Long Case Exam

The long case exam is one of the exams that can occur during the clinical years of some medical courses, and is also a staple in postgraduate exams for certain specialties/fields (quite notably the barrier exams for BPT, Basic Physician Training in Australia which is usually 3 years' long before one applies for an Advanced Medical Specialty).

It typically involves a student/doctor candidate seeing a randomly allocated patient from a predetermined pool of hospital/outpatient patients who were deemed as "suitable long case material", relatively cognitively intact, and gave consent to participation. The candidate then has a limited time (on average ~ 1 hour) to interview the patient about their history of presenting complaint, hospital admission, past medical history, social history etc, and then perform the relevant physical examinations (documenting the findings), then formulating a summary, issues and management plan catering to that patient's "unique" presentation and needs. When the time runs out, the candidate then goes into another room to do an oral presentation in front of a few (often 2, maybe 3) examiners who are doctors themselves, regarding the patient's complete history, relevant findings, summary and management issues within a time limit (eg 15 minutes), which is then followed by answering questions from the examiners about detail clarification or about the discussed medical conditions.

My Medical Course has the long case exam as a hurdle, which means that you MUST pass this in order to pass the whole subject (as opposed to the Multiple Choice Exam where you're technically allowed to get < 50%, but still pass the whole subject if you compensate in other exams to get an overall mark of 50+%). I did my long case exam recently, and I was really anxious, for multiple reasons (same for many other med students too). While I have received reassurances from a few students in the year above (and a few doctors in lectures) that the long case exam at med school standard is not too harsh, and that the examiners want to pass you, I was still super freaked out. The long case exam was THE ONE that I was fearing my whole time this year (OSCEs and MCQs were less anxiety-provoking in comparison).

I can think of the following factors that contributed to me feeling like this:

            1. I didn't know what patient I was going to get for the long case exam (that's the point of the exam!).

            2. Due to other issues that made me extremely stressed this Semester, I didn't have sufficient alertness or mood throughout the Semester to thoroughly make notes on all the listed conditions (let alone the un-mentioned ones) in the Block/Rotation guides. So hypothetically, what am I supposed to do if the patient has a condition that I was supposed to know about?

            3. My AS means that I usually have a reduced verbal fluency (and increased difficulty with forming coherent sentences relative to NTs) when trying to talk/ask about things that I'm not familiar with and haven't rote-memorized or practiced a lot (which gets exacerbated by the previous point).

            4. My holidays before the next Semester were short, and I didn’t want to have it reduced by spending more time preparing for a resit exam should I fail. I was already tired from studying for the MCQ and OSCEs the week before, and really wanted to have more days to sleep and bum around.

I did my Long Case Exam outside of my home clinical school. I went into the listed room and registered my details while frantically reading my long case guidebook on the different core conditions. Sooner or later, it was my turn, and I had to leave my bag in the room, and carry my stethoscope, pen and paper and other testing tools into the ward.

The “administrator” guided me to the relevant ward, by then I was already having clammy hands and palpitations.  I waited outside the patient’s room while the “administrator” spoke to and prepared the patient for the 1 hour interview. The waiting felt like ages and for a short while I thought she was trying to mess with my mind by adding extra suspense by delaying me from starting it.

She came out later and said I could go in, with time starting now. I said “Ok thanks” and entered the room. It was a bit annoying coz there were a few other patients in the room with their relatives talking. I wasn’t sure if they were aware that I was doing a long case exam.

The long case patient I had was an elderly woman. I introduced myself and told her that I was doing an important exam with a time limit, so I’ll have to ask lots of questions and have to cut her off at times, with an apology. She said it was perfectly fine coz she had been a patient for numerous other candidates at other hospitals in the past.

I started by asking her name, age, address, past occupations, allergies, and comorbid conditions (name only). When it came to comorbid conditions, she talked a lot about each one and mentioned about some past operations. I then asked about those. This went on for about 20 minutes because she had the tendency to go off-track and I was too afraid to cut her off a lot at the time lest she get pissed off at me and refuse to cooperate. I think around this point, I asked her what medications she was on for each one, and she said she couldn’t remember. I then checked the folders on her bedside, but could only find one listing Vital Signs (the medications list got taken out!).

I was getting really freaked out coz they forgot to include the medication list. I asked her to push the “ASSIST” button to attract one of the nurse’s attention. I then remembered that I had to ask her about her presenting complaint (omg silly me, I should’ve asked that sooner), and then she went on about how she was experiencing a lot of pain etc several weeks ago. I was able to ask the relevant history questions and form a plausible story in my folder as she was talking. I decided to cut her off more times than before and ask numerous direct questions because I really wanted to hurry to the psychosocial history before starting physical exams.

By the time I finished the history of presenting complaint, there was about 20 minutes left. I rushed through the psychosocial history bit in about 10 minutes, asking her about her husband, 1^st-degree relatives (I had to cut her off again when she wanted to talk about her cousins and grandchildren in excessive detail), hobbies, diet, activities of daily living, and mood. Unfortunately I was absent-minded enough to not ask her about alcohol and smoking. She kept on talking about G-d and how he was so glorious to give her and her husband a long life, and I tried to “acknowledge that”.

After rushing through those questions and writing her comments, I checked my watch. There were 10 minutes left and I haven’t started my physical exams or formulated a summary and management plan yet. In my mind I was thinking “OMG OMG OMG OMG OMG OMG OMG OMG I’M SCREWED” .

The patient could tell that I was stressed out, and she said to me that if I continued on like this, that I wouldn’t live as long as her and that I’d get a heart attack. She said that I was one of the most stressed students that she has met so far. She may be right, but I didn’t want to argue with her, so I said “Thank you for your observations”.

I said to her that I had to do physical exams now and managed to do a very gross (basic) assessment of her Cardiovascular, Respiratory and GIT system before time was up. I said to her that I was sorry for being rushed and abrupt, but she said that she was happy to help students and that she wanted to make a contribution in the remaining years of her life. In my mind, I was thinking that I was going to fail my long case exam coz I didn’t write *anything* at the back of my folder for the summary and management plan.

The “administrator” came to pick me up, and I walked with her back into the hall to wait outside the examiner’s room. While walking, I felt like a lamb being led to the slaughter. During the 1 minute wait, I was profusely formulating management issues (the “topic titles”) but didn’t have time to further elaborate on it.

One of the 2 examiners opened the door to their room and let me in. I went in and started presenting my findings as they asked. I was afraid that I would muddle up my sentences when I spoke them, so I tried to speak in a relatively slow (compared to my “normal” speed when talking random stuff) rate, using simpler sentence structures that I could manage. I couldn’t tell if they thought that I was speaking too slowly/robotic.

I was halfway through presenting my physical findings when the timer buzzed, and it was question time. I didn’t have time to present my summary or management issues (which I didn’t exactly prepare for), so it was a double-edged sword, a possible blessing in disguise?! I knew that part of the marking criteria included the ability to formulate relevant treatment and referrals for the patient, but I technically didn’t mention any of that, so I feared I’d get a 0 in that section.

The 1^st examiner who was a medical doctor asked me various questions to clarify the patient’s history. I was able to answer most of them, except for the bit about smoking and alcohol. One of his questions was “Did she really say that her pain was 13/10?” That was what I said (based on what the patient said), and I thought he was trying to manipulate me and make me change my mind, but I said “Yes”.

The 2^nd examiner who was a surgeon asked me about physical signs, and I missed out on several vascular ones as I didn’t check all the pulses. He asked me about investigations, which I suggested a few, but not all of the relevant ones. It was embarrassing but educational when he stated the others that should’ve been ordered.

Question time ran out, and I was told to leave. It was strange, I no longer had palpitations, but there was huge unease. I had to wait several (“very long”) days to find out if I passed this exam or not, in which I did.

I got the lowest pass mark, but was still very relieved coz I didn’t have to do a resit, but I was still disappointed in myself based on the experience. Sure, this is an exam which can provoke anxiety, but so is the workplace where you might have to clerk several new admissions a day, and be expected to do so in a timely fashion. I understand that I’m still a student and expect to improve with time in terms of structure, asking in a systematic manner, and cutting off more frequently and strategically, but I predict I may get turned off it (in the very long term).

She was a kind woman who was willing to talk, but I still felt like an asshole for cutting her off a lot (relative to when I normally clerk patients on the wards, which is more relaxed and has more chit-chat). After what I’ve been through in the past, I don’t want to become a horrible asshole when I work, and I fear that such time pressures may give me the propensity to do so in my innate desire for efficiency and systemizing information (to reduce my being overwhelmed by details) instead of maintaining a balance, because systemizing and following an internal routine is when I am most productive (as an Aspie), especially if I enter hyperfocus mode.

I felt like I was objectifying the patient, and not taking into consideration all of the things that they value. My psychiatrist has told me of ways to redirect the discussion, and I’ll probably improve with more practice, but I still felt guilty and upset given her vulnerable state and my “exploitation” of her during the exam.

Superficially for now, if I pass the med course, I feel that I might be less suited for a general medical specialty, and would be better suited to a specialty with less patient contact such as Pathology. Less direct patient contact means that there’s more focus on the technical/procedural work itself, with most of the other communication with other doctors. I feel that if I manage to pass the med course and later on enter Pathology, I am statistically less likely to offend patients and let them complain about me. It's not that I hate patient contact, it's just that I fear I will perform a disservice to them if I were to work in my optimum Aspie style.

Let’s see what happens in the future…

Experiences and Impressions from Clinical School (Part 5: Clinical Patient Interactions)

“Robert” (TERMINAL CANCER) Last Semester, I spoke to a patient called “Robert” who had an M1 cancer (cancer that has metastasized), and was considered to be terminal (incurable, patient will die from cancer complications). He was one of the first terminal patients that I spoke to. A classmate recommended that I speak to him coz he had “interesting” physical presentations and was nice but was feeling quite sick. I wanted to see his physical presentations, but was initially hesitant on doing him coz he was feeling sick, and may not have wanted to spend energy speaking to another medical student, but I decided to try, because that’d be the only way to find out, and I didn’t like the uncertainty of never knowing what happened to him.

I went into the room, greeted Robert and introduced myself and asked if he could answer my questions regarding his medical history. He consented, and so I asked about his symptoms. He noticed a few lumps in his chest earlier last year, which later grew in size and became very painful to touch, and he felt a pain akin to being “hammered in the chest” whenever he breathed normally. He visited a GP and complained about the pain, in which he was prescribed analgesics. Eventually, investigations for his chest pain (X-ray, CT, biopsies) indicated that he had cancer which metastasized to his chest, and he was planned to start on “chemotherapy” quite soon. He was still experiencing a lot of pain in his chest and back, and found it disruptive and upsetting. I was able to see several lumps on his chest, and on his sternum.

He said the doctors may be considering radiotherapy as well, but he wasn’t looking forward to it because he thought that surgery would’ve been better (even though surgery isn’t usually indicated for his metastatic kind). Although I wasn’t 100% sure that his cancer was terminal (I only knew that when I spoke to the Oncologist later on), I suspected that the radiotherapy wasn’t curative, and was to treat the bone metastases, aiming to reduce its prominence on his ribs. I wanted to try to make my thoughts be more “valued” by him so I had to figure out what was of his biggest concern atm, which I (luckily) guessed was pain. I was confident that he was going to die within a few years or even a few months coz of his Cancer staging, and felt that long-term survival would be more important, but I DIDN’T DARE TO SAY THAT TO HIM coz I thought that informing him about death wasn’t my role yet, and I was scared that being an NT, he’d be more likely to get angry/offended instead of facing reality. This led to my hypothesis that he cares more about his quality of life.

I told him that he’s experiencing a lot of pain and it’s one of the negative things directly affecting him, and that the chest pain is likely to be caused by the metastases, and that if the radiotherapy targets the tumours and make it smaller, it may place “less pressure” on the intercostal nerves, thus producing less pain in the long term. He was pleased by this explanation and changed his attitude towards the radiotherapy and was optimistic, saying “oh that’s great then!” I wasn’t sure if he only thought of cancer as causing pain, and that he was aware that the radiotherapy was most likely not curative, but more to alleviate pain, and systemic complications leading to death are still highly likely. I didn’t want to instill false hope and tell him that it was going to be a cure, so I was trying to talk about the benefits of the treatment in terms of what he valued, and he was joyful. I initially felt kinda guilty coz I made radiotherapy sound really good (although it wouldn’t restore life, I didn’t say this) but I looked back and realized that I technically didn’t lie, and I’m sure that his priorities may have been different to mine, hence his response countered my initial concerns.

I was aware that he had pain, and I asked what medications he was on. He said he was currently using Endone and Oxycontin (IR and SR-oxycodone), Panadol, and an anti-inflammatory drug. I asked him if he felt constipated, nausea and loss of appetite on the Endone/Oxycontin. He said yes, and that it accelerated his weight loss, and that he can go for days without passing a bowel movement even if he ate 3 meals/day. I also asked him if it made him feel drowsy or spaced out, and he said yes, he felt sleepy and spaced out with poorer short term memory. He was happy that I knew what he was going through and said that I was the first person on the ward to tell him about these possible side effects, and said that I knew how he was feeling.

This experience made me realize that while I’m unable to intuitively empathize towards most patients, I could simulate “empathy” for most patients at a technical level by studying the common side-effects of varying medications at a pharmacological/physiological level, and ask them about these experiences. It can then give these patients the impression that I know what they’re going through, and that I value their experiences and “psychically” know them “better” (even though that’s sometimes not the case). The statistically more predictable effects of medications has given me more inspiration to study pharmacology in more detail when I have spare time, coz it enabled me to connect to patients (especially NT patients) more easily and make them feel a bit more comfortable even though I’m not the one looking after them.

His daughter phoned him, and he let me say “hi” to her on the mobile. I didn’t know why he asked me to say hi to her as I didn’t know her, but the gesture made me happy, coz it indicated that I didn’t piss him off, and I felt good that I made him feel a bit more comfortable that day even though his prognosis was technically poor.

I recently checked the patient database this year and discovered that he died a few months after my encounter (in the Palliative ward). RIP…

Self Directed Learning (as opposed to Didactic Education)

I should’ve posted a few months ago, but I was busy with other tasks and was “procrastinating”, my apologies. I hope everybody has had a safe and happy Christmas (or another festival if you don’t celebrate Christmas) and New Year’s Day.

This is a relatively controversial post, certainly among the medical academic staff and students, but I can’t resist my thoughts any longer, and I refuse to shut up and be “politically correct” in this regards. I’ll type about less “bitchy” things later on.

I’m rather disdainful of the concept of “Self-Directed Learning” in Med School, as I personally find that for me, it is counterproductive and obstructive to my optimal acquisition of knowledge, and I get frustrated by it. Yes, there’s definitely an element of personal responsibility in studying and putting in the effort to visit patients, speaking to them, and writing your own notes, but I feel that the burden has been placed way too much on the student, with insufficient guidance from the main medical faculty.

To put it in simpler terms, the concept of “Self-Directed Learning” primarily involves med students planning out what topics to learn and to what detail, with less didactic education given by lecturers/tutors in past medical curriculi. While this may sound simple and practical, this is far from the truth for me (and possibly many other students). A major issue is that the field of Medicine is so broad, and that there are so many medical conditions to learn, and so many textbooks, websites, medical papers discussing them, it’s hard to gauge which medical conditions should be studied (besides the really obvious ones like stroke, diabetes, cardiovascular disease, epilepsy), and how much we should know. I do receive handbooks for each of my rotations, but from experience I’ve noticed that other “significant conditions” that get discussed by consultants are sometimes not mentioned in it, instead including more “rarer conditions” instead! Also the handbooks don’t give a generic idea on what boundaries we should learn up to, before it becomes excessive/overkill. There are a few objectives that are vaguely stated, but I find this to be insufficient, especially when they don’t even tell you the steps on how to do it.

As an Aspie medical student, I have a much stronger tendency to process information as details and have trouble seeing the big picture (not just medical academics, but in social situations and generic reading comprehension for fiction). I also have a strong tendency to want to know a lot of details about the particular aspects of a medical issue, because I feel uncomfortable simply memorizing facts and I want to know the deeper aetiology/physiology/cause. I was aware that you don’t need to know, eg, 10 pages of the genetics of Marfan’s Syndrome, but it’s very hard for me to modulate how much depth of each section to learn. I feel guilty and uncomfortable if I only learn a few sentences about one aspect, and I feel like I’ve wasted my time if I learn too much about something when it’s not going to be examined or used (in a pragmatic sense) in the clinical setting for a JMO (junior medical officer).

I get frustrated by how each block is “only” around 6 weeks long comprising of 2 - 4 medical specialties, eg Haematology, Gastroenterology, Cardiology, and yet we’re somehow meant to learn the major conditions for those specialties in that time limit, without them telling us which is more important and how much. IMO 6 weeks is barely enough for 1 specialty, let alone 2-4. It feels like a very strenuous task, and later in the Semester, I tended to spend more time in the library trying to type notes on a condition (that might be trivial but still mentioned in the exams from experience) when I personally would much rather spend more time on the wards trying to practice my Clinical Communication skills and Physical Examination techniques with patients. I feel that I’m eating, sleeping and shitting Medicine and studying inefficiently through insufficient guidance when I could’ve had more time to talk to patients or even spare time for myself. I was very tired, and may be really tired/burnt out again when I start my next Semester.

People have told me the following - “If you don’t like the course, then leave.”

- “This is how your Uni arranged the curriculum, just accept it. Who knows, in 50 years’ time, the curriculum will change again, and the med students then will have to accept it with their heart.”

- (even more insultingly) “Suck it up, you’re just not trying hard enough.”

- “Self directed learning is to prepare you for the workplace, where you’re not getting spoonfed anymore.” (this operates under the assumption that everyone has adequate insight into the clinical setting + medical issues, which isn’t necessarily the case)

It’s not just frustration for my own comfort at the moment, but also for my future vocationally-wise. I DON’T want to end up accidentally hurting a patient through negligence of certain information coz I was spending so much time learning more trivial minutiae in med school. WE'RE LOOKING AFTER PEOPLE’S HEALTH/LIVES. The generic purpose of the Medical course is to prepare medical students for Internship, where they start engaging in “paid” service-provision in the care of patients, under the supervision of more senior medical staff and working in cooperation with nurses and other allied health people. IMO I don’t think the current medical course (maximally) efficiently prepares students for internship given the lack of practical guidance, and there’s a risk that students may spend too much time studying topics and details just for the sake of passing the exams, as opposed to improving their functioning on the wards. Yes, the work is applied knowledge, and medical information gets updated all the time, and yes I don’t expect to be completely spoonfed, but I really think that at the stage of a medical student, the faculty should provide more clear-cut guidelines so everyone can learn the imperative basics before moving on and learning things independently as they become more senior medical staff. Now, it’s all a mish-mash, VERY wishy washy and nebulous.

There has been speculation that some medical faculties are emphasizing on “Self-Directed Learning”, and not breaking the medical subjects down into more specific categories (eg Anatomy. Physiology. Pharmacology.) and teaching it didactically coz they wanted to save money. I can’t comment on that, but if that was true, then I’d be very disappointed. However, there were a few studies, starting from Canada, which came up with findings that “Problem-Based Learning” with a weekly-based medical issue is somehow a superior way of learning medicine compared to previous didactic styles, but I’d like to digress as I don’t think it that alone sufficiently addresses the amount of information we need to know, a block having 6 X weekly medical issues when the handbook contains 40+ (and probably at least 10 more that aren’t listed), ie not a complete substitute. The studies may show it works, but in practice I don’t think it’s noticeably superior.

Ideally I would prefer to receive extra time for each medical specialty (at the expense of graduating later), and/or be told directly what the main issues are along with generic boundaries for med students in their clinical years.

Compensation strategies (outside of official sources) that I have used include:

- Limiting myself to 2 or 3 pages for each medical condition, (painfully) forcing myself to limit each section (eg Symptoms, Investigations, Treatment) to a specific textbox.

- Limiting myself to only 2 or 3 textbooks, a major one being “OXFORD HANDBOOK OF CLINICAL MEDICINE” which happens to summarize the information for me (so I don’t have to figure out how to summarize it).

- Speaking to patients a certain number of times each week (but have to moderate it, otherwise I’ll be “occupying” too many patients and not giving other classmates a chance).

- Asking a family friend (who’s a doctor) for help, he tells me what’s important and what conditions I should just leave til I’ve covered the others.

I hope these strategies work for now and the future, but I’m somewhat displeased with how things are going atm. Even then, me artificially restricting myself as a preventative measure to avoid learning too much about each aspect of the condition may prevent me from gaining sufficient knowledge of areas that might need to be learnt to a deeper depth. I feel like I’m going to become a super duper Jack-of-all-trades just to cope, the lowest of the low : (

We'll see what happens for this Semester...