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, 1st-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 1st 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 2nd 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…
