patient (Approximately 20 minutes) Take a problem focused history on the patient’s presenting problem. Perform a problem-focused physical exam relevant to the patient’s presenting problem. Exit the patient's room. On the computer screen, click “stop encounter.” Written tasks following the patient encounter (Approximately 15 minutes) Follow the instructions on the screen. You will document  A p roblem focused HPI, including pertinent PMH/SH/FH/ROS (no need to include PE findings)  A relevant differential for the patient’s presenting problem  Your plan for any further workup of patient.  A plan for treatment over the next few days  Instructions as to when the patient should follow up  Any relevant prevention issues that should be discussed with this patient

5. THE PATIENTS WITH ACUTE COMPLAINTS DETAILS ON WRITTEN TASK These will be the exact questions you will be asked on the OSCE Written Task 1 - History Document the subjective portion of a SOAP note (a problem focused HPI, including pertinent PMH/SH/FH/ROS). The note should contain relevant positives and negatives. The note should be brief. You do not need to use complete sentences. Written Task 2 - Differential Based on history obtained from patient and physical exam findings given to you by the patient, list the five most important diagnoses that should be considered in this patient. Include those things that are common but also those that are less common but serious. Do not include the rare and unlikely.

6. THE PATIENTS WITH ACUTE COMPLAINTS DETAILS ON WRITTEN TASK These will be the exact questions you will be asked on the OSCE Written Task 3 - Evaluation What labs or studies do you want to order to help clarify what is going on with this patient? Be judicious about what further evaluation you order as such studies will not only add to the cost of care but can also lead to false positives. There are times when no further studies are needed. There are other times when further studies are essential. Written Task 4- Management What management plan would you suggest for this patient at this time? You do not yet know the results of any tests you ordered. Include what further test and studies you want to order, how you will treat the patient (medications and/or non pharmaceutical interventions) and when and where you want the patient to follow up. If you ordered a test that would change the management plan, write the variations of the treatment plan based on the different results you might get back.

7. THE PATIENTS WITH ACUTE COMPLAINTS DETAILS ON WRITTEN TASK These will be the exact questions you will be asked on the OSCE Written Task 5- Prevention Based on this patient's age, gender and history list TWO areas of prevention that should be recommended to this patient at THIS VISIT. List recommendations that have Grade A Evidence from the U.S. Preventative Services Task Force. Do not list areas that are not due. For example, this patient already had their blood pressure checked today so do not list blood pressure screening. Do not repeat recommendations made above under management. The areas of prevention do not need to relate to the current complaint.

8. THE PATIENTS WITH ACUTE COMPLAINTS SAMPLE WRITE UP Written Task 1 - History Patient is a healthy 54 yr old woman with no chronic illnesses who presents with generalized fatigue for 1 month. Felt well until that time. Fatigue has gradually worsened over the last 4 weeks to the point that she has missed 2 days of work this week. Pt describes fatigue as ‘feeling so tired I can’t get out of bed in the morning’. She is sleeping well, at least 10-12 hours per night but doesn’t feel rested. Also notes that she has been somewhat constipated on and off for the last few weeks. No blood in stools, no chest pain, no shortness of breath, no lightheadedness. Both parents have passed away in the past 6 months and was given clonazepam 2mg BID for anxiety by another physician. Endorses decreased interest in activities, appetite is the same, no weight changes. No SI/HI. No h/o depression Written Task 2 - Differential Medication side effect, Hypothyroidism, Anemia, Chronic Fatigue, Depression Written Task 3 - Evaluation PHQ -9, CBC, TSH Written Task 4- Management Would decrease clonazepam by half and monitor symptoms while we wait for the labs to come back. Would teach stress relaxation techniques. Offer referral to counseling services for grief counseling. Call patient with lab results and she will return for follow up in 4 weeks or sooner if any worsening or new symptoms. Written Task 5- Prevention Pap smear (none on record x 5 yrs), Colon cancer screening

9. THE PATIENTS WITH CHRONIC ILLNESS OVERVIEW Summary of task: This station focuses on your ability to share results with a patient and develop a management plan together with the patient. Obtain a focused history and physical exam assessing the patient’s control and management of chronic illness. Develop a management plan for patient and briefly discuss with patient. This may include focused counseling, suggestions re medication changes, and or recommended follow up. Leave sufficient time to complete written task. You have 40 minutes to complete the case. Suggested times given below are only a guide Student enters the room at signal. The following announcements will guide your time management: “15 minutes remaining,10 minutes remaining, 5 minutes remaining, you must now leave the room. All Students will be required to leave the patient room when there are 5 minutes left in the exam.

10. THE PATIENTS WITH CHRONIC ILLNESS SUGGESTED TIME MANAGEMENT Review the patient's chart (Approximately 5 minutes) When you are ready, click “start encounter” on the computer screen and enter the room Time with patient (Approximately 25 minutes) Share with patient recent test results what they mean for management of chronic condition. Take a history of the patient’s symptoms (control and management) Perform an focused exam for the patients chronic condition Stay in the room and discuss with patient how to manage his condition and counsel on behavior changes. Apply the evidence based guidelines relevant to his particular situation Exit the patient's room. On the computer screen, click “stop encounter.” Written tasks following the patient encounter (Approximately 10 minutes) Follow the instructions on the screen. You will document  Focused note of patient chronic history (no need to include physical exam)  A problem list  A management plan for each of the patients problems on the problem list  Any relevant prevention issues that should be discussed with this patient

11. THE PATIENTS WITH CHRONIC ILLNESS DETAILS ON WRITTEN TASK These will be the exact questions you will be asked on the OSCE Written Task 1 - History Document the subjective portion of a SOAP note. The note should document relevant parts of chronic illness care, contain relevant positives and negatives and describe relevant aspects of social context. The note should be brief. You do not need to use complete sentences. Written Task 2 – Problem List Create a problem list based on this patient’s prior medical history and current information.

12. THE PATIENTS WITH CHRONIC ILLNESS DETAILS ON WRITTEN TASK These will be the exact questions you will be asked on the OSCE Written Task 3- Management What management plan would you suggest for this patient at this time? You do not yet know the results of any tests you ordered. Include what further test and studies you want to order, how you will treat the patient (medications and/or non pharmaceutical interventions) and when and where you want the patient to follow up. If you ordered a test that would change the management plan, write the variations of the treatment plan based on the different results you might get back. Written Task 4- Prevention Based on this patient's age, gender and history list TWO areas of prevention that should be recommended to this patient at THIS VISIT. List recommendations that have Grade A Evidence from the U.S. Preventative Services Task Force. Do not list areas that are not due. For example, this patient already had their blood pressure checked today so do not list blood pressure screening. Do not repeat recommendations made above under management. The areas of prevention do not need to relate to the current complaint.

13. THE PATIENTS WITH CHRONIC ILLNESS SAMPLE WRITE UP Written Task 1 - History Patient returns today for routine follow up of diabetes. He feels generally well and has no specific questions or complaints today. He does not report any episodes of hypoglycemia. He has had no chest pain, shortness of breath, vision complaints, pain/ numbness in his feet, or problems with sex. He has been taking his Metformin as prescribed and not reporting any side effects. He does not have problems with missed doses as he leaves his medication beside his toothbrush. He has been able to avoid sweets but still snacks a lot. He has not increased the amount he exercises. He checks his sugars once a day with values between 140-160 fasting. Still smoking but wants to quit. Written Task 2 – Problem List Diabetes. Tobacco Abuse, Health Literacy Written Task 3- Management DM- Patient with control slightly above goal. Long discussion about use of insulin. Patient would like to focus further on diet and exercise modifications before making this step. Discussed better choices for snacks. Will call friend and recruit as daily walking partner. No labs today as up to date. Continue Metformin and recheck in one month. A1c at that time. Tobacco Abuse – discussed strategies for cessation, trial patch, 1-800-QUIT-NOW # given Health Literacy – literacy appropriate review of visit and education material provided to patient Written Task 4- Prevention Colonscopy (none on chart), Lipids.

14. THE PATIENT EDUCATION CASES OVERVIEW Summary of task: This station focuses on your ability to communicate medical information to a patient. You DO NOT need to perform a full history OR physical You have 17 minutes to complete the case. Suggested times given below are only a guide Student enters the room at signal. The following announcements will guide your time management: “5 minutes remaining, you must now leave the room” All Students will be required to leave the patient room after 17 minutes (this gives the patient time to complete their checklist)

15. THE PATIENT EDUCATION CASES SUGGESTED TIME MANAGEMENT Review the patient's chart (Approximately 1 minute) When you are ready, click “start encounter” on the computer screen and enter the room Time with patient (Approximately 17 minutes) Take a very focused history to identify the patient’s learning need Stay in the room and provide patient education using written notes for the patient as necessary Exit the patient's room. On the computer screen, click “stop encounter.” There is NO write up for these cases

16. ….AND FINALLY A WORD ON GRADING Simulated Patient evaluates whether you ask key questions during interview Simulated Patient evaluates whether you perform key components of PE. Video recording of encounter allows review of case if you disagree with grading Clerkship director evaluates written portion of OSCE (if you don’t write it down, I cannot give you credit!) Reassurance and Suggestions:  Remember there are many items so missing one or two will not significantly affect your grade  See next page for sample grade form. Mean of OSCE is generally in mid 80s so there is no expectation that you will get every item correct

18. QUESTIONS? Contact your campus clerkship director or Email clerkship director, Kelly Bossenbroek Fedoriw at kelly_fedoriw@med.unc.edu