Examination Medicine: A Guide to Physician Training, 7th Edition

CHAPTER 3. The clinical examination

This is a very testing part. It is more difficult than the written test.

Nick Talley and Simon O’Connor (1986)

The examination format

The clinical examination is divided into two sessions (morning and afternoon), each comprising two parts (one long case and two short cases), and now takes up a whole, rather exhausting, day. There is evidence to suggest that lengthening a clinical examination improves its reliability.

Candidates are notified of the starting time of the ordeal after their success in the written examination. Be on time for the clinical examination: it runs to a strict timetable and no allowances can be made for late arrivals.

On the exam day

For half of the candidates the first session begins with a long case. At the appropriate moment, each candidate is escorted to the patient by a proctor attendant or ‘bulldog’ (a term derived from the name of proctors attendants at the universities of Oxford and Cambridge).

The proctor attendant is usually a resident medical officer working at the examining hospital who has an interest in sitting the clinical examination. They introduce the candidate to the patient and then leave. If ever you have the opportunity to work as a proctor attendant, you should take it. There is no better way to come to understand what is expected of candidates in the exam.

There are never any examiners in the room during a long case. The time is limited to 60 minutes with the patient. A 5-minute warning is given after 55 minutes. At the end, the candidate is escorted by the proctor attendant from the patient’s room to a chair outside the examiners’ room. Ten minutes are allowed for candidates to pull themselves together and get to the examination room. A glass of water or weak orange juice is usually offered at this stage. If not, do ask for a drink if you need one.

A bell then rings and the candidate is taken in, seated and introduced to the examiners. Try to appear self-assured (even if you are weak at the knees), but don’t give an air of nonchalance (e.g. by slouching in your chair). By the time the last long case candidate of the day has arrived, it may be the examiners who are slouching in their chairs.

As a rule there are two examiners in the room, but there may be three (one as an observer only) and there may be a proctor attendant sitting in as well. One examiner will be a member of the Committee for Examinations (CFE), National Examination Panel (NEP) or Senior Examination Panel (SEP), and the other will be an experienced examiner who is a local physician (a co-opted examiner), perhaps even the DPE. Local examiners and NEP and CFE members undergo ‘calibration’ exercises before they examine. Even experienced examiners are not allowed to examine unless they have been ‘calibrated’ that year. Immediately before the examination, the examiners interview the long-case patient. Usually one examiner does this ‘blind’; that is, without reference to the patient’s problem list. Patient notes are no longer provided to the examiners, who only have a summary of the patient’s problems to look at. This ensures that the history is up to date, helps gauge any difficulty in terms of the patient’s ability to give a history and enables the examiners to assess the physical signs. If the examiners cannot agree with each other, or don’t agree with the summary about signs, they do not expect a candidate to find those signs.

The examiners assess the candidate’s ability to take a detailed history and complete the examination. They also assess the candidate’s ability to identify the patient’s active problems and to recognise priorities for investigation and management. The examiners are interested in seeing whether the candidate recognises the effect of the patient’s disease on the patient and his or her family.

The examiners mark the candidate’s performance in each of these ‘domains’ according to set key criteria. It would be wise for candidates to examine these anchor statements carefully; they are available on the College website or from the DPE at each hospital.

Concise, standard questions will usually be asked. Only two examiners will ask questions; one ‘leads’ the discussion and the other follows near the end for 5–7 minutes. The lead examiner will usually introduce him or herself and the other examiner and then ask if there were any problems during your time with the patient. For reasons of fairness, it is unusual for specialists to ‘lead’ the examination of a candidate on a patient with problems in their own field. Examiners will not lead if they know the patient or the candidate. Twenty-five minutes are spent with the examiners, presenting the case and discussing diagnosis and management. The discussion period is critical to passing (or failing).

At the end of the time a bell will ring and the candidate is taken to begin the short-case examination (Fig 3.1). There are a few minutes available, however, for drinking weak orange juice. Many candidates ask the proctor attendant about their performance. We believe this to be an unwise policy, since the resident medical officer is usually junior to the examinee and so is liable to give an incorrect assessment or an inappropriate cryptic remark, such as, ‘You were very unlucky this time’.

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FIGURE 3.1 A candidate presents her short case findings.

The candidate is then introduced to the short-case examiners. The examiners for the first short case are never the same as those who examined for the long case, but you may see the long-case examining team for your second short case. Again, one examiner in each team will be a member of the CFE or NEP. Fifteen minutes is allowed for the first short case; a second short case is then examined after a 5- or 10-minute break. The new examination system does not allow for more than two cases per session. This, and the extension of time to 15 minutes for each case, means that examination of each patient is a little less rushed. However, the result of this extra time means that there is a greater opportunity for the examiners to ask questions related to the physical findings. The examiners assess five domains during the short-case examination:

1. the way the candidate approaches the patient

2. the thoroughness of the candidate’s examination technique

3. the candidate’s accuracy in detecting physical signs

4. the candidate’s ability to offer a diagnosis on the basis of the findings

5. the candidate’s ability to use investigations to support the physical findings.

The key criteria and the skills that are required to achieve a satisfactory standard are available from the College or the DPE. Examining centres have also been told to have X-rays, CT scans, MRI scans and electrocardiograms (ECGs) available for discussion. If technology has achieved anything, it has made it more difficult to find X-rays and scans for candidates. Most hospitals have electronic storage of scans. There is often a problem logging on to the system and preventing the screen from turning itself off every few minutes. This tends to cause episodes of panic for the proctor attendant and organisers (and sometimes the examiners).

The other half of the candidates do this routine in the reverse order.

After lunch the second session begins, and this time the order of the short and long cases is reversed for each candidate. There is no longer provision for extra short cases for candidates who are thought to be borderline.

The marking system

The mark required to pass the examination is 40. Each long case is worth 21 marks and each short case is worth 7 marks – so the total mark possible is 70.

The mark awarded for each short case is out of 7, as follows: 1, very poor performance; 2, well short of expected standard; 3, short of expected standard; 4, expected standard; 5, better than expected standard; 6, much better than expected standard; 7, exceptional performance. In 2006 part marks were introduced for the short case, so now for both the long and short cases the scoring system incorporates positives and negatives (part marks) between 1 and 7, giving a 19-point scale. The use of part-marks helps some candidates who are very close to a pass overall. For example, if the examiners agree that a candidate’s performance was better than a 4 but not deserving of a 5, a 4+ is awarded, while if the candidate’s performance was much better than a 4 but not deserving of a 5, the mark will be a 5–. When the marks are added up at the end of the day, for example, 4+ will be 4.33 and 5– will be 4.67. Once a ‘raw score’ out of 7 is awarded, it is weighted; the long-case scores are multiplied by 3. This means that it has been possible to pass the exam with two good long-case scores, but without passing any short case. The examiners have begun to suspect that some candidates have decided preparation for the short case is not very important and have been concentrating on their long cases. From a candidate’s point of view this may seem a reasonable strategy, but it may mean suffering embarrassing humiliation in front of the short-case examiners. From 2013 the rules have been changed so that candidates must pass one short case at least to obtain an overall pass. We would argue this is still too lax!

The examiners try very hard to be fair. Each candidate’s performance is discussed at the end of each long- and short-case session. Each examiner scores independently: if there is disagreement about a mark, this is discussed and a consensus mark is chosen. If the examiners cannot agree, the NEP member has the final say. Examiners record any special considerations that may have caused difficulties for the candidate (and flag the assessment sheet with the infamous ‘red dot’), so that these can be considered later by the executive, if necessary. The Chief Examiner of the day (always a member of the CFE or NEP) is responsible for collecting the marked score sheets and dealing with any red dot matters. The examiners do not know the candidate’s marks in other sections of the exam (including the written examination), and therefore they do not know the effect of their own mark on the candidate’s overall success or failure. The examiners see the same short case four times with four candidates. They give a mark at the end of each session and cannot change this after assessing the other candidates’ attempts at the same case. The examination is not meant to be competitive. This means that every candidate can pass if the required standard is achieved.

Rather than trying to pass candidates (as at undergraduate level), the examiners are trying to evaluate the true standard of each candidate. Examinees must prove to the College that they are ‘good enough’; that is, they must demonstrate that they have mastered the material and have reached the required standard. The standards are very high, but the College emphasises to the examiners that the standard is that which is required for a person to enter advanced training and not the standard expected of a consultant physician. The rationale for this approach is that trainees who are likely to begin training in a sub-specialty should know how to examine all the systems of the body properly and have a sensible approach to the management of medical problems outside their specialty. A senior chest physician, for example, will always be able to boast that he or she once knew how to expertly examine the cranial nerves.

To achieve uniform standards, the CFE has been constantly working on improvements. Senior members of the CFE examine more often with less-experienced examiners. The CFE also holds regular formal calibration exercises, in which all examiners view video recordings and mark a candidate’s performance. A general discussion is then held to try to develop a uniform approach. The calibration is far from perfect; however, the CFE is working towards eliminating obvious mistakes.

NEP examiners are given a chart showing where each of them sits as to the average mark he or she awards. There is surprisingly little variation between examiners considered to be hawkish and those with a reputation as doves. Experienced examiners submit reports on their junior colleagues at the end of the exam period. This helps the examinations committee choose new members for the NEP. If there is a disagreement between examiners about the suitable mark (a rare event), the NEP member can override the co-opted local examiner.

The overall pass rate (for the written and viva examinations) in any one year in the past was about 40%. The eventual pass rate after success at the written examination and over four vivas (the old system) approached 85%. Under the new system, the pass rate has increased to 70% or more for the clinical year.

The mini-CEX

In 2008 the mini-CEX was introduced for basic trainees in their final year and is now used in all years of basic training. This is quite separate from the clinical examination and although it has to be performed, it does not count towards marks in the formal clinical examination. The trainee undertakes four mini-CEX exams a year, usually in the trainee’s own hospital and marked by the DPT or a suitably trained delegate. Each exam lasts about 30 minutes and is a cross between a long and short case. The trainee is introduced to a patient and given a clinical problem; for example, ‘Mr Smith has had problems with dyspnoea for a year and has noticed a recent deterioration in his symptoms. Please take a relevant history and examine him.’ The trainee is expected to ask directed questions about the symptoms and then examine the relevant system or systems of the body. This is all observed by the examiner. The trainee then presents the findings and a differential diagnosis, and suggests investigations and possible treatment.

Preparation for the clinical examination

For one mistake made for not knowing, ten mistakes are made for not looking.

JA Lindsay

The clinical examination aims to test not only clinical ability but also attitudes and interpersonal skills. For most candidates a successful approach to the viva depends on seeing a large number of long and short practice cases (Figs 3.2a and b). It is usually too late to start practising these cases after passing the written examination; preparation should start at least several months beforehand.

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FIGURE 3.2(A) Short case practice.1

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(B) Long case (guess who the examiners are).2

To practise for the long cases, try to set aside a regular time each week. Most physicians, if approached, are only too willing to test-run candidates. Being exposed to many different examiners (of variable severity) is desirable. It will help iron out mistakes and provide practice in answering different types of questions. Although most teaching hospitals have a training scheme in which long cases are examined by consultants or senior registrars, this is not enough. It is difficult to quote numbers, but we believe 50 formal long cases (across all disciplines) in which different specialists and senior registrars act as examiners represents the bare minimum requirement for preparation.

Practice examiners have not usually interviewed the patient and are therefore not quite like the real examiners. This does make a difference to the way they will mark your case.

Remember also that each time a patient is admitted to hospital, practice can be gained in the long-case technique – this turns overtime into useful preparation time. Practising cases is also critical in order to be able to cope with management problems in Paper 2 of the written examination.

Many candidates now video-record their long case presentation practice cases. This can be a useful way of assessing your technique. A number of recorded cases are available from the College. The cases in this book are available via Inkling with our enhanced eBook edition and via Student Consult with the print book.

Practice for the short cases is also important. More examinees used to fail these than the long cases, although this has changed now that the long cases are receiving more emphasis. It is valuable to have senior colleagues, as well as peers, take you on short cases. Travelling to other hospitals to practise is also worthwhile, because you have to examine patients in strange surroundings while being watched by unfamiliar examiners. It also relieves the boredom somewhat. The best practice examiner is the one who frightens candidates a little but does not demolish them when they make an error. Seek out constructive criticism. For example, many candidates practise in pairs, with each person taking turns to be the examiner. Practising being an examiner helps you to appreciate the bad habits that annoy the real examiners.

Equipment is always provided at the hospital where the examination is held. However, it is important to take the following:

• a familiar stethoscope that you have used for a long time. Do not buy a new fancier stethoscope the day before the test; it takes time to get used to a new instrument. Electronic stethoscopes are not generally allowed unless a candidate has a hearing problem and has obtained permission from the College

• a hand-held eye card – obtainable from OPSM for a moderate charge and essential for cranial nerve or eye examinations (see Ch 16)

• a red-tipped hatpin – you can buy a plain one and paint the top with nail polish; this is invaluable for visual field testing (see Ch 16)

• paper and pens.

It is debatable whether candidates should take in their own bags of instruments. Many favour bringing their own ophthalmoscope and pocket torch (with fresh or recharged batteries in both). Others also like to have cotton wool, neurology pins (an unused one for each case) and spatulas, as well as tuning forks (256 Hz and 128 Hz) and a patella hammer, which is too much to carry in the pockets. This has led to a trend for leather briefcases to house all the equipment (see Fig 3.3). However, the occasional difficult examiner has been known to complain about this! There is a legend about one candidate’s briefcase, which was filled with such elaborate equipment, including an inverted cardigan for testing dressing apraxia, that his examiners spent their time inspecting the contents rather than watching him examine the patient (not a recommended approach!).

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FIGURE 3.3 A candidate’s bag

1. Eye charts

2. Buttons and long patella hammer (underneath)

3. Stethoscope

4. Torch

5. Tape measure

6. Tuning forks

7. Ophthalmoscope and auriscope

8. Hatpins (red and white)

9. Jar with lid (containing key for key grip assessment)

10. Disposable neurology pins

11. Cotton wool

12. Spatula

13. Cotton buds and spare patella hammer

14. Carefully shaped foam inserts

A few more cautionary tales:

• Candidates who have just bought their bags have been known to forget the combination number needed to release the lock at the critical moment in the exam when the bag has to be opened.

• One candidate placed her open bag on the sink in the examination room for her first case, only to have the bag flooded with water when one of the examiners leaned closer to watch the examination and accidentally turned on the tap above the sink (Fig 3.4).

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FIGURE 3.4 Incorrect positioning of bag #1

• Leaving your bag on the floor might also be problematic. Many a examiner has been anxious that a candidate might walk backwards, trip over his or her bag and be impaled by a patella hammer (Fig 3.5).

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FIGURE 3.5 Incorrect positioning of bag #2

• During the assessment of the patient by the examiners one examiner mocked the old-fashioned stethoscope of his colleague: ‘You have a 19th-century stethoscope and I have a 21st-century one,’ he said. On going to examine the patient with his electronic stethoscope (not usually allowed to candidates), he stopped and said; ‘Ah, the battery is flat.’ ‘Don’t worry, you can borrow mine,’ said his helpful colleague. If you have permission to use one make sure it is charged. It would be embarrassing to have to ask to borrow the examiner’s.

• Most candidates fly in to the examination city on the day before their exam. At least one candidate arriving in jeans and a T-shirt found that his luggage, containing his suit and tie, had been sent by the airline to Hawaii (or somewhere). It was too late to buy more clothes. He sat the exam in these casual clothes, having explained to the exam organisers what had happened. The story had a happy ending, but the anxiety caused by such an occurrence is probably best avoided. Carry your exam clothes onto the aeroplane with you. Check, however, that there is nothing in your exam bag that will disturb the airport security people. They are easily alarmed.

• It is important that clothing used in the exam fits properly. The examiners were alarmed to see a candidate whose suit was either borrowed from a smaller person or had not kept up with his weight gain. When he bent over to examine the patient his shirt and trousers separated and the examiners thought he must have had a previous career as a plumber.

HINT

1. Remember your bag lock combination number.

2. Do not place your bag on a sink (or behind you on the floor).

3. Make sure all your batteries are charged.

During practice sessions, it is always a good idea to place equipment in the same pockets each time. In the exam, you do not want to be fumbling at this crucial time – it will only create a poor impression. Consultants, other than cardiologists, carry their stethoscopes or put them in their coat pocket; rarely do they place them around their neck. This seems a sensible policy for aspiring consultants also. Candidates who do carry a briefcase into the test (and many neurologists carry one everywhere) can usually place it on the patient’s bedside table and leave it open so that its contents are easily accessible.

Some candidates take beta-blockers on the day of the test to remain calm. An interesting story from the Lancet highlights this very situation. A Scottish physician refers to a British censor who had the habit of counting the temporal pulse of candidates: if he found that the pulse rate was less than 60 beats/minute, he would take this fact into account when giving his mark (M G Bamber. Dope test for doctors. Lancet, 1980. ii:1308). We are unaware of a similar practice in Australasia. However, candidates intending to use these drugs should give themselves a dose during a practice session. One doctor who did not do this learnt to his horror during the actual examination that beta-blockers caused him severe bronchospasm (he failed).

Nervous individuals with a tendency to sweat can have problems. One candidate (now a professor), who was balding and wore glasses, found that during times of intense anxiety rivers of sweat would roll down from his forehead and fog up his glasses, washing them from his nose. His solution was antiperspirant (unscented, of course) applied generously to the forehead (he passed).

Dress is important. The medical establishment is well known for its conservatism, and the nonverbal messages that your appearance gives should not be forgotten when dressing. Traditionally, men and women wear a conservative suit and men a noncommittal tie. Almost all examiners wear suits and ties (or perhaps a bowtie). In fact, a suit (for both men and women) is a sort of uniform and by far the easiest thing to wear. The most important thing is not to wear something that will make you feel self-conscious and distract you from performing well in the exam itself.

Other important considerations for men are having short tidy hair, a neatly trimmed beard if you cannot bear to shave it off, and a neutral smell. Dress formally, with care to project an air of quiet efficiency. White coats are never worn. However, being well dressed is no guarantee of success. There is a story of two male candidates, wearing grey suits and with recently cut hair, who were viewing with satisfaction a third examinee whose long hair was tied neatly in a bun and who was dressed in a flowing Kaftan-like garment – they felt their own success assured with such competition. However, it turned out that they were unsuccessful and their colleague passed.

Preparation is the key to success. Like an Olympic athlete, obtain plenty of sleep in the week before the ordeal; take no alcohol or tranquillisers in the 48 hours before it; and do not study during the final 24 hours. Make sure that you eat something before the examination and avoid taking a long trip to the examination city on the morning of or the night before the test.


1Diagnosis? See p. 324 (Fig 10.6) for an answer.

2The examiners are Simon O’Connor, holding the patella hammer, and Nick Talley observing intently.