Not reading the instructions carefully
Read the task as well as the patient problem. The verbs in the instructions matter, as do the limits stated in the questions. For example:
- If the task is to conduct a focused history, then you will only get credit for taking a history in a clinically appropriate manner. You will not get credit for educating the patient or advising him or her when the assigned task is to take a history.
- If the task is “assess and advise” OR “discuss” OR “counsel”, then will get credit for tasks like eliciting key information about the patient’s problem, understanding how the patient perceives the problem, AND for actions like advising the patient, providing information and recommending follow-up, depending on the nature of the presenting problem.
- If the task is “assess and manage”, then you will get credit for assessing the patient (e.g., relevant history and/or physical exam) AND for managing the problem, which may include ordering investigations and making immediate treatment decisions.
In each station, you must decide what information and actions are the most clinically relevant, given the patient information provided in the instructions AND the time allowed. Ensure that you have a list of priorities.
Asking too many questions
Asking as many questions as you can, especially if done in a rapid-fire, disorganized fashion, in hopes of asking enough of the right questions, is not a good strategy. The relatively short amount of time allowed for each task requires that you organize your approach, preferably around a differential diagnosis or around generating a differential diagnosis.
Misinterpreting the instructions
Sometimes candidates approach a station by trying to figure out “what is on the test”, rather than basing their actions on a clinically appropriate approach to the patient problem. For example, the patient information describes a belly pain problem and you are asked to conduct a focused physical examination. Even if a complete basic abdominal exam is performed (inspection, auscultation and palpation of the four quadrants) it is generally not sufficient to achieve a good rating on the station. You may have conducted some maneuvers that were irrelevant to identifying the most likely diagnosis.
The emphasis in a focused physical examination should be making a diagnosis and ruling out differential diagnoses. In the preceding example, an abdominal examination is certainly important but based on the patient information given to you and whatever findings (or lack of findings) you discover, there are other maneuvers and/or systems you will need to assess to rule in or rule out your differential diagnoses.
Using too many directed questions
Using open questions is helpful in this exam, just as it is in clinical practice. While the broad question “Tell me why you are here” may not lead patients to share all the information you need, it will certainly provide a starting point. Questions such as “Can you describe the pain for me?” or “Have you noticed any other changes?” are helpful. You will likely have to follow up with more directed questions to get the full picture from the patient but it is easier to start with their initial comments than to run through endless “yes/no” questions that limit the patients to saying yes or no.
Remember that, as in real life, patients cannot report what they do not have and may not report changes that do not relate to the presenting problem. However, your score is based on eliciting critical information, not only on eliciting specific pertinent positives. If a patient says he or she has no other symptoms but you need to know whether there has been any weight loss or specific neurological changes to determine the diagnosis, then you should ask specifically about these points.
Not listening to patients
Patients often report that candidates do not listen to them and therefore miss crucial information. If a patient’s answer is not clear AND the issue is important, then explore further. For instance, you ask the patient if he or she has ever had this problem before and the patient responds with “not like this”. You may want to know what was meant by this statement.
If you appear indifferent to their concerns, the patients are expected to react accordingly – you will get less information from them. They are not required to give everyone their whole story. You are expected to elicit their story. And as in clinical practice, patients will be reluctant to confide their underlying fears or embarrassing information if they feel you are indifferent, judgmental or hostile to them.
Not explaining what you are doing in physical examination stations
Please note that you cannot receive credit for genital, rectal or vaginal examinations unless you indicate to the examiner that you would do such an exam. In most cases, the examiner is given findings to report to you, but he or she can only do so after you state which examination you would do.
Saying what you are doing when examining a patient will aid the examiner in scoring you. You do not need to justify what you are doing – just state it. For example:
If you inspect the abdomen before auscultation but say nothing, the examiner is left guessing whether you did inspect the abdomen or if you were frozen momentarily.
Indicate when you are doing light palpation or deep palpation so the examiner can better judge your technique. If you only do light palpation and don’t specify, the examiner will not be sure what you intended.
Report positive findings – pain, loss of range of motion, difficulty with gait, shortness of breath, etc., so that the examiner knows that you observed the finding. Similarly, stating that there is a lack of findings or that what you found was normal can be helpful. For instance, informing the examiner that bowel sounds are normal.
Not providing enough direction in management stations
In management stations where a nurse is present, remember that he or she is there to help you. However, you must provide clear directions. If the nurse asks for more direction, answer as best you can, as clarifying what you want will likely improve your performance.
Missing the urgency of a patient problem
With urgent patient problems where an acute problem or trauma must be managed, set clinical priorities. Do the most important things first, then go back and get more information, if you need it, or make further orders. Beware of ordering investigations or treatments by rote before you understand a particular patient’s situation. This can be dangerous in practice and will be flagged as such on your examination sheet.
Talking too much
Sometimes candidates talk so much while with the patient that they lose valuable time and miss information. Efficiency does not exclude the professional courtesies of introducing yourself or explaining briefly why you need to ask a difficult question or conduct a painful maneuver; however, it is not necessary to talk incessantly. You are expected to speak to the patient in language that he or she will understand, not to quote textbooks to the examiner. Your manner tells both the patient and the examiner a lot about your attitude to the patient; you do not need to do it all with words. Avoid lecturing and showing off.
Giving generic information
In some stations, you are expected to provide the patient with information or advice relevant to his or her problem. Some candidates seem to miss the purpose of these stations and only offer very general statements like “There are risks associated with X and you should really do Y.” If you are expected to advise a patient then you are expected to provide him or her with the quality of information that reflects your abilities as a physician, assisting in informed decision-making by the patient and going beyond what is available in the public domain.
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