Computer based case simulations, aka, the nerdiest video game ever created.
You have a problem to solve, a limited amount of time to do it, you get points for making good moves, and lose points for making bad moves. It’s a game. And you can learn to play it, just like any other game. And it’s okay if you enjoy it. I won’t tell anyone.
I love CCS cases. Probably because I also happen to be a huge nerd.
I may be the only person out there who enjoys them, but I am not ashamed.
CCS cases require you to put your medical superpowers to the test while working-up and treating disease. They involve all the aspects of real-world patient care minus the patient interaction. That sounds like my kind of party. Probably also explains why I’m a radiology resident.
I’m only joking, of course. I love patients.
From a respectable distance.
On the job learning
I used CCScases.com to prepare. I highly recommend this because of the interactive environment. It’s just like the real thing and has 140+ cases. Everyone says that the biggest hurdle is learning to use the Primum software.
Each case on CCScases.com is given a user generated rating of relative high-yield-ness, so you can see a mix of cases and figure out what kind of random tests you might order.
One of the reasons I’m a big fan of the CCS cases portion of the exam is that your day-to-day work as a resident translates really well to success on the cases. It’s like real life only better. Because the presentations will be classic more often then not. You are being tested on your ability to provide the entire spectrum of care for 13 different conditions. And they won’t be zebras. They will be bread and butter interesting cases. So, look out, you may not have been expecting to learn something useful while studying for Step 3, but you just might.
Building your approach
“I knew exactly what to do, but in a much more real sense, I had no idea what to do.” – Michael Scott
You may have heard that a cookie cutter approach to most cases will score you a bunch of points. This is pretty true. The caveat to this approach is that if you order tests and physical exam maneuvers all “willy-nilly”, then you could be docked points if they are deemed “unnecessary” or “delay treatment”. So, build a standard approach, yes, but don’t expect a single “order set” to take you to the promised land of top tier percentile scores.
I want to equip you with a basic framework for approaching cases, and I fully encourage you to add, remove, and re-order to your hearts content. My process came about organically after doing many practice cases of my own and finding the areas where I was losing out on easy points. You will likewise perfect your own approach.
I just hope to give you a starting point so that maybe your first 10 practice cases will give you confidence rather than an ulcer.
1. The Prompt
May be presented as a triage note, interval history (clinic note), or EMS report. The goal here is to write down a few notes so you don’t lose time referring back. Anything you would normally highlight in a question stem; you should quickly jot down. Remember, just the stuff that stands out to you and helps you build your initial differential for what the heck is going on.
- Patient demographics: age, gender, chief complaint
- Medical history: chronic conditions, allergies, pertinent family history, new meds
- Any recent exposures or other risk factors
- Abnormal vitals
2. Sick vs Not Sick (stable vs unstable)
The first major branch point in the decision tree. If you see hemodynamic instability, then you might want to address this before obtaining a physical exam. You may be docked points if your actions “delay treatment” in emergent situations.
- Unstable Patient → emergency orders → focused physical exam
- IV access+/- fluids, oxygen, monitoring (pulse oximetry, cardiac), repeat vitals, CXR, EKG, troponins, CBC, BMP, antibiotics, type and cross, beta HCG (obviously the exact labs vary widely depending upon situation)
- Stable Patient → Physical exam
- Focused if the problem is limited to a specific system.
- Complete exam if routine physical or wellness exam. (You might not have a clue what’s going on yet if you’re contemplating this)
3. Diagnostics (pay attention to your context)
- Grab a few standard labs if in the emergency department to round out your knowledge of the situation. A couple standard labs like CBC, CMP, UA, +/- Beta-HCG. Remember that you need enough information to decide on treatments as well. (Renal function, for example)
- At the same time, I will do other things like repeat vitals, insert an IV, obtain pulse oximetry, place on cardiac monitoring, and anything else I want to include in my first round of orders.
- Things will take longer in the clinic, so you might need to counsel the patient, send them to get labs, and then schedule a follow-up in a day or two (or week). Or send them to the ED for labs if they have a more urgent issue.
- Rinse and repeat. If you have no clue what’s going on, then you start casting a wider net with your labs and imaging studies.
4. Treatments
- IV fluids, antibiotics, anti-hypertensives, steroids, nebulizers, anxiolytics…the possibilities are endless. I had a bad habit of ignoring the patients’ pain.
- You can start by treating symptoms if you’re still working on the diagnosis. Tylenol, ibuprofen, morphine, anti-emetics, etc.
- Consults. You have like 10 words to type a consult “60yo male with ascending aortic aneurysm, please advise.” etc.
- After you order treatments, make sure you repeat pertinent physical exam maneuvers, check interval history, and repeat vital signs.
5. Admit or DC
- Don’t forget to change context as appropriate when deciding on treatments. You can start people on vasopressors and insulin drips in the ED, but you get points for transferring appropriately.
- If you think you might be discharging a patient, then consider if they will need any counseling regarding their new diagnoses or new medications. Schedule them follow-ups, schedule appropriate future labs, counsel on safe sex practices, smoking cessation, alcohol cessation, etc.
- Don’t forget to stop treatments you don’t want to continue if appropriate.
6. “Case will end in 2 minutes of real time”
Eventually you will get to this message. This is triggered if you complete the intended action (administered definitive treatment or started appropriate management) or if maybe you got stuck and progressed time far enough that you reach the end of the simulation…or maybe you do something drastic and fatal to the patient…I don’t know.
- This is your opportunity to add in last minute orders, administer counseling, schedule follow-up imaging, order age-appropriate cancer screening, CANCEL labs, meds, studies, etc.
- Sometimes you will hit this weird twilight zone where you know the diagnosis, and know the definitive treatment you need to offer, but still have like 7-8 minutes left in the case. Especially after you’ve done a bunch of cases. You can spend a few minutes jotting down all the stuff you need to do during the 2-minute window to give yourself a checklist. You don’t necessarily want to spend too much time here in case you’re wrong, but it can be helpful to think ahead.
- Don’t do too much counseling and scheduling of follow-ups and such before administering the definitive treatment or else it might be interpreted as “delaying treatment”.
