Ece Story Two

How to Pass Exemptions Clinical Examinations

Wednesday, 31 January 2007

After going through the grueling process of preparing for written exams in March 2006 and thereafter-clinical exams in November 2006 we have a few thoughts to share about the whole process of examination.

Most of what we have written about how to approach the examinations is our personal view, which may or may not agree with other candidate’s views who may have passed or are preparing for the exams. This worked for us! There have been a few disagreements amongst us as well but overall we did agree for most of what we have written.

We will start with our limited experience of preparing and appearing in clinicals because it is relatively fresh!

The first thing, which I think helped us stay focussed and motivated, was preparing with each other. We both were fierce critics of each other’s performances and looking back that actually helped us raise our standards to the level required by the College for passing the exams. Besides this, we did most of MOCI and MOSCE practice together with one acting as a candidate and other as an examiner in addition to the available examiner. This helped us in understanding what it felt like being an examiner and what was expected of the candidate. Needless to state that it was useful in improving our skills (both as a candidate and as an examiner!)

It is important to find a stable, likeminded study partner to stay focussed through out the process. We acknowledge not everyone would be able to find a study partner and this is particularly true for our friends who are working in country areas but it could be ‘the’ thing for staying focussed and improving skills.

The second most important thing, which helped us, was getting a mentor who had just finished his clinical exams. We don’t hesitate in stating that his guidance and constructive criticism went a long way in shaping the way both of us approached the examinations. Looking back, the help, which he provided by being available after-hours to do MOCI practice and MOSCE practice on weekends was instrumental in our preparation.

Our second advice is that one must attempt to find a mentor who can give an honest opinion about your performances and more importantly tell you how to improve. The mentor can be anyone who has done their exams and knows the standards required. This person should ideally be working with you for the entire process of examination and help you build skills required for the exam.

It is extremely hard to remain focussed and motivated through out the process of examination preparation. We prepared for about 5 – 6 months before the Sydney exams. Now since College doesn’t give you the opportunity to sit immediately after the written examinations, most of the candidates would be preparing for at least this amount of time before they sit the clinical examinations. Since this is a long period it is very easy to get tired, bored, distracted and fatigued. Lot of the candidates can reach the peak before the exams and tend to fare poorly in the actual exams.

I made the mistake of going full throttle all the way and was extremely tired by the end of my preparations (AV).

It is important to be mindful of this when preparing. It is important to take breaks between your practice sessions in order to cope with the fatigue.

Now talking about specifics:

M-OCI

There is lot of information about exams on college website.

It is good to read the College instructions to candidates and more importantly instructions to examiners to get an idea about various domains used for marking, the marks allotted to each domain and also the standard required to “achieve” and “surpass the standard” because that is what one should be aiming for. It is also important to read what is included in “standard not achieved” to make sure that one doesn’t commit hanging offences. Keep revisiting these instructions from time to time. Make sure that you have a fair insight into your performances.

This was a very different exam for us. People can have variety of difficulties ranging from different style of interviewing, difficulties in synthesising the data and/or problems in making a prioritised and personalised management plan. The exam pattern was new for us (as it is for all of us) and we had to practice a lot to finetune each of these areas.

PRACTICE is the key word. Not only doing yourself but also observing others is important.

One should aim to do one proper MOCI (exam conditions) every week with different examiners, different kind of patients, different sites and at different times of day (you never know what time you will be doing the exam MOCI). We were lucky that we had access to and could organize MOCI’s with different examiners, at different sites and different times, including speciality patients.

Even if you don’t get an examiner to observe you (there would be situations like that) the study partner can act as an examiner. Every MOCI, which we did, the other person besides being examiner also gathered information as if he was doing the MOCI and at the end both of us formulated and developed a management plan in 20 minute thinking time. This way we ended up doing at least two MOCI’s per week. Believe us, it helps even if you are not interviewing the patient…you think as an examiner and so you get an idea, what an examiner wants.It is important to be aware of the broad areas where you are deficient in (trust me you will become aware of more as you go through the process of preparation.)

One needs two sets of examiners…one who is a mentor who can critically scrutinise your skills and advise how to improve them. He should be the key person and one should do at least a few OCI’s with him/her before starting out with other examiners.The other set is the senior examiners who will give you an overall feedback rather than identifying minor deficiencies.Besides this, your study buddy should help in this process by nitpicking!

Practicing the skills of MOCI in day-to-day clinical work is very important. It is good to do a busy rotation before the clinical examinations. Someone told us to treat all encounters with patients as invaluable opportunities to learn/practice skills of MOCI and MOSCE. We found this a very useful advice.AV did an extremely busy CL and ECATT job at busy hospital in the months leading up to the examination and VL did a CATT – ECATT job during this period. This allowed us a number of new assessments every week, which we tried to do as one would do in exam. It helped us improve our interviewing skills and the ability to manage the interview time with variety of patients in variety of settings. This also led to improvement in comprehensiveness of the assessments and a better degree of clinical care. One can also decide to practice certain areas with some patients eg. personal history, cognitive testing etc. Formulating or at least attempting to formulate the presentations of new patients you see is another good way to hone the skills at synthesising the data.

A few thoughts about the practice MOCI:

Keep your common sense intact and utilize it! This definitely helps. Act like a reasonable person rather than trying to do things differently.

Examiners definitely remember the first and last things you say to patients and them, so first impressions count.

Practice opening the door, opening statement, handshakes, offering the chair to the patient and forgetting about the examiners during the next fifty minutes. I (VL) wrote down the opening statements and practised it but you need to be careful, as it should not sound mechanical/rehearsed, so it needs lot of practice with different patients.

Orient yourself to the room; particularly make sure that tissues and drinking water are easily accessible.

Utilize the interview time (50 minutes) carefully. Though you need to be flexible you need to have a hidden agenda, which is to get through the fifty minutes and demonstrate to the examiners that you have covered relevant areas without being un-empathic to the patient. Do not make your hidden agenda become visible to the patient or the examiners (this is a common criticism).

Being empathic but not apologetic is a key thing in the interview in both MOCI and MOSCE. Shea’s book is quite useful in this regard. Watch your language during the interview. Use words carefully. This is particularly important for candidates from Indian subcontinent as English is not our first language and one can come across as rude/un-empathic/lacking confidence with certain choices of words. Your mentor should identify these issues and address them.

We got a very good advice from one of the senior examiners that your interview should be geared towards understanding the life story and clinical story of the patient and the questions should be asked to identify the links between the life-story and the clinical story and this is what formulation is all about.

The other important advice was that the interview should be focussed towards identifying the aspects of patient’s life, which would need intervention in a biopsychosocial framework and this should take care of the personalisation and prioritisation of the management plan. So, while interviewing one should be thinking about formulation and management plan and ask questions accordingly (hidden agenda!).

Start with open-ended questions and nail it down by asking more direct questions. Do not get too bogged down in the open-ended questions. It is acceptable to interrupt and ask direct questions as well.

Every question you ask in the interview should be aimed at finishing items in your hidden agenda. There are no marks for unnecessary questions.

Keep your senses alive to the clues given by the patient and do not ignore them (because examiners would have picked them up!).

Practice how to interrupt without being rude as you have a limited amount of time

It should not sound as a diagnostic interview. It is important to demonstrate to the examiners that you do not close the diagnostic possibilities very quickly. Thus, even though you conduct the interview with certain diagnostic possibilities in my mind (which you would have picked up in initial 5 – 10 minutes of interview) it is important to ask screening questions for other Axis 1 disorders. Practice firing the screening questions on every patient you assess (don’t forget empathy).

First five minutes of the interview are the most important. This is the patient’s time to talk and your time to listen and plan how you are going to conduct the interview in next 40-45 minutes. The sacrifice of first five minutes aids in building the rapport with patient (and to some extent with the examiners) and giving you an idea, where to start and which line of questioning to take.

In a standard patient we used to spend no longer than up to 30 minutes on history of present illness, D & A history, past psychiatric, treatment and medical history. We made sure that we moved on, by 30 minutes, to family and personal history and spend anywhere between 10 – 15 minutes on these areas. Spend at least 5 minutes on cognitive examination if you are planning to do one and aim to do at least a brief and focussed physical examination. This structure may not be possible on each occasion and you need to be flexible to make changes to it depending upon the requirement.

Aim to finish by 48 minutes. Closing the interview is as important as opening it. Remember examiners definitely remember the first and last things you say.

Taking notes while you interview is also a important skill, which develops with practice. We used manila folder like most of the Victorian candidates. Now, there are different ways to use the manila folder and each has got it’s own advantages and disadvantages. We used it the way our mentor taught us and it worked for both of us very well.

Think of all possible scenarios in the MOCI and have plan for it in advance eg. Patient walking out in middle, overtalkative & circumstantial patient, withdrawn patient, guarded & hostile patient, demented patient, emotionally labile patient, OMG (oh my God!) patient etc.

Utilize the next twenty minutes judiciously as that will decide whether you can “make sense” of the data which you have collected.

We decided to spend 2- 3 minutes writing the opening statement. We think it is important to spend time and write it rather than fumble at the start (first impressions count!).

We spent next 6- 7 minutes developing the formulation by using a biopsychosocial grid and making plausible links between the life story and the clinical story and trying to answer the question being asked from us -“Why is this patient presenting at this time in this manner?”

We then spent next 30 seconds to 60 seconds writing the multiaxial diagnosis.

Rest of the10 minutes were spent in making a management plan. It is easy to get bogged down in formulation and neglect the management. We think it is very important to give equal amount of time to management section as it carries equal amount of marks. Again here the trick is that it should be around the issues, which are pertinent to the index patient, and hopefully you would have elicited those issues in the interview. This is the reason why data content gathering becomes very important because it impacts on the quality of your formulation and management.

The next big task is to stick to the time while presenting to the examiners. Most of the candidates who are starting fresh struggle to stay within the time limits. There are several reasons for that. We observed a lot of local trainees present their summary and formulation (they get only seven minutes) and tried to learn the way they were able to tell a beautiful story without much of a struggle. It is all about being selective about the information you are going to present. We found that there was not much use spending lot of time in rephrasing the present complaints and history (examiners have already listened to the story). For us the important chunks which decided whether you “achieve the standard or not” in the data synthesis domain depends upon your MSE findings and formulation.

Sound and act like Consultant i.e. calm and confident, use nonverbal gestures and make it sound like a conversation between colleagues (this is what they expect!).

We spent about 1- 1.5 mins reading put the opening statement trying to contextualize the patient’s problems. One of the examiners told us that the opening statement should be short and catchy something like headlines of the newspaper! We made sure that we started with MSE and cognitive findings at 5 mins mark and tried to spend at least 2 minutes there.

The next 2 – 2.5 mins would be spent on formulation and the last few seconds reading out the multiaxial diagnosis. We would go into details of diagnosis only if we had time otherwise we would just list the diagnostic possibilities in a multiaxial format and wait for questions from the examiners.

The next 20 minutes of examination is about management plan. We aimed to finish by 12 – 15 minutes. Everyone says that the management plan shouldn’t be grid like and generic and this is another common criticism from the examiners that management plans, which are presented in the exams, are not personalised and prioritised. So, you have to have a grid in the mind but keep it hidden from the examiners as far as possible.

It is very important to give the examiners 5-6 minutes to ask questions, as they would try to revive you if you had gone astray in your presentation.

Many of these things will change and you would discover different ways of improving as you practice. We didn’t get all these things right in the beginning itself and it took us some time to see what worked for us and we did change things if they were not working. What we have written above was more or less the final thing we agreed on. You need to finalise this quickly as you don’t want to try something new in exam that you have not practised. Remember it is all about practise!!

One last advice from me (AV), do not get mislead by the body language of the examiners. During the practice OCIs most of the examiners give ample indications, which tells you whether you are going in the right direction, or not. However, in the real OCI at Sydney clinicals I couldn’t make out from the examiners body language as to whether I was performing satisfactorily or not, if anything I thought I was performing miserably because they didn’t appear ‘happy’! Fortunately for me I was wrong!

M-OSCE

Again with M-OSCE the trick is practice and being able to act in an artificial situation.

There are only a certain number of situations which can be tested in the MOSCE and thus it is much more predictable than OCI. But since there are more than one stations and the time is limited it becomes a bit tricky to shift the cognitive gears.Read the instructions to candidate and examiners (published by the College) to get familiar about the standards required by the College.One advice, which we got again and again, was to get into the ‘role’ as quickly as possible and manage the time effectively.There are individual marks for each and every task, so it is extremely important to complete all the tasks. It is important to plan during the five minute thinking time as to how one will go about completing all the tasks.For the actor based MOSCE one must keep in mind the domains of marking – APPROACH, ASSESSMENT, DIAGNOSIS and MANAGEMENT.Very quickly, after reading the scenario, one must ‘diagnose’ what is being tested here and according to that plan how to spend the next 15 minutes with the actor.It is important to have a structure for assessment and/or management but try not to sound unempathic when going through the ‘hidden agenda’. One can use the usual history taking format and grid for management. The advantage with a structured approach is that you do not miss anything and there is a low risk of making “hanging offences”.Even though the time is limited it is worthwhile to spend 1-2 minutes trying to establish rapport because it gets the actor (and the examiners on) your side.There are various tricks which you learn as you practice the actor based MOSCE’s, particularly how the actors are trained to drop hints, when to believe and when to probe further when the actor gives an answer etc. This can be better understood if you read instructions to actor in the available MOSCE’s.There are sample and previous examination MOSCE’s on College website which should be practiced. Make sure to read the instructions to the actor and the marking sheet if you can’t find an actor to assist you.For the viva based MOSCE’s, it is good to read the Curriculum for Advanced training in Adult General Psychiatry which has details about the roles, based on CANMED domains, being tested.Again with the viva based MOSCE’s it is important to plan before starting. One usually does well in the first question because of the five minutes reading and thinking time, after that it is pretty much thinking on your feet as you go.The same principle applies here, identify quickly which CANMED domains are being tested in this particular station and plan how you are going to word your reply without losing focus.Stick to the task! No marks are given for an excellent speech, which is not relevant to the question.Again an advice, which we found very useful. Resist the temptation of speaking too much and utilizing all the time. Give the examiners at least 1 –1.5 minutes to ask questions and revive you if you have gone wrong.It is reasonable to spend up to 30 seconds, thinking and planning, when given the second and the third question rather than waffling for entire five minutes.Practise MOSCE’s (not only one at a time but also two or three at a time as you would find lot of things can go wrong if you do them consecutively. Besides this, it helps test your set shifting ability).Do not forget to act like a Consultant!

READING

The following list is not an absolute necessary requisite for passing, as this examination is not designed to test you theoretical knowledge. However, we found the following resources very useful.

Psychodynamic Psychiatry in Clinical Practice by Glen O Gabbard – An excellent book for people who do not like psychodynamics, easy to read and helps in getting ideas about formulation.The Psychiatric Interview by Daniel J Carlat – Very good and handy book for interviewing techniques.Psychiatric Interviewing The Art of Understanding by Shawn Christopher Shea – Very useful for interview technique, lot of reading but easy to read and good with examples.Management of Mental Disorders (two volumes) – Very easy to read and extremely useful for both writtens and clinicals.Treatment of Anxiety Disorder – Gavin AndrewsA good book about disorders, which we do not get to see in public system a lot. Has good information about how to educate patients about things like CBT, panic disorder etc.Cogintive Assessment for Clinicians – John HodgesUsed by most of the local trainees, thus examiners know and feel more comfortable about the tests, which you will be doing in MOCIDSM IVClinical Examination by Tally & O’Conner – nothing special except that it is a local bookWestmead guide for clinical examination- Though it is for the local trainees examinations, it is a very useful resource to get rid of demons and paranoia in your mind about the clinical examinations.Mark Walterfang’s write up about Consultancy viva – has got good grids though I found them a bit cumbersome and complicated. There are some other resources about old consultancy viva, which are eually good.Clinical Practice Guidelines of RANZCP- Some are good others not that good but you must read them well because you can quote them as evidence and this would make examiners happy. It is also worth reading the Consumer versions of the guidelines because it can be used in MOSCE’s where you need to educate a patient about certain disorders.Position statements, Memorandums, Media release, Code of Ethics etc from College website.ANZAPT website – a very useful site, particularly the discussions in the forum

WORKSHOPS & COURSES (most of it is relevant only to Melbourne)

ECE workshop – We attended the ECE workshop at Harvester Clinic in Melbourne and found it was reasonable. At least if you are new to this examination system, you get to know the structure of examination but beyond that it depends on the individual person how well one can utilize it.Kym Jenkins’ examination workshop at Alfred Hospital.Sathya Rao’s workshop for clinicals at Dandenong Hospital.Try to get into tutorials for local trainees if you can. They are very useful.Encourage your colleagues/seniors to organize Mock MOSCE’s for you before the actual examinations.

ACCESSORIES

Digital timer – Cut the wires to the speaker to make it silent.Folder – You do not necessarily need to buy expensive ones. I had the cheapest one I could get in Officeworks (AV).Keep two pens – One for the patient to use when testing for cognitive functionsDictaphone – I found this a useful investment. Record yourself and listen to your voice again and again (it is difficult to listen to yourself making mistakes!). Also record others who you and others think are good (with their permission) and listen to them. Record the feedback you get from the examiners (again this a difficult thing to listen to but it pays!) – AV. VL also bought a dictaphone but didn’t use it much though it could have been used more.Use your video camera to record yourself at least once before the examination. A cheaper alternative is to present in front of the mirror. VL couldn’t do it but it would have been useful.

Ashis Vikas (AV)Vinay Lakra (VL)

There is a lot more to write and many issues may have been left out. We are happy to answer any queries people have. The exam is difficult but definitely passable in first attempt as we did. You can mail us on -ient, demented patient, emotionally labile patient, OMG (oh my God!) patient etc.Utilize the next twenty minutes judiciously as that will decide whether you can “make sense” of the data which you have collected.We decided to spend 2- 3 minutes writing the opening statement. We think it is important to spend time and write it rather than fumble at the start (first impressions count!).We spent next 6- 7 minutes developing the formulation by using a biopsychosocial grid and making plausible links between the life story and the clinical story and trying to answer the question being asked from us -“Why is this patient presenting at this time in this manner?”We then spent next 30 seconds to 60 seconds writing the multiaxial diagnosis.Rest of the10 minutes were spent in making a management plan. It is easy to get bogged down in formulation and neglect the management. We think it is very important to give equal amount of time to management section as it carries equal amount of marks. Again here the trick is that it should be around the issues, which are pertinent to the index patient, and hopefully you would have elicited those issues in the interview. This is the reason why data content gathering becomes very important because it impacts on the quality of your formulation and management.The next big task is to stick to the time while presenting to the examiners. Most of the candidates who are starting fresh struggle to stay within the time limits. There are several reasons for that. We observed a lot of local trainees present their summary and formulation (they get only seven minutes) and tried to learn the way they were able to tell a beautiful story without much of a struggle. It is all about being selective about the information you are going to present. We found that there was not much use spending lot of time in rephrasing the present complaints and history (examiners have already listened to the story). For us the important chunks which decided whether you “achieve the standard or not” in the data synthesis domain depends upon your MSE findings and formulation.Sound and act like Consultant i.e. calm and confident, use nonverbal gestures and make it sound like a conversation between colleagues (this is what they expect!).We spent about 1- 1.5 mins reading put the opening statement trying to contextualize the patient’s problems. One of the examiners told us that the opening statement should be short and catchy something like headlines of the newspaper! We made sure that we started with MSE and cognitive findings at 5 mins mark and tried to spend at least 2 minutes there.The next 2 – 2.5 mins would be spent on formulation and the last few seconds reading out the multiaxial diagnosis. We would go into details of diagnosis only if we had time otherwise we would just list the diagnostic possibilities in a multiaxial format and wait for questions from the examiners.The next 20 minutes of examination is about management plan. We aimed to finish by 12 – 15 minutes. Everyone says that the management plan shouldn’t be grid like and generic and this is another common criticism from the examiners that management plans, which are presented in the exams, are not personalised and prioritised. So, you have to have a grid in the mind but keep it hidden from the examiners as far as possible.It is very important to give the examiners 5-6 minutes to ask questions, as they would try to revive you if you had gone astray in your presentation.Many of these things will change and you would discover different ways of improving as you practice. We didn’t get all these things right in the beginning itself and it took us some time to see what worked for us and we did change things if they were not working. What we have written above was more or less the final thing we agreed on. You need to finalise this quickly as you don’t want to try something new in exam that you have not practised. Remember it is all about practise!!One last advice from me (AV), do not get mislead by the body language of the examiners. During the practice OCIs most of the examiners give ample indications, which tells you whether you are going in the right direction, or not. However, in the real OCI at Sydney clinicals I couldn’t make out from the examiners body language as to whether I was performing satisfactorily or not, if anything I thought I was performing miserably because they didn’t appear ‘happy’! Fortunately for me I was wrong!

M-OSCE

Again with M-OSCE the trick is practice and being able to act in an artificial situation.

READING

The following list is not an absolute necessary requisite for passing, as this examination is not designed to test you theoretical knowledge. However, we found the following resources very useful.

WORKSHOPS & COURSES (most of it is relevant only to Melbourne)

ACCESSORIES

Ashis Vikas (AV)Vinay Lakra (VL)

There is a lot more to write and many issues may have been left out. We are happy to answer any queries people have. The exam is difficult but definitely passable in first attempt as we did.yourself at least once before the examination. A cheaper alternative is to present in front of the mirror. VL couldn’t do it but it would have been useful.

Ashis Vikas (AV)Vinay Lakra (VL)

There is a lot more to write and many issues may have been left out. We are happy to answer any queries people have. The exam is difficult but definitely passable in first attempt as we did.