Passing Clinical Examinations
BACKGROUND
Clinical examinations come in all shapes and sizes. Most medical students focus on their licensing or ‘final’ exams, doctors in training on exams testing further skills, such as the MRCP, or those that provide specialist status, such as the Boards in the United States.
The examiners in all these examinations have the same objective: to test the candidates’ competence in areas that are important in clinical practice. In devising the examination format, the examiners are aware that:
Thus, examiners continually amend the format of the examination so that it is more valid, more reliable and more closely aligned to clinical practice. Currently the trend is away from ‘spot diagnosis’ to an observation of limited focused clinical examination. This aims to replicate what happens clinically, and to encourage candidates to learn the skills they will need in practice.
These examinations have differing formats but almost all include a requirement for the candidate to perform the following stages:
• Stage 1: Examine a patient neurologically, observed by an examiner.1 The examiner will be looking for a systematic, appropriate and thorough neurological examination, using reliable examination technique. They will also observe for communication skills, including rapport with the patient, professional manner and treating the patient with appropriate consideration and empathy. In other words, ‘what you do’.
• Stage 2: Describe the findings, coming to some sort of conclusion.1 The examiner will be looking for a correct identification of abnormal physical signs, an appropriate interpretation of these abnormalities, and a reasonable synthesis of the findings and suggested diagnoses and differential diagnosis. In other words, ‘what you find’ and ‘what it means’. Interpreting the signs depends on getting the signs right and this will depend on having done the examination properly—so stage 2 depends on stage 1.
• Stage 3: Discuss the further investigation or management of the patient’s problem.1 The examiner will discuss aspects of further investigation and management. This tests the candidate’s knowledge relating to this particular clinical problem. This is not the focus of the clinical part of the examination, as this knowledge is often tested using other examination formats. Discussing these elements further depends on having an appropriate diagnosis or differential diagnosis—so stage 3 depends on stage 2, which depends on stage 1 (Fig. 29.1).
Figure 29.1 Three steps to success
Most candidates run into problems with stages 1 and 2, and may not get to stage 3. The examiners may try to help, with prompting or leading questions (let them).
The best way to pass the exam is to be competent. This is why this chapter is at the end of the book. So, if you turned straight to this section, go right back to the beginning of the book (unless it’s an emergency2).
WHAT TO DO
Consider each stage of the examination in turn.
Stage 1: Examine a patient neurologically, observed by an examiner
You are not meant to reach a stunning diagnosis but to demonstrate that your examination is:
The difficulties arise because:
• you are unable to undertake a systematic, practised, reliable, appropriate and thorough examination
The solution is to sort out the first point; when competent at examination, you will use time more efficiently and become confident.
Systematic, practised and reliable
This book is set out to allow you to develop a systematic approach to clinical examination using reliable methods.
To develop a system you can rely on, you need to practise. Professional golfers practise hitting the ball thousands of times on the driving range so when under pressure in competition they know just what to do. Neurological examination is just the same. What you need to do has been described throughout the book; the more you do it and the quicker you become, the less you are concerned about what you should do next and the more confident you are in your findings being normal or abnormal. Generally speaking, you will also look slicker.
Practising with someone watching you can help this further—preferably someone more experienced, but colleagues can also help. Think about ‘demonstrating’ physical signs so that your spectator will also see any abnormalities you find. You can learn by watching— anyone; you often learn as much watching someone having difficulties doing something as watching an expert. You will also be less anxious in the exam if you are used to being watched.
Appropriate and thorough
In some clinical examinations you are asked to do only a partial examination and are usually provided with only a limited history: for example, ‘Please examine this man, who has had progressive difficulty walking over the last year.’ This is not as artificial as it seems. In clinical practice most patients will have one problem that will be the focus of the neurological examination and the rest of the neurological examination is effectively a screening examination. You should therefore be able to work out what is ‘appropriate’ in the context of the exam (Table 29.1). It is useful to think of ‘appropriate’ in this context as ‘what is needed to solve the clinical problem’.
Table 29.1
| Clinical problem | Focused examination | Common syndromes |
| Walking difficulties | GaitMotor system; tone, power; reflexesSensationCoordinationConsider: fast repeating movements; eyemovements; speech | Cerebellar syndromeAkinetic rigid syndromeSpastic paraparesis (with or without sensory signs)Peripheral neuropathy |
| Numb hands and feet and loss of dexterity | GaitMotor system; tone, power; reflexesSensationCoordination | Spastic tetraparesis with sensory signsPeripheral neuropathy |
| Weakness in arms and legs | GaitMotor system; tone, power; reflexesSensationCoordination | Spastic tetraparesis with or without sensory signsMixed upper and lower motor neurone syndromePeripheral neuropathy |
| Speech difficulties | SpeechFaceMouth | DysarthriaDysphoniaAphasia (less likely) |
| Double vision | Eye movements | Cranial nerve lesion VI, III or IVMyasthenia gravisThyroid eye disease |
| Visual problems | AcuityFieldsFundiPossibly eye movements | Optic atrophyHomonymous hemianopia Bitemporalhemianopia |
A systematic examination that is appropriate will inevitably be thorough; that is, it will cover all the necessary parts of the examination. It does not have to be obsessional or fussy to be thorough; indeed, this would waste valuable time.
Professional
Be polite, courteous and considerate—as you should be with all patients (and colleagues!).
