You will have a more meaningful experience if you practice with the interactive software on our website prior to taking the examination. Practice with interactive cases can have a positive impact on performance. It is essential that you become familiar with both the software interface and the background information provided. Cases are allotted varying amounts of maximum real time, but you may not need to use the entire time.

Description

Each case is a dynamic, interactive simulation of a patient-care situation designed to evaluate your approach to clinical management, including diagnosis, treatment, and monitoring. The cases provide a means for observing your application of medical knowledge in a variety of patient care situations and settings over varying periods of simulated time. As simulated time passes, a patient’s condition may change based on the course of the underlying medical condition(s), or your management, or both. Patients may present with acute problems to be managed within a few minutes of simulated time or with chronic problems to be managed over several months of simulated time.

The cases used in the CCS portion of the Step 3 examination are based upon a CCS examination blueprint. The blueprint defines the requirements for CCS examination forms. The CCS blueprint is used to construct CCS examination forms focusing primarily on presenting symptoms and presenting locations. Presenting symptoms are related to the USMLE Content Outline and include, but are not limited to, problems of the circulatory, digestive, renal/urinary, endocrine/metabolic, behavioral/emotional, respiratory, and reproductive systems. Presenting locations include the outpatient office, emergency department, inpatient unit, intensive care unit, and the patient’s home.

Case Interface and Format

You will manage patients using the software. Information about a patient’s condition will be displayed on the computer screen. At the start of each case, you will receive a brief description of the reason for the encounter and the patient’s appearance and status along with the vital signs and history. You must initiate appropriate management and continue care as the patient’s condition changes over simulated time. Patient information will be provided to you in response to your requests for interval history and physical examination findings, tests, therapies, and procedures. Requests for interval history and physical examination automatically advance the clock in simulated time. To see results of tests and procedures and to observe effects of treatment, you must advance the clock in simulated time.

Physical examination should be requested if and when you would do the same with a real patient. You can begin management by selecting the desired components of a physical examination, writing orders before examining a patient, changing the patient’s location, or advancing the clock in simulated time. If physical examination reveals findings that you believe render selected orders inappropriate, and the orders have not yet been processed, you can cancel those orders by clicking on the order and confirming the cancellation. At subsequent intervals of your choosing, you can also request interval histories, which are analogous to asking the patient, “How are you?”

You will provide patient care and management actions by typing on the order sheet section of the patient chart. The order sheet enables you to request tests, therapies, procedures, consultations, and nursing orders representing a range of diagnostic and therapeutic management options. It is also your means of giving advice or counseling a patient (eg, “smoking cessation,” “low-fat diet,” “safe-sex techniques”). The order sheet has a free-text entry

Note: You can place orders only in the order sheet section of the patient chart. You cannot place orders on any other section of the chart (ie, Progress Notes, Vital Signs, Lab Reports, Imaging, Other Tests, Treatment Record).

In some locations (eg, the office, the inpatient unit), there may be cases where a patient already has orders on the order sheet at the beginning of the case. In these situations, the patient’s orders will be displayed on the order sheet (eg, “oral contraceptive”) with an order time of Day 1 @00:00. You must decide whether to continue or cancel the orders as you deem appropriate for the patient’s condition; these orders remain active throughout the case unless canceled.

Advancing the clock is what “makes things happen.” You must advance the clock in simulated time to see results of tests and procedures, and to observe effects of treatment. After you enter and confirm all the orders you deem appropriate at a given time, you will see report times displayed on the order sheet. You must advance the clock to the indicated report times or the next time you wish to evaluate the patient in order to receive the study result and observe the effect of therapies. Note: In CCS numeric lab tests, normal ranges are included with the results; these normal ranges may differ slightly from those in the MCQ portion of the examination.

As simulated time passes, you might receive notification of change in a patient’s condition through messages from the patient or the patient’s family or from other health care providers if the patient is in a setting such as the hospital. You decide whether these messages affect your management plan.

Note that if a clock advance to a requested appointment time is stopped after reviewing results from processed orders, the requested appointment is canceled. Also note that if you advance the clock in simulated time and no results are pending, the case will advance to the next patient update or to the end of the case.

Cases end under different circumstances and after varying amounts of simulated and real time. A case will end when you reach the maximum allotted real time. Alternatively, a case may end when you have demonstrated your skills sufficiently. Encountering the Case-end Instructions screen before you think you are finished managing a patient does not necessarily mean you did something right or wrong. Once you are prompted with the Case-end Instructions screen, real time permitting, you will have a few minutes to finalize your orders and review the chart. At this point you can cancel orders and add new ones. Note that after receiving the Case-End instructions screen, you cannot order physical examination components, change the patient’s location, order a follow-up appointment, or see the results of any pending tests. After finalizing patient care, you must select Exit Case to enter the final diagnosis and exit the case. If you use the entire real time allotted after the Case-end Instructions screen, you will not be able to enter a final diagnosis. Note: Diagnoses entered are not used in scoring your performance.

If a case has not ended and you feel you have finished management of the case, you can end it by advancing simulated time. Use the clock as you normally would to receive results of pending tests and procedures. Once there are no longer any pending patient updates, tests, or procedures, use the clock to advance simulated time until the case ends.

The Patient

Simulated patients may be from any age group, ethnicity, or socioeconomic background and may present with well-defined or poorly defined problems. Patients may present with acute or chronic problems, or they may be seeking routine health care or health maintenance with or without underlying conditions. Assume that each patient you are managing has already given his or her consent for any available procedure or therapy, unless you receive a message to the contrary. In the case of a child or an infant, assume the legal guardians have given consent as well.

Responsibilities of the Physician

In the simulation, you should function as a primary care physician who is responsible for managing each simulated patient. Management involves addressing a patient’s problem(s) and/or concern(s) by obtaining physical examination results, diagnostic information, providing treatment, monitoring patient status and response to interventions, scheduling appointments and, when appropriate, attending to health maintenance screenings and patient education. You will manage one patient at a time and should continue to manage each patient until the end-of-case screen is displayed.

Assume that you are the primary care physician for each patient you manage. In this generalist role, you must manage your patient in both inpatient and outpatient settings. Sometimes this may involve management in several locations—initially caring for a patient in the emergency department, admitting the patient to the hospital, and discharging and following the patient in the outpatient setting.

You should not assume that other members of the health care team (eg, nurses, consultants) will write or initiate orders for you. Some orders (eg, “vital signs” at the beginning of a case and upon change of location) may be done for you, but you should not make assumptions regarding other orders. For example, orders usually requested to monitor a patient’s condition, such as a cardiac monitor and pulse oximetry, are not automatically ordered. You are responsible for determining needs and for making all patient management decisions, whether or not you would be expected to do so in a real-life situation (eg, ordering IV fluids, surgical procedures, or consultations). If you order a procedure for which you are not trained, the medical staff in Primum cases will either assist you or take primary responsibility for implementing your request.

As in real life, consultants should be called upon as you deem appropriate. Typically, consultants are not helpful since computer-based case simulations are designed to assess your patient management skills. However, requesting consultation at appropriate times may contribute to your score. In some cases, it may be necessary to implement a course of action without the advice of a consultant or before a consultant is able to see your patient. In other cases, a consultant may only be helpful if called after you have obtained enough information to justify referring the patient to his or her care.