MMED: Whose faults if candidates don't shine?

The MMED examinations were just over. Pass rate for Part I, II and III (UKM centre) were 63%, 76% and 100% respectively. Well done and congratulations to successful candidates. To the unfortunate ones, my advise: Failure is just another way of discovering how NOT to do things right. So, do look back, and ponder upon yourself. Start by looking at YOU, before thinking of the examiners and patients, or unfriendly-looking invigilators!

Though I have always been on the candidates' side, I have to admit, as we get more and more familiar with both undergraduate and postgraduate examinations, as examiners, I realise the very one quality that we badly need: being objective. So, beside having 'kesian' etc., we need to be objective. Furthermore, I begin to suspect, there may be relationship between bad examination performance and actual clinical practise - this is yet to be subjected to a longitudinal study...

So, basically as examiners, we need to be objective when it comes to assessing the candidates. During the exam of course, we even have to put aside our 'opinion' on candidates outside examination (ie a candidate may be excellent in the exam, but in the ward he or she is so-so but this should not influence our judgement). Weakness or failure in one particular aspect of examination does not automatically fail you. For example, an (external) examiner gave 8/10 marks to a candidate in the long case, when in actual fact she missed a gross hepatomegaly. He argued that she had made a thorough assesment, discussed the diagnosis and management well and answered all questions appropriately.

There are a few comments by the examiners, worth noting here. Surprisingly, in the Part II short cases, out of 30 candidates, there was only ONE candidate who passed ALL the short cases! Every other candidate failed at least one short cases, and most failed badly ie given a mark of 3. Many failed the CVS and Neurology stations. More surprisingly, many were discovered to display poor examination techniques, and missed gross physical signs like past pointing in cerebellar syndrome, or prothetic click in an MVR. There were a number of candidates who failed 2 short cases, total average score in short cases <50%,>50%, but still failed the overall exam because he failed 3 out of 4 short cases.

Calibrating the examiners - Has the gap narrowed or remains in status quo?

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.

HOT TIPS FOR MMED

First of all, let me tell you the experience of sitting in a panel of 'MMED exam Vetting'. The panel is led by a senior Professor and members represent lecturers from all the three universities. Each of the University will be given 'assignment' eg. To pick a number of questions on Cardiology, Neurology etc. Each of those questions, be they MCQ, MEQ whatever, will be discussed. Here's how they select the questions.

First, the question must be easily understood by all the members present. If one of the members strongly object a question with good reason, most likely the question will be turned down.

Second, for MCQ for example, it should be 'answerable' by all the members in the panel. Generally if most of them think they can answer 3 out of those 5 items, the question is considered ok.

They will then go on to change wordings and phrasing of the question as necessary.

Where all the members are unable to explain certain doubts, they will either refer to 'Google' the material on the internet, or simply ring the respected specialtists to get clarification.

Sometimes they do change the questions completely, in order to make the question more 'understandable' and 'answerable'.

For MCQ, of course you understand what is called Bloom Taxonomy (I don't really, just know it superficially…). Each question can be given a grade of difficulty and whether it tests comprehension, deduction, logic etc. Good set of MCQs should contain mixtures of those.

What I am trying to put across here, is that, the examiners also have 'difficulty' in creating and finalising questions for the exam. Since all of them are Generalists and Specialists in their field, when it come to subjects beyond their specialty, their knowledge is probably just above an average MMED candidate! (Presumably their vast amount of experience in Medicine help them to understand things in broader sense…). Knowing this could be very useful, since then, you probably think that, no question is really difficult. If you find one as such, it is either you have not been studying (enough!) or that there are certain wordings or terminologies in the question that you need to understand deeper. Once this is overcome, you should be able (as an average performer) to answer at least 60% of the questions correctly. This applies to MCQ, MEQ, Problem solving etc.

Sample of MEQ

Unlike Problem solving, in MEQ information is presented in stage. You should answer each package on itself, ie based on the currently presented information. Basically, step by step approach. It is common that in MEQ, you will not have any clue of what is the final diagnosis till near the end. So, just go by the flow…

Package 1

A 45 year old lady was admitted due to chronic cough and difficulty in breathing. She was well until about three months earlier when she had productive cough and fever. She was admitted to a private hospital and treated as community acquired pneumonia. Her symptoms partially improve after one week admission.

She continued to cough with whitish sputum. There was no haemoptysis. She claimed has normal appetite but has lost about 7kg of weight. She is non-smoker. Her grandfather has pulmonary tuberculosis.

On examination, she was mildly dyspnoeic. She was not pale or cyanosed. Her temperature was 37.5C.There was no lymphadenopathy. There was fine crepitation heard over the right middle and lower zones. The left lung was clear.

1. Discuss the differential diagnosis
   

Your differentials should cover broad possibilities like unresolving pneumonia, cryptogenic organising pneumonia, atypical pneumonia, absess/empyema, Pulmonary TB and lung Ca

1. List 5 investigations that you would like to do at this stage. Give reason
   

Remember, at this early stage, you are talking about basic investigations that include things like CXR, ABGs, FBC, Blood/sputum cultures, atypical pneumonia titres and perhaps Mantoux

Package 2

A 45 year4 old lady à chronic cough and difficulty in breathing à loss of weight à crepitations over the right middle and lower zones.

The results of investigations were as follows:

1. Blood count
   
2. Hb 9.8
   
3. TWBC 8.6
   
4. Plt 250,000
   

2. ESR 110mm/hr

3. Arterial blood gases

pH 7.36

pO2 77

pCO2 38

HCO3 23

O2sat 91

1. Mantoux test 9mm at 72 hours
   

CXR:

Comment the above investigation results

Describe the abnormalities seen in the CXR

(Xray showing Alveolar opacification of the right lower zone obscuring the right hemidiaphragm and lower end of the right heart, suggestive of consolidation)

Package 3

A 45 year old lady à chronic cough and difficult in breathing à loss of weight à consolidation over the right lower zone

CT scan of thorax was performed

1. Describe the abnormalities in the CT scan
   

Massive right pulmonary consolidation involving right basal segments of the right lower lobe and middle lobe

1. State the differential diagnosis of the CT findings
   

Lung Ca, Connective tissue disease

1. State further investigations that you would like to perform
   

Autoantibodies, bronchoscopy and transbronchial biopsy

A 45 year old lady à chronic cough and difficulty in breathing à loss of weight à consolidation over the right lower lobe and middle lobe

The screening for connective tissue disease was negative.

Bronchoscopy and transbronchial biopsy was performed. The histology was reported as bronchoalveolar cell carcinoma.

1. State the stage of her lung cancer
   

Since it involves both lobes, this is advanced lung Ca stage 4

1. Outline the management of her lung cancer
   

Include everything from counseling the patient on diagnosis, counseling the relatives, palliative chemotherapy, treat underlying infection, manages her electrolyte balance etc.

A 45 year old lady à chronic cough and difficulty in breathing à loss of weight à consolidation over the right lower lobe and middle lobe à bronchoalveolar carcinoma

She agreed for palliative chemotherapy. While waiting for chemotheraphy to be administered, she suddenly develop sudden onset of chest pain. It was associated with worsening dyspnoea. On examination she was dyspnoeic and tachypnoeic. The blood pressure was 120/70 and HR 120/m. there was no new respiratory or cardiac findings on examination.

What is the most likely diagnosis?

Didn't know? Has got to be PE

State 3 further investigations that you would like to perform.

CXR, arterial blood gases, D-dimers, CTPA

A 45 year old lady à chronic cough and difficulty in breathing à loss of weight à consolidation over the right lower lobe and middle lobe à bronchoalveolar carcinoma à sudden onset of chest pain

Her ECG revealed sinus tachycardia. She is hypoxaemic. A CTPA confirmed a pulmonary emboli in the right main pulmonary artery.

Outline your management at this stage

This is on how to manage PE. Goes from option for thrombolysis to short and long term anticoagulant. Screen the peripheral limbs for DVT

PROBLEM SOLVING

A 50 year old man presented to the A n E Department. He had been unwell for the past 3 weeks with fever, night sweats, non-productive cough and loss of appetite. He woke up on the morning of admission coughing out red blood, feeling breathless at rest and unable to move his right foot fully.

Examination whowed he had a respiratory rate of 40 breaths per minute. Blood pressure was 140/80 mmHg, pulse 110 regular, temperature 39C. there wer multiple splinter haemorrhages in all fingers of both hands. His maxillary sinuses were tended to palpation. A soft systolic murmur grade 2/5 was heard at the left sternal edge with no radiation. There was bronchial breathing dound in the upper zone of both lungs. Power of right ankle dorsiflexion was 2/5. No rash or peripheral oedema was noted.

Hb 9.7

WCC 6x109

Plt 733x109

Na 138

K 5.5

Urea 29.3

Creatinine 344

Albumin 30

Ca 2.24

Alt 30

ALP 63

Urine analysis

Protein 0.25

Ery 22/ul

Leu 1/ul

Red cell casts found

CXR :

Consolidation with several cavitaging lesions measuring 3-4 cm in both lung apices

Blood cultures x 3 no growth

1. Give four important interpretations of the investigations shown (8marks)
   
2. State one complete unifying diagnosis
   
3. Suggest three further investigations to confirm the diagnosis, stating also the results you would expect (6)
   
4. Outline your short and long term management of this patient
   

1. Acute renal failure (Ca normal)
   

Glomeruolnephritis (RCC)

Cavitating pneumonia/pneumonitis

No evidence of bacterial infection

Normocytic anemia (1 mark)

1. Wegener's Granulomatosis (2) with renal (1) and pulmonary (1) involvement with mononeuritis multiplex of the right common peroneal nerve
   

1. ANCA testing – positive c-ANCA, positive also for proteinase 3 antigen
   

Renal biopsy – pauci-immune glomerulonephritis (+- crescents)

Nerve conduction studies – mononeuritis multiplex of right common peroneal nerve

Sural nerve biopsy – vasculitis of vasa nervorum

Echocardiography to rule out presence of vegetations/myxoma

1. Ensure adequate oxygenation
   

Fluid resuscitation with central venous monitoring

Careful monitoring of renal function

Renal replacement therapy if needed

High dose corticosteroids (either IV methylpred or oral pred 1mg/kg)

Cyclophosphamide (oral or pulsed intravenous)

Plasmapharesis

IV immunoglobulin

A 27 year old lady, G3P2 at 10 weeks pregnancy complained of acute onset of left sided weakness for 4 days duration. She had history of severe vomiting prior to the weakness. On the day of admission patient initially developed focal seizures involving the left upper limb and lower limb with secondary generalization, which lasted for few hours. Her 2^nd child was 6 months of age and she had no family history of epilppsy. Examination showed L hemiparesis. Other systems were unremarkable.

State 2 differential diagnoses

Ischaemic stroke – due to preeclampsis, HPT, SLE, antiphospholipid syndrome

Venous infarcts – due to sagittal sinus thrombosis

Space occupying lesion – tumour, abscess

Intracranial haemorrhage – AVM, aneurysm

State 3 investigations required for this patient

CT brain/MRI

Connective tissue screening

EEG

If CT normal – LP

State your immediate management

Control seizures – IV diazepam/phenytoin

Hydrate patient

Start anticoagulation

As for MCQs, questions that test knowledge per se, should be able to be tackled in a very straight forward way. It is either you know or not! Eg.

Regarding treatment for Heart Failure:

1. Addition of ARB on ACE-I improves prognosis
   
2. Digoxin reduces rate of hospitalization
   
3. Betablocker is contraindicated in NYHA functional class III
   
4. Calcium channel blocker increases cardiac death
   
5. Warfarin reduces risk of stroke
   

All of the above questions, are derived from clinica studies some of which as old as 15 or 20 years! Though you can make intelligent guest, one who has read reasonably extensively, and perhaps attended some of the cardiovascular symposium would have answers to the above within seconds. Correct answers are TTFTT.

Questions that test knowledge can be very straight forward (if you know) or can be 'difficult' one – if you have not enough grasp. In this case, perhaps you should limit your attempts with what you know, it's mostly safer that way. So, even if they are pure 'recall' test, they are not necessarily easy! Eg

Regarding management of severe sepsis

1. Clinical trials have failed to consistently demonstrate a difference between colloid and crystalloid in the treatment of septic shock
   
2. Norepinephrine has been sown to be superior to dopamine as a vasopressor in patients with persistent hypotension despite fluid resuscitation
   
3. Elevated serum procalcitonin levels is a good predictor to distinguish sepsis from nonseptic systemic inflammation
   
4. The time to initiation of appropriate antimicrobial therapy is a strong predictor of mortality
   
5. Combination therapy has been proven to demonstrate superior overall efficacy compared to monotherapy in gram-negative septicaemia
   

Like the question on digoxin in heart failure, stem B test our very fundamental grasp on daily clinical practice, since we mostly use NE over dopamine in septic shock. So those clinically orientated people will straight away answer True! However, all of these statements are backed by evidence, so it is either you know the evidence or not. If you don't, better not attempt it. If you know half-half, perhaps you can attempt it…correct answers TFFTF

In general, many of the less common diseases or syndrome for instance, if they are asked, the questions will be of those 'recall' type. They are seen as difficult, but if you have come across them or learn them somewhere, you are the lucky one. Eg

Tuberous sclerosis (err when did I last hear about this?)

1. Is inherited as autosomal recessive
   
2. Is characterised by the development of multiple hamartomas distributed at various sites throughout the body
   
3. Tends to affect bone marrow
   
4. The earliest visible sign is facial angioma
   
5. Mental retardation is a feature
   

Either you know or not, isn't it? Of note, the vetting committee usually will not allow statement like B to appear, because they are actually a combination of two sentences, therefore, if one part of it is false, the whole sentence becomes false. This is considered unfair to canditates. Same like in C, you will not come across answer like 'Tends to affect the skin, brain, eyes and bone marrow' – since, though this statement appears wholly true, the truth is now 'contaminated' by the eyes!! Correct answers for the above FTFFT.

Another example in rheumatology

Regarding viral infections and inflammatory arthritis:

1. Parvovirus B19 infection is known to lead to chronic erosive arthritis
   
2. The arthralgia of Chikunguya infection responds to corticosteroids
   
3. Infection with HIV improves rheumatoid arthritis activity
   
4. Infection with HIV improves psoriatic arthritis activity
   
5. Symptoms of reactive arthritis will improve is the original viral infection is treated
   

I hardly could recall the above, but it sounds like B is true, E is false. The rest…guestwork? Correct answers here TTTFF

While some questions test your knowledge plus deduction eg

Transfer of patients with ST-elevation MI to Percutaneous Coronary Intervention Centres should be considered in the following situations

1. When fibrinolytic therapy is unsuccessful
   
2. When cardiogenic shock occurs
   
3. Patients presenting less than 3 hours of chest pain onset
   
4. In patient presenting with large anterior infarcts, 6 hours from the onset of pain
   
5. In asymptomatic patients with late presentation
   

Some of this information can be obtained directly from the guideline, while others require your logic and deduction, understanding the pathophysiology of acute MI. Correct answers TTFTF

This one tests understanding:

A 78 year old man had sudden onset of right sided hemiparesis two hours ago. The following are true:

1. Hypertension is the most important risk factor
   
2. The presence of dysphasia indicates cortical involvement
   
3. Aspirin cannot be given before a CT scan of the brain is done
   
4. Recombinant tissue plasminogen activator (r-tPA) is indicated if the CT scan shows the infarct
   
5. Blood pressure of 180/90 mmHg should be treated with IV antihypertensive agent
   

Whatever it is, E definitely sounds false even to orginary laymen…correct answers TTFFF

Some do test mixture of scientific and clinical knowledge, almost a pure recall too, but it calls for your understanding of the subject eg

Regarding COPD

1. Best documented genetic risk is present of circulating inhibitor of serine protease
   
2. The risk for COPD in smokers in dose-related
   
3. The pattern of inflammation is characterised by neutrophils, macrophages and B-lymphocytes
   
4. Emphysema is most associated with gas exchange abnormalities than with reduced FEV1.
   
5. Pneumococcal polysaccharide vaccine is recommended for patients > 65 years old.
   

Correct answers TTFTT

Fit to be a Clinician - welcome to the Clinical exam!

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.

Tips for MMED...

I have to withdraw the earlier posting and perhaps re-post it next week...

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

PBL MYOCARDIAL INFARCTION

PBL MYOCARDIAL INFARCTION

Trigger
Mr. Hafiz, 57 year old retired Manager, has a history of type II diabetes Mellitus for 7 years and hypertension for 15 years. He is a life long smoker. Mr Hafiz presented to the Emergency Room with 2 hours history of severe central chest pain accompanied by syncope.
On admission he is alert and conscious but in obvious distress.
You are the House Officer on-call. Outline your management plan on this patient.

History of Present Illness
Mr. Hafiz is a 57 year old ex-Manager of a hotel. He has 7 year history of Diabetes, and long standing hypertension. He attends the Endocrinology Clinic for his Diabetes. He has been completely well up to 4pm today when he suddenly developed increasing chest pain while gardening. His pain is described as constricting, located at the centre of the chest, radiating to his neck. He noticed sweating and nausea. While on his way by ambulance to the hospital, he felt breathless and obtained mild relief from the oxygen.

Past Medical History
Diabetes Mellitus – 7 years
Hypertension – 15 years
No surgical history

Family history
Father died suddenly at 55, also diabetic. All other family members well. Has 3 brothers and 2 sisters, all well. He is the eldest in the family.

Social History
Smoker – 20 cigarettes a day for 40 years
Does not drink
Retired Manager, doing light work at home. Lives with his wife.

Physical Examination
Alert and conscious but in pain. He looks pale, no jaundice or cyanosis. No pedal oedema. He has normal temperature, BP 135/85, pulse rate 100 per minute, Respiratory rate 20 per minute.
Cardiovascular system:
He has bilateral corneal arcus and xanthelasma on his left eye.
The JVP is normal. Heart sounds 1st and 2nd heard as well as 3rd (gallop). There is no murmur or other added sounds.

Respiratory examination
Normal chest expansion. Equal air entry with moderate bilateral fine crepitation at both lung bases

Abdominal examination
Soft, non tender abdomen with no organomegaly.

Nervous System
Full GCS. Normal tone, power, reflexes and sensation symmetrically.

Investigation:
ECG
CXR
FBC
Biochemistry
ABG
Urinalysis: glucose 2+
ECG later
Coronary Angiography
Creatine Kinase 258 U/L (24 - 204)
Troponin-T 0.06 ug/L (0 – 0.1)

Renal Profile
Sodium 136 mmol/L (135 - 150)
Potassium 3.5 mmol/L (3.5 - 5.0)
+ Urea 21.2 mmol/L (2.5 - 6.4)
+ Creatinine 155 umol/L (62 - 106)

Liver Function Test
- Albumin 30 g/L (35 - 50)
- Total Protein 64 g/L (67 - 88)
+ Bilirubin Total 75 umol/L < 23
+++ ALT 1691 U/L ( < 44)
ALP 86 U/L (32 - 104)
+ Creatine Kinase 321 U/L (24 - 204)

White Cell Count 12.6 x10^9/L (4.0 - 10.0)
Red Cell Count 4.65 x10^12/L (4.5 - 6.3)
Hemoglobin 14.4 g/dL (14.0 - 17.0)
Hematocrit 41.8 % (39.0 - 52.0)
Mean Cell Volume 89.8 fl (77.0 - 91.0)
MCH 30.8 pg (26.0 - 32.0)
MCHC 34.3 g/dL (32.0 - 36.0)
RDW 13.1 % (11.3 - 14.6)
Mean Platelet Volume 8.5 fl (6.3 - 10.2)
Platelet 212 x10^9/L (150 - 400)
Fasting Serum Lipid
Triglycerides 1.7 mmol/L < 1.40
Total Cholesterol 5.9 mmol/L <5.0
- HDL-Cholesterol 0.85 mmol/L >1.20
LDL-Cholesterol 3.8 mmol/L <3.0

Fasting Glucose 5.1 mmol/L (3.0 - 6.7)

ABG
+ pH 7.32 (7.35 - 7.45)
- pCO2 32.0 mmHg (35 - 45)
+ Std Bicarbonate 23 mmol/L (22 - 26)
Base Excess 1.7 mmol/L (-3 - +3)
+ pO2 80 mmHg (65 - 100)
+ O2 Saturated 98.0 % (90 - 96)

The patient was given oxygen, morphine, GTN and Aspirin 300mg. He was immediately thrombolysed with tPA and the ECG showed some resolution of the ST segment elevation. He was transferred to the Coronary care unit.
One hour after arrival he developed weakness and sweating. The monitor showed Ventricular Tachycardia. 100mg IV lignocaine was administered with immediate resolution. He was continued on heparin, aspirin, metoprolol and clopidogrel.
The following day coronary angiogram performed. This showed severe mid Right coronary artery stenosis and severe stenosis of the left main stem. Left ventriculography showed good left ventricular ejection fraction with no evidence of mitral regurgitation.
He was stable in the CCU. Echocardiography confirmed good left ventricular function with hypokinetic inferior wall. He was referred to the Cardiothoracic Surgeon for coronary artery bypass surgery.