Examination Medicine: A Guide to Physician Training (6 page)

At the end of the time a bell will ring and the candidate is taken to begin the short-case examination (
Fig 3.1
). There are a few minutes available, however, for drinking weak orange juice. Many candidates ask the proctor attendant about their performance. We believe this to be an unwise policy, since the resident medical officer is usually junior to the examinee and so is liable to give an incorrect assessment or an inappropriate cryptic remark, such as, ‘You were very unlucky this time’.

FIGURE 3.1 
A candidate presents her short case findings.

The candidate is then introduced to the short-case examiners. The examiners for the first short case are never the same as those who examined for the long case, but you may see the long-case examining team for your second short case. Again, one examiner in each team will be a member of the CFE or NEP. Fifteen minutes is allowed for the first short case; a second short case is then examined after a 5- or 10-minute break. The new examination system does not allow for more than two cases per session. This, and the extension of time to 15 minutes for each case, means that examination of each patient is a little less rushed. However, the result of this extra time means that there is a greater opportunity for the examiners to ask questions related to the physical findings. The examiners assess five domains during the short-case examination:

1. 
the way the candidate approaches the patient

2. 
the thoroughness of the candidate’s examination technique

3. 
the candidate’s accuracy in detecting physical signs

4. 
the candidate’s ability to offer a diagnosis on the basis of the findings

5. 
the candidate’s ability to use investigations to support the physical findings.

The key criteria and the skills that are required to achieve a satisfactory standard are available from the College or the DPE. Examining centres have also been told to have X-rays, CT scans, MRI scans and electrocardiograms (ECGs) available for discussion. If technology has achieved anything, it has made it more difficult to find X-rays and scans for candidates. Most hospitals have electronic storage of scans. There is often a problem logging on to the system and preventing the screen from turning itself off every few minutes. This tends to cause episodes of panic for the proctor attendant and organisers (and sometimes the examiners).

The other half of the candidates do this routine in the reverse order.

After lunch the second session begins, and this time the order of the short and long cases is reversed for each candidate. There is no longer provision for extra short cases for candidates who are thought to be borderline.

The marking system

The mark required to pass the examination is 40. Each long case is worth 21 marks and each short case is worth 7 marks – so the total mark possible is 70.

The mark awarded for each short case is out of 7, as follows: 1, very poor performance; 2, well short of expected standard; 3, short of expected standard; 4, expected standard; 5, better than expected standard; 6, much better than expected standard; 7, exceptional performance. In 2006 part marks were introduced for the short case, so now for both the long and short cases the scoring system incorporates positives and negatives (part marks) between 1 and 7, giving a 19-point scale. The use of part-marks helps some candidates who are very close to a pass overall. For example, if the examiners agree that a candidate’s performance was better than a 4 but not deserving of a 5, a 4+ is awarded, while if the candidate’s performance was much better
than a 4 but not deserving of a 5, the mark will be a 5–. When the marks are added up at the end of the day, for example, 4+ will be 4.33 and 5– will be 4.67. Once a ‘raw score’ out of 7 is awarded, it is weighted; the long-case scores are multiplied by 3. This means that it has been possible to pass the exam with two good long-case scores, but without passing any short case. The examiners have begun to suspect that some candidates have decided preparation for the short case is not very important and have been concentrating on their long cases. From a candidate’s point of view this may seem a reasonable strategy, but it may mean suffering embarrassing humiliation in front of the short-case examiners. From 2013 the rules have been changed so that candidates must pass one short case at least to obtain an overall pass. We would argue this is still too lax!

The examiners try very hard to be fair. Each candidate’s performance is discussed at the end of each long- and short-case session. Each examiner scores independently: if there is disagreement about a mark, this is discussed and a consensus mark is chosen. If the examiners cannot agree, the NEP member has the final say. Examiners record any special considerations that may have caused difficulties for the candidate (and flag the assessment sheet with the infamous ‘red dot’), so that these can be considered later by the executive, if necessary. The Chief Examiner of the day (always a member of the CFE or NEP) is responsible for collecting the marked score sheets and dealing with any red dot matters. The examiners do not know the candidate’s marks in other sections of the exam (including the written examination), and therefore they do not know the effect of their own mark on the candidate’s overall success or failure. The examiners see the same short case four times with four candidates. They give a mark at the end of each session and cannot change this after assessing the other candidates’ attempts at the same case. The examination is not meant to be competitive. This means that every candidate can pass if the required standard is achieved.

Rather than trying to pass candidates (as at undergraduate level), the examiners are trying to evaluate the true standard of each candidate. Examinees must prove to the College that they are ‘good enough’; that is, they must demonstrate that they have mastered the material and have reached the required standard. The standards are very high, but the College emphasises to the examiners that the standard is that which is required for a person to enter advanced training and not the standard expected of a consultant physician. The rationale for this approach is that trainees who are likely to begin training in a sub-specialty should know how to examine all the systems of the body properly and have a sensible approach to the management of medical problems outside their specialty. A senior chest physician, for example, will always be able to boast that he or she once knew how to expertly examine the cranial nerves.

To achieve uniform standards, the CFE has been constantly working on improvements. Senior members of the CFE examine more often with less-experienced examiners. The CFE also holds regular formal calibration exercises, in which all examiners view video recordings and mark a candidate’s performance. A general discussion is then held to try to develop a uniform approach. The calibration is far from perfect; however, the CFE is working towards eliminating obvious mistakes.

NEP examiners are given a chart showing where each of them sits as to the average mark he or she awards. There is surprisingly little variation between examiners considered to be hawkish and those with a reputation as doves. Experienced examiners submit reports on their junior colleagues at the end of the exam period. This helps the examinations committee choose new members for the NEP. If there is a disagreement between examiners about the suitable mark (a rare event), the NEP member can override the co-opted local examiner.

The overall pass rate (for the written
and
viva examinations) in any one year in the
past was about 40%. The eventual pass rate after success at the written examination and over four vivas (the old system) approached 85%. Under the new system, the pass rate has increased to 70% or more for the clinical year.

The mini-CEX

In 2008 the mini-CEX was introduced for basic trainees in their final year and is now used in all years of basic training. This is quite separate from the clinical examination and although it has to be performed, it does
not
count towards marks in the formal clinical examination. The trainee undertakes four mini-CEX exams a year, usually in the trainee’s own hospital and marked by the DPT or a suitably trained delegate. Each exam lasts about 30 minutes and is a cross between a long and short case. The trainee is introduced to a patient and given a clinical problem; for example, ‘Mr Smith has had problems with dyspnoea for a year and has noticed a recent deterioration in his symptoms. Please take a relevant history and examine him.’ The trainee is expected to ask directed questions about the symptoms and then examine the relevant system or systems of the body. This is all observed by the examiner. The trainee then presents the findings and a differential diagnosis, and suggests investigations and possible treatment.

Preparation for the clinical examination

For one mistake made for not knowing, ten mistakes are made for not looking.

JA Lindsay

The clinical examination aims to test not only clinical ability but also attitudes and interpersonal skills. For most candidates a successful approach to the viva depends on seeing a large number of long and short practice cases (
Figs 3.2a
and
b
). It is usually too late to start practising these cases after passing the written examination; preparation should start at least several months beforehand.

FIGURE 3.2(A) 
Short case practice.
¹

(B) 
Long case (guess who the examiners are).
²

To practise for the long cases, try to set aside a regular time each week. Most physicians, if approached, are only too willing to test-run candidates. Being exposed to many different examiners (of variable severity) is desirable. It will help iron out mistakes and provide practice in answering different types of questions. Although most teaching hospitals have a training scheme in which long cases are examined by consultants or senior registrars, this is not enough. It is difficult to quote numbers, but we believe 50 formal long cases (across all disciplines) in which different specialists and senior registrars act as examiners represents the bare minimum requirement for preparation.

Practice examiners have not usually interviewed the patient and are therefore not quite like the real examiners. This does make a difference to the way they will mark your case.

Remember also that each time a patient is admitted to hospital, practice can be gained in the long-case technique – this turns overtime into useful preparation time. Practising cases is also critical in order to be able to cope with management problems in Paper 2 of the written examination.

Many candidates now video-record their long case presentation practice cases. This can be a useful way of assessing your technique. A number of recorded cases are available from the College. The cases in this book are available via Inkling with our enhanced eBook edition and via Student Consult with the print book.