Thursday, March 4, 2010

HOW TO COUNSEL during USMLE step 2 CS exam


COUNSELING

One of the most important factors that may affect the outcome of your CS exam is the counseling part. You dont need to be creative or over concerned since this is a standarized exam where you are doing a limited show in place and time. I collected the formats which have been used over the years by doctors who passed this exam. This is the most successful and reliable collection you may find.

HOW TO COUNSEL:
It is better to counsel at the end of the case just before your final comment on next steps you are going to do for him, as these standarized patients (SPs) are trained and used to hear it at that part of the test and are ready to score it for you.

SMOKING:
Mrs. XYZ, as a concerned physician, I must tell you about the bad-effects of smoking on your health. Smoking can damage your heart and your lungs. And can cause cardiac and vascular problems. I understand that people experience difficulty in giving it up due to stressful symptoms. But you can use Nicotine patches or Gum to help reduce those withdrawal symptoms and we even have a professional team to help you deal with it better. Feel free to contact me anytime if you decide to quit.

ALCOHOL:
Mrs. XYZ, as a concerned physician, I must tell you about the bad-effects of alcohol consumption on your health. Excess alcohol consumption raises your risk of high blood pressure, strokes, car accidents, and is known to cause Liver Cirrhosis and inflammation of the pancreas.- Limit intake to one drink per day (for women) or two per day (for men).- Avoid drinking before or when driving, or whenever it puts you or others at risk. We have a professional team that can help you deal with it better. Feel free to contact me anytime if you decide to quit.

Diabetes:
Mr. XYZ - we will begin your treatment once I have evaluated your lab results. I want you to know that besides drugs, there are other simple but important measures to keep yourself healthy and reduce complications. 1. Follow regular exercise and diet instructions that will be provided to you 2. Diabetic patients are vulnerable to injury-induced ulcers on the foot, so make a habit of using soft footwear whenever you walk - indoors or outdoors. 3. Be regular in blood-sugar monitoring so that dose adjustments can be done on time.

Hypertension:
High blood pressure could indicate that your blood vessels are having trouble. It could cause stroke, affect the functioning of the heart, and even the kidneys. Again, regular exercise, reduction of weight (if the patient appears overweight), and limiting salt in your food could help in keeping your hypertension in check. I strongly advise you to take regular health maintenance examinations to help control your blood pressure. What do you say, Mr. xyz?"

Enuresis: (Bed wetting)
Mrs. XYZ, kids with bedwetting usually undergo natural healing with age, but this problem needs tenderness. Punishing your child could worsen it - a much better technique would be to rather reinforce positive behavior by praising and rewarding him if he stays dry while sleeping. I would advise you to monitor your child's drinking habits before going to bed and encourage the child to go to bathroom before going to bed. We also need to do some tests to rule out other conditions.

MEMORY LOSS:
Mrs. XYZ thank you for your kind cooperation. What I think so far from the answers you provided and from the physical exam I did, is that your memory problem might be due to one of the following possibilities: Alzheimer’s disease, vitB12 deficiency, thyroid problem and depression , we need to run some tests and imaging studies in order to figure out what is the exact cause. Mean while I want to ask your permission to speak with one of your family members about social support and safety at home. Is't ok?. We have an excellent social worker that can help you in managing your daily activities and future living plans in case you needed it. When we get the test results back, we can sit down together and discuss your diagnosis and further treatment option.

Sexually transmitted diseases: STDs
Mr XYZ being your physican i am much concerned about you health. I need to warn you that you are not observing safe sexual practices. It puts you at risk of getting STDs (sexually transmitted disease) which include hepatitis and even AIDS. I would strongly recommend you to use condoms regularly. (If patinet or partner is on OCPs you can add) I would also like to tell you that Oral Contraceptive pills don’t protect against sexually transmitted disease. Watch for symptoms of STDs, such as unusual discharge, sores, redness, or growths in your and your partner's genital area, or pain while urinating. I would also like you to take a blood test for HIV If you need any help don’t hesitate to contact me. I am here to assist you.

Overweight-diet:
Mr. Green, we have a lot of evidences that weight reduction program alone, could reduce the symptoms that you have by 50% or even more". or "Recent studies show, that weight reduction in patients with DM and HTN could eliminate the symptoms completely without medications. We have a very good dietary specialist here in the clinic so, if you would like I can refer you to him/her, and I believe it will help US a lot to treat you condition."

Loss of consciousness:
ms xyz, at this time i must ask that you not drive again until we are sure what caused you to loss consciousness, I understand that this might be an inconvenience, I assure you that I will do all I can to get to the bottom of your problem so that you can resume your regular activities of daily living, do you have any questions or concerns for me at this time?"

Asthma:
"Mr. Smith asthma is a chronic disease that needs long term therapy. Most common cause of recurrence of asthma symptoms is interruption of controller medications. The inhaled medication (name it if the patient told you the name) is a steroid that suppresses swelling of your airways and prevents symptoms. You should take it every day without missing a single dose. I am happy to see that you are regular with your follow up checkups and I would like to see you again in about 3 months for a checkup. Do you have any questions regarding the treatment plan Mr. Smith?"

Depression:
"Mr Smith I know dealing with depression can be extremely difficult. Depression causes immense physical and emotional stress. But we can beat it. We have a number of techniques and medications that help with depression. I advise that you make an appointment with our counselor at the earliest. Mr Smith I am also going to write you a prescription for an antidepressant. We need to do some lab work including a blood cell count and electrolyte levels prior to that. Also Mr Smith you should remember that antidepressants can take up to 4-6 weeks to show effect. So you have to be patient. If you ever feel like hurting yourself or others you must at once seek medical attention or at the least talk to a friend."

Domestic violence:
"From what you said I understand that at times you feel unsafe at your own home. That sounds very frustrating Mrs Smith. I am glad that you came to seek attention. If you ever need someone to talk with do not hesitate to call our office. If ever you feel unsafe or are hurt you should seek attention from the police or appropriate authorities. And if you do not feel comfortable doing that you can always come to us for help and if you wish we could arrange for someone to go to the police with you. Does it sound reasonable to you?"