Does anyone know how to deal with the following:
ordering say, Lipid panel for a pt with hypertension- results will be available on day 3. Case ends before that. In the final orders I still have that Lipid panel pending. Do cancel it? Do I prescribe statin empirically?
Similarly, if I admit a pt to inpatient and order cultures and the case ends before that b/c the pt has something non-infectious and the cultures are still pending on my final list do I cancel them?
Generally, is it better to over-order labs? FOr example, a pt with AMS and I think I know it's caused by a non infectious etiology but I still order blood and urine cultures? Or should I only order the bare minimums?
Also, which vaccines do you guys typically give at the end? I have been doing Tdap and flu for almost everyone and shingles for the older pts.
@Creed_Bratton
1. It is very important to act based on the simulated time. Simulated time is the time since you first evaluated the patient on CCS software. As per what I understood from **********, many people have failed CCS component because of misunderstanding the "simulated time" concept and
prematurely discontinuing the orders once they reach 2-min screen. Two-min screen is meant to review the orders, add any orders that were missing and to set up follow-up monitoring tests in future. These follow up tests that are done to monitor efficacy and toxicity of intervention are scored.
You would not prescribe statin empirically unless you have the lipid panel back. Lipid panel will be considered valid and scored only if you leave it on order sheet until that report time is reached and order executed. If report time is not reached, and you end up on 2-min screen, leave it alone and set up a follow up appointment for patient after the lipid panel report time ( select date of follow up from calendar on the 2-min screen).
2. Same as point #1. Watch the simulated time and report time of the order and leave them there. Reaching 2-min screen does not mean patient is being discharged so why would you discontinue the orders? Discontinuing before they are executed them means you felt they are not necessary and therefore, you will not receive credit for it ( simulated time is a point time in patient's life and you manage based on that). If you really feel the order is not necessary, you may cancel. However, note you will not be penalized for ordering just some extra labs tests.
Here is a free sample of Archer that I found on YouTube:
3.
Cost is not an issue on STEP 3 CCS. Invasiveness is! As mentioned in **********, "
you will be penalized if you order unnecessary, invasive test like cardiac cath etc in a patient that does not need it. You will not get a negative score if you ordered extra lab tests which are non-invasive even if they are felt to be unnecessary, in retrospect.
4. This is one of the important questions lot of people keep asking. I think this has become a norm for many people to add vaccines because they got this info from uworld when case-end screen used to allow 5-min luxury time years ago. Case end screen changed to 2-minutes a few years ago and uworld still gives incorrect information to do routine screening, vaccines etc on 2-min screens. They have incorrectly fed us the input that these are scored, no they are not. On step 3 USMLE website, they as you to place orders on 2-min screen pertinent to
current scenario/ problem. On a 2-min screen, you really DO NOT have much time! If you end up doing routine counseling, you will not have time for crucial orders and essential orders. In Archer videos, I have seen him talking about how many people
fail to do necessary things on 2-min screen by focusing on this routine orders like vaccines etc which are not meant for an
active inpatient case with other acute problems. Archer review mentions most scored components on 2-min screen are "
follow-up monitoring" tests which can be ordered after selecting the "later" option and calendar date. Follow up monitoring is important to check if your intervention worked or if your intervention had toxic effects ( for example, when you start statin, check Lipid panel in a month - here you are monitoring efficacy. Orders LFTs in 3 months by choosing later date where you are monitoring for statin toxicity. These are ACC guidelines). These take time.
Remember you can order "LATER" tests only on 2-min screen and not on active screen. To meet the guidelines, you have to order them at certain time intervals. Your 2-min is used for this crucial purpose, not for counseling patients to wear a seatbelt or adding a tDAP vaccine. Archer enumerates some examples to illustrate how only case-specific counseling and case-specific vaccines is scored on the exam.
Case-specific counseling means the type of counseling that matters and makes an impact in managing that case. These include 1. sexual partner needs treatment in a trichomonas case. If you do not do that, your patient risks re-infection 2. Diabetic related counseling in new DM cases or poorly controlled DM cases where counseling matters in achieving good patient outcomes- types of counseling are highly scored, but not routine counseling. Also, adding pneumonia vaccine in COPD patients and pneumonia cases on 2-min screen is important, not for all cases. For a wel-health checkup that shows up in office, you can add all screening orders and vaccines, but do not waste your precious time on these in inpatient/ ED acute presentations. All the best!
