Once again I would like to share my short experience examining today. This was 'OSCE' exam for the Part I MMED. Though it is for the part I, I think, in general a lot can be reflected from our observation as examiners.
Of note, these days, all the clincial examiners are encouraged to examine the case 'blindly' prior to the exam, without looking at patients' records, in order to ensure a fair and transparent examination. Obviously, as an examiner, you will not expect to penalise a candidate who failed to detect mild jaundice, when you yourself are not fully convinced of the finding during your examination. At the same time, both examiners can come to agreement right from the beginning on what are expected from the candidates, based on their assesesment on the difficulty level of the case eg. a mild splenomegaly - a candidate may be given a second chance, since, the other examiner also has difficulty detecting it!
First, the OSCE is basically short cases exam, in which a candidate will be rotated to four different stations and given a case from each consisting of a system like CVS, respiratory etc. In order to pass the exam, you must score at least 50%, and not fail more than 2 stations.
One of our most frequent comments on candidates is their extreme nervousness which have led many to committing silly mistakes; second is exaggeration of false signs. We got to know of one particular examiner who failed 75% of the candidates, and yet gave 80% marks to one of the passers who did well! It happened that the system that he was examining at his station was CVS - I am not too surprised. Though in clinical practice you always auscultate the heart, the actual performance of CVS examination in the exam have exposed many candidates of their weak points.
For example, that one examiner quoted a candidate mentioning the presence of a thrill, when in actual fact the patient did not even have a murmur! Then he told us how upset he was, when a particular candidate did not even know how to measure a JVP...Another examiner was puzzled as a candidate failed to demonstrate examination technique for retrosternal goitre.
One of the candidates I examined (abdominal system) have forgotten to palpate for the spleen, and yet concluded (correctly) that there was a splenomegaly. However, the worst thing about abdominal examination is, this is a one particular examination that will demonstrate your gentle approach to patient. At least 3 of candidates I examined were rough during palpation of abdomen, one of the patient quietly complained of abdominal tenderness. Of note, in a hurry, a candidate had become so erratic, palpated an abdomen deeply, as if she has forgotten that she was examining a real human patient - I am very sure, in the actual clinical practice she won't do that.
O' please, do not be so robust for the sake of exam! Consider your patient, in fact it is more correct to avoid deep palpation, if your patient complains of tenderness. Remember, the object of the exam is to demonstrate your professional skill as a clinician, and not to find clinical signs.
We know that, in exam situation, people do get nervous and panic. But there is no excuse whatsoever, to project your nervousness by being rough and inconsiderate to patient. And you will not be forgiven either for exaggerating findings. I recalled in one of the Part II exam last year, we had one of this difficult case of renal mass (APKD). Most of the candidates failed to detect the kidney, and amazingly, 90% of the candidates mentioned that there was hepatosplenomegaly when there was non whatsoever!
Why I said amazing, because physical examination is a basic skill right from the time you are in medical school. So there is no excuse of not being able to apply correct examination skill and come with findings - where are not talking about fundoscopy to yield a mild central retinal vein thrombosis or detecting a mid diastolic murmur in a patient with moderate mitral stenosis. We are talking about clear cases - large spleen, loud murmur etc.
One more thing - do get this. If a physical signs are obvious, you may not necessarily pass the exam for detecting the findings - this particularly applies in Part II exam. There is no bonus for coming up with the correct finding of 'hepatosplenomegaly' in someone with obvious liver and splenic mass. Correct technique, correct diagnosis (that means, coming up with the diagnosis of HSM eg. chronic liver disease, lymphoma etc) and being able to discuss on the investigations and appropriate management will earn you marks.
So do not go to the exam without having clearly in you mind a list of differential diagnosis for HSM, pure splenomegaly, pure hepatomegaly (hell...these abdo masses are so common), abdominal masses, lymphadenopathy, etc. I like the old Myers and Ryder book for MRCP, these days there are many such books that teach and guide you on clinical exam skill.
I think, you will pass the exam comfortably by behaving like in your daily clinical practice (provided you have practiced correctly). There is no substitute for good clincal skill. You need good clinical skill not just for exam, but it is your basic everyday tool as a doctor. So, the best thing is, in your daily clinical work, do approach patients as 'exam' subjects - do apply the correct techniques and be honest with yourself. Of course 'complete' physical examination is rarely possible due to time constraint, but it is worth devising a way to conduct 'swift' clinical examination of ALL systems within not more than 10 minutes. Of course you can concentrate on the relevance, based on the history or presentation, but how else would an accidental findings of exophthalmus, clubbing, splenic mass or Cushingoid features discovered if not by routine system examination?
What else? Just be yourself. The problem will surface once you start to act beyond your usual person.
Tuesday, November 11, 2008
Thursday, November 6, 2008
Wednesday, November 5, 2008
Tips for MMED!
Good luck to those sitting the MMED or MRCP exam. If you think they are difficult exams, indeed you are right. I could only recalled the old days struggling to get through the Irish MRCP. Life was a hell...nearly. Fortunate enough I got a very strong moral support from the wife and people around. What is most challenging aspect of sitting the exam is, as a full working doctor and a family men as well as a member of society – you are virtually left with so little time to study and cope with the 'loss' in case you fail.
Some people are good in theory but abysmal in their clinic, while others, the opposite. I was of the latter type. It took me several sittings to pass the papers, while I got borderline in my first clinic attempt, and passed in the following (despite getting 4 difficult short cases – all neurology!).
As regard MMED, of course I never sat for one. So my knowledge is purely guided by being a committee member of various levels in the MMED exam. However, as a principle, it is essentially the same exam like MRCP, with a bit more detail paper consisting of MCQs, MEQs, PS and OSPE. That's really a lot to chew.
The MCQs are really like the MRCP type, except that many new questions are designed by a mixture of new and established specialists. Therefore the difficulty varies from 'not so difficult'– means >50% candidate can answer all the items; to difficult ones which you are not expected to get all correct, so be careful. In general, the total question answered should be between 220-240, considering that you will be 'wrong' in between 20-30 questions. Remember, it is negative marking. Answering too little may be inadequate to cover for your mistakes, answering too many put you at risk too unless you are a pure genius. You can gauge your chance by estimating the number of 'first go' ie how many questions you can answer the first time you skim through the paper. You should not get less than 190+, to be comfortable. The 'first go' has the highest chance to be the correct answers – you could be up to 90% correct.
The distribution is question is quite even, on average 4-6 questions from each specialty. There is no subsitute for 'experience'. You must have practiced answering MCQs before exam, the percentage you get in your daily practice will be closely reflected in the actual exam (provided you have practiced using the correct materials). So if your 'handicap' is 60%, you will have all the chance of passing the exam with confidence.
PROBLEM SOLVING
This usually comes in the form of short clinical scenario accompanied by data like ECG, CT scan, MRI or histopathology. Questions are short and asked directly eg. Interprete the biochemistry, diagnose based on the data etc. Lastly, they will definitely ask on treatment or management, this should cover all angle taking the patient a whole.
Questions on problem solving can range from any system. It does beg your in-depth knowledge in that particular specialty eg. What are typical echo findings in HCM? Or interpretation of Flow-volume loop etc.
'Systemic syndrome' tends to recur because it is a broad subject. eg. A patient may present with pneumonia, X-ray shows something suggestive of consolidation or cavity. When accompanied by renal failure, then you can guess where the case is heading! On top of this a neurological deficit will lead you to Wegener's etc. Do know how to treat the condition as well, since they will test your knowledge in it.
However, in all cases, you must be prepared to outline a general management of cases, eg. The most sensible thing to do for a patient presenting with pyrexia should include blood/urine cultures, or even dengue serology if indicated. Sepsis should be a famous subject that is known to all candidates, since, again it can present in various ways. What are the roles of steroid or drotrecogin?
Neurolgical or haematological scenario seems a bit challenging to me. CT scan, MRI a real no no! But for you guys doing MMED, it is a must to know! At least you should know how a haemorrhage look like on a CT and MRI. Bear in mind, systemic syndrome like SLE or antiphospholipid syndrome may present with neurological symptoms or causing venous or arterial thrombosis leading to stroke like syndrome. Ever recall how a sagittal vein thrombosis look like on MRI? Or how multiple sclerosis can present with what look like space occupying lesion or cavitation? How about features of thalamic or cerebellar infarct?
MEQ – Modified Essay Questions
There will be two questions, each come in ‘packages’ of 5 or 6. It can be anything that start with pulmonary, neurological, endocrine presentation which will have a ‘flow’ like real life case progress in the ward! For each stage ie clinical presentation, imaging, biochemistry, questions will follow regarding the differentials, interpretation of data etc till diagnosis confirmed, then what follow will be the management. Basically like ‘problem’ data but presented in stages.
This can be quite distressing, as when the next package presented, you can already guess how you have done in the previous one, but unable to do anything as it is too late! However, you should keep going, treating each package on its own, answer all relevant questions, even if you have missed or ‘messed’ the previous packages…
You will start with a scenario eg. A young man presented with respiratory symptoms, then blood results, Xray given – showing some air space opacities. At this stage you can only interprete individual finding eg. Acute nephritic syndrome based on urine/serum creatinine. Then X-ray already showing suggestin of pulmonary haemorrhage. Only at the next package then you will be given more clinical scenario along with summary of previous package, when ‘most likely diagnosis’ will be asked. Sound like what? Unmistakably Goodpasture’s, but other differential of Wegener’s PAN Churg Strauss should be entertained.
So the scenario will be diverted to ‘confirmatory diagnostic step’ which obviously a renal biopsy. Of course, the next thing is they ask what are the expected findings! Or else, they will show the histology leaving you to interprete. The next most obvious steps would be treatment and management. Obviously this depend very much on your correct diagnosis.
Imagine a slightly different scenario – could resemble the above clinical presentation, but in a lady, who has a more prolonged symptom, accompanied by weight loss. Already treated as pneumonia, so you will suspect something more serious, not forgetting lung carcinoma. So something as common diagnosis as bronchoalveolar carcinoma could be a subject here. But the emphasis in this series of packages will be the correct interpretation of various tests including CXR, CTscan, and how you stage the disease. The rest is almost effortless (ie how do you manage it, don’t forget all the points including proper counseling). For the ignorant, the bold approach of surgery will be recommended even though an advanced Ca detected, so be wise – do get to know things like this, eg staging of Lung Ca etc.
OSPE
Aagh, this will be too tiresome to write about, since they could ask you just about anything! But obviously they would be things like ECG, CXR, CT, MRI, histopathology, blood film etc., so do prepare for this shorties. Most of the time it is whether you get it or not! But something as weird as Barret’s oesophagus or CSF pic of crytptococcal organisms could be shown here. So be cool, think wisely and be sure you will fly through this session.
VIVA
People are afraid that Viva questions can be about anything, but remember, the examiners also do worry, and more so, they have to agree to certain standard, therefore they will be given a set of questions (and answers!) so you just relax. I always told the MMED candidates, examiners are general physicians, their knowledge on specialties beyond theirs are pretty basic, and may not be superior to the candidates! But they have the advantage of experience, and of course knowing the answers of their questions…
You should be prepared to answer questions on ethics in patient management, counseling patients and relatives, transplant in brainstem death patients, cardiometabolic syndrome (aren’t they popular subjects these days). But mundane things like short and long term management of cirrhosis or varices may come up. Remember, for MMED 2, they emphasis on long term/chronic management, while that for Part I on emergency and acute medicine.
CLINIC
This…to be continued
Some people are good in theory but abysmal in their clinic, while others, the opposite. I was of the latter type. It took me several sittings to pass the papers, while I got borderline in my first clinic attempt, and passed in the following (despite getting 4 difficult short cases – all neurology!).
As regard MMED, of course I never sat for one. So my knowledge is purely guided by being a committee member of various levels in the MMED exam. However, as a principle, it is essentially the same exam like MRCP, with a bit more detail paper consisting of MCQs, MEQs, PS and OSPE. That's really a lot to chew.
The MCQs are really like the MRCP type, except that many new questions are designed by a mixture of new and established specialists. Therefore the difficulty varies from 'not so difficult'– means >50% candidate can answer all the items; to difficult ones which you are not expected to get all correct, so be careful. In general, the total question answered should be between 220-240, considering that you will be 'wrong' in between 20-30 questions. Remember, it is negative marking. Answering too little may be inadequate to cover for your mistakes, answering too many put you at risk too unless you are a pure genius. You can gauge your chance by estimating the number of 'first go' ie how many questions you can answer the first time you skim through the paper. You should not get less than 190+, to be comfortable. The 'first go' has the highest chance to be the correct answers – you could be up to 90% correct.
The distribution is question is quite even, on average 4-6 questions from each specialty. There is no subsitute for 'experience'. You must have practiced answering MCQs before exam, the percentage you get in your daily practice will be closely reflected in the actual exam (provided you have practiced using the correct materials). So if your 'handicap' is 60%, you will have all the chance of passing the exam with confidence.
PROBLEM SOLVING
This usually comes in the form of short clinical scenario accompanied by data like ECG, CT scan, MRI or histopathology. Questions are short and asked directly eg. Interprete the biochemistry, diagnose based on the data etc. Lastly, they will definitely ask on treatment or management, this should cover all angle taking the patient a whole.
Questions on problem solving can range from any system. It does beg your in-depth knowledge in that particular specialty eg. What are typical echo findings in HCM? Or interpretation of Flow-volume loop etc.
'Systemic syndrome' tends to recur because it is a broad subject. eg. A patient may present with pneumonia, X-ray shows something suggestive of consolidation or cavity. When accompanied by renal failure, then you can guess where the case is heading! On top of this a neurological deficit will lead you to Wegener's etc. Do know how to treat the condition as well, since they will test your knowledge in it.
However, in all cases, you must be prepared to outline a general management of cases, eg. The most sensible thing to do for a patient presenting with pyrexia should include blood/urine cultures, or even dengue serology if indicated. Sepsis should be a famous subject that is known to all candidates, since, again it can present in various ways. What are the roles of steroid or drotrecogin?
Neurolgical or haematological scenario seems a bit challenging to me. CT scan, MRI a real no no! But for you guys doing MMED, it is a must to know! At least you should know how a haemorrhage look like on a CT and MRI. Bear in mind, systemic syndrome like SLE or antiphospholipid syndrome may present with neurological symptoms or causing venous or arterial thrombosis leading to stroke like syndrome. Ever recall how a sagittal vein thrombosis look like on MRI? Or how multiple sclerosis can present with what look like space occupying lesion or cavitation? How about features of thalamic or cerebellar infarct?
MEQ – Modified Essay Questions
There will be two questions, each come in ‘packages’ of 5 or 6. It can be anything that start with pulmonary, neurological, endocrine presentation which will have a ‘flow’ like real life case progress in the ward! For each stage ie clinical presentation, imaging, biochemistry, questions will follow regarding the differentials, interpretation of data etc till diagnosis confirmed, then what follow will be the management. Basically like ‘problem’ data but presented in stages.
This can be quite distressing, as when the next package presented, you can already guess how you have done in the previous one, but unable to do anything as it is too late! However, you should keep going, treating each package on its own, answer all relevant questions, even if you have missed or ‘messed’ the previous packages…
You will start with a scenario eg. A young man presented with respiratory symptoms, then blood results, Xray given – showing some air space opacities. At this stage you can only interprete individual finding eg. Acute nephritic syndrome based on urine/serum creatinine. Then X-ray already showing suggestin of pulmonary haemorrhage. Only at the next package then you will be given more clinical scenario along with summary of previous package, when ‘most likely diagnosis’ will be asked. Sound like what? Unmistakably Goodpasture’s, but other differential of Wegener’s PAN Churg Strauss should be entertained.
So the scenario will be diverted to ‘confirmatory diagnostic step’ which obviously a renal biopsy. Of course, the next thing is they ask what are the expected findings! Or else, they will show the histology leaving you to interprete. The next most obvious steps would be treatment and management. Obviously this depend very much on your correct diagnosis.
Imagine a slightly different scenario – could resemble the above clinical presentation, but in a lady, who has a more prolonged symptom, accompanied by weight loss. Already treated as pneumonia, so you will suspect something more serious, not forgetting lung carcinoma. So something as common diagnosis as bronchoalveolar carcinoma could be a subject here. But the emphasis in this series of packages will be the correct interpretation of various tests including CXR, CTscan, and how you stage the disease. The rest is almost effortless (ie how do you manage it, don’t forget all the points including proper counseling). For the ignorant, the bold approach of surgery will be recommended even though an advanced Ca detected, so be wise – do get to know things like this, eg staging of Lung Ca etc.
OSPE
Aagh, this will be too tiresome to write about, since they could ask you just about anything! But obviously they would be things like ECG, CXR, CT, MRI, histopathology, blood film etc., so do prepare for this shorties. Most of the time it is whether you get it or not! But something as weird as Barret’s oesophagus or CSF pic of crytptococcal organisms could be shown here. So be cool, think wisely and be sure you will fly through this session.
VIVA
People are afraid that Viva questions can be about anything, but remember, the examiners also do worry, and more so, they have to agree to certain standard, therefore they will be given a set of questions (and answers!) so you just relax. I always told the MMED candidates, examiners are general physicians, their knowledge on specialties beyond theirs are pretty basic, and may not be superior to the candidates! But they have the advantage of experience, and of course knowing the answers of their questions…
You should be prepared to answer questions on ethics in patient management, counseling patients and relatives, transplant in brainstem death patients, cardiometabolic syndrome (aren’t they popular subjects these days). But mundane things like short and long term management of cirrhosis or varices may come up. Remember, for MMED 2, they emphasis on long term/chronic management, while that for Part I on emergency and acute medicine.
CLINIC
This…to be continued
Subscribe to:
Posts (Atom)