Ece Story One
How to Prepare for the Exemption Clinicals
Friday, 25 August 2006
I recently passed the June 2006 Exemptions Candidate Exam (ECE). In this document I have described my experiences of the exam and how I prepared for it. This is not meant to be exhaustive, and is only my point of view. I hope it will be helpful to people about to sit their clinicals. There may be omissions as some things are covered elsewhere (see resources section) plus I have had to balance content with getting it out in time for my colleagues who are currently preparing for exams.
Resourcessample OSCEs from college and ANZAPT websitesCollege CDROM for clinical examWestmead Guide
Prof Condon’s Formulation talk ( I have copies of my notes)
Shaun Christopher Shea’s book ‘psychiatric interviewing, the art of understanding’
College memoranda ( on website)
College CPGs
College code of ethics
Present State Examination booklet
The College ECE Workshop (ECE candidates only)
Form an exam practice group
Join a study group, ideally with 2-5 others. We met 2x week to practice OCIs and OSCEs. Join the group 1 yr – 6 months before you sit. Start by observing other group members who may be sitting the exam before you and by being examiners / patients for them. Familiarise yourself with the exam structure and marking scheme.
When you start to be the candidate yourself you’ll already have seen yr mates try it several times and will have had thoughts about how you would approach it.
I found that it helped to make the practices as similar to the actual exam as possible, especially as your time approaches (see under OSCE below, but this also applies to OCIs)
Video yourself or get a friend to give you honest comments about the way you sit, hold your hands etc. - I fondly remember Hiran’s honest, but very helpful comments Wink
Tape record some of your sessions and play them back at home, think about what you did well and what you’d do differently next time.
It is the quality of your practices and what you learn from them, not the quantity that matters.
Try to use consultants who have been examiners or people who have passed the new exam to help with your practices.
THE OCI
Look up your hospital on the net. What is the demographic of the local area (refugees / low SES / high drug use?) Do you know of any special units in the area? Talk to colleagues who’ve worked in that country / city. Consider calling a registrar there or the exam coordinator.
Go to the hospital a day or 2 before your exam, time how long it takes to get there and note whether your real exam will mean travelling in the rush hour or not. Arrange to meet the exam coordinator there and check out the waiting area, loo, exam room so you can start to run through in your mind how the real day will go.
If your exam is in Australia, bear in mind the differences in drug use between there and here (NZ) eg: they like amisulpride and some areas use aripiprazole. Also sertraline is used more. Drug addicts may be on heroin rather than methadone. These are things the patient may bring up. Other differences eg: in MHA don’t matter as these vary from state to state and the examiners may not be local.
Think about what you want to achieve in the interview – ie: to put the patient sufficiently at ease so that they give you the information you require to help write a formulation / differential diagnosis.
Think about how are you going to do this?
Even tho ‘data gathering , process’ is only 10% of the OCI marks, without doing this well, you wont get a reliable history
Travelling to the examBook a decent hotel in advance so you don’t have to worry about little things during the exam days. The college probably won’t be able to let you know exactly where your exams will be in the city until very near the time. I chose a hotel near transport connections and the CBD. The OCI may be in a remote hospital (mine was 1 hr by train) but the OSCE will usually be in the main central hospital.
The exam itselfAsk the Bulldog the examiners names before the exam and write them down. Write down the clients name (with subtlety) when you are introduced ( I always forget names under pressure)
How I spent my 2 mins:I shook hands with the examiners ( I had practiced my entry a few times in the hotel room the day before, made sure I wasn’t going to fall off my heels etc) then sat down and put my clock on the table but didn’t start it until the patient came in. Then I wrote out my headings (you will find your own preferred style for this, orif you wish you can contact me for a copy of mine). I had timed writing this out so knew how long it would take out of my 2 mins. Then poured water for me and the client and sat down again. There were about 30 secs left, felt like a long time and awkward sitting there not looking at examiners.
When client enters, stand up, smile, shake hands. Offer them a seat if they don’t automatically sit down.Don’t move the chairs unless you think there’s a big problem but do attend to any obvious problems if necessary eg: pts disability / discomfort or difficulty hearing you.
Orienting the client:Introduce yrself, ask client how they would like to be addressed, introduce examiners. Thank the client. Explain briefly that its an exam, examiners will be watching you and making notes. You’ll talk for about 50 mins, in that time you’ll be asking questions, apologise for limited time and the possibility you might have to interrupt. Ask the patient if they mind if you make a few notes ( I felt this gives them some autonomy in an anxiety provoking situation)
First sentence + opening the interviewHave a rough idea about how yr going to kick off after the intro. Practice a few different ones. Eg: I’d like to find out a bit about you, can u tell me how old you are? Where do u live? Who lives with you? Job? There is debate about whether to ask at this point if the patient is currently on a ward / under MHA – possibly depends on the patient / situation
My patient told me it was about to be her birthday so I asked her what her plans were, in quite a conversational way and chatted about it for a min or so. Seemed to put her at ease, though this may not be appropriate for every client.
Begin the interview proper with an open question. This may follow on from something the patient has just told u eg: tell me about how things have been since you were discharged from the ward / what sort of things led up to you being admitted 6 months ago. Or it may be more generic eg: how have things been going for you recently.This helps the patient to feel like you are interested in them, gives you some factual info + allows you to observe them eg: their verbal and non verbal communication, their level of anxiety and get an idea of what might help you engage more with them, plus their level of comfort with open relatively unstructured interview time. Briefly Ax their mental state as they talk eg: are they paranoid, cognitively impaired? You can then adjust your interviewing style accordingly to- show the examiners you can be flexible and start from where the patient is at rather than imposing your own stance on them (= principles of motivational interviewing)- use it as a way to show off yr skills in managing this type of presentation eg; may need to be more structured with a manic patient, respect the personal distance of a paranoid patient, try to open up a withdrawn person etc
This should take about 7 mins. Put some empathic statements in this time. Their function is to put the patient at ease with you and keep them talking until you’ve got an idea about what you’re dealing with.
You might want to end this section of the interview with a summary. Examiners like summaries: they show the examiners you and the patient are on the same page and tell the patient you’ve been listening + gives the patient a chance to clarify / correct anything you’ve misunderstood
Body of the interview
Then (at about 7 mins) start to structure the I/V. You will need to think about prioritizing as the examiners / college know there’s no way to get a full Hx in 50 mins, but they want to know how intelligently you can focus the I/V on the relevant areas and prioritise what you want to find out.Eg: for a client with an established diagnosis like BPAD / SCZ, focus more on the pts goals, EWS, meds etc rather than the details of each episode.
The college workshop I went to spoke of 2 styles of questioning,1) following the patients lead :empathic but can become a rambling interview2) menu approach: each question throws up an answer which throws up more leads and you choose which to follow, ie: your direction over patient’s.
There is a balance to be had between both but important points to keep in mind are
- if the patient says something of significance (eg: great personal importance / strongly emotional)don’t ignore it. Use verbal and non verbal (more powerful) methods to communicate to patient that you understand the significance of this for them eg: pause, maybe offer a tissue if they are tearful. Say something like: ‘this seems quite important / a bit upsetting, do you mind if we talk about it for a while?’.
- If something obvious is going on in the room don’t ignore it. It is likely to be an important partof the patient’s presentation and the examiners will have noticed it too and will be wondering why you haven’t addressed it. Eg: ‘it looks as if you don’t really want to be here today, can we talk a bit about that’ / ‘a lot of people might feel anxious in this sort of situation, I was wondering if you felt like that at all?’
- Don’t fire off random questions even if they make some sense as this will take you off yr line ofquestioning and you’ll have to follow the new line (since u introduced it)
- Within reason try not to leave an area of questioning until you’ve asked enough about it to confirma hypothesis / make a diagnosis otherwise you’ll end up with lots of unfinished areas and will lack structure. So eg: for depression, make sure you ask enough to make a diagnosis before you head off into risk or anxiety for example. If you do have to leave an area, remember to come back to it later eg:’ I’d just like to come back to X ‘ / ‘hear more about X for a moment…’
- Signposts: examiners like to see you orient the patient throughout the I/V so let the patient knowwhy you’re interested in their childhood / other lines of questioning that may not seem obvious to non medics. Something like eg” I’d like to ask a bit about your childhood /past as it helps me get an idea of the person you are now”
For Depression:
The College told us at a workshop that making this diagnosis depends on Quality of mood as well as biological criteria. So always ask about anhedonia / hopelessness / guilt + sense of deserved punishment as well as poor sleep, appt etc. Apparently candidates often omit the former as its harder to ask about.
Think about how you would ask patients about difficult issues eg: domestic violence, substance use, sexual abuse.Try out different styles of questions, write them down, play with them. Read them into an audio recorder / Dictaphone and listen back to them as if you were the patient. How does the question make you feel? Like you want to talk more or not?
If the patient doesn’t want to talk about something don’t force them. Try and shift the focus to the Sx instead eg: whether the patient has nightmares / memories rather than their content. You can mention in your presentation that there were areas they preferred not to talk about.
Things you can’t forget to ask:
Risk: never omit this. Risk from patient to self or others (including domestic violence + kids) and risk to the patient from others
Personality: never omit this. You can’t write a decent formulation without it. Think how you’re going to elicit enough of this / exactly what questions you’re going to ask in order to do this.
MSE
Assess this as the interview is going on. Jot notes to remind you.Try to remember what the person is wearing / make up / tattoos etc as you talk, for your MSE presentation later
Closing the interview
During the I/V think about what cognitive Ax and physical exam you need to do. (I had a 32 yr old woman with BPAD so didn’t do a cog Ax but did check for Li tremor and Thyroid). This helps you work out how much time to leave.A few minutes before the end orient the patient to the fact you’ll be ending soon eg: ‘we’ll be coming to the end shortly, but before we finish I’d like to ask you about / examine…’After the physical, I sat back down, thanked the patient for coming and let her know we’d come to the end. Then got up and showed her to the door.
There was no desk available for my use in the exam room though regulations say there should be so I asked the examiners if I could use their table. They didn’t seem to mind.
Thinking time:
How twenty minutes feels like 5….
The structure of your presentation is:
Summary
MSE / cognitive / physical
Gaps
Formulation
Differential
Management
Try not to deviate from this as the examiners are expecting this order and get confused if you mix it up.
Greg Spencer had advised me to write down exactly what my first sentence was going to be and practice it. I did this.
Some people suggest making your first sentence a statement that reflects to the examiners that you know what you’re dealing with. Others don’t like this. It’s a personal choice and also depends on the patient. My client was quite straightforwards so I didn’t see the need to tie it into a summary, so my first sentence went along the lines of “ Ms X is a 32 yr old woman who presents 6 months after D/C from hospital following what sounds like a mixed episode of BPAD…..” I guess if your patient is complex, some sort of summary might orient you and the examiners to your history.
I wrote double spaced, on one side of the paper and tried to keep my writing legible. I used a highlighter to mark the points I actually wanted to say when I presented it.
The Westmead says that you should practice formulating on patients you see in your working day but I found this difficult in a noisy office etc though I did it once or twice. Instead, a few weeks before the exam I started thinking about different structures my presentation might take and experimenting to see which worked best. About 2 weeks from the exam I started writing presentations for patients from my caseload, from memory. One per day. I timed them and worked out how much I needed for the summary, MSE, formulation etc. I found this a helpful guide to timing in the pressure of the 20 mins, and was reassuring as I knew for example that I could bash out a reasonable management plan in the final seven mins.
I had found the formulation part quite difficult to crack in my practices, but in the end feel that the Westmead guide gives a very good format.
Management:
My structure was:
- Introduction- if necessary eg: the main points regarding the management of this ladyare…
- Information: collaborative Hx, re-interview, GP notes etc
- Investigation: physical, bloods etc
- ‘First aid’ Leanne Fisher advised mentioning how you would manage urgent situations first eg: shouldthe patient be in hospital? Under the MHA? Suicide / violence risk? You can skip these if not relevant. I said ‘there do not appear to be any urgent issues to resolve so my management will focus on…”I then went through medication, and addressed the rest of the management in chronological order ( short term , medium then longer term issues)
Use the prompts the College gives in the marking schemes. Something like:
- Prioritizing the management
- tailoring your plan to the patients needs
- using appropriate levels of evidence to support your intervention
- identifying barriers to treatment / likely problems
- likely prognosisDont forget to include these points in your presentation.
Also don’t forget A+ D use, ethical issues (informed consent etc), cultural issues, social stuff eg: back to work schemes / benefits
The viva
This was a blur. Started OK but I felt it soon began to deteriorate. This only goes to show that you have absolutely NO IDEA how you’re doing as the viva progresses so don’t even try to think about it. Keep trying til the end. Be ‘bullet proof’. Even if you think you’ve made a serious error, either correct it or don’t worry about it as the examiners may be thinking differently – I omitted to ask my patient her PMHx and didn’t mention that I’d forgotten it. Yet I still achieved the standard in data gathering so I guess if you do OK overall, they can forgive omissions.
The examiners will terminate the exam. Thank them and decorously leave the room.
THE TIME IN BETWEEN THE EXAMS
Its very hard to not be disheartened after the OCI and think about all the things you could have done better. I had to let this happen for a while before I could move on. I went for a walk, sat in the sun etc. Then realized that if I hadn’t done well I could compensate with a strong OSCE score so focused on trying to do as well as I could in this.THE OSCEPractice:Practice lots. Make them as similar to the real thing as possible eg: induce tension.Put the instructions to candidate on the door. Don’t talk to the ‘candidate’ before the exam practice. Give them exactly 3 mins then run the exam quite formally until the OSCE (s) are over. You don’t have to be so formal in your very first exam practices but you should be doing them like this as the exam approaches. DO A MOCK EXAM, it’s a great experience. You will stuff it up, that’s the point. I failed mine but learnt heaps.Get all the College OSCE stations from the RANZCP website and mocks from ANZAPT. It is possible to get hold of UK OSCEs and some people find they give ideas (eg: the CPR station in the May 06 OSCE had come up several times in the UK exams). But remember the timing and depth of response required is different. The RANZCP OSCEs come with marking sheets so help you work out what our College is looking for. Don’t be afraid to get feedback from your study mates, its much better to hear it from them than to fail the exam.The actual OSCE:
Again go the the hospital a day or so in advance. Look at the area where the exam will be held and try to imagine how the real exam day will go.
Think about how best to use yr 3 minutes (see Westmead for suggestions)I used the last 60- 45 secs to really imagine that the scenario I was about to enter was real, how I might feel, what I would say first etc.
In the stations the time passes quickly but as you’ll have discovered in practice, you can get quite a bit done in 17 mins.I used a timer (but also set the stopwatch on my watch as the first bell sounded in case I left my timer in a station). I put the timer down first in every room and this meant I could see exactly how the time was going without having to keep checking my watch. I started to wrap things up a min or so before the end (a la Westmead) and tried to leave just as the bell sounded. Managed it once, it felt quite cool.
Many of my answers felt jumbled and after the exam I could think of several things I’d done wrong. This again shows that it’s very difficult to guess how you’re going. The examiners have strict marking criteria and you don’t know what they are. So, during the exam at least, don’t start doubting yourself as this may lead you to be less good in the next station – the opposite of what you need to do if indeed you have stuffed something up. Again stay bulletproof and strong til the end. Then you can worry if you want to.
After the OSCE people will be saying all sorts of things. Ignore them, 90% of it is bulls**t.
GENERAL POINTS
Different supervisors will give different advice. Choose how much you will take on board the comments of a particular supervisor based on their areas of skill / personality etc.
Decide which supervisors will be best for exam practices nearer the big day – you may not want people who leave you feeling demoralized for example.
Do practices with clients / subjects you are not comfortable with until there are no subjects you fear coming up in the exam eg: eating disorders, A+D, elderly, forensic, cognitive Ax
I did about 1 OCI per week for 8 weeks before the exam and one OSCE. I used my normal supervision time for exam practice.
The Run up to the examThink how you’re going to manage the 2-4 months before the exam. Eat well, drink less alcohol, go for a walk / exercise most days. Take multi vits (I did) and try to sleep well. Plan your study time to suit you. Ask your supervisor / boss if you can have study leave (I had 3 weeks including the week of the exam).
Decide what you’re going to wear. Linda Kader gave me great advice about this from a girls point of view, so I thought about everything down to what earrings to wear / nail varnish or not (went for clear in the end) etc. Get your suit a few weeks before the exam and do one or two exam practices in it.
ECE EXAM
The timing in the exam is a bit different but most of the other stuff is the same. Practice in a group of ECE candidates or find some friendly registrars who are sitting the registrar exam.
The big differences are
- more emphasis on management in the ECE OCI
- the consultancy viva style stations in the OSCE
- exam set at consultant level as an ‘exit exam’.
You can get information about the old Consult. Vivas on ANZAPT or I can copy you mine. The new vivas aren’t that different.
I practiced Consultancy type vivas with my consultant in supervision. If you don’t have a supervisor, ask a peer who you respect. Ideally someone who has done the vivas or been an examiner.
Tom Flewett advised me to consider both the ‘patient’ as well as the ‘system’ in my answer (the ‘patient’ is the central character in the viva eg: the nurse / drug rep / student etc, the ‘system’ is the team, the dynamics etc). this makes you think widely and at a more sophisticated level about the scenario.
Don’t forget ethical and cultural issues.
These are a set of core competencies set down by the Canadian college of physicians in 2000 and embraced by the post graduate medical world as areas we should have skills in. They are:
- Medical expert
- Communicator
- Collaborator
- Manager
- Health Advocate
- Professional
- Scholar
Please feel free to contact me if you want to add things or discuss any of it.JavaScript?
Amanda RedversWellington, NZ