Examiner’s dilemma…
It’s exam time again, and as usual, the examiners, as much as the candidates are under stress. Well, if others don’t agree, I certainly, as one of the examiners to have this feeling! Frequent long travel (though, fortunately in a Business Class), hectic schedule (constrained by the exam schedule, you got to be at one spot, almost disconnected from the rest of the world) and the worse part is this examiners dilemma … I am I being fair to the candidate, hmm I don’t know so much about this thing, how could I examine? In other word, am I fit to be an examiner??
I used to dread going to the exam, now I begin enjoying it a bit. But I am still surrounded by that uncertainty especially when faced with ‘difficult’ cases like complex neurological or haematological cases, or all those new development in other specialties beyond my own… another serious dilemma was having to examine your own junior doctors, who have worked with you. I don’t find this particularly comforting, since, if I pass the candidate, there is always this element of ‘bias’ (especially if you encounter one of your ‘favourite’ students). On the other hand, if the student doesn’t perform, this is a more serious thing, as I will struggle to pacify him or her later when the result was known. I have the feeling that many examiners are having the same dilemma, whether or not they are willing to admit it!
This time around, I was paired with a very senior, eminent Emeritus Professor whom all these while known to be as a ‘hawk’, in fact in my previous writing, during one of those Exam calibration session, this particular senior Professor was the one who awarded a 3/10 marks to a candidate who appeared to perform well in a long case exam, and marked 6/10 or higher by others.
This time I was assigned to Part II MMED clinical examination in USM. One thing I like about examining in USM, is that everyone feels equal, since all of us were assigned to do the same sort of works – all required to examine long and short cases. Though at some points this resulted in some hiccup (such as examiners ended up examining the same candidate in the long and short cases!).
We started with the short cases. I have already prepared myself to be humbled by his seniority and eminence. I asked the Professor to take the lead, instead, he was quick to ask me to be the ‘first’ examiner, I took most of the candidates and started the cases with them, then handed over towards the end for the Professor to take over.
Prior to the actual exam, we were required to ‘callibrate’ ourselves by examining the patients, preferably blinded, in order to simulate real exam situation for the prospective candidates. I decided to go ahead of the Professor and started assessing the short cases, then caught up with him while he was still examining the long cases. I found him gentle and pleasant, and unduly thorough in the examination, checking for every possible signs. Then he pronounced the finding, and told me how he expected the candidates to find them. I could not agree more!
While the candidates were being examined, the Professor was fully focused, he kept writing on his examiner’s file, almost like notating every single words blurted our by the candidates. Then he threw in his questions and patiently waited candidates answers. He rarely interrupted, no interjection, and no condescending remarks whatsoever, though I have the impression that some candidates could be apprehended by his eminence, almost none perhaps, were frightened by his way of questioning. I found his line of questions as intelligent, discriminative and fair. In fact I learned a lot…and enjoy this experience.
Contrary to my expectation, the Professor was quite fair in his judgement and awarding marks. In most instances we differed with the markings, usually not a very wide margin, typically at 0.5 to 1 (out of 10) range, which was quite a surprise to me, and what a relief I thought, as it only means that I am getting better at examining now!
On two occasions we differed in markings, in fact I gave lower marks than him! The Professor looked at me, and remarked, ‘eh, how come, I am more generous than you?’
I awarded a ‘borderline’ pass to one candidate, while the Professor gave a clear pass.
A candidate who did so-so, both of us agreed that she did not do well, I gave her a 5, and the Professor 4.5 (so close!) – as this candidate was from his university, the Professor, in fact asked ‘my opinion’ before giving his marks, then he made up his mind, by giving a slightly lower marks.
Candidates’ Performance vs Examiners’ Performance…
Abdomen – most of the time is an easy system. This is more so when they put up all the barn door cases such as huge polycystic kidneys and massive hepatosplenomegaly. Therefore, examiners may not be impressed with your finding per se, in this case the diagnosis has to be spelt out correctly or else little chance of getting a clear pass (6 or above marks).
Our focus on candidates, on APKD cases is of course correctly diagnosing ‘End stage renal failure, on haemodialysis, secondary to APKD (in full sentence)’. Funny when our season examiner asked a candidate, why did you say that this is an AV fistula? The candidate took a moment before coming up with half correct answer…The other half of the marks given for correctly explaining about APKD including genetic & clinical association, plus screening. Genetic testing for APKD was also discussed.
One of the cases of massive hepatosplenomegaly with jaundice (the liver enlargement was not homogenous, mainly the right lobe, with firm consistency and irregular edge – yet, surprise, many candidates could not come out with this finding…) – due to chronic liver disease, with suspected hepatocellular carcinoma. The other case was a large hepatosplenomegaly where the liver has also craggy, somewhat smoother edge which almost fused with the spleen, due to enlargement of the left lobe. The patient was also jaundiced though not pale. Correct diagnosis was thalasaemia (HbE).
It was surprising to see the way many candidates examine the abdomen, bearing in mind they are close to being a specialist. There is always a difference between the undergrad and postgrad level of examination. For an undergrad, they just apply the usual technique of touching the abdo, asking patient to breath, then come out with HSP, and bingo they pass. But for a postgrad, this is not the case. Not all enlarged liver is the same. Some may be tender, some hard, some soft, some with smooth and some with irregular edges – all represent possible different pathology. When asked to ‘define’ the mass, many failed because they just simply apply the same technique of laying their fingers on the abdo and ask patient to breath! Don’t they remember one of the purposes of deep palpation is to feel and define the margin of abdominal masses?
One of the classic MRCP book said that, you never go the exam without knowing things like differential diagnosis of HSP – in contrast to Hepatomegaly alone, or splenomegaly alone, or large liver with just palpable spleen – all represents different diagnoses and should be at the fingertips before the exam. Don’t wait till you get such a case to start scratching your head trying to put things together.
Most importantly, most candidates should have known what kind of cases could be up in the short – most of the time they are about the same common things, though, yes I did get some of the weirdly rare one like Charcott marie Tooth, or XLA agammaglobulinaemia etc, etc. Even in those rare diagnostic condition, usually the examiners would have mercy on you and give some clue, and yet the main emphasis in this case is correct technique and finding, and display of reasonable knowledge about the condition in general.
Long case – in contrast to the short cases, long case is a test of how you manage a patient. Contrary to many candidates believe, long case is not about getting the correct diagnosis. So, forget about correct diagnosis. It is about synthesising patients problem and prioritising them correctly, and next addressing them in your management. In essence it is akin to your daily practice of clerking and presenting patients in the ward. Yet, many candidates fail to shine because of this oversight.
We had a case of diabetic patient who presented with polyneuropathy (and diagnosed as diabetic at the same time), the final diagnosis was CIDP. However, we as examiners were not interested in how the candidate could diagnose CIDP (since, the patient can readily tell them!), rather we wanted them to come with problem list, and of course they should be able to outline how this condition was diagnosed, along with differential, and how you distinguish it from the diabetic neuropathy.
Decision time
At the close of the exam, all the examiners gathered. The purpose of this gathering is just to formalise the marks for each candidate and any issue arising. There was one particular candidate who passed 2 short cases and barely passed the long case, earning a mark of 48.25%. (in our Final MB, they will qualify for re-examination). There is no re-examination in MMED. One of the lecturers suggested we relook at his/her marks and consider raising it a bit to a pass level or so. However, this was rejected by a number of senior examiners, stating that it is not fair to other candidate and the marks should not be changed even by 0.1% once they are finalised. I think this makes sense, though we as much as possible would like to see more passes, reconsidering marks can be tedious and controversial, so to keep to the status quo is perhaps the best.
Our external examiner made a comment that this is a clinical examination therefore the emphasis should be on clinical skill and less on theory, therefore a candidate may not be failed because of their deficiency in theory, rather in clinical finding. But of course, they should be able to synthesise the diagnosis. They should not be penalised (too much) for not knowing in depth on a particular subject. I think this is a balanced opinion and all examiners should adhere to this rule.
The funny thing about the clinical examination is the marking scheme. There are just two rules out of many for one to pass:
1. The total score (long and short cases) must be 50% or more
2. A candidate need to pass at least two short cases (any pass marks) – even though their total marks for short cases is less than 50% of total!
Because of this ruling;
Some candidates scored just bare pass (5 or 6) for the two short cases, failed the other two, and scored 8 (or even 9) in long case, and still pass the exam.
On the other hand, another candidate had borderline fail in three short cases, pass the long case with good mark, passed overall exam (score >50%) and yet fail (because of rule 2 not fulfilled).
It is still possible that a candidate passed three short cases and pass the long, but still fail – assuming his/her short case score was 5,5,5 and long case was 5 or 6, but he failed miserably in the other short (scored 1) = total marks <50%.
Well that is the game – you just have to play by the rule! The truth – in any of the exams, you rarely find a candidate passing all the four short cases – even the best of them sometime fail one of the short cases with abysmal marks (2 or 3!). The moral – if you find yourself not doing well in one case, never despair, because you are not going to fail just because you did badly in one (but you will if you did badly in 3, for sure!).
