TSR Med Students' Society Part III

Could you justify why you'd want to test more microbiology/immunology as opposed clinical knowledge? Could you justify why an FY1 doctor would need to understand underlying pathology vs clinical scenarios?

Does anyone actually carry the BNF around with them on the wards? Seems like it'd be a pain to juggle that with OHCM/notepad and pen too.

Cos basic sciences underpin clinical knowledge?

It would be with a legitimate patient. Granted it won't be standardised as an OSCE but it does give examiners a chance to see how soon to be doctors would treat patients holistically. Maybe I could alter the way the long cases are done and use actors as opposed to real patients, although then you could be undermining the authenticity of the assessment. Then again OSCEs which are like the gold standard use actors sometimes so maybe thats not such a bad idea...

True point about the overlap. Hadn't thought about it - maybe an OSCE station on prescribing (which I imagine already happens at most medical schools anyway?). Apparently most errors with junior doctors seems to be down to prescribing and this was my rather feeble attempt at trying to solve that!

The only reason I wanted an extra pathology exam was because it is really underrepresented in the current medical school exam system. I think Imperial had (still have?) that extra pathology exam students sit in the 5th year - so it'll test stuff like microbiology, immunology etc.

I'm regretting being stuck in a two year contract with a rubbish phone! Although after it's up I'll definitely get an iphone. Cheers for the heads up!

Yeah it's Futurama New series this year, hope it lives up to the rest...

We have real ill patients in our 4th year OSCEs and a prescribing station (last year they asked students to prescribe blood - I can do antibiotics, warfa/heparin, insulin stuff, saline etc but don't think I would learn blood transfusion unless I'd known about it as I do now).

I would be against using actors in finals - granted the standardisation issue, but when you get to 5th year you should be competant in doing the examinations and you should be using patients who are ill because this is the last time you'll be assessed before going out into the 'real' clinical environment. Besides actors are much easier to examine than ill patients so you'll be able to see how students perform under stress.

Perhaps use double ended steths in blood pressure/CVS exams to make it fairer. We had double ended steths for blood pressure which made it fair as the examiner could check you were listening rather than making up a blood pressure value or saying that their pulse was weak etc.

What do you mean about the pathology exam - as in ordering tests?

Very good idea about the double steths, we used them in our B/P examination but the clinician examining us didn't put his one on.

The big issue with the standardisation in my head is would you be okay accepting a patient with a very discrete, difficult to notice murmur (using this example as my presentation is on this ) where in real life you'd shout for a consultant if you expected to hear one vs a patient with a very pronounced murmur? As this is in an examination it's unfair in my eyes for student X to have an easier time than patient Y.

Very good idea about the double steths, we used them in our B/P examination but the clinician examining us didn't put his one on.

The big issue with the standardisation in my head is would you be okay accepting a patient with a very discrete, difficult to notice murmur (using this example as my presentation is on this ) where in real life you'd shout for a consultant if you expected to hear one vs a patient with a very pronounced murmur? As this is in an examination it's unfair in my eyes for student X to have an easier time than patient Y.

Cos basic sciences underpin clinical knowledge?

Very good idea about the double steths, we used them in our B/P examination but the clinician examining us didn't put his one on.

The big issue with the standardisation in my head is would you be okay accepting a patient with a very discrete, difficult to notice murmur (using this example as my presentation is on this ) where in real life you'd shout for a consultant if you expected to hear one vs a patient with a very pronounced murmur? As this is in an examination it's unfair in my eyes for student X to have an easier time than patient Y.

Agreed. Knowing pathology and the causes of things is the only thing differentiating medics from the lady in Sainsbury's armed with wikipedia. The whole point is that we're supposed to know a bit more than the patients. The whole point of medicine - as opposed to Sainsbuy's lady 'oh he looks ill' is to systematically assess and quantify how ill and why. That's what you're paid to do - diagnose and treat. If you don't understand how the system is meant to work, and how it goes wrong, you cannot practice medicine - that would be called guessing.

The problem is (as I'm finding out in my bsc) that causality if very difficult to pin down...and the treatments are even harder

The only issue I'd have with real patients is that patient X could have a really discrete murmur where as patient Y's murmur could be really obvious. If you were only assessing how they treated patients as opposed to what they're treating then it would work. For example, would it be okay in the exam for a student to say "I couldn't hear a murmur" as long as they checked for one? Realistically they would call for a consultant to double check if they thought they would have one but that's not available in an exam situation.

So, if you're assessing something like attitude as opposed to knowledge then the full patient examination would be fine. Otherwise I'd question the validity of it. Actors would eliminate that and for examinations you could present them with scenarios. So, you could have a patient who you take a history and examine. Then you could be presented with information from the examiner like "imagine when you examined that patient they had a mid systolic low rumbling murmur".

While pathology is under-represented couldn't you just adjust the EMQ exam? If it's covering basic science and knowledge just slightly reduce the amount of basic science and add in more pathology? This is only suggestions though. Could you justify why you'd want to test more microbiology/immunology as opposed clinical knowledge? Could you justify why an FY1 doctor would need to understand underlying pathology vs clinical scenarios?

I think one of the major **** ups of junior doctors isn't due to the prescribing but due to interactions as well. Feel free to correct me as I can't source it at the moment. You could pitch scenarios such as this is patient X with A/B/C conditions what would you prescribe them? I think this would be a very useful examination but it would be done in a sort of SAQ style which is less efficient to the EMQ style of examination. I think it would be difficult to incorporate prescribing interactions into an EMQ style exam but maybe that's something you can work on.

We have real ill patients in our 4th year OSCEs and a prescribing station (last year they asked students to prescribe blood - I can do antibiotics, warfa/heparin, insulin stuff, saline etc but don't think I would learn blood transfusion unless I'd known about it as I do now).

I would be against using actors in finals - granted the standardisation issue, but when you get to 5th year you should be competent in doing the examinations and you should be using patients who are ill because this is the last time you'll be assessed before going out into the 'real' clinical environment. Besides actors are much easier to examine than ill patients so you'll be able to see how students perform under stress.

Perhaps use double ended steths in blood pressure/CVS exams to make it fairer. We had double ended steths for blood pressure which made it fair as the examiner could check you were listening rather than making up a blood pressure value or saying that their pulse was weak etc.

What do you mean about the pathology exam - as in ordering tests?

Hmm I'd expect examiners to be a bit stricter for finals.

Screen patients before recruitment so there aren't issues with borderline postivie clinical tests... but then you start to question the validity of the whole thing, if you're picking the 'healthier' ill patient - then that won't be representative of treating ill patients, but then again it's unfair on the patient too. However I don't think medical schools will be picking very ill patients.

Therefore (after a good deal of waffling) recruit patients for OSCE through a lax screening process so they are ill with fairly positive signs, and use double ended steths in BP/CVS stations.

The scenario type prescribing exam could work well I think, even with SAQs. They aren't the most accurate examination tools, but because it is only testing prescribing skills, that should make it a lot easier and fairer to allocate marks. It also means that you are testing a students ability to actually think of an answer and not just use the process of elimination to select an answer.The exam won't be worth a lot, but it would be still assessed so that doctors are still prescribing accurately.

By interactions. are you referring to comm skills? If so, that would be covered on one station in the OSCE or something. By final year though, you'd probably have had a lot of comm skills assessments by then - I'd much rather assess more practical skills.

The pathology exam would literally be testing specific aspects of your basic science (microbiology, immunology, haem, etc) because people just forget that useful side to medicine. Ordering tests will most likely fit into the prescribing exam or the one OSCE station or in the long case examination.

I was referring to drug interactions as opposed to comm skills. I was pretty drunk when I was posting this (I'd take anything after ~11pm with a pinch of salt) so most of it is utter crap.

How do you guys present clinical histories? I've been told that it should be broken into significant positive and negative findings. I was under the impression that this format is only for examinations and I'm not quite sure how it would be applied to history taking (risk factors, maybe?)

Any tips?

Don't do that for history presenting.

Start with the presenting complaint. So a sentence or a few sentences on the presenting problem. Then go to history of presenting complaint, where you elaborate on the back story of the presentation. Then go to each heading (past medical, drug, family, social, then systems review). Then it's often worth doing a summary.