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…