Clinical Exams and "Random Questions"
Jun 23, 2024
College clinical examinations have a notorious reputation for being "random" and "not assessing things that matter". But why is this?
Well, it comes down to what the "examiners" aka Colleges think is important vs what we think is important. We might feel that purely clinical medicine is important, whereas Colleges are under a whole plethora of pressures to assess a whole batch of things which aren't purely clinical - particularly from advocacy groups and ministers, as well as part of their broader curricula.
So, what does this mean and why does this matter? Well, a typical clinical exam might be weighted like this - where each of the 6 categories below receive equal weighting (i.e. equal emphasis):
-communication and consultation skills
-data gathering (i.e. history and examination)
-clinical management (i.e. diagnosis and management)
-population health
-professionalism
-clinical governance
To put this another way, only 33% of the exam is about "normal clinical medicine" - which by default means that "random" questions must come up.
In my experience, random questions aren't very random - they are rather predictable. And if they are predictable, it means we can prepare for them.
Consider this made-up Clinical Exam question:
Neil James, 40 years, presents with tiredness for several months. He says that he has had a poor appetite. He is still overweight, but he thinks he may have lost about 5 or 10 kg weight without even trying. He has no past medical history of note and is not prescribed any medications. He works as a carpenter.
(a) Outline your approach to the further evaluation and differential diagnosis of his clinical presentation.
(b) You find his random blood sugar level to be 14.5. Discuss your differential diagnosis and approach to management.
(c) He tells you that he cannot afford the proposed treatment plan. discuss your approach to this scenario
This question would tick off almost all the above categories. It has preventative and population health, data gathering, management, clinical governance, professionalism and communication.
So how should you answer this? This is what I would expect:
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(c) He tells you that he cannot afford the proposed treatment plan. discuss your approach to this scenario.
In a scenario where Neil cannot afford the proposed treatment plan for managing his newly diagnosed diabetes, it is essential to address his financial concerns while ensuring he receives the necessary care.
Approach to Managing Financial Constraints:
- Assess the Patient's Financial Situation:
- Understand the extent of the financial difficulty: Determine what specific aspects of the treatment plan (medications, dietary changes, monitoring equipment) are unaffordable.
- Discuss insurance coverage: Check if Neil has any health insurance and what it covers. Help him understand his policy and explore any benefits he might not be aware of.
- Explore Low-Cost or Free Resources:
- Generic Medications: Prescribe generic versions of medications, which are often significantly cheaper than brand-name drugs.
- Patient Assistance Programs (PAPs): Many pharmaceutical companies help programs for patients who cannot afford their medications.
- Community Health Resources: Refer Neil to local clinics or community health centres that offer services on a sliding scale based on income.
- Government Programs: Check eligibility for government assistance programs such as Medicare Safety Net, PBS, Closing the Gap, Centrelink, Pension Cards or other state-specific health programs.
- Simplify the Treatment Plan:
- Prioritize Essential Medications: Focus on prescribing the most critical medications. For instance, Metformin is an effective and low-cost option for managing Type 2 Diabetes.
- Lifestyle Modifications: Emphasize lifestyle changes that cost little to no money, such as walking for exercise, choosing water over sugary drinks, and preparing meals at home using affordable, healthy ingredients.
- Self-Monitoring: Suggest cost-effective ways for blood glucose monitoring. Some programs or organizations may provide glucometers and test strips at a reduced cost or for free.
- Financial Counselling and Social Work Referral:
- Referral to a Social Worker: Social workers can assist in navigating financial assistance programs and provide resources for managing healthcare costs.
- Financial Counselling: Some healthcare facilities offer financial counselling services to help patients manage medical expenses and explore payment plans.
- Community and Support Networks:
- Diabetes Support Groups: Encourage Neil to join local or online diabetes support groups where he can get advice on managing diabetes on a budget.
- Nutrition Programs: Programs like SNAP (Supplemental Nutrition Assistance Program) can help with food costs, ensuring Neil can afford nutritious food.
- Education and Empowerment:
- Education on Low-Cost Healthy Eating: Provide Neil with resources and education on how to maintain a healthy diet on a budget. Simple recipes, meal planning, and shopping tips can be beneficial.
- Physical Activity: Promote free or low-cost physical activities, such as walking, running, or using community recreation centres.
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