Top tips for the clinical exam

By Dr Genevieve Yates

The process is just as important than knowing the exact diagnosis. The process (eg. structure of the consultation, safety-netting, patient explanations, examination skills, formulation of a differential) is just as (and sometimes more) important than knowing the exact diagnosis. Getting the correct ‘answer, e.g diagnosis, does not mean you’ve passed the station. Conversely, getting the wrong ‘answer’ doesn’t mean you’ve failed the station.

Don’t forget your basic communication skills and end up rushing through the doctor/patient interaction, worrying about time. When appropriate, use silence – think and listen, then speak. Remember that the ‘patient’ may be anxious, teary or angry. Be aware of your own emotions. Allow ‘patients’ to express their emotions. Bolster their self-confidence. Involve ‘patients’ in decision making. Make certain your non-verbal cues match your words.

Read the question fully. I know this has already been mentioned but I can’t emphasise it enough! Familiarise yourself with various Instructions for Candidates – you must follow these instructions to score marks and knowing how many tasks you have to do will help you manage your time. Pay close attention to whether you’re instructed to discuss issues with the ‘examiner’ (this can be done quickly and using medical jargon) or with the ‘patient’ (need to use a patient-centred approach / appropriate language while still showing off your knowledge to the examiner). A useful technique is using the correct medical term then explaining. E.g. “The tests show that you have a condition known as ‘x’. This means “blah blah”. Have you got any questions about this?”

Learn to ignore visual clues during the exam. This can be one of the hardest things to adapt to as we gather a lot of information about our patients from their external appearances. The role player will probably be a different age and body shape to the ‘patient’ and may even be a different gender. While the role-playing examiner will try to give you appropriate non-verbal cues (facial expressions/ body language etc) not all of them are great actors, so it may be hard to gauge (but try your best to work it out). The best way to prepare for this is by doing mock stations with your colleagues, friends and family.

Don’t assume that there won’t be any clinical signs if asked to examine a ‘patient’, thinking it is a healthy ‘role player’. It might be a real patient with real signs! On the other hand, don’t invent signs to fit with your presumed diagnosis (this sounds obvious but you’d be surprised how many people do it!)

If the ‘patient’ presents with symptoms of anxiety or depression, it is worth requesting the results of a depression/anxiety rating scale as part of the examination component. It may not be available, but can be very helpful if it is.

You have to say it aloud to score marks, you cannot just imply. Verbalise actual diagnoses, test names, medication names etc. if you know them. Talk through your examinations as you go.

If you’re not sure about something, say what you think it is and admit you’re not certain, then follow it up with something like, “I will look it up on ‘x’ website” or “I’ll discuss it with ‘x’ specialist”. This shows that you’re practising safely and may make the difference between passing or failing the station.

When in doubt, talk about: patient education, support and counselling, lifestyle modification, patient information handouts, follow up plans and safety netting.

Physical examination – don’t forget: General appearance, BMI, vital signs.

You may find it useful to do a systems review if you’re not getting anywhere with the history and you’re feeling a bit lost. One mnemonic that may be of use in the clinical exam is SYSTEMS:
S – Sleep
Y – Your weight (loss/gain)
S – Symptoms – constitutional (eg. fever, malaise)
T – Travel history
E – Eating (diet / appetite)
M – Mood
S – Sexual health.

Once you’ve finished a station, put it out of your mind. Don’t ruminate – you can’t go back and change it. Focus on the next station. Take a deep breath and use your three minutes reading time to plan it out.

Use the rest stations well, clear your mind and relax your body. You may want to find and practise a 10 minute meditation or relaxation exercise for this purpose, especially if you are prone to performance anxiety.

Don’t overdose on the lollies or the water provided at the rest stations. Your performance will not be enhanced by a sugar high, and while keeping hydrated is good, you don’t want to be busting to go to the loo!

Have your usual caffeine intake on the day of the exam – not more, not less. It is not the time to be going through caffeine withdrawal, nor the time to drink a triple espresso for the first time.

While it is an artificial and stressful set up, and you need to learn how to play the exam game, remember that the aim is to assess whether you are a safe and competent GP. The best preparation you can do is by being as good and conscientious a doctor as you can every day with your patients. Ask structured histories, examine your patients properly, give good patient education and always make follow-up plans and safety net. Then come into the exam and be your usual GP self!

Remember: “We are what we repeatedly do. Excellence, then, is not an act, but a habit.” Aristotle

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Good luck everyone!

This content has been kindly provided to us by Dr Genevieve Yates from her popular blog.

(Views expressed are those of the author, not of their employer. Thanks to Nispa Krongkaew for her contributions to the above list.)