The FCPS examination is drawing near. All the candidates are boning up for the exam. Most will fear failing the examination and having to bone up for it again. Why do people fail? Candidates spend their time making mental lists of the information in the textbooks and learning by heart and trying to reproduce it for the examiner’s benefit. The examiner is asking questions to match his clinical experience. That is why students are strongly advised to attend ward rounds right up to the time of the examinations and remember and learn the answers to the questions that the consultant is asking. The sort of answer that is expected is the sort that your consultant expects. Remember that examiners are clinicians who come from a busy ward or private practice to take your exam. They do not memorize long lists of causes or complications or esoteric clinical signs before the examination. You should not waste your time doing this either. So how should you prepare? Remember that in the long case and short case you are being asked questions relevant to the case you are being examined on. Do not give answers that do not fit in with your clinical findings.
An example is a patient with ischemic heart disease who has atrial fibrillation. When asked what is the cause of atrial fibrillation interpret “what is the cause of this patient’s AF” and do not start of with “thyrotoxicosis” if your patient does not have thyrotoxicosis. The examiner, without waiting to hear the other causes in your list will ask “Does this patient have thyrotoxicosis?” assuming that you think that is the cause in this patient, “What is the relationship between hypothyroidism and AF?”, “What is central hypothyroidism and do you expect AF in such a patient?” Look up Medscape. You will be spending your time being examined on thyroid disease for which you are not being awarded marks as your patient has ischemic heart disease. I would answer the examiner’s question as follows: I think this patient has ischemic heart disease and has been in long standing heart failure. I would like to see his X ray chest and ECG (you are allowed to see investigations that you ask for) I would like to do his echocardiogram and also I would like to check out his thyroid function tests as there is a condition called the apathetic thyroid where signs of thyrotoxicosis do not develop clinically. Most physicians will check out the thyroid functions in AF even when they do not suspect the thyroid to be the causative factor.
The commonest cause of AF currently is ischemic heart disease.
Please do not say “This patient is a known case of this or that disease. The patient may have misunderstood or misinterpreted the reason why a test is being done (a patient with epilepsy may be having his blood sugar checked repeatedly because his clinician is looking for hypoglycemic episodes and not because the patient has diabetes) and the patient tells you that I have diabetes because my previous doctor kept checking my blood sugar. You should check his blood sugar level to clarify the situation. All critically patients with diabetes need to have the blood sugar checked on entry, as well as the HbA1c level and the blood sugar needs to be checked at regular intervals to ensure that the treatment being used to control their diabetes is adequate. Just saying this is a known case of diabetes is not going to be of much help.
A “known case” of SLE comes to the hospital with severe breathlessness for the last 6 months which has worsened in the past 4 days. The question asked was what tests will you do for her now? The answer was “Blood CP” or complete picture. When asked will you check the SLE serology, the candidate answered “no she is a known case so I will ask for her old record.”The correct answer is “yes I will send her SLE serology after I have checked her oxygen saturation with a pulse oximeter and determined her current blood gas analysis and blood pH. The reason I will do the serology is that I want to know whether the original disease is SLE or a variant, and how active it is. I will then look for the WBC level and platelet count and the coagulation profile including anti cardiolipin antibodies and lupus anticoagulant.”
“Does your patient have pericarditis as chest pain is a prominent feature?”
“No because there is no pericardial rub”
“How often do you hear a rub in pericarditis?”
“35% of the time” The candidate has shown his/her own mistake. 65% of the time there is no rub.
Correct answer : “There is a possibility as it is a manifestation of SLE, I cannot hear a rub but I would like to do an ECG and echocardiogram.”
Display your knowledge before being asked a question.
So folks have fun trying out how to figure out what questions the examiner will ask and what answer to give.
I will write more about this soon. Throw out your textbooks, read the New England Journal, the BMJ, Medscape and UptoDate. Remember that you are not being examined in the part 2 on your clinical methods or ability to take a history. It is your interpretation of clinical signs, history taking and how you synthesize it into a diagnosis or differential diagnosis and what treatment you think appropriate to start which is important. Have fun rethinking your studies.