Hot Tip MMED exam
It was Sunday, Mother's day. And we also got a wedding to attend – one of our Department's senior staff getting married. And yet, we 'were forced' to congregate at UMMC early morning at 8am for the Exam Calibration. The event supposed to last the whole day, therefore ruling out the possibility of celebrating either of the above social occassions!
I intended to attend, but slightly off the starting time, expecting that the crowd will congregate slowly in view of Sunday. I was right - despite nearly losing my way driving on the new Duke's highway to PJ, I still managed to arrive just past 8.30am. As I steered my 4WD to the parking, I spotted a familiar maroon merc, no doubt I immediately recognised that a 'Hawk' and a 'dove' couple is on its way – so I know that, even if I was late, I was not the only one!
The purpose of this Exam calibration is to close the gap (disagreement/discrepancies) between examiners (in awarding marks to candidates), and hope that examiners will be more objective in marking the candidates, and hence come close to consensus. Sadly, I doubt if it achieved its objective, all I learn from this meeting is – there are those 'hawks' most of those prominent professors, who will stand by their views no matter what, so if I got paired with anyone of them, tough luck, I may end up agreeing with them. There were many 'doves' certainly, but I quickly found out that 'doves' may easily get 'eaten' away by the Hawks, therefore end up agreeing with them...
Let me give you a brief highlight of what's happening. We were given two cases – one long and one short. Each of us was instructed to mark the candidates. Then we split in groups, each group discuss the candidate and come to a consensus on the final marks. The results? Shocking...
First candidate – long case. A complex case of longstanding hypertension, developed resistant hypertension, only diagnosed with Conn's after nearly 30 years of treatment. Concurrent diabetes/IGT. The case was presented in comprehensive way. Candidate arrived at correct diagnosis. Assesment of patient in term of HTN complication, CV risk etc a bit deficient. I initially was a bit flustered and thought that he should be marked down, perhaps a borderline pass. But it all depends on 'prompting' the candidate. In the video, the examiners did not actually attempt to probe deeper into this. There were clear questioning on the social aspect, interpretation esp ECG (which the candidate was hesitant), but not so much on patient's assesment. Perhaps it was not a very good long case after all, but candidate could certainly do better.
Sow, how do the examiners mark him? The range of marks were 4 to 6 (4 – borderline fail, 6 – clear pass). A prominent Professor A gave him a mere 3, when asked to comment – he simply said:
I assess this candidate by comparing him to me. I do not think he is equal or better than me, no, not all.
I must make it clear that this is a postgraduate exam – all this candidate did was telling us story! An undergraduate candidate can do the same – what is the difference between him and a year 5 student – none. So, how can I pass him?
External examiner 1 – I passed him, gave him 5. I think there is patient factor here, we cannot confidently say that this candidate was not objective enough.
External examiner 2 – I initially gave him 4 (borderline fail) – he missed assesment of this patients risk eg. IHD, end organ damage etc., if they were negative, they were important negative. However, I also rely on local people, how you set the standard.
Prominent Prof. B – This candidate has not done anything – has not outlined the problem at all – he failed social assesment (simply because he forgot to ask patient about his wife's condition!). No comprehensive assesment of clinical organ damage, CV risk. Did not clarify, why patient still hypertensive post operatively. So I gave him 3!
'Doves' group – well, we think the candidate has addressed most of the problems, he did miss a few things like social aspect, important negative findings etc., but he got most of the stuff – we gave him 7!
Take home message – if you are a candidate – please pray you get those 'doves' then you will be safe or even a chance to get honours grade!
Err, yes, Prof. Wan did mention in his opening, a candidate approaced him and asked him, please, please Prof, pray for me. He replied, I prayed for all of my students. But the candidate insisted, please, make a special prayer for me. He was puzzled, so he asked for clarification. The candidate immediately replied – please, pray that I will not get Professor A in my exam! (A here did not refer to the earlier A above!).
Next were were shown a candidate performing on a short case. Mixed mitral valve disease, query IE. Previous mitral valvuloplasty, so the MS sign was no longer prominent.
Range of marks – again between 4 to 6. This time, only one group (that is mine!) awarded the candidate with a 6 – after finalising our initial score of 5.5.
Prof. B – This candidate should be failed, given a 3. He missed displaced apex (got it on prompting). He did not check RF delay (is there a need?), did not qualify how to accentuate a diastolic murmur (wow, sounded like a prominent cardiologist).
Prof. C – In fairness, he looked confident. He got the apex, on second prompting. His technique was good overall, we did mark him down for missing the apex, but his overall is clear pass, therefore we gave him a 6.
External 1 – We gave him 5.5, then we finalise by rounding the number, to 6. His overall performance is satisfactory, missing one or two things, but he showed confident techniques to elicit those signs.
External 2 – I gave him a pass (I can't recall whether he said 5 or 6) – his performace was satisfactory – good cardiovascular examination to a standard of a physician.
What about the 'doves group' (they were sitting at the same corner, so I conveniently put them in the same group). Surprisingly, perhaps after listening to prominent Prof. A words, they have now realised their 'naivity' and now prepared to go on the invasive. So, what did they say:
We gave him 4. He missed a few things. Assesment not very systematic. Caused patient discomfort, as he did not ask permission for the second examination. He also missed important signs like apex beat, and made up loud P2...
Take home message – don't pray you get a 'dove' in the exam – in case the dove has been brainwashed by the hawks!
At the end of the session, I approached Prof. C and aired my confidence and relief on her – Prof, glad to know that you are so fair, and going to pass most of our candidates...
Then I patted Prof. B's back, and remarked – I am sure you just did that for exercise, in the actual exam, I believe you are kinder and much more lenient! Perhaps, to defend himself, he simply said: In the exam .... I will smile a lot at them, but still give them a 3!
So, the lesson – there are three factors that influence your performance in the exam. They are: the patient, the examiners, and YOU. Two of them, you cannot change, it is entirely up to destiny which patients and examiners you will get. However, if you prepare to be the highest standard candidate, then you will sail through the exam, God willing.
In summary, I attached a table on Criteria of Assessment for Long and Short cases
LONG CASE
(remember, you will be marked on all of these aspects, be prepared!):
Only two markings (4 – borderline fail, 6 – clear pass) shown, the marks range between 0 – 10.
Clear Pass (6)
History – emphasis on appropriate details, appreciates subtleties, interpretes significant aspects of the history.
Exam – includes important relative negative signs, appreciates significance of more subtle signs
Synthesis & Priorities – Confidently identifies essential problems, shows maturity in recognizing lesser issues
Impact of Illness on Patient/Family – Shows persistence in exploring subtle psychological issues, or issues that impact on the patient or family
Management Plan – proposes appropriate management plan with good understanding of social impact lifestyle and psychological aspects of disease, good use of discriminating investigations, accurate interpretation of results
Borderline Fail (4)
History – Poorly organised, omission of some key issues, need to clarify important details
Exam – omission of some important physical signs
Synthesis & Priorities – Problems poorly prioritised, significant problems undervalued
Impact of Ilness – Fails to recognise some important aspects of the disease on patient or family, misses some aspect affecting functioning or reaction to illness
Management – Lacking confidence and including some errors in arranging a management plan, erratic and non-discriminatory use of investigations, errors in the interpretation of tests, lacking some apprectiation of complication of treatment
SHORT CASES
Again, you will be marked on the following aspects. (15 minutes each case, 4 cases)
Clear Pass (6)
Approach to Patient – Introduces oneself, preserve patient's modesty, request permission for sensitive aspects of examinations
Technique – Systematic, not smooth
Findings and Interpretation – Identifies all essential signs, correctly interprets all major findings
Diagnosis, Differential Diagnoses – Able to give diagnosis with confidence, able to carry out a satisfactory discussion
Borderline Pass (5)
Approach to Patient – Less than the above (vague!)
Technique –Not smooth, require prompting before proceeding to the next step
Findings and Interpretation – Require prompting
Diagnosis, Differential Diagnoses – Not confident with diagnosis
Borderline Fail (4)
Approach to Patient – Less than the above (what's the difference with Borderline Pass?)
Technique – not Systematic, require prompting on two occassions
Findings and Interpretation – require prompting on two occassions
Diagnosis, Differential Diagnoses – require prompting
Finally, very best of luck in your exam. I pray that you will be in your best form, get the right patient and the right examiners, so you will sail through the exam.
