Facing the Examiner in the FCPS 2 Exam in Medicine.
It is time for you to be assessed in the knowledge and skills that you have acquired in the last four years of your training. Some of you underwent the training earlier maybe several years ago and have settled into a routine you use daily with your patients but shortcuts have slipped in and methods not academically acceptable are being used by you. These may appear to work but may actually be delaying the diagnosis or needing to be supplemented by a lot of tests which may be unnecessary. Unconfirmed diagnoses are being treated with shotgun therapy. So candidates who have been practicing on their own need to go back to basics so that they may be successful in the exam.
First please remember there is no “formula” which must be followed. Rely on clinical common sense. One common cliche to remember is that common things are common. A runny nose is most likely caused by a common cold and least likely by CSF rhinorrhoea! Anemia is most likely caused by either a dietary deficiency or a bleed somewhere rather than an HLTV causing a rare leukemia. Ask about the diet. The daughter of a domestic cleaner is very unlikely to eat meat, chicken and eggs daily. Ask her what the menu is on a typical day in her home. That is why a personal history becomes important in history taking. If the patient appears well fed then skip the diet.
Another simple rule to impress the examiner is to talk to the patient politely and in a socially acceptable manner. Don’t shout or bark questions at them. Many trainees who come from a hospital OPD and its noisy environment tend to shout loudly. Being asked “Do you have heavy periods?” or “Do you have problems during sex since you started taking this medicine?” are not questions the patient wants the whole hall to hear.
You do not have to ask detailed questions about every symptom that either you or the patient has mentioned. If the patient mentions fever ask if he or a doctor or nurse ever used a thermometer to document it but if the patient only feels feverish please do not spend time in the usual litany of “Is it in the morning or evening; is it high or low; is it with a rigor; etc” Remember your clinical acumen is being assessed as well as your ability to evaluate the significance of the patient’s symptoms.
The patient may not tell you immediately about the essential symptom because either they are afraid or do not understand the importance themselves; weight loss and poor appetite, somnolence are some that are missed unless you ask them. Understand the relevance of the questions you ask. You may be asked why you wanted some particular information. Please refrain from asking questions just to show that you know about a disease especially if the patient does not have the disease. It may backfire.
Remember the guidelines commonly used for either the diagnosis or for assessing the severity of an illness and also remember who has set the guidelines and when. You may be quoting outdated guidelines. For example there are guidelines for assessing the severity of esophageal varices and there are differences in the treatment of each grade; kidney diseases are divided into stages dependent on creatinine clearance; the severity of heart failure has its own guidelines so does COPD. There are many others.The real test is how you present the information you have gathered. You will need to edit the information that the patient has given you into a form that makes clinical sense, The trick is not to miss out an important detail. If you understand why you asked certain questions and if you understood the answers not just the language; the relationship of the question to the diagnosis and how the answer clarifies the clinical problem, then your presentation will be good. Here is where you think about why, what and how: why am I asking this question?
- Be polite but not obsequious i.e. excessively polite.
- Remember the answer to your questions so that you do not have to repeat everything.
- Write down an important point but do not write down the answer to all your questions.
- Evaluate the information you are getting from the patient and divide it in your mind into
- essential information or the reason that the patient is seeking help. If you get this wrong you are going to get your whole diagnosis wrong.
- information that will help in making clinical decisions like is the patient a diabetic or has renal failure or is allergic to a drug or make the diagnosis clear.
- incidental information which may or may not influence the diagnosis and treatment.
- When you present the history do it in the above order.
- Why did the character of the pain or symptoms change?
- What difference does the answer make?
- What is the duration of the symptoms? Is it chronic or acute? Longstanding or recent?
- What weight-age should I give the answer?
- How did the disease progress? Is it getting worse or is a new complication developing? Remember most patients come to us with complex diseases or more than one disease.
- If the disease is infective pay attention to the epidemiology; where did the patient get it? Has the patient passed it on to someone else? Does the patient need to be treated in isolation? Do you or your staff need to be shielded from the disease?
- Why did the patient take so long to come to a hospital or consult a doctor? The reason may be financial or lack of access to medical care for geographical reasons, lack of awareness or treatment by practitioners of alternate treatment or by a doctor who had got the diagnosis wrong. I once came across a 12 year boy drugged to the gills for the last 1 year, with antiepileptic drugs, so drowsy that he had stopped going to school. His episodes of hypoglycemia were giving him the fits and eventually the insulinoma was removed and he no longer had epilepsy.
- What treatment has the patient already taken? How has this treatment modified the symptoms or the signs?
- How am I going to present the case? Which symptom or symptom complex should I talk about first?
When you are presenting the case and want to make a good impression change the the emphasis from the written history. In the written case file, you are required to write the patient’s bio data first e.g. name, age, marital status, occupation, home address, telephone, next of kin, person to call in an emergency. Do not recite all this when you are presenting the case. During the presentation it is sufficient to give the name, age, occupation briefly and what the patient was doing at the time of onset of the symptoms if this was sudden or related to exercise and duration. Start with the most significant symptom or symptom complex. Talk about the co morbid conditions or lack of them; talk about the medication the patient is already taking. You can give the personal information after you have given the clinical information.
Try to give the information in your presentation so that you are leading up to a probable diagnosis. Even if your initial diagnosis is not accurate it does not matter. You can make up for it when you are presenting the clinical findings. Just randomly presenting symptoms without leading towards any diagnosis leaves a poor impression.
For example “This patient vomited blood two days ago. He has had no malena i.e.black tarry stool so it appears to have stopped. He has not had jaundice in the past, is not an alcohol drinker and has not been tested for Hep B or C.” This case may turn out to be a malignant peptic ulcer or even a bleeding disorder but you have shown clinical acumen by talking about liver disease and have scored good marks on presentation.
Or another example: “This 56 year old-lady, who is a school teacher, has come in with swelling of her feet for the past 5 days. She is not breathless and has no cough. She is diabetic but has never had her urine tested for proteins. Her blood pressure is also high so her major risk is either from diabetic nephropathy or hypertensive nephrosclerosis. After assessing her renal functions she may need a renal biopsy to clarify the diagnosis”. by saying this you have pre-empted a lot of questions and have exhibited your knowledge. The examiner then has time to ask you questions about management, recent advances, research and give you a better score.
Have fun preparing. Lots of confidence is what is needed. The examiner is not out to kill you only to help you pass.