Approach to the examination

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Chapter 1 Approach to the examination

Positive mindset

All paediatric clinical examinations test the following aspects:

1. Clinical skills—history taking, physical examination, interpretation of findings, construction of a diagnosis or differential diagnoses, method of investigation, overall management of the patient.

2. Attitudes.

3. Interpersonal relationships.

Candidates invited to postgraduate clinical examinations have usually satisfied their relevant learned college regarding their factual knowledge. Consequently, their factual knowledge should be at a standard appropriate for making management decisions in the case being examined.

Clinical skills are usually taught adequately to most candidates at the hospitals where they were trained. However, little if any attention is paid to developing proper attitudes and interpersonal relationship skills. Advertisers and sales representatives know the importance of personal contact. They realise that appearance, personality and speech are crucial in successful negotiations. The ‘viva’ is very similar in that candidates have to ‘sell’ themselves and their knowledge to the examiners. Successful candidates usually possess certain characteristics, namely:

1. A positive, confident response to personal confrontation. People with strong personalities have little trouble, but those who are easily embarrassed and shy away from confrontation between equals may do poorly. This response can be changed by methods described in this book.

2. Ability to sort out relevant from irrelevant information. Those who ‘think’, ask questions, seek explanations and try to understand rather than learn by rote do well.

3. Familiarity with the method of examination.

4. Endurance. Candidates who are ‘street-wise’ and naturally confident tend to have little difficulty, whereas their less confident colleagues are left to learn the hard way and eventually succeed or fail.

Preparation for the ‘viva’ requires effective communication skills during physical confrontation. Attitudes, interpersonal skills and projection of a confident, professional consultant image can be learned and developed.

Techniques include:

1. Mental rehearsal, visualisation, affirmations (see Chapter 4).

2. Body language.

3. Eye contact.

4. Breath control.

5. Dress sense.

6. Speech training.

7. Development of equanimity.

8. Ability to summarise.

9. Reasoning skills.

10. Examiner assessment.

Body language

Non-verbal communication in the form of a person’s gestures is a very accurate indicator of his or her attitudes, emotions, thoughts and desires.

In order to learn body language, set aside a couple of minutes a day to study and read other people’s gestures. Examine your own body language. Copy the body language of people you admire and respect, such as a consultant who you feel would have no difficulty passing the clinical examination. The model you choose does not necessarily have to be a real person: he or she may be a composite of ideal body language.

There is an old saying: ‘If you would be powerful, pretend to be powerful’. One way to adopt an attitude that helps you achieve any objective is to act ‘as if’ you were already there. If you change your posture, your breathing patterns, your muscle tension, your tone of voice, you instantly change the way you feel. For example, if you feel depressed, consciously stand up straight, throw your shoulders back, breathe deeply and look upward. See if you can feel depressed in that posture. You’ll find yourself feeling alert, vital and confident.

An important component of body language is consistency. If you are giving what you think is a positive message, but your voice is weak, high-pitched and tentative and your gestures reveal poor self-confidence, you will be unconvincing and ineffective. Individuals who consistently succeed are those who can commit all of their resources, mental and physical, towards reaching a goal. One way to develop consistency is to model yourself on individuals who are consistent. Copy the way they stand, sit and move, their key facial expressions and gestures, their tone of voice, their vocabulary, their breathing patterns and so on. You will begin to generate the same attitudes that they experience, and experience the same successful results. Effectiveness comes from delivering one unified message.

When you next attend a place where people meet and interact, study the individuals who have adopted the gestures and postures of the individuals with whom they are talking. This mimicry is how one individual tells another that he or she is in agreement with their thoughts and attitudes. You can use this unconscious mimicry to your advantage. One of the best ways of establishing effective personal communication is through mimicking the breathing patterns, posture, tone of voice, gestures, words and phrases of the person or people with whom you are interacting. Once you establish contact with someone, you create a bond and reach a stage where you begin to initiate change rather than just mimicking the other person, a stage where you have established so much mutual contact that when you change, the other person unconsciously follows you. If, when you try to lead someone, he or she does not follow, it simply means there is insufficient rapport. Mimic, strengthen the mutual contact and try again.

Eye contact

When answering questions or making a point, look the examiner straight in the eye. Powerful individuals have always been characterised by exceptional eyes. If you have difficulty maintaining eye contact, there are a few techniques you can use to develop a more effective gaze.

Work on not blinking. Practise unblinking eye contact, especially when under pressure. If you are intimidated and unable to look directly into the examiner’s eyes, a little trick is to concentrate your gaze on a point midway between the examiner’s eyes. Another helpful hint is to imagine a triangle on the examiner’s forehead, with the apex at the highest point and the base of the triangle formed by an imaginary line between both eyes. Keep your gaze directed at this area. In the mirror, practise narrowing your lids a bit but do not squint. When you move your eyes from one point to another (as from one examiner to another), do it without blinking. When you look from one person to another without blinking, it is unnerving for anyone watching you. To further emphasise this powerful gaze, move your eyes first without blinking and then follow with your head movement just behind the eye movement. Slightly lowering your head forwards while maintaining the gaze also adds power to the eye movement.

Breath control

Often, especially in a viva voce or an important interview, you find yourself struck by a sudden panic attack. Breath control can be particularly useful to regain composure, prevent fear, reduce stress or fatigue, and generate energy. It is a technique developed by the samurai to regain control during life and death struggles. Take a deep breath, then exhale slowly and imperceptibly. As you are exhaling, contract your abdominal muscles so that you feel as though you are tightening a corset. Relax the muscles at the end of exhalation. Do not expel all the air. Leave about 20% in the lungs. Then inhale gently. Your lips should be slightly parted, expelling your breath over your lower teeth with your tongue gently touching your hard palate. You may repeat breath control as often as required. Practise breath control until it is second nature and then use it whenever you are under any physical or mental stress.

Dress and grooming

You have to ‘sell’ yourself and your knowledge. Your appearance is your most important ‘equipment’ for the clinical examination. It must reflect the public expectations of the professional person. Look around at what is worn by successful individuals in the respected professions (such as your examiners). Ask yourself: ‘Do I look like a mature, careful, conservative and respected junior consultant?’ Male candidates should avoid colourful suits, jackets and trousers, and unusual ties. Dark suits (greys, navy blue, pin-stripes, non-committal ties, red ties) are more suitable (this is termed ‘power dressing’ by image consultants). Female candidates should preferably avoid revealing or tight dresses as well as showy jewellery. Footwear should be clean and appropriate.

Long hair and beards should probably be avoided, but if you cannot bear to shave your beard, at least keep it neat and trimmed. It is safer to be clean shaven and have tidy hair. Visit the hairdresser a couple of days before (and not on the day of) the clinical examination so that it does not appear as though you have had it done just for the examinations.

If you have difficulties with perspiration when under pressure, use an unscented antiperspirant on the day of the examination. Apply the antiperspirant to your forehead, hairline and neck to prevent beads of sweat appearing during the ‘viva’ (one of the previous co-authors used this method successfully).

Speech training

Poor speech will definitely adversely affect your ‘viva’ performance and is surprisingly common. By poor speech we mean poor diction, inaudible voice and bad vocabulary. Tape-record yourself speaking or have someone sit about 2 metres from you and listen to you speak. Then note:

1. Whether or not every word was heard clearly.

2. Whether or not what you said was understood.

3. Whether or not you used jargon, slang or abbreviations.

Addressing these three points will help you assess whether or not your speech is a problem. Take note of the pitch and rapidity of your speech. If you do speak too quickly, make a conscious effort to slow down by reading aloud at a pace that allows a listener to make a note of the content of your speech. Another useful exercise is to study the speech of newsreaders. Note that they speak clearly, concisely and slowly so that every word is understood. They also use very little jargon, slang or abbreviations. Try mimicking a newsreader’s speaking style the next time you present a case.

Other methods of improving your speech are:

1. Enrolment with a professional teacher.

2. Using a video camera to film your efforts and then playing back the result.

Equanimity

Sir William Osler suggested that physicians should possess equanimity: composure under pressure, and when faced with the adversities of life. This is particularly true during the clinical examination, where your long case may be an uncooperative, crying child, for example. Candidates may experience stress as a result of physical confrontation, inadequate knowledge, low self-confidence and poor physical health. Equanimity, although coming more easily to phlegmatic personalities, may be cultivated. Knowledge and experience create confidence, which in turn leads to calmness. The above causes of stress can all be overcome by more study (to improve knowledge base), more practice, mental reprogramming and then actively seeking out stressful situations to increase experience. Adequate exercise, a well-balanced diet and enough sleep should go a long way towards maintaining physical health.

Ability to summarise

The ability to summarise, encapsulate the essence and emphasise the major issues without losing too much detail requires understanding and experience. However, it is a necessary skill for the physician, and therefore needs to be developed through practice. Remember: practice makes the impossible possible. Note that the limit of effective retention of verbal information is usually less than 15 seconds, so the better you can convey the essential details to the examiners in the ‘viva’, the greater the effect.

Reasoning skills

Reasoning skills involve the ability to analyse a problem rapidly, break it down into manageable parts and then formulate a solution. An adequate knowledge base, experience and rational thinking are needed.

To assist in developing these skills, make a habit of meticulously examining every detail of a child’s clinical records. Analyse the data, learn to pick out any vital information that is missing and ignore irrelevant information. Deduce from available data what other information you need to justify your conclusions.

Assessment of examiner

An ancient Chinese general, Sun Tze, once stated, ‘Know the enemy and know yourself, and you can fight a hundred battles with no danger of defeat’. Although examiners are not exactly the enemy, you still need to assess:

1. Whether or not the examiner is friendly or unhelpful.

2. The quality of communication between the examiner and yourself.

3. The strength of the examiner’s personality compared to yours.

On occasions, it may be worthwhile doing some reconnaissance work and finding out some information about your potential examiners (likes, dislikes, areas of interest).

The clinical examination

Preparation

The road to success in any ‘viva’ usually entails doing a large number of long and short cases. You need to begin seeing cases at least several months before the clinical examination. Your service commitment should provide you with all the material you require for training and preparation. Treat each patient you see during the course of your daily work as a practice long or short case. Endeavour to do at least one (but preferably two or three) long case(s) per week. Try to expose yourself to as many different examiners as possible.

Preparation for the short case requires much practice, especially when more candidates fail their short cases than their long cases. If possible, visit other hospitals, especially if these have a reputation for teaching. Experience as a ‘bulldog’ (i.e. observing an actual examination and assisting the candidate) is also invaluable in gaining insight about the conduct of the examination and the expectations of the examiners. Taking turns as an examiner during practice sessions with your colleagues is worthwhile because it allows you to experience first-hand the annoying habits of candidates. Mental rehearsal of short cases (and long cases) will accelerate learning (see Chapter 4, Achievement psychology).

Most major teaching hospitals hold trial and mock examinations a few weeks before the actual ‘viva’. These simulated examinations provide invaluable feedback about your progress.

Part of your preparation involves obtaining all the relevant information from the appropriate learned college about the requirements for paediatric training; this is invariably available in booklet form or is downloadable from the college’s website. Familiarise yourself well with the contents and study the regulations. About 6 months before the examination, write to the college for an application form. Fill in your application form a few months before the examination and ensure that the form and your examination fee reach the college before the closing date. Remember to apply for examination leave from your employer.

If possible, in the last few weeks before the ‘viva’, do some reconnaissance work and locate the examination venue as far as you can. Check it out in relation to where you will be staying, ascertain the suitable modes of transport, public transport timetables and the length of time it will take to travel to the venue at the times scheduled for the examinations. Remember to check your accommodation arrangements in advance.

In the week before the examination, check the clothing you intend to wear (make sure it fits!), check that you have the right equipment and remember the appointment with the hairdresser. In the few days before the examination, try to get some mental rest and leave study aside. Avoid any major changes in your daily routine and lifestyle.

A checklist (prepared in advance) of what you need to do on the day may be helpful. Make sure you arrive at least 30 minutes before the examination is due to start, so that you can recover from the trip, relax, go to the bathroom and so on. The longer the travelling distance, the more provision you need to make to cover for delays during travel (one of the previous co-authors experienced car trouble on the day of the ‘viva’).

There are certain ‘rules’ that you need to obey at the ‘viva’. Do not enter the examiner’s room until asked. Do not sit down until invited. Do not slouch when seated but sit four-square and upright (it creates the impression that you mean what you say). Minimise nervous hand movements. If you tend to fidget, turn your hand movements into gestures. Bags should be placed under the chair (or given to the ‘bulldog’) and removed when leaving. Do not stare, smile politely and always answer courteously. Remember to speak up and be as brief and factual as possible. Avoid jargon, slang, clichés, abbreviations, brand names (of medications), meaningless expressions, and rising inflections at the end of sentences. Most importantly, do not antagonise or argue with the examiners. You will always lose! Some examples of antagonising behaviour include patronising answers, appearing to show little or no interest in the subject matter and a negative response to criticism.

If you decide to use beta-blockers during the examination, it would be wise to use the drug during at least one practice session, particularly if you have asthma. It would be inconvenient to have an asthma attack at the examination, as happened to a colleague who took a cardioselective beta-blocker. After 12 puffs or so of salbutamol, he passed.

Equipment

Equipment is always available at the examination. However, it would be wise to take the following with you:

1. Pens (more than one and make sure they work), pencils and paper.

2. Your own stethoscope.

3. A hand-held eye chart for testing visual acuity (with a piece of string attached to the chart, the length of which is the recommended distance from eye to chart; this allows you to quickly position the chart at the correct distance from eye).

4. Cotton wool (fine sensation), new blunt pins.

5. Watch, preferably with a sweeping second hand.

6. Pocket tape measure.

7. Torch with new batteries and bulb.

8. A red-topped hat pin for visual field testing in the older child.

9. Toys, red woollen ball on a thread to test visual fields in infants, small container of hundreds and thousands (or equivalent) to test hearing, raisins (pincer grip), coloured cubes for developmental assessment.

10. Other: pocket ophthalmoscope, pocket tendon hammer, spatulas, tuning forks, Denver II developmental chart, percentile charts for height, weight and head circumference.

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