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Review Session

OSCE Mock Exam 1


June 2014
By:
Dr. Cyrus Salimi
Stations Feedbacks

• See individual Feedbacks on your feedback


sheets as they particularly apply to you

• At this session we will review some general


feedbacks which can apply to everyone
Pre-eclampsia
• Examiner’s Comments:
– Communication and over all feedback:
• I believe a smile at the examiner in the beginning could have a
positive impact on her impression from you. Most of the doctors
ignored the examiner completely.
• More than 50% gave their roll of sticker to examiner (me) and did not
make it ready before interring the room. Please peel it off before
• Some that finished their questions and history earlier than 8 min Buzz,
asked examiner if she has question for them or not. They should use
their extra time
– a) To ask missed questions
– b) To communicate with patient
» especially about social history (professionally and depends on situation)
– c) Wait for buzz
• In this scenario most of them were disorganized. They jumped from
Present Medical Illness to PMH. Then to Medication again to present
illness and so on.
• Knowledge and Content:
– In this case : 44 years old 34w pregnant+ tiredness+ swelling in feet, hands and face +weigh
gain+ one time BP:140/90 , I believe the best diagnose is gestational hypertension( based on
SOGC guidelines 2014). However, due to the fact that patient is puffy with turbid urine,
Preeclampsia should be on top diagnosis I
– I checked the diagnose box for those mentioned preeclampsia and Gestational Hypertension.

• Preeclampsia is defined as gestational hypertension plus one or more of the


following:
• ● new proteinuria, or
• ● one or more adverse conditions, such as headache, CP, visual symptoms, O2
desaturation , elevated WBC, INR or PTT, low Plt count, elevated Cr, LDH, AST, ALT,
low plasma albumin, increased FHR
• ● one or more severe complications.*
• Severe preeclampsia is defined as preeclampsia plus one or more severe
complications, such as leukoencephalopathy, cortical blindness, stroke, TIA, pul
edema, uncontrolled HTN, INR>2
– In all pregnant patients, especially in second half of
pregnancy, don’t forget to ask about fetal well-being:
– Change in fetal movement (especially decrease)
– Vaginal bleeding
– Contraction
– Broken water bag
– When there is a chance of preeclampsia they need to ask
about sign and symptoms to recognize that, the severity
and complications. Such as: headache, epigastric pain (not
hearth burning) , visional disturbance, SOB, chest pain,
N/V, seizure, Evidence of IUGR or Oligohyramnios, urine
color change, bleeding from different parts and so on.

• Unfortunately just one case asked about Cocaine directly and BG of
both partners. Based on my understanding when we have new
onset of high blood pressure it is not bad to ask directly about
Cocaine besides smoking and alcohol.
• Always in pregnant patients ask about LMP.
• Also in all women in OB&GYN cases ask about last Pap smear.
• Generally, most candidates did well in this station and almost all did
not miss the Red Flag which is preeclampsia.
• Test and investigations: Make sure to order relevant ones: (urine
for protein, serum albumin, AST, ALT, Plt, LDH)

• I wish success and good luck for all the candidates.


• Patient’s comments:

• There are a few candidates that really stood out and the reason they did
was because they walked into the room confidently and gave a big smile
(not always appropriate of course), they spoke in a clear, strong
voice. They really listened to what I was saying and offered appropriate
empathy. There were no fake lines or contrived dialogue because they
were actually having a conversation with me. They asked questions in a
systematic and organized fashion to get to the root of my complaint. They
then wrapped up the situation and let me know what next step would
be. The bottom line is, the more natural and real you are with the SP, the
better your interactions are going to be. So many of the actual OSCE cases
are not really about medical knowledge but rather about communication
skills and when candidates are giving fake empathy or not being authentic,
it is very apparent.
• -Please do not say lines like 'that must be really hard for you' and 'how is this
impacting your life' unless it makes sense and you can say it without it sounding
like a line. I saw about a hundred people the other day and almost everyone said
lines like this which weren't really appropriate for my station anyway and the way
it was delivered it was obvious it was from a checklist of some sort.

• -Checklists are fine to keep you on track but the most important thing is that you
really have a conversation with the SP and hear what they are saying (we are
offering many clues which will lead you). If you do this, not only will you probably
stay on track but you will also have a naturalistic conversation.

• -Please allow your personality through. No one wants to talk to someone who
doesn't seem authentic or is just trying to get marks. SP's recognize that this is an
artificial and high stress environment for you but we truly try to make our
scenarios/performances as realistic as possible. It is disheartening to be talking to
someone that seems very robotic or like they aren't really in the room with us.
• Use mnemonics in order to have a good flow and an
organized and systematic approach but please don't get too
rigid in this. You still must be flexible depending on what
the SP is giving you.

• -Be mindful to check in the SP. Sometimes I found the


candidates were doing most of the talking. Always
appropriate to say things like 'are you following me?' or 'do
you have any questions about what we have talked about
so far?‘ or “does it make sense to you what I said?”.
• Interactions are like a tennis match and you need to make
sure the ball is going back and forth.
Newborn juandice
• Examiner’s Comments:
– This was a fairly simple station and it was handled quite well by
a majority of candidates.
The main areas comment worthy are in the following 4
catagories:
TIME
1. A great many candidates finished everything including
the wrap up before the first buzz.
• 2. Some students began a wrap up within 2 mins and then
went back to the case to fill up the gaps. This was probably
because the diagnosis was make so quickly that the process
of doing a complete interview was abandoned. The process
of interviewing yields a lot of points more than the
diagnosis.
CONFIDENCE
– Candidates did display a great degree of knowledge but
still appeared very nervous. While this is understable it is
still a good area to work on. Being so nervous can cause
you to block.

COMMUNICATION
There was a high level of overall verbal communication
skills on desplay during interviews. Excellent. Non verbal
communication was much weaker and it is a good
reminder here that non verbal communication includes
dress, confidence, gestures, posture, eye contact and even
how far (or close) you stand from the patient.
• Remember not to make your wrap up
comments too technical.
• There is a natural tendency to want to expalin
using medical terminologies as it gives an
insight into your knowledge but remember
the patient can feel overwhelmed.
• Patient’s comments:
• EMPATHY
– In order to meet the empathy requirement of the mock exam,
many candidates said lines such as “That must be very difficult
for you” or “I’m very sorry to hear that.” Those candidates did
not follow up on their statement and often squeezed it into the
interview, making it sound very unnatural and not genuine. Such
lines made me as the patient feel like the doctor does not in fact
care about my condition but rather are just saying it to fill time.
– As a patient I find it most effective when candidates show
empathy through body language and through their personality
so that it is shown in a genuine and real way so that the patient
is able to connect with the doctor. This was demonstrated
throughout the exam when candidates made eye contact,
remained relaxed and used facial expressions to demonstrate
empathy. I also felt empathy from the candidates when they
were compassionate and showed me-as a concerned mother
that they understood and cared about my daughters wellbeing.
• QUESTIONS
– At the beginning of the interview many candidates asked very general, open-
ended questions such as “Can you tell me more about what happened?” or
simply just “What happened?” These general questions are good to start with
but we answer in a general way such as what you see on the stem question, so
that the SP will not be volunteering any key information.
– Many candidates asked specific question one at a time to minimize confusion
for the SP, such as “Where is the baby yellow? Does she have any pain?, Does
she take any medications?” individual questions allow the SP to focus on one
question at a time and does not get confused with what questions are being
asked.
• ORGANIZATION
– Many candidates had organized questions that transitioned well into one
another, however; some would say: “Oh I forgot to ask, are you smoking,
taking drugs...etc?” These cases broke the fluidity of the interview and
disrupted the flow of the questions.
• NOTE-TAKING
– Almost all the candidates used notes during the interview; however, some
would use them to write small things when they did not have anything to say,
therefore using them as a security when they were thinking. However, many
made fast notes that they were able to use at the end of the interview that did
not disrupt the flow of the interview and therefore, were not a distraction for
the patient or the candidate.

• Miscellaneous REMARKS
– Some students said “Do you take alcohol?” instead of “Do you drink alcohol?”
OR “Do you use smoking?” instead of “Do you smoke?”
– Some candidates also didn’t use the correct gender when they were
addressing the baby and often used the pronouns “him,” “he,” or “his” when
they should have been addressing her as a girl. This would show that the
doctor is in fact listening to what mom is saying and cares about her concern.
– Overall the students did a great job; with almost all making the correct
diagnosis and I wish them all good luck!
Knee injury
• Examiner’s Comments:
• General Feedback:
• Overall this station was well done. Some candidates performed very well and
covered literally all the aspects of the history and examination. However, others
lagged especially in communication skills both verbal and non-verbal, and in their
physical examination skills.

• History:
• The station involved a 33 year old male presenting with an acute injury to his knee.
The first part of the station was making sure you read the stem and entered the
room with purpose. The best candidates started by confirming the stem when they
walked into the room, “Hi Mr James, I am Dr. (name), I was told you hurt your knee
playing soccer this morning (wait for response from patient confirming yes). Could
you tell me more about what happened?” Some really good candidates made a
joke about the world cup, and you could see the patient instantly feel more
relaxed. That is how you score big in the patient-doctor relationship scoring.
• The important part of the history is to recognize this is
MECHANICAL knee pain. So while you will ask all the questions
about the pain, (site, quality, intensity, timing, etc), ask associated
questions relating to MECHANICAL pain. For example: catching,
locking, instability, etc. Then ask about INFLAMMATORY symptoms:
swelling, redness and finally INFECTIOUS/NEUROLOGICAL: fever,
weight loss, numbness/tingling, weakness. You need to know if
there is an underlying cause to the knee pain, or an underlying
condition predisposing the patient to injury.

• After eliciting the major symptoms, ask him how he has been
dealing with the pain. For example, pain medications, tensor bands,
crutches for walking, etc. Ask what, when and how frequent he is
taking these medications. Is anything helping?
• Next you will ask about previous injuries to the knee, his baseline exercise
tolerance, and occupation to get a better idea of the patients FUNCTION.
Ask how the injury will affect his job, his ability to cope at home, or life,
etc. Show that you care.
• Lastly do your 30 seconds of questions on his PMH, medications, social
history (smoking, drinking, drugs), allergies, FHMx of joint disease. Do not
spend too much time on this. This is where you are going for as many
points as possible, in the shortest amount to time.
• Make sure that you organize yourself at the door and as how to divide the
interview questions with respect to time and prioritize your questions
accordingly. This would help you using your time efficiently and not
running out of time leaving questions unasked and issues uncovered.
NOTE: do not just ask the AMPLE history as written in Toronto Notes.
There will be significant gaps in your history. You have enough time to ask
all the questions as mentioned above.
• Examination:
• Overall this was poorly done. Although it was evident that some people
knew the steps f the exam, it was obvious you did not practice. The steps
are always the same:
• Wash hands and ask for vital signs at the same time.
• General comments about the patient sitting at rest (body habitus and if
they are comfortable. Avoid saying anything about habitus is the patient is
overweight or obese. Might be awkward.)
• Ask them to walk for a couple steps. Comment on gait… likely antalgic.
• Inspection of limb. (colour, swelling, deformities). Please do this in under
10 seconds. Don’t waste time as some spent 1 of the 8 minutes in the
station on this step… WHY?! Literally spend 10 seconds. Its worth 1-2
points out of 60 and you just have to say “I am inspecting for…..” and then
say a few things to get the point.
• Move the limb. Active ROM, then Passive ROM. Do this with the patient
lying supine. Comment on deficiencies.
• Special tests.
– Colateral ligaments
– ACL drawer and Lachman
– PCL
– McMurray
• NV and pulse (not through the socks please as almost 20% of
people did)
• Please note: It was evident when people had no idea how to
perform the maneuvers in the exam. Please practice.
• Also, if you want to narrate your physical findings, please don’t
pause at each step to speak. It is a waste of time and many of you
didn’t finish because of this. Narrate while you are doing your
examination maneuvers. Its time efficient and looks a lot more slick.
• Patient’s comments:

• Dedicated listening is still very much a concern. The candidate would ask me a
question, and then cut me off in the middle of responding. They also need to be
able to gage the patient’s pain level better. Some candidates were very rough with
me, and some I could barely feel. More consistency required.

• QUESTIONS
• Candidates need to really focus on the stem outside the door, so they will enter
the room armed with the knowledge of the case. As a patient, I don’t feel
understood, if they ask “what brings you here today,’ or “tell me about what
happened.” If they walk into the exam room and say; “I hear you injured your knee
playing soccer,” I feel much more included and confident in their ability to resolve
my issue. I felt more comfortable with the students that would walk in the room
and ask “Mr. James Lazzam?” “Would you like to be called James or Mr. Lazzam?”
• The candidates that I felt the most at ease with, were the ones that immediately
established a rapore with me. Said something casual to “break the ice.” Such as;
“so, I hear you got caught up in “World Cup Fever, and hurt yourself playing
soccer?”
• Again with this case, candidates would waste their precious time, asking the same
question, re-phrased 3 different ways. Once is enough, if you are listening.
• ORGANIZATION
• Student need to organize their examination, prioritizing what is truly important to the case. My
case was a physical exam with focused history, but they went far too deep into areas such as social
history, which ate up their time on the clock. For example, if I am complaining about pain at a level
of 10 out of 10; now, is not the time to lecture me on quitting smoking, and enrolling in smoking
cessation courses. Or, inquiring in-depth about my sex life, and whether or not I am faithful to my
wife. Relying on notes, was again a distraction. Breaking contact with the patient to constantly refer
to notes is counter-productive.

• OTHER USEFUL POINTS:
• Key points for candidates to consider are: speak up (be assertive, take command, articulate, and be
the boss). Watch out for “tics” or repetitious verbal crutches that you lean on such as; Um’s, ah’s,
uhuh’s, etc…
• Stop constantly apologizing. When a candidate is going to conduct a physical exam, let the patient
know right at the start, that some of this may be painful. Once that is established, you do not have
to apologize for every single test you conduct after that.
• Be careful of using Medical jargon or terminology with a patient.
Trauma
• Examiner’s Comments:
• Overall the trauma station was a difficult station and it is one that
requires extra practice. As I recall, approximately less than 50 % of
the candidates were able to manage this station with confidence
and effectively.
• There were a few candidates who were extremely assertive and
knowledgeable and who showed that they are competent and
confident physicians.
• Also there were few candidates who could not manage this station
and who just chose to have a discussion about the case instead.
• I took the opportunity to provide verbal feedback for most of the
candidates and it was well received.
• There was one candidate who was offended by my remark and I am
very sorry for that and I hope she can see in retrospect that I meant
her no harm, I only had her best interest at heart.
• I would like to encourage the candidates to practice this case more and to
be on autopilot for the real exam as it is evident when the candidate is
thinking they get stuck and time moves rapidly at those times.
• Also most candidates will benefit by reviewing the ATLS protocol for all
trauma cases and applying the algorithms appropriately.
• Most candidates fell down in the secondary survey although they had a
very good start.
• Some candidates will benefit from projecting their voices better and using
better intonation. Monotonous speech is boring and the fact that this is an
emergency case also allows for the candidate to have a certain tone and
rhythm in managing the patient.
• I think with practice most candidates will be able to score much better
should they be presented with a polytrauma patient is the real exam.
• Thank you and I wish everyone Goodluck in your future endeavors.
• Patient’s comments:
• General feedback:
– I felt from my position as a ‘role player’ on the Mock Exam
that several of the candidates were portraying a very
‘Robotic’ body language and talking in a very ‘monotone’
voice style. Because of this appearance, I felt it very
difficult to be ‘engaged’ with the candidate during the
‘interaction’.

– Also, many Candidates looked down at their notes, or


constantly wrote information on their notes through out
the interaction, rather then really look and listen to the
‘role player’.

– The reason for this could be the result of being ‘VERY


NERVOUS’. Candidates will have to find a way to control
their ‘nerves’.
• Also, on several occasions, I observed candidates not just glancing over at the assessor, but
actually staring right at the assessor to ‘gage’ there reaction to the ‘interaction’ with the role
player.
• On several ‘interactions’ I felt the candidate looked over at the assessor more times than
looked at me. Again, this made me feel disengaged from the ‘interaction’.
• Candidates should be reminded to always ‘engage’ the role player as if the assessor is not in
the room.
• EMPATHY:
• On several occasions I felt as a ‘role player’, Candidates lacked empathy. This was observed
by both their verbal and non verbal communications skills. Such as not maintaining direct eye
contact with the ‘role player’ during the response to very personal and sensitive subject
information in the ‘role player’s’ medical history. (Such as, looking down or writing on their
notes.)
• An example of lack of ‘empathy’ in one of my interactions was when I revealed very sensitive
personal information about my medical case, the Candidates very next remark was,
• ‘... do you have any allergies..?’
• This made me feel completely ‘not heard’ in the interaction
• APPEARENCES/DRESS:

• A few of the Candidates entered the station with


their shirt collars mixed up or one up and down.
This is a small point, but one should look and act
professional. As a ‘role player’, I would stare at
this ‘mixed up/down collar’ and wonder ‘why’ is
it! Not paying full attention to what the
Candidate was saying. This then becomes a
distracting feature from the Candidates intended
purpose.
Diabetes diagnosis
• Examiner’s Comments:
– Type II DM is a huge topic with a lot of details in diagnosis and management. Having all
aspects of it in one station puts candidate under pressure of time. As you'll see on
checklist, most candidates couldn't get to answer long term DM management plans as
they were mostly short of time. This station could be divided up to two stations one
being history and diagnosis and the other one counseling and management plan in
details. Also, checklist was missing few important points in history and lab tests which
was mentioned by some knowledgeable candidates but I couldn't give them mark.

– Introduction:
– Most candidates understood the stem well; however, some were not sure how to
approach that BG reading. Some gave the type 2 DM diagnosis right away and some
knew that test needs to be repeated. Candidate should make sure what to say when
disclosing a test result or diagnosis.
– Some candidates had difficulty pronouncing patient's name which is totally
understandable. I wouldn't repeat calling patient's name if I have difficulty saying it
unlike some candidates...
– I would remind candidates to be aware of their body language. I know it was a long day,
late evening, etc. but DO NOT LEAN on chair while saying a patient he needs to check
blood sugar for the rest of his life and he might end up losing his leg or his eye sight,
having MI, etc.
• Interview:

– Please don't give false promises. “You'll never end up having amputation” is
not appropriate. They can say “with good BG control we can delay or even
make it less likely that you develop long-term DM complications like
amputation, etc.”
– Ba aware of your use of words pre-diabetes, diabetes, IGTT, etc. You should
know the definition of each word before giving the information.
– No need to jump to extensive sexual activity questions early on interview. In
this case the only valid question regarding sexual activity was ruling out
Impotence which didn't have a check mark.
– Always explain why you asking personal questions. You can say “DM can affect
large and small vessels and it can cause some symptoms. For example, some
people have lower limb pain after limited physical activity. Some other might
experience difficulty in their sexual activity specifically with erection as
genitalia vessels can be similarly affected. So, have you experienced any of
these?” Some candidates asked “Are you having erection?” and it's very
inappropriate. Sexual orientation has no value in this station.
• I highlight this part: Many candidates had no or minimal
organization is their interview. I believe it comes with practice but
organization will significantly affect their scores and global ratings.
• Final points:
– Over all, candidates usually have a good core knowledge but lack of
organization and not using proper language make them at risk of low
score or failing the station. I would highly recommend they do more
scenario practice than just reading for the coming exam. Also, I would
suggest watching interview skills and common family practice
scenarios on You tube to learn proper language use and asking
sensitive questions professionally.
– It's unfortunate that competition is crazy and being outstanding is not
easy. But I believe communication skills and having control over the
medical interview is way more valuable that knowledge in OSCE
stations and can improve their scores significantly.
– Best of Luck to all!
• Patient’s comments:

– Technical Issues
• Because this was your first mock exam experience, I sometimes
gave answers which prompted you in a particular direction. Be
aware that you can't expect the standardized patients in the real
exams to be so generous, and I will not do this for your next mock
exam.

• Before you enter the room, have your stickers ready on your sleeve
to immediately give to the examiner. Fishing them out of your
pocket wastes time and distracts you, and it's too easy to forget
them. Do not hand over a roll of stickers and expect the examiner
to peel them off for you -- they'll probably see that as disrespectful,
which may color their evaluation of your performance. Practice
doing this every time you rehearse scenarios on your own, so it
becomes automatic
• All of the information in the stem question on the door is relevant,
so read it carefully. In this case you were given the specific issue to
discuss with the patient. Greeting him with the words, "What brings
you here today?" or "What can I do for you?" is unnecessary and
wastes time if he feels he has to explain. The first thing you should
do after greeting the patient and introducing yourself is explain
your understanding of his issue. He'll appreciate that you've taken
the time to familiarize yourself it.

• It's good to have a rehearsed greeting, but don't be inflexible about


it. Repeating the same greeting no matter what the patient says to
you in response makes him feel like you're not listening. Pay
attention and respond appropriately. One thing I did appreciate was
that most of you asked the patient if he'd like to "have a seat"
before you sat down yourself.
• should practice addressing the patient by name in the manner typically
expected in Canada. This patient's name was Robert Pearson -- if you use
the title "Mr." it precedes his family name, i.e. "Mr. Pearson," not "Mr.
Robert." Some of you asked the patient if you could call him "Robert."
When meeting a patient for the first time, using Mr./Mrs./Ms. would
probably be seen as more respectful. If the patient seems relaxed and
friendly enough that you think he might prefer his first name, I
recommend asking him, "How do you like to be addressed?" Asking him,
"May I call you Robert?" may make him feel pressured to agree even if
he'd prefer not to.

• I know you've received conflicting advice as to whether to automatically


shake the patient's hand when you enter. My own preference is that you
take your cue from the patient, but I can't blame you if you follow
someone else's suggestion. But if you do shake hands, make sure you do
so firmly, not limply.
• Empathy Issues

– Generally speaking, there was a wide range of visible emotion in your


performances. Some of you were very warm and expressive, while
others were quite mechanical in your physical manner and speech. I
suggest you imagine you're talking to someone whose welfare you
genuinely care about, such as a friend or family member, and how you
would express yourself to offer them comfort and support.

– Many of you used appropriate empathetic comments when the


patient expressed his concern or upset, but some of you spoke them
like a memorized formula, without any sense of sincere emotion
behind them. That won't convince a patient to trust you. You should
also try to collect a variety of such phrases, so you don't keep
repeating the same one.
• If the patient sounds and acts relaxed, smiles or cracks a joke, you should feel free
to respond in kind. On the other hand, if the conversation turns serious or the
patient is bothered by something your demeanor should reflect that.

• Unless the patient is very distracted due to a psychological problem or emotional


distress, interrupting him while he talks, or continuing to talk when he's trying to
say something, is disrespectful and will make him hostile toward you. While you
need to complete your agenda, you also need to listen.

• Many of you plunged into asking lifestyle questions without introducing the
subject to the patient first. This may confuse or offend him. It's also not enough to
say, "These are standard questions I ask all my patients," or, "I need to know more
about you." You need to explain that these questions are relevant to his complaint,
because they could be contributing to his condition. If you do offend the patient,
saying "I'm sorry, I didn't mean to offend you," or "I apologize, what I meant
was..." is a good empathetic tactic.
• You should try to strike a balance between either the patient or yourself
completely dominating the conversation. You want the patient to feel like
he's being heard, but you also have an agenda which you need to fulfill to
complete the station. If the patient is doing most of the talking you should
try to politely redirect him toward the areas you need to address. If you
realize you're doing most of the talking you should give the patient a
chance to express himself, perhaps prompting him with questions
(preferably about areas he's already expressed interest in).

• This patient gave you some obvious verbal and physical clues to areas you
should explore. For example, mentioning his grandmother had "a lot of
trouble" with her diabetes, "especially recently;" that his present level of
stress was "not as bad as it had been;" or his body language reflecting
discomfort when asked about his alcohol consumption. You need to watch
and listen for responses that seem unusual.
• Diabetes Issues

• I was surprised at how many of you asserted almost immediately
that this patient definitely had diabetes, based on one not-
exceptionally high test result. There could be a number of reasons
for that result -- without more information and testing you can't say
for sure. Moreover, in the exam you should generally avoid stating a
definitive diagnosis from only history. Because this patient had
personal reasons for being afraid of diabetes, telling him this early
on left him upset for the rest of the interview.

• It's usually worthwhile to ask a patient what he knows about his
illness. Those of you who asked this patient his understanding of
diabetes discovered that because of his relative's experience he
knew quite a bit, which eliminated some of the things you would
need to educate him about. But don't assume he's also aware of
issues he doesn't mention.
• Many of you emphasized treating the patient's diabetes with
medication, with little or no mention of diet and exercise. At this
early stage changes in lifestyle might be sufficient to control the
patient's glucose level, and he should be made aware that there's
more than one possible approach. He might prefer one or another,
which would make him more motivated to follow it.

• I was disappointed at how many of you presented your treatment
plan to the patient in terms of things that you will do, or things he
must do. The patient-centered model of care emphasizes allowing
the patient input into decisions regarding his own treatment. You
should remember to phrase your plan in terms of
recommendations, suggestions, and in cases like this one, options
which the patient may be able to choose. There is actually a lot this
patient can do at this stage to help himself, and emphasizing that
helps empower him.
• Other Medical Issues

• CAGE questions for alcohol were probably appropriate in this case, as


would be suggestions of cutting back; but remember that this isn't an
addiction counseling station, so don't devote a lot of time to it. Putting the
patient's alcohol consumption in terms of a risk factor for his diabetes will
show him its relevance to his chief complaint, and probably make him
more motivated to reduce it as part of an overall treatment plan.

• When you do screen for alcohol, remember to establish its quantity,


frequency, and the duration of his drinking pattern. That will help you
determine if it's a serious long-term problem, or as with this patient, a
relatively recent change triggered by stress.

• Keep in mind that the older the patient, the more sensitive he's likely to
be to lifestyle questions.
Mania
• Examiner’s Comments:
– Avoid shaking hand when you see stem question reading
“he is not himself” as this might refer to a confused
person, schizophrenia or mania (who might break your
hand with hard handshaking)
– Try to follow the patient’s story and ask the questions on
that context (eg; how long have you been thinking like
this?)
– If patient pacing in the room, you sit down
– Few people knew how to ask about “pressure of speech”,
“flight of ideas”, ….
– No one asked about “irritability”, “indiscretion” while
these are also symptoms of mania
• Exercise in your mind how to make rapport with
this kind of patients; you can ease off the
connection by listening to their story and
extracting your checklist questions out of that
• Don’t attempt to cover 100% of checklist!
• Don’t limit yourself to diagnosis only; you have to
rule out other DDX as well; so ask about anxiety
symptoms, hallucinations, bizarre thinking, ….
• Overall most candidates got the diagnosis right
• Patient’s comments:
• EMPATHY
– For the most part there were quite a few candidates who did not show
a genuine display of empathy. One example specifically would be
when I would begin explaining how I lost my job 2 years ago. I would
get the “that must have been very hard for you” response but it was
not genuine and seemed like it was something you were trained to say.
Throughout the whole interaction the candidates expressed interest in
what I was saying verbally, but their actions and tone did not reflect an
empathetic manor, they came off as quite dismissive. I saw some eye
rolling, a lot of candidates interrupted me while I was speaking, and a
few laughed. I heard a lot of “the book sounds really interesting, but
we’re here to talk about you. We can talk about that after.”

– On a more positive note there were a good number of candidates who


showed interest in my story, no matter how bizarre it may have been.
They responded genuinely, they listened and by them letting me get
thorough all my story points they learned facts that were beneficial to
the diagnosis. These were the candidates who were extremely
organized and confident in the room.
• QUESTIONS

– Every candidate asked appropriate questions, some stuck to a more rigid


format (i.e double checking their check list they prepared before coming into
the room) and some went with the flow of the information they were given. I
can say that the candidates who let me get through my entire story in the first
2 minutes were able to gather usable information to minimize other questions
they needed to ask; they arrived at a diagnosis by the end of the station.

– Other candidates who dismissed my story in the first 2 minutes and seemed
annoyed/bothered/uncomfortable by it ended up asking me questions that
they would have gotten the answer to (i.e. “have you spent large amounts of
money in the last little while?”). Also, if you know you have a quiet voice or if
your English isn't as clear as it should be you need to speak up or slow down
when asking a question. I know nerves play a big part in this and there are
time constraints, but I found myself having to ask the candidates to repeat
their questions.

– As a whole there were a lot of questions that were rarely asked which the
patient had the answers to, such as asking about sexual partners and safe sex,
trouble with the law and suicide or urge to hurt someone else.
• ORGANIZATION
– Most candidates were organized and confident, but I did notice a
lot of confidence in the room came off as being dismissive. There
were a few instances where candidates would get into a flow of
asking questions then got to a point where they were lost. I heard
“ummm” followed by a long pause and looking down at their
notes. This did not demonstrate organization and when it
happened, it was always 3/4 of the way into the station, just before
they would get to a diagnosis.

• NOTE TAKING
– From what I noticed, the candidates who didn't take as many notes
arrived at a confident diagnosis a lot quicker. A lot of candidates
took quite a few notes, but then they would get lost in their paper
and didn't arrive at a confident diagnosis.
• MISC REMARKS
– There was a lot of dismissive actions in this station. I know the patient
was “out there” and had a lot of energy, but you need to consider that
even though this is a fake patient, what they say could be just as
important as a patient going through physical pain.

– There were a handful of you that I could see in an ER tomorrow, and a


big part of that came with the confidence you let off and your ability
to be empathetic to the patient.

– A big note for most would be to work on your confidence, and not to
have to it come off as being dismissive. Take control of the room but
listen to the patient.

• I want to wish everyone the best of luck on their exams, just try to
look at the patient as a human , not just a case!
Eeasy bruising
• Examiner’s Comments:
– I was really impressed with the overall performance standard of this
group of candidates compared to ones I have examined in the previous
sessions. Most of them seemed to be ready for real exam.
• INTRODUCTION:
 Introduction was done very nicely by majority of doctors. The
only issue was difficulty pronouncing the last name of the patient. I
always recommend asking the patient directly how to pronounce
the name and how he/she would like to be addressed. It’s more
professional compared to pronouncing wrong name.
• CHIEF COMPLAINT:
• It was analyzed briefly and nicely by majority, reaching to
conclusion that it’s new in onset and not congenital which helped
them a lot in reaching to correct diagnosis.
• ASSOCIATED SYMPTOMS:
• Here the organization was little lacking. Try to explore bleeding from any
other sites, severity of symptoms, anemic symptoms in associated before
proceeding to past and medication history instead of jumping from
present to past and then back to present symptoms. Many did excellent
job here but missed Red flags/ constitutional symptoms e.g Fever, weight
loss, Bone pains as it was new onset symptom so could be hematologic
malignancy.
• PAST AND FAMILY HISTORY:
• Past and family history should be asked specifically e.g bleeding disorder,
Hepatic disease. It should not be simply asking that any significant history
as pt might not understand the importance of describing other illnesses.
• Headache and OCP history was given as a clue to reach to etiology but
some got distracted spent 90% of time in exploring headache and OCP.
Proper time management is always crucial in OSCE set up.
• MEDICATION HISTORY:
• In this type of scenario, again medication should be asked specifically and any
positive finding need to be explored appropriately in chronological order.
• SOCIAL:
– One or two candidates went too much on alcohol issue. You cannot call someone alcoholic by
drinking one glass of wine per night. That is very normal for Canadian families (be careful on
your statements!)

• EMPATHY:
• Empathy was lacking in many encounters despite perfect medical knowledge of
the condition. Show empathy at least once as it was a great distressing factor for
the patient’s day to day life.
• WRAP UP:
– Wrap up was done very nicely by majority of candidates with good explanation of etiology and
appropriate advice.
– I would say again that overall performance of this batch was excellent and there is not much
to add to their style.
• GOOD LUCK!!!!!!!!!!!!!
• Patient’s comments:
– Safety & Sensitivity
• As a patient who drinks a glass of Shiraz a night, I heard a
couple of doctors say statements to me and the examiner
including, “She’s alcoholic”, and maybe, “you should cut
down”. “Cut down” statements were made without
explaining why or that doing so might alleviate the
symptoms I was presenting. This comes across as
judgmental. With or without a diagnosis of alcohol
addiction, I would be defensive and shut down instead of
opening up and possible getting needed help.
• One candidate asked, “Have you ever used recreational
drugs?” When I answered, “No”, he replied, “Oh, that’s very
good.” If I had lied and were, in fact, struggling with drug or
alcohol addiction, I would not be inclined to open up and
receive help from this doctor. Only in an environment of
safety and sensitivity might delicate issues such as addictions
be revealed and dealt with, if applicable.
• Only one candidate linked alcohol to my migraines as a
possible migraine trigger. Within this context, it would
be appropriate to encourage cutting down.
• It was great to see many doctors avoid making
oppressive, heterosexist assumptions about my sexual
orientation, leaving it to me to indicate that I had a
“boyfriend”.
• Please be careful to couch a question like, “How many
sexual partners have you had” within the context of
your line of medical questioning. Explain why you are
asking so it does not come across as unnecessarily
intrusive, judgmental or irrelevant.
• Authenticity & the Wet Fish Handshake
– So many candidates gave me a wet fish handshake. It cannot
be overstated how incredibly offensive a limp, flat-palmed
handshake without a “shake” actually is in North American
culture. It feels like disdain, repulsion, disgust or
condescension. It’s better to not shake hands at all if you
cannot execute a handshake with a firm, closed grip with an up
and down motion while maintaining eye contact.
– It doesn’t matter how sincere, friendly or great you are as a
doctor, if I received a wet fish handshake in that first
appointment I would likely not return. People may not always
tell you that they were offended but you may notice patients
not returning for subsequent appointments.
– I would humbly recommend that time be set aside for the
candidates to practice shaking hands.
• People can spot when you are disconnected and not being
your true self. Nervousness aside, it is important that you
be yourself. You may admit that you are nervous and that
it’s the first time to meet your new patient. Perhaps you
can introduce an icebreaker question or comment to help
create rapport. This can come later the more you learn
about the patient.
• Please smile, relax and be natural and authentic in your
doctor-patient interactions.
• Best wishes to you all!

• Thank you Jinoos and Dr. Salimi for having me assist you
and your candidates.
Cranial Nerves examination
• Examiner’s Comments:
• INTRODUCTION:
• Most students did well here. However, a few need some
improvement. The first thing you must do when you walk into the
room, is to acknowledge the patient by making eye contact with
him and then greet him with a smile. Don’t wait for the patient to
greet you first.
• Please don’t ask, “what brings you in today?” because you already
know that from the stem. Instead, say “I understand that you are
here for a physical examination required by the Canadian Airforce”.
In this way you would save time by not asking an unnecessary
question.
• WASH HANDS: Please!!!! Don’t loose mark for not doing a simple
action!
• ORGANIZATION:
– Please organize the physical exam into steps, write
them down and practice them in that order with
your study partner each time. This way you won’t
forget steps, look organized on the exam and save
time by not having to figure out what to do next.
A few candidates were jumping from 2nd nerve to
7th to 12th and then back to 2nd which looked very
disorganized. Some would stop in the middle and
start wondering what to do next. Please practice
more.
• 1ST CRANIAL NERVE:
• Don’t forget to examine the first cranial nerve. In this case, the
examiner was supposed to prompt you that it’s normal but you
have to still show the intent to receive credit. On the actual exam,
they might expect you to examine the 1st cranial nerve so don’t
forget to look around for strong smelling ingredients that you can
use.
• VISUAL ACUITY:
• There was some confusion about the distance of the visual card
from the patient and also whether the patient should be examined
with spectacles on or off. Please discuss this with your students.
Many students failed to examine one eye at a time and most failed
to report visual acuity as bilaterally 20/20.
• PUPILS:
• Please shine the light into the patient’s eye from the side for his
comfort and ask him to focus on a distant object.
• VISUAL FIELDS:
• Many students need to review the correct
confrontation method. Please sit if the patient is sitting
on a chair and stand if he’s sitting on a high bed to be
at the same eye level as him and attempt to keep your
fingers midway between yourself and the patient.
• EXTRAOCULAR MOVEMENTS:
• Ask patient for diplopia when assessing extraocular
movements.
• HEARING ASSESSMENT:
• Some students snapped their fingers next to the
patient’s ears. It’s better to rub them gently.
• INSPECTING UVULA AND PALATE:
• It’s better to shine a light into the patient’s mouth when asking him
to say “ah”.
• EXTRA CREDIT:
• Please don’t forget minor things like corneal reflex, gag reflex,
swallowing, taste etc which you will not assess but will get credit for
by just mentioning them.

• CONCLUSION:
• Overall, it was a good attempt by the students. Please remember
that on the actual exam, you will only get credit for physical
examination done adequately with proper technique. Therefore,
just performing the step is not enough; you have to perform it
correctly. Please learn the correct technique and keep practicing.
Best of luck!
• Patient’s comments:
• For the cranial exam, I was to focus mainly on
whether they washed hands beforehand,
communication, and whether their touch was
gentle or too rough. On the last point, I found
it took several excellent candidates - well into
mid-day - before I really felt able to gauge the
degree of "firm gentleness" that was exactly
right for the face and neck muscle resistance
from both patient and candidate.
• Introduction to a well patient only there for this brief exam, is of course
subtly different than that offered an ill patient. This was I think the
first time I played an entirely well patient and I found I instinctively said
"Hi" as they came in; this often seemed to relax them as they usually
said "hi" in response or with mine and extended their hand in easy
introduction. But a sadly large number only barely acknowledged me,
occasionally not even making initial eye contact as they seemed more
interested in the examiner. In one case (toward end of a very long
day), I returned a candidate's greeting and he instantly riposted "I
wasn't talking to you", asked the examiner a question and then
condescended to deal with me. In this, he showed only slightly more
skill; nonetheless as he left and the examiner expressed anger at his
cloddish rudeness, it made me realize that although critical, I'd in fact
been far too kind in my written assessment and if time, would have
taken it back to alter "downward" a second time.
• This was an extreme case, but roughly half the time I felt
that even pleasant candidates were following a "script" in
their introduction rather than saying the same words I
realize are inevitable, but doing so with simple sincerity. I
do empathize that such lack is usually just nerves, and that
relaxation when nervous is a craft - but it can be
acquired. Not unnaturally, older candidates are usually
much better at this - "relaxing on your feet" so to speak -
but some young people have found the gift, too: that
immediate focus and ease of rapport which brings this
thought to the patient's mind: "This is a pro, a true
physician; maybe I'll be all right."
• If people would only try to just enjoy a firm handshake and smile, and
give their name clearly, surely that's more than half the battle. At least
80% of the time, I had to repeat it to try to clarify the name - that is,
when I'd heard it clearly enough to even do that! This relaxed concern
on the doctor's part, can surely never be overstated in its
importance. Surely you must never forget that the patient is nervous,
too.

• Nervous and, very likely, also frightened out of their minds or at least
extremely and understandably worried. And they've never met you,
either.

• "I wasn't talking to you" just doesn't cut it, even for a presumably well
patient.
• Yet most people offered an acceptable introduction. When it's specific
and clear, above all relaxed and thus enjoyed, it is more than
acceptable; it's good. Some, achieved this - and then, the meeting can
become pleasant for both: the ice is broken.
• Hand-Washing marks were much lower. I'd say at least 40-50%
didn't even bother with a few drops of sanitizer, before placing their
hands on my face. Fatima told me this can spread fatal disease to a
patient. Yet the sign on the door made clear it was a cranial
examination. I just wish those hands had been far cleaner.
REMEMBER YOU ARE TOUCHING PATIENT’S EYES, FACE, …

• Communication and Touch Pressure were both much better


achieved.

• A majority of candidates communicated clearly, and with sufficient


empathy; and very few used too much hand pressure in conducting
the exam of the face. Remember this is only a role player; please be
gentle!!
Surrogate decision maker
• Examiner’s Comments:
• Read stem question carefully:
– 70-year-old man brought to hospital by neighbor.
Patient was found to be hypotensive due to sever
internal bleeding for a prolonged time and also has
history of chronic alcoholism. Even after treatment,
the patient’s condition is critical and is now in
vegetative state. The patients’ family has come in and
you are asked to break the news to the daughter and
also discuss about the next steps.
• what comes to your mind when you read this?
• ISSUES INVOLVED HERE:

• Breaking bad news
• Legal issues and end of life decisions
• Expressing a lot of empathy

• GENERAL INSTRUCTIONS:

• On the whole, I felt like we had a good set of candidates.


Most of you knew what the stem meant and dealt with
almost all points. But there were some doctors who were
unsure about the stem and did not address the issues right.
• 1) To being with, a lot of students came in and asked the patient
“How can I help you today”? Please DO NOT use this sentence
especially when the stem clearly states that the daughter has come
in and you are to talk to her about her father’s condition.

• 2) There were a few candidates who sat very close to the patient.
You must always respect the patient’s space so try to maintain the
right distance from the patient.

• 3) A lot of students kept looking at the paper or elsewhere while


talking to the patient or cutting the patient off in between, which
seemed very disrespectful. Try to avoid this and bring out your
listening skills in this station and make good eye contact as this
shows that you are genuinely interested.
• 4) This station was a good opportunity to express empathy. Though
a few students used words like “This must be a difficult time for
you”, they did not really show empathy with their expressions. Try
to look natural and involved and show how much you care for the
patient, and eventually you will be able to express empathy well.

• 5) There were a few students who were smiling in the middle of the
conversation, which seemed very inappropriate. Please be very
mindful of the serious situation and avoid this.

• 6) A few students got stuck in the middle and were not sure how to
proceed. My advice would be, if you have time and suddenly in the
middle feel blank, don’t stop. Try to make conversation and keep
talking to the patient; you will automatically start getting your
points then.
• POINTS SPECIFIC TO THE CASE:

• 1) One of the biggest challenges for a lot of students was to explain


the patient’s condition to the daughter. Think of the patient as a
layperson and use simple non-medical terminology (DO NOT use
words like hypotension, haemorrhage) to explain the vegetative
state of the patient. Have a good understanding of this and explain
accordingly. One candidate went into the depths of anatomy to
explain brain death- you don’t need to do that.

• 2) Once you enter the room, try to spend the initial few minutes
just to develop a good rapport with the patient instead of directly
jumping to the explaining the vegetative state.
• 3) Once done with the explanation of the father’s condition
in simple terms, ascertain that the daughter is the
substitute decision maker (SDM). You could find out about
the other members of the family at the same time. This is a
very important point and most students assumed the
daughter to be the SDM and skipped this point!

• 4) After this, address the legal issues- any advances


directives, legal power of attorney, written will. Also, ask
about expressed wishes of the patient.
• 5) As this is a very sensitive and difficult station, try to be
supportive and provide counseling/social work/chaplain
services for support to family.
• 6) Organ donation was addressed by one student, which was a good point. The
only problem was, this was mentioned quite early in the conversation and this
seemed very insensitive to the patient’s situation. You could address this issue, but
towards the end of the conversation, after the decision to pull the plug is made.

• 7) A lot of students also assumed that the daughter agreed to pull the plug
without actually getting her consent. There were a few candidates who even
suggested pulling the plug even before they asked about the patient’s wishes or
what the family thought about this!

• 8) There were also a few candidates who were initially very unsure about the
patient’s condition. They gave hope to the daughter saying that they would still
need to confirm what the condition of the patient is by examining him, before they
make any further decisions. Remember what the stem says- that it is confirmed
that the patient is in a vegetative state and now you have to break the bad news to
the family! Read the stem carefully before you enter.
• 9) A lot of students started taking a history of alcoholism of the
patient and one candidate took depression history of both the
patient and daughter! Please follow the instructions of the stem
carefully. This was not a history station. Even if you did take a little
alcohol history make it very short to just get an idea and move on
to the ethical points. You do not want to waste time on things that
are not required and miss out on other important points.

• 10) Before you finish, always ask if the patient has any other
questions or concerns to address.

• Overall, it was a good attempt by the candidates. I wish you all the
very best in the exams and in your career.
• Patient’s comments:
• I found the candidates asked relevant & important questions . They
spoke clearly ,& directly .
• Actually , their communication skills looked excellent ..Good
listening skills , body language ,& eye contact, & they took a lot of
time explaining the patient' s issues , diagnosis , & prognosis
• Perhaps , some could become more comfortable with the common
language ; English.
• Empathy : The level of empathy the students displayed is excellent .
They showed a genuine interest ,& concern for the patient ,& family
members.
• Voice : They spoke in clear voices &made every attempt to use their
voices appropriately & to show empathy , concern , professionalism
,& friendliness .
• On the whole I found the students made a tremendous effort
Increased abdominal girth
• Examiner’s Comments:
• I am glad to report that most of the students performed well in this
station however there were also some issues that I would outline
below.
• In the most cases students followed the check list however the
majority of students thought about liver dis. and ascites caused by
portal hypertension . This is in part was caused by the Pt. habit
to drink Vodka few times / week .

• The increased abdominal girth has many etiologies and “Alcoholic


cirrhosis” is one of them; so candidate's need to stay broad in their
questioning and ruling out other causes.

• I think this is a great mistake that “I got the diagnosis right in the
beginning”. This could entrap you into a limited questions!
• The point here is not to memorize all the questions in the check list
but to proceed with a kind of methodology in mind. This will start
with Review of the risk factors for cirrhosis and ascites after
someone exhausted the associated symptoms . Also it can be
reviewed under ROS .
• While some of the students asked about blood transfusion only less
than a handful of students asked about “Tattoos , Ear nose tongue
piercing and no one inquired about acupuncture “ .
• Many people got Hep B and subsequently cirrhosis of the liver in
the era of reused needles for injections (resteralized by boiling at
100 degrees) instead of using one needle / patient, or in the case
of the people who share needles . . By the same token with shared
needles , Acupuncture , piercing and tattoos can inoculate the virus
of Hep B or C .
• Sexual activities in the past is a big one to ask!
• Ascites is a feature of cirrhosis together with Edema ,
due to low oncotic pressure , Gynecomastia and
Decreased libido due to accumulation of Estrogen ,
Splenomegaly. Mild to moderate Thrombocytopenia
due to splenic sequestration , Encephalopathy which
was reflected in patient ‘s episode of Confusion and
for which 2-3 MMS questions would be appropriate .
Finally The esophageal varices could explain the
Hematemesis (vomited blood) that patient reported
he had respectively: 2 days and 6 months prior to
presentation . So ask all the relevant questions to
excule above!
• When the students reviewed the blood work report provided at 8
minutes many students encountered difficulties of interpreting the
numbers and looked separately at the CBC and the LFT, making
many assumptions around. I would like to stress that the BW
report, no matter what is the content of the station add little to the
Dx . They confirm the Dx taken by Hx and PE
• In our case we confirmed that we are dealing with a heavy drinker
who has an elevated MCV which reflected that he had
Megaloblastic anemia due to consumption of B12 and folic acid
hence low Hb .
• The PLT was at the lower level of normal due to splenic
sequestration of Thrombocites as explained above
• The liver enzymes confirmed that we have elevated transaminses.
Also we know in alcoholic AST>ALT, which was the case here.
• Finally when the plan was requested with a decision
of admitting or not admitting to the hospital the
decision making was split something like 65/35 for
admitting / not admitting . I wrote separately for each
student the answers to the examiner’s questions
provided .
• I would like to stress that in ANY case of NEW ONSET
SYMPTOMS like this patient with new onset ascites
and severely altered BW, ADMIT for investigations or
maybe parasynthesis !! As well as the SAFTY
concerns which are heavily tested in any exam ,
especially for IMGs!!
• Paracentesis should be performed if there is :
– New onset ascites
– Abdominal pain and tenderness in a distended
with signs of ascites abdomen.
– Fever in a known patient with ascites .
– Therefore this new onset ascites needs admission
and cirrhosis work up!
• Some students referred to the SP as “Mr.
Robert” instead of “Mr. Clinton” as it is
appropriate in any professional encounter . Pls
ask the permission to use the first name before
actually using it . If the age of the patient is not in
the stem question simply ask !
• A few students wanted to do a physical exam on
the SP and had to be prompted to read carefully
the STEM question. Please be mindful of what is
being asked!
• Patient’s comments:
• Overall Feedback
– Questioning Techniques: In general, I found most
candidates were genuinely interested in finding out
what was the cause for my discomfort. They were
inquisitive and interested. Almost everyone asked the
exact same questions, and when they reached “do you
ingest alcohol?” they ultimately were able to decide
what was occurring with the patient. I believe in the
entire day of 72 simulations only one or two people
weren’t able to decipher that alcohol was an issue,
and I believe this was because of past medical history
involving a blood transfusion.
• Empathy:
– Throughout the day, I observed that most of the students were
genuinely empathetic to this patient. Phrases like “I’m here to
help”, “I’ll do my best to figure out what is going on”, were
voiced. Only a few students exemplified no empathetic qualities,
and I think this had to do with nervousness, and only a couple
candidates showed a sense of empathy that felt contrived and
rehearsed.
• Organization:
– In general, I found the organization of most of the students to
be quite clear and consistent. I was asked the same questions
repeatedly, in almost the exact same order. Thus, the reveal of
cirrhosis tended to come around three quarters of the way
through the interview, and would therefore cause a quick
diagnosis and wrap up.
• Voice:
– I felt that the vocal volume of the students were clear and
audible. Only a couple of candidates stood out as being soft
spoken or shy, which I noted on their feedback forms. Also,
English speaking abilities were quite strong throughout, except
where thick accents occasionally forced me to ask candidates to
repeat their questions for my understanding.

• Final note:
– Overall, I feel this station was successful in presenting a case of
cirrhosis. Over 90% of the students were able to solve the stem
and glean most of the information I was provided with to share.
– Good Luck!