How to Excel in MMed Part II Long Case

Master of Medicine part II is honestly a very tough exam. What intrigues me is the absolute lag of guides in part II exams for long case. There were no books or tips and tricks to tackle this exam. This triggers me to share my experience and my personal tips to prepare for the long case and how to handle it during real exam settings. A word of advice though: as this is a personal experience sharing, do take it with a pinch of salt as some advice may not be suitable for you. Feel free to post questions or any comments.

Long Case Exam Structure

Long case constitute a quarter (25%) of the total mark (theory + clinical). As you may have known, it is crucial to pass the long case to be considered as passing the part II exam. The minimal passing mark is 45%.

As this is a exit exam, you are expected to perform like a specialist in terms of your presentation skills. The thinking  process has to be mature and a sound plan is expected from you. You need to be analytical in your though process.  The cases included in the examination is usually a long and complicated management issue. Examples like long-standing diabetes with target organ damage, issues with adherence and hypoglycaemia, hypertension and disability at work caused by his poor eyesight due to PDR. Otherwise, you may get a case with diagnostic problem like rare combo disorders such as MEN 2a, Miller Fisher variant. Most often its a mixture of both diagnostic and management problems.

You will be given 1 hour with the patient. History taking, clinical examination, analysis of the case and formulation of a sound plan is expected during this one hour. There will be a 10 minutes gap to gather your thoughts and organizing your words. This is followed by 30 minutes of discussion with 2 examiners. During this time, you are expected to present your case and the examiners may bring you to the patient to elicit some signs. Then the discussion moves on to the management of patient.

Truth be told, time flies during the exam. I will share on how to approach and divide your timing during the exam in the following section.

Before The Exam: How To Prepare?

There is no standard textbook. I guess this is due to the vast diversity of cases that may occur in exam. However, there is always a pattern to be spotted. There are main diseases in each subspecialty that need to be covered before going for the exam. Examples are diabetes mellitus and its complications, SLE, HIV etc. One need to prepare for the diagnosis and its differentials, investigation and a sound plan for the patient. The book I used was "Mastering the Medical Long case 2e" by S Rohan.

Apart from the clinical aspect, one need to go in depth with patient's social issues. How does the patient cope with the disease, and who provides support for the patients? Assessment of a person's functional status gives an overview to the implication of disease to the patient. The idea is to see patients as a whole and practice holistic approach. 

Try to practice long case as if you are taking the exam the next minute. Limit yourself to 1 hour. Divide the timing into 3 blocks of 20 minutes each. First 20 mins is crucial to get the targeted history and the presenting complaint in depth. Relevant past history should be obtained. The next block is the physical examination. Do a relevant systemic examination according to history. You can still ask the patient and clarify any doubts. Lastly which is most important is to organized the thought and prepare your opening statement. If the history is longer than anticipated, you can change the block into 30 minutes of history, 10 minutes of examination and 20 minutes of structuring your case. In short, non of the component can be neglected, especially the last component.

During The Exam
 
Patient, to me, is the most important factor. You need to establish rapport as soon as possible with the patient. Convinced them this is a professional exam and no information shall be withheld and to put forward the medication list up front. This is to avoid unnecessary surprises towards the end of clerking. If there is a surrogate around, try to involve them as well.
 
Leave the opening statement to the last. You need to gain as much picture into the case, then only you can come out with a good summary.

For the history segment, try to write each issues in separate pages. Pay as much attentions to the chief complaints, as this is most likely to be scrutinized during the presentation. Try to move away of presenting symptoms, instead analyze the collection of symptoms and give a reasonable differentials. Examples:

a.   "Mr Jude presented with 3 weeks history of shortness of breath especially on exposure on dust. Symptoms worsen during working days and wane during off days."

b.   "Mr Jude has symptoms suggestive of occupational asthma as evidenced by worsening shortness of breath at work and better during off days" 

The first examples history as its selling point. Technically it is not wrong, but it feels like the candidate did not put effort to analyze the case. The latter example puts a reasonable differential up front and followed with the supporting history. This is the preferred way to sell your case as it exhibit maturity and confidence.

Do not skimp on the detail. You will be surprised the amount of information they (the examiners) has in their answer script. As the script is based on not only clerking, but also the investigation and intervention done on the patient, it is crucial to get as much details as possible. It's rather embarrassing for the moment of silent when they try to extract the information that you don't have and trying to confabulate doesn't help as well. One useful tip is try to get the detail picture of admission or visit of patient into the examination hospital. Usually the detail of admission to the respective hospital will be most detailed and will be asked the most.

Examination of the patient should be done in systematic manner and prioritize the systems that the patient complains. Do not forget the vital signs, urine dipstick, body weight and blood glucose if relevant. As the examiner may ask you to demonstrate the finding later, make sure get the relevant positive and negative signs ready.

The last part of the preparation is the summary of case, construct your long case into a logical and interesting case. You may want to go back to the main history and add on any missed points. More importantly you need to construct differential diagnosis, investigations and formulate a plan for the patient. After all is done, take time to construct the opening statement.

Opening statement is a powerful and catchy phrase that contains all the crucial points of your case, yet not too lengthy. If it is too short, it will not give the examiner a whole picture of the case. If it is too lengthy, it will bore down the examiners. Starting with a weak opening statement will cost you dearly in the exam. To make the matter worse, there is no standardized way to make a good opening statement.  Let me show you an example.

Ms Janet, is a 36 years old clerk from Puchong with diagnostic and management issues of SLE complicated with lupus nephritis now in end-stage renal disease. Other inactive problems such as exogenous Cushing's syndrome secondary to prednisolone and osteoporosis. She is also having depression and in financial constraints.

From the examples above, it gave the examiners a snippet of the case of SLE complicated with ESRD due to lupus nephritis. She is also depressed and having financial difficulties. Putting in a social issues makes you look holistic and concerns about patient psychosocial aspects. Always identify 1-2 of the most important part to include in the opening statement and in the clerking later.

Put Up A Good Show

 After the bell rang, you have approximately 10 minutes till the examiners call you in. Use the time to rehearse your case, especially the opening statement. Try to picture it like a movie and see the flow of the history. You are given 30 minutes. Present like a salesman, convince the examiners to buy your story. Eye contact is very important. There will be 2 examiners and try to give them both equal attentions. They may stop you intermittently to clarify your case.

If they are satisfied with your case, they will bring you to bedside to demonstrate the findings.

Next part of the discussion is about investigation and management. Time is scarce and investigation must be focused to the case. There may be a scan or radiograph that need you to interpret.

The tip is to be calm and engaging to the examiners. The examiners can feel your knowledge and understanding of the case by looking at your non-verbal cues. In no time at all, the examination will be over. If you did badly, try not to carry forward any feelings ito the next section as you may still have a chance to redeem yourself.

Pain in the Nether Region

Lately, I had encountered a difficult person. She had a few medical conditions, but worst of all, she had manic depressions. My first encounter with her was back in February. She was admitted for a lung condition which needs anticoagulation therapy. However, she refuses to go home when the therapy was initiated and going on well. Everyday, she would follow us for ward rounds, interferes with our ward discussion. She come with many little complaints. Finally, after 3 weeks or so, she was discharged back home.

She had a complicated history, due to her illness, her husband left her for another woman, and the disease manifest itself, like a vicious cycle. She had been to many private centres. All with the similar complaints of short of breath. She did CT coronary angiogram that was normal but found and incidental pulmonary embolism. Then she was referred to us for further treatment.

Due to her psychiatric condition, not many people can tolerate her. She was even being scolded by a renown private cardiologist for her persistent complaints, saying that she is a pain in the nether region and she is going to die with her illness!

I saw her again in clinic last week.

She was with her usual flowery and bright dress. I thought trouble came back knocking on the door again. The first few minutes of consultation, I was half hoping that she didn't dwell into the old problems. I let her talk. She went on with her family problems, how her disease actually concerns her. She had been compliant to the treatments and her INR was within target range. I praised her for her effort. I didn't interrupt her and I let her ventilate. She went on and on. After 15 minutes I came to a conclusion, set her targets and set an appointment date for her.

It seems to go on very well this time.

The morale of the story is, we can't cure a disease all the time. Nor we can solve the family matters, the financial woes and issues around. We can listen. Hear the problem out. Take some time to let them ventilate. Give a reassurance nod from time to time. Be patience. The answer to the their problem often lies within them.

Cheers.

There's No Monkey Business Here

Today my consultant taught me a very important lesson, especially for the young doctors like me. It struck me like a thunder. seriously.

My wards have been a dumping zone, nursing home, shelters for some and house for some permanent residents. One of them is a very old Chinese man, very unkempt, bed ridden for 3 months and came with multiple bed sores, dehydration and pneumonia. The relatives called an ambulance to pick up this man and since then, passed the responsibility to us to take care for the rest of their parent life. Since that day of admission, we never see any relatives, nor any number to contact. This old man remains gaga. Another man is young and fit man, unfortunately get involved with drug early in his life. He is unemployed, staying with a drug lord in Chow Kit and runs errants for him. In return, he gets his high. Recently, he had a row with the Boss, and he is left on the street. Left with no food or clothes, he had to fake his signs and request for admission. Lastly, there is another middle age man, active smoker and heroin chaser, had burned holes through his lung. He needs long term oxygen, yet reluctant to give up his cigarettes and old habits. A little bit of cough will straight away bring him to the hospital and the admission unit is always kindly enough to put him to our ward. He will be admitted at least 3 times a week, and scowled at us if we discharge him.

It has been a serious headache for me and my other colleagues. Our registrar is under constant pressure to reduce these unnecessary workloads.

On the contrary, my consultant is exhibiting la belle indifference towards this matter. He just nod when we shoved him with loads of our complaints. If the man do not want to go home, keep him for another day. We were puzzled at first, but today he shared with us a story.

He is used to be a very proactive, eager, hot head doctors once upon a time. He always upright the juctice, not allowing any wrong, no allowance for these hanky panky stuffs. One fine day, he received a call from his son's headmaster, asking permission to meet him in person. His son was in primary five in a nearby Chinese school. On a separate occasion, his wife received another phone call from their son's form teacher, asking to meet in another time. Puzzled with this events, they decided to turn up together to meet up the headmaster. The headmaster was shocked initially, seeing both of them turn up together. He explains that the reason for meeting them in different time is because they thought there were family issues between both parents, i.e a divorce. The headmasters proceed to inform them that their son, who was a top scholar, drastically deteriorates in terms of school performance lately. My consultant was taken aback, when the headmaster ask for how long they haven't check on their son's school work and academics. The son was so into the video games that makes him neglect his school. All these time spent up holding the rights, making sure the ward runs in order and all other stuffs had cause a toll on his family. Since then, he had taken a step back. Prioritized the important things in life and learned to put family first.

That little story suddenly give me an insight. Learn to prioritize.

Crawl...Walk...Fall...Walk Again

A baby learn to walk is no easy feat. It will start with a small steps, small and uneasy steps. The gait is waddling, the toes are in-curling. There will be numerous falls and bumps. Numerous bruises on forehead, scratches over limbs and endless cries. Given enough time and practice, small steps become big steps, uneasy become steady, then there is no more falling down, Walking become the second nature.

Isn't it the same with life? House officers learn from experience, numerous failures, many ups and downs, to become a safe doctor, and a better person?

New ruling created by the day to help these 'underpriviledged' group of people. First come the rule of house officers not allowed to follow in ambulance. Then came the shift work system to cut back the working time to 60 hours. Now there are hospitals that won't allow them to clerk case and examine patients! Looking at all these rules, it follows after certain events.

First, there were an incident of a house officer in Melaka Hospital involved in road traffic accidents while transporting patients. While we cannot predict the future, shit does happens to anyone. I witnessed a case of a staff nurse sustained a fracture of the radius bone while transporting a pregnant mother to general hospital for delivery because the new ambulance driver hit on a wild boar and the ambulance go turtle. Do we bar the nurses from sending patient? Certainly not! While I cannot say the ambulance is the safest ride home, even a fully registered doctors like us cannot prevent any untoward things to occur.

Then, house officers complaining of long working hours in the hospital. Hospital basically become the second home. There is no social life, love life or party life next to working. Then came the shift work implementations. Initially was full of glitches, but thing smoothed out in the end. The draw back is the oncall claims was with held. Then complaints starts again become there is not enough money to cover the car installment and side expenses, so another 600 bucks given on top of the shift work. What they didn't realized that without the adequate exposure, there is simply a disaster in the making. Not only more officers will be extended for the lack of skills and knowledge, they will be less equipped when sent to places that has no senior people to back up. The situation is similar in most of the government hospitals.

Are we doing them any good? Ask yourself, in years to come, will you want to go to any government doctors when you fall sick? If the answer is no, then please review the system again. For me, to be a great person, one have to fall many times, then when he stand up one day, he will be standing up tall. The scar is to mark how resilient you are, and prove to the world that you are not a weak doctor! 

The Dog-faced and The Dog-breathed

Someone to hold your hand

Last night, another kid try to take his life.

He is the dog-faced. We (the semi-alert on-call doctors) are the dog-breathed.

He is an 18 years-old. He had met his hurdle in life, and I am sure this might not be his first. There is always a mixed feelings when examination results were released. Yesterday was SPM results announcement. He is unhappy with his results. And he took a total of 50+ tablets, containing a mixture of paracetamol, loratadine, cinnarizine, and maxolon. The mother found him 4 hours later, in severe abdominal pain, but luckily he is not intoxicated.

I could remember how elated my feelings were when I get hold on to the results slip. It wasn't because my results were that good, just seeing that what I had worked for bring fruits and what I prayed for were answered. It is a relief that is beyond words. It is a feeling of putting down a stone from the inside your heart. But soon after that, another stone will starts to grow and the cycle repeats again...

There are many ways we can choose to handle the critical situation. He might had flung his examinations, but there is always a way to go about it. He can ask for help. He can talk to his friends or parents or his teachers. He can share it out. He can get self-help, or learn to forget. Is there something wrong with our society's support system that makes it difficult for young adults like him to get help?

I try to talk to him, to peel into his self defense. Unsuccessful. He choose to keep it a secret. Or he is too shy and regretted to what he did. All his vitals were stable and blood parameter were luckily normal. IV's were pumped in to rehydrate him. He survived, at least for another day.

If we try to see our problem from different perspective, or just stand back and looking at the problems again, the matter might just shrunk and disappeared after all. There is always a way to every situation and there is always something good behind things that seems so bad. For example, you fall sick, very very badly and recovered from it, you will develop immunity and become stronger.

For me, the best way to overcome a problem is with a song. Singing put away all your stress. It is as good as any tranquilizer. And there is just the perfect song for all troubles. "Let It Be" by The Beatles. My all-time favorites.

The MMA Pahang Second Annual Scientific Meeting: Handout

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Handouts

Negative Psychology

Human... A very difficult subject to study. Half the time, I do not know what I am dealing with.

Having busy myself to prepare the upcoming scientific meeting in my area, makes me realized one thing. You need a lot of negative psychology to deal with people. The program was heavily sponsored, safe to say, participants pay only a quarter of the actual amount. Yet, the respond for the participation had been underwhelmed, with only a handful of early adopters, the rest were 'dragged' into the program. I spent 1 whole evening calling every possible places, all the nearby health clinics and hospital, even rang up the health centres in nearby university, just to plea for participants. However, the past conferences that I attended to, which we have to fork out between RM 400 to RM 800 each, it was a full house, and I was actually being rejected for admission to one of the conference held in Penang! Probably, when people pay, they will actually feels the pinch and think it is a very important thing instead!

Same with patients that I see day in and out. The healthcare cost is pretty much covered by taxpayers' money when one admitted to the ward or visits the clinics. However, a person I knew was diagnosed with lung malignancy. He refused treatment in general hospital for the sake that it is free and free means it is no good or second class. He rather fork out hard earned money to get chemotherapy in Singapore instead. Currently, he is in Beijing getting some novel 'cold' therapy for his cancer. Same as generic versus labeled medicine. I have a colleague who encountered this type of patient that we labelled as 'fussy'(not uncommon, certainly seen in daily practice). She was seen by other doctors for her diabetes and hypertension. First line medications were given to her and explanations made. However, she wasn't satisfied because she received the generic medications and made a big fuss to complaint if we do not change her medications to the box type that has fancy colours. Probably its a good idea that the generic pharmaceutical company made their medication in better packaging and interesting colours instead!

Human... When can I finish learning this subject? Probably never.

Thirty and Wasted

This is a true story. 

This is a story of a boy. He is 30 years old, and paralyzed. A freak accident 6 years ago took away not only his limbs and his freedom, but also his dreams and his life. A boy that has plenty of future, ended up lying on bed more than 20 hours a day.

We pass urine without even break a sweat. He needs to self catheterized. "Or else I will have retained urine." He said. Passing motion is a automatic response. Moving around means a lot of work transferring himself to wheelchair and back, involving many helps and energy-consuming. He and caretakers resorted to the simple way out, that is not moving at all. He has a loving wife, staying beside him, answering to whatever his needs are and tend all his errands. Whenever he is admitted, she will stay beside him, like a shadow.

But he is not always a good boy, to start with. He has issues. He can't get over the fact that his life has changed. He did drugs. And he had complications from it. The heart fails as we witnessed that he has worsening oedema all over his body. He is breathless at rest. He is tired all the time. And he makes his wife suffers. The newly gained weight caused him more disability. As a result, there were multiple pressure sores over the buttock and the prominence of the hips. And it sure smells bad too.

With good medications and nursing care, we bring him out of the disaster.  His failure symptoms resolving. His infections under control. Proper rehabilitation goes a long way to restore his function and self esteem. Last I saw him, there is a shine in his eyes that were absent previously. The smile that he and his wife gave us tells us a lot.

This is not only Malaysian dilemma, I believe it is rampant all over the world. Illicit drug is a very serious problem, both in term of healthcare burden and social aspects. Most of the drugsters are of the young and so call productive group. The country lose out the brilliant assets when these people getting high in some dark alleys. They are prone for blood-borne illness, as well as creating sense of insecurities in the neighbourhood. Many ended up in correctional facilities or prison, some even to the hang rope. 

I don't despise these people. I felt sorry for them. I will try to help them, if it is within my ability. I don't deny that many treat them as a nuisance, a self-inflicted illness, 'high risk' for infection transmission case, and difficult vascular access case. But I sincerely hope it will change. It start from within your. Please...

MM Kills the Doctors

No. It is not Marilyn Monroe. And it is certainly not your M&M sweets (although some might argue that the high sugar content will cause harm). No, I am not talking about multiple myeloma either.

Its maternal mortality.

Just mention this term among your colleague, it will certainly bring chills to their spine. Some had nightmares of going through the painstaking process of being interrogated. Months of sleepless nights, loss of appetites, anhedonia, and suffers in term of performance at work. Some even loss their money and worse case scenario, losing jobs. 

I want to share a personal experience of my recent encounter with MM:

Mdm Z was a 24 years old expecting mother. She enjoys good health previously. She had a loving husband, and a caring family. This was her first pregnancy, and she had lots of hope for it. The first trimester of pregnancy passed through like a breeze.

During her second trimester, she had fever for a week. To cut short the stories, she was found to have infective endocarditis of the native valve. She was told of the problem and treatment commenced. As she was pregnant, many drugs were contraindicated, so the choice of antibiotics were limited. After about a week, she developed heart failure, probably because the infections cause valvular insufficiency. However, as of many Malaysian, they have predominating mindsets that alternative medicines works, and refused the trial-proven therapy. So the family brought a Shaman at midnight to her cubicle (without our prior consent), chanting spells for 2 hours, spraying water all over (nevertheless, causing massive rain inside ward and disturbed the other patients). You know what, the fetus died the next day!

Couple of days later, she delivered. Treatment was continued (and many 'I told you so, yet you don't want to listen'). Finally she was discharged well after weeks of antibiotics and planned for operative management in near future. Just a week after discharge,  patient condition deteriorated at home yet family refused to bring her to hospital. When we rang up to follow up her condition, that's when we knew she had met her maker.

Who's at fault?

Sooner or later, there will be inquiries regarding this maternal mortality case. We have to attend countless of meeting, fired with many questions and waste many time in between.

MM also created a culture of defensive medicine where managing team will priorities the non-emergent case over others to save themselves from this MM inquiries hassle. What do you think?