[Medical education] Answering questions

Exams are anxiety-inducing for almost every student. If you are prone to anxiety, this can feel particularly stressful and unfair. This series will aim to help you to enter exams with realistic expectations, and to keep an eye on the pitfall traps.

 

The structure of assessments

1. Examiner reads opening statement and introduces candidate to patient
2. Candidate takes medical history
3. Candidate performs physical examination
4. Candidate summarises to examiner
5. Discussion and questioning

This article will focus on parts 4 and 5.

 

Perspective and attitude

For a final year medical student, consultants will be thinking about the candidate as an FY1 doctor. Many examiners won't fail a candidate for seeming anxious, or giving a suboptimal performance.

However, once something unsafe is said, there is an ethical obligation to give the candidate a fail grade. This prevents unsafe doctors from progressing to greater responsibilities before they are ready. This protects patients from iatrogenic harm.

Additionally, once a candidate becomes an FY1, the responsibility for their errors lies with the local consultants (except prescribing mistakes). The production of unsafe FY1s from medical schools, adds potential stress to the professional lives of consultants.

Pride can be seen as arrogance, and arrogance is considered dangerous. Many examiners take a sadistic pleasure in punishing candidates for mentioning rare diseases by asking extensive questions about the topic.

 

Suggesting the differential diagnosis

In exam settings, it is very common to panic and give an unstructured answer. However, the best answers are as structured as possible.

• It's sensible to take a moment to consider a question, before speaking. If it's a long pause, it would be helpful to signpost this by saying "Please can I take a moment to gather my thoughts before I answer that?" A reasonable examiner should allow an unpenalised 15 seconds as a bare minimum. 
• Systems such as the surgical sieve can prompt recall of broader knowledge. Read more here about the surgical sieve.
• Differentials should start with common diseases and gradually progress towards uncommon diseases.
• Any rare diseases should be mentioned at the end and clearly signposted as rare. Knowing rare diseases shows enthusiasm, but not intelligence. Beginning with rare diseases is often interpreted as a lack of diagnostic reasoning.

 

Suggesting investigations

Investigations should be suggested in a sensible order.

 

Suggesting management

If an examiner asks "This is your patient, what will you do next?", they are setting a trap to see if the candidate recognises their limitations. The candidate must imagine that they are in the role they are preparing for (e.g. FY1 doctor). They must not suggest that they would treat a complex, life-threatening, or rare condition alone.

• A fail answer: "I would suppress the immune system, for example, with ciclosporin."
• An ideal answer: "This is a condition which requires specialist expertise. I don't have enough experience or training to manage this alone. I would make a call to gastroenterology and ask for specialist input. The management might include immunosupression, for example, with ciclosporin."