TO THE PHYSICIAN TRAINEE
The long case is an art that needs mastering. Long case mastery will not only help candidates to pass the examination but will also equip the trainee with the skills and expertise to handle any complicated medical case. These skills are vital to the candidate’s future life as a physician. While preparing for the clinical examination, the candidate is expected to acquire as much expertise as possible within a very short time. Such intense learning will not happen at any other time in your career. Therefore, it is important to approach this time of preparation knowing what to do and how to go about doing it. The preparatory period should be well planned and executed, with utmost commitment to your goal. It is important to plan this preparation systematically, so that no aspect of clinical medicine is missed or omitted. It is also important to achieve your peak level of performance at the right time. Peaking too early can lead to exhaustion and a lacklustre performance by the time of the examination, and peaking too late may mean ‘missing the boat’.
An ideal way to start preparing is to fully understand what the preparation is for. It is therefore important to become familiar with the examination and what exactly will take place on the day. At the examination the candidate is usually given 1 hour to spend with the patient unobserved by the examiners or the ‘bulldog’ (the bulldog is a basic trainee registrar from the host hospital assigned to attend to the candidate on the day of the examination). During this period, a detailed history needs to be obtained, and a thorough physical examination performed, focusing particularly on the main system involved. The candidate is usually given a warning 10 minutes before the end of his or her time with the patient. Then another 10 minutes is given as preparation time before the candidate is introduced to the examiners. There are usually two examiners for each candidate on the long case, one being a member of the National Examining Panel (college representative or censor). Occasionally there may be a third member present, acting as an observer. This member of the examining team is usually a new examiner learning the examination process. The ‘grilling’ is carried out by the two main members of the examining team; later in the day, the ‘observer’ may swap seats with the college censor to actively participate in the ‘grilling’ process.
The examinee is expected to present a clear, sufficiently detailed and well-organised long case within 7–10 minutes and develop a comprehensive management plan. The candidate may be interrupted at any time during this period if further clarification is needed on any aspect of the case. The candidate usually spends 25 minutes with the examiners, and after the presentation there should be sufficient time for the examiners to assess the candidate’s knowledge. Of course, this is extremely valuable time for the candidate to demonstrate as much knowledge and clinical wisdom as they can. Ideally, if the candidate is confident with the case, they will be able to control the discussion, and this will convey an air of competence.
During the discussion, the candidate should mention the relevant investigations that they would perform. At this point, the examiners will present a radiological imaging study or a blood or serology test result and ask the candidate for an interpretation. Other investigation results—including electrocardiograms, lung function studies, nerve conduction studies, hormonal studies and nuclear medicine scans (but not pathological specimens)—may also be produced.
A practical tip
It is important to have a set approach to the long case, and to use this system repeatedly during practice cases until you have mastered the long case. Candidates should develop a format to address the history and the physical examination, and thereby avoid any ‘fatal’ mistakes or omissions.
A stack of cards can be very convenient for taking notes when with the patient. This also provides a hard surface to write on, as often there will not be a table available by the bedside. The best technique is to use the cards according to a prepared format. Mnemonics (see p 5) can be used to remember the format even in the stressful circumstances of the practice exams and the real exam. The way you organise the cards is also important. The long case can be divided into sections, and cards organised accordingly; this will make your presentation easier as well as neater. An average case may need about 20 cards, and these should be clearly numbered at the top right-hand corner.
• Card 1 should contain the patient’s name, age and the opening statement, which is a concise but sufficiently detailed introductory overview of the case.
• Card 2 should be for the presenting complaint and then associated conditions. Past history, medications, allergies, family history, occupational history and social history should be placed in that order.
The social history has to be very detailed; accordingly, this section comes as a subset of cards, with a separate mnemonic to help remember all aspects of the social history. Another advantage of using cards is that they can be held close to eye level with your head held high, thus facilitating constant eye contact with the examiners. It is important to maintain eye contact. (In fact, some senior examiners expect so much of it that one examiner advised his candidates to learn the long case by heart and stop using written records of the case at all.)
Taking a history
Establishing trust and confidence
The first 20 minutes of the hour with the patient should be spent on history taking. In the exam setting you should try to obtain as much help as you can from the patient by quickly explaining how important the exercise is to you. A strong bonding with the patient can be achieved from the outset by being very courteous and polite. Smile broadly and shake the patient’s hand warmly, using both hands. Generate genuine empathy with the patient and be considerate at all times. Try to create an atmosphere of trust and confidence. Establishing a good rapport will ensure that the patient opens up without any hesitation. It is easiest to begin by asking the patient about the medications he or she is currently taking. This may give you a comprehensive overview of the patient’s problems and save much valuable time. On some occasions at the real examination, the examiners leave the list of medications with the patient, with instructions to hand it to the candidate only if they request it.
Mnemonics
History and physical examination are the cornerstones of your clinical assessment of the patient. Your whole plan of investigation and management as well projections on the prognosis will be based on what is garnered during your clinical assessment and the case that is built upon this vital information. Therefore, it is essential that your history taking and physical examination be comprehensive, foolproof and watertight—you cannot afford to miss anything! One proven way of ensuring that you don’t miss anything is to have a ready-made, comprehensive and complete checklist consisting of everything you need to learn during history taking and physical examination. You will need to memorise this checklist and be able to recall it readily during the examination. Mnemonics are a very useful tool in this regard. This section of the chapter introduces some mnemonics that have been developed for this purpose. Or you might find it easier to develop your own set of mnemonics.
The following mnemonic for history taking is comprehensive and covers almost all aspects of the history:
P P M A F O S T
P Presenting complaint and the details thereof
P Past history, intercurrent illnesses and relevant details
For each disease mentioned in this section of the history, it is important to get the following details:
1. When, how and who made the diagnosis.
2. What treatment has been administered and whether there have been any complications or side effects associated with it. For each drug the patient is currently taking, mention the dosage and frequency. The candidate is expected to know the generic name of each drug and should be able to identify the generic names of almost all the commonly used drugs.
3. What the current level of disease activity is and how the patient is affected by it.
M Medication history
If all the patient’s current medications have been mentioned already in the previous section, it will be sufficient just to mention the list of medications again as a brief summary. Some examiners like to hear the list separately. Listing the medications may also provide the candidate with an opportunity to see whether there are any drugs with significant interactions.
A Allergies
F Family history
O Occupational history
S Social history
T Travel history
Relevant in cases with infectious diseases and exotic conditions.
Social history
Many a fatal mistake can be made by not addressing the social history adequately. Therefore it is important to have a separate mnemonic to probe into all the important aspects of the social history. The mnemonic for the social history is:
S E M I G — C H D P — N S — D I P — V A S P
(It is easier to remember this if you break it up into five segments as suggested here and review it many times a day.)
S Smoking history
E Ethanol/alcohol history
M Marriage
Marital status, previous marriages and, if single, reason for not marrying etc.
I Independence
Level of independence with activities of daily living. If the patient needs assistance, find out who the main care provider is and how well they are coping.
G GP
Relationship with the patient’s general practitioner, frequency of visits etc.
C Children
Number of children and other relevant details such as ages, gender, who they live with if the patient has a broken relationship with their partner.
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