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.
No comments:
Post a Comment