Format of the Comprehensive Objective Examination in INTERNAL MEDICINE

Transcription

1 Format of the Comprehensive Objective Examination in INTERNAL MEDICINE The Internal Medicine comprehensive objective examination assesses candidates' competence to function as an Internal Medicine consultant across the CanMEDS domains of medical expert, communicator, collaborator, leader, health advocate, scholar and professional. It consists of two components: 1. Written Examination 2. Objective Structured Clinical Examination (OSCE) Comprehensive objective examinations make it possible to obtain a more complete evaluation of the candidate's strengths and weaknesses. The important feature of comprehensive objective examinations is that candidates do not need to pass the written component in order to take the oral component. The comprehensive objective examinations are considered a "whole" and cannot be fragmented. Candidates who are unsuccessful at this examination must, if within their period of eligibility, repeat all components of the examination. I. Written Component The written component is designed to examine the domains of Medical Expert and Scholar in the field of Internal Medicine, the basic sciences as applied to Internal Medicine, critical appraisal and clinical epidemiology. A. Scheduling of the exam: The written component takes place over a period of two days in the regional written centres across the country. For both French and English candidates, this component occurs in early spring. B. Format: The written component consists of two three-hour papers, with candidates completing one paper on each day of the exam. Each paper consists of multiple choice questions. Some questions will be case vignettes, which will include pertinent data from the history, physical examination, and investigations. Normal values for laboratory tests will be provided in both SI and US/Imperial units (see Appendix A). Specific resources for studying for this exam and example questions are provided at the end of this document. II. OSCE Component The OSCE component is designed to assess all the CanMEDS competencies required to function as an Internal Medicine consultant in the ambulatory, emergency department, hospital ward and critical care settings of a community hospital. Scheduling of the exam: The OSCE component (French and English) takes place in Ottawa. The OSCE component runs over a single day in May or June. The Royal College assigns the examination time and date and

2 once assigned, the examination appointment (time and date) cannot be changed. Format: The OSCE component will be approximately 2-1/2 hours in duration and will consist of eight examination and two rest stations, each of 15 minutes duration. There will be 4 minutes between stations. At each station, candidates will be asked to address one or two scenarios and over the course of the entire OSCE will be asked to address approximately: a. Five bedside scenarios, including one with a cardio-pulmonary simulator - These scenarios may test physical examination skills and/or bedside procedural skills. Performance on these stations includes attention to infection control principles and appropriate draping and attention to the patient. In 2016, there will be no cardiopulmonary simulation (Harvey). This will be replaced by a cardiac audiovisual simulation. Format A brief clinical scenario, followed by instructions for the candidate to perform a relevant, focused, observed physical examination on a standardized patient who may have abnormal physical findings including appropriate infection precautions. May also include the recognition of simulated abnormal physical findings. b. Seven clinical scenarios - These scenarios may test skills in data gathering, data interpretation, case synthesis, investigative strategy, interpretation of investigations, patient management, clinical reasoning and/or application of evidence. Some scenarios will require interpretation of data rather than collection of data. Format A brief clinical scenario, followed by instructions for the candidate to discuss their approach to the clinical problem. May cover a range of problems relevant to Internal Medicine (see the OTR), a range of situations from ambulatory to emergent and the range of body systems encompassed by internal medicine. May include the indications for and interpretations of diagnostic tests. c. Two communications or ethics scenarios these scenarios may test communication skills, professional attitudes and/or ethical principles. Format A brief clinical scenario, followed by instructions for the candidate to undertake an observed discussion of the clinical scenario with a standardized patient. These scenarios assess the candidates' ability to communicate relevant information (to medical learners, colleagues, consultants, family doctors, patients or family members) or to deal with relevant professional behaviour and ethical issues. Specific resources for studying for this exam and example questions are provided at the end of this document. Examination process: The examination has multiple timed components and all candidates will experience every component. One or two examiners will be present at each station. In addition, an observer may be present during the examination. The observer will not interact with the candidate or the examiners, will not contribute in any way to the candidate s evaluation, and is there to observe the conduct of the examination. Examiners are responsible for monitoring time and moving candidates along to ensure all the material and questions are covered. Examiners may take notes throughout the examination to document performance. They may appear neutral in their reactions to answers. They have been instructed not to give any positive or negative feedback to candidates.

3 What must be brought to the OSCE examination: As outlined in the appointment letter, candidates must bring a stethoscope. The Royal College will provide a blood pressure cuff and a diagnostic kit (including ophthalmoscope, reflex hammer and sensory exam tools). Dress code: Business casual: Candidates are advised to NOT wear a white lab coat or any other form of identification pertaining to their hospital/university affiliation. Possible resources for studying for the examination: Candidates from prior examination years have been surveyed about the resources that they found useful for studying for the examination. Here are the results of the survey. The resources listed are not exhaustive and are provided to you to help guide you in your preparation for the examination. % of candidates who thought % of candidates who% of candidates who thought resource was helpful were neutral resource was not helpful Harrison s Principles of Internal Medicine Cecil Textbook of Medicine Cecil Essentials of Medicine The Washington Manual of Medicine MKSAP JAMA The Rational Clinical Examination Talley and O Connor: Clinical Examination Talley and O Connor: Examination Medicine Sapira: Art and Science of Bedside Diagnosis Bates Guide to Physical Examination and History Taking McGee: Evidence Based Physical Examination DeGowin s Diagnostic Examination Oneexamination.com CMAJ-guidelines Marriott: Practical Electrocardiography Dubin Rapid Interpretation of EKGs Mayo Clinic Internal Medicine Review The John Hopkins Internal Medicine and Board Review Harrison s Principals of Internal Medicine Self Assessment and Board Review The Cleveland Clinic Intensive Review of Internal Medicine

4 Examination content by discipline: The combined written and OSCE examination is developed using a blueprint to ensure that components are well balanced. Questions are classified to a primary discipline and more than one classification may apply for a specific question. For example, hypertension can be classified under multiple disciplines including cardiology, endocrinology, and/or nephrology. The relative frequencies (in alphabetical order) with which the various disciplines are sampled across the examination are: Very Frequently: Cardiology, Gastroenterology, Respirology Frequently: Endocrinology, Infectious Disease, Neurology, Nephrology, Rheumatology Less Frequently: Allergy, Critical Care, Dermatology, Geriatrics, Hematology, Oncology Sample of written examination component questions: 1. A 50-year-old woman with chronic obstructive pulmonary disease is referred to your office. She describes shortness of breath when walking less than a block. Her FEV1 is 35% predicted. Physical examination reveals hyperinflation, decreased breath sounds and the occasional expiratory wheeze. The cardiac examination is normal. There is no peripheral edema. Screening blood work reveals a hemoglobin of 120 g/l (12.0 g/dl) with a normal hematocrit. The EKG is normal. Long-term continuous oxygen therapy would be recommended if her PaO2 is less than or equal to: a. 65 mmhg b. 60 mmhg c. 55 mmhg d. 50 mmhg Correct answer: c. Comments: This patient has hypoxemia with severe airflow obstruction. She has no evidence of right sided heart failure, peripheral edema and she does not have polycythemia. In this setting the Canadian COPD guidelines recommend home oxygen if PaO A 35-year-old multiparous woman presents with marked dyspnea and orthopnea in the ninth month of what is known to be a twin pregnancy. She is in atrial fibrillation, and the blood pressure is 130/95 mmhg. She has elevated jugular venous pressure, cardiomegaly, and a third heart sound (S3). There is a grade 2/6 pansystolic murmur at the apex. Chest examination reveals bibasilar inspiratory crackles. In addition to digoxin and furosemide, which of the following medications would be MOST appropriate? a. Captopril b. Prednisone c. Warfarin d. Hydralazine Correct answer: d. Comments: This patient has decompensated heart failure most likely secondary to peripartum cardiomyopathy. She requires afterload reduction (hydralazine). ACE inhibitors are contraindicated in pregnancy as is warfarin. There is no role for corticosteroids in this setting. 3. A 36-year-old man has had stable ulcerative colitis for five years. He has been treated with 1000 mg tid of sulfasalazine. On routine follow-up he is found to have an ALT of 250 IU/L, AST 225 IU/L, alkaline phosphatase 450 IU/L and a bilirubin of 2 µmol/l (0.1 mg/dl). Ultrasound of the abdomen reveals no bile duct dilatation or gallstones. Endoscopic retrograde cholangiopancreatography (ERCP) reveals multifocal strictures and dilatations of both the intrahepatic and extra hepatic bile ducts. What is the MOST likely diagnosis? a. Common bile duct stone b. Primary biliary cirrhosis c. Sclerosing cholangitis d. Drug-induced hepatitis Correct answer: c. Comments: This patient has elevated liver enzymes with an ERCP characteristic of sclerosing cholangitis. The ERCP rules out biliary stones. Though sulfa drugs can give hepatitis this would not account for the findings on the ERCP.

5 4. A 33-year-old woman presents with a cellulitis of the dorsum of the right hand 24 hours following a cat bite. A Gram stain of serosanguinous discharge from a puncture site shows neutrophils and small Gram negative rods. What is the treatment of choice for this patient? a. amoxicillin/clavulinic acid b. norfloxacin c. cefazolin d. gentamicin Correct answer: a. Comments: The majority of skin infections resulting from cat bites are polymicrobial. Sixty percent will have mixed aerobic and anaerobic bacteria. Pasteurella multicida is a small gram negative coccobacilli found in the normal oral flora of cats. Antibiotic treatment in this case should include coverage of the skin organisms as well as the flora commonly found in cats mouths (including anaerobes and pasturella). Amoxicillin/clavulinic acid is the drug of choice in this clinical setting. Sample of OSCE Examination component questions: 1. Bedside Station with a Standardized Patient Scenario read to candidate: This patient presents with acute shortness of breath. Demonstrate and describe how you assess the jugular venous pressure (JVP) and abdominojugular (hepatojugular) reflux (AJR). A successful candidate would: Introduce themselves to the patient, appropriately drape the patient and explain what they are doing, treat the patient with respect. Position the patient at an appropriate angle, examine the right internal jugular vein. Inspect the JVP, describe how to confirm they are visualizing a venous pulsation compared to the carotid pulse, measure the height of the JVP above the sternal angle. Demonstrate the AJR with firm pressure on the upper abdomen for at least 10 sec, looking for a sustained rise of > 4 cm. Know the accuracy of this manoeuvre. 2. Communications Station with Standardized Patient Scenario read to candidate: For this patient, you recommend an ACE Inhibitor for their worsening heart failure. You have explained the indications for an ACE Inhibitor. She/he then asks you about the risks of an ACE Inhibitor. In the next 5 minutes, please discuss the consequences of taking an ACE Inhibitor by conducting a conversation with the patient as you would in a real life situation. Assume that the patient is fully competent and able to cooperate. Candidates would be assessed primarily on the how they conduct the interview (using tools such as the Bayer Institute for Health Care Communication E4 Model, Calgary- Cambridge Observation Guide) and secondarily on the content of the information conveyed to the patient. A successful candidate would: Process: Demonstrate appropriate interviewing skills Demonstrate appropriate interpersonal skills Content: Discuss a few common side effects of such as cough, worsening renal function, hyperkalemia, hypotension Discuss how they would monitor and manage the side effects e.g. monitor creatinine and potassium. For cough, lower dose or discontinue and switch to ARB.

6 3. Clinical scenario in an Objective Structured Clinical Examination (OSCE) format Scenario read with candidate: A 20-year-old male who lives alone is brought to the Emergency Department after being found in his apartment which had caught fire. At the time of evaluation, the patient is alert and oriented but feels short of breath. Describe how you would approach the management of this patient. A successful candidate would: Describe how they would assess the stability of the patient. Describe the appropriate monitoring for the patient s problem(s). Request from the examiners the pertinent items of a directed history and physical exam as dictated by the clinical situation. Generate an appropriate synthesis of the data. Formulate a differential diagnosis and then the appropriate diagnostics to allow definitive definition of the patient s problem(s). Generate an appropriate management plan and discuss their choice(s) of treatment as necessary. In some scenarios, explain their management choices based on the best available evidence Demonstrates organized, effective, safe, timely and appropriate consultative skills April 2016

7 APPENDIX A CLINICAL LABORATORY TESTS REFERENCE VALUES This table lists reference ranges (expressed in both SI units and traditional units) for the most common laboratory tests and is intended for interpretation of the results as they are provided in the examinations. Most of the values apply to adults and where they differ for children it will be indicated. Many important laboratory reference values are not listed here, because of the less frequent use of these tests. Such values are inserted parenthetically following the result recorded in the examination question. Tests SI Units Traditional Units Activated partial thromboplastin time (aptt) sec sec Albumin (serum) g/l g/dl Amylase (serum) IU/L U/L Bicarbonate (HCO 3) (serum) mmol/l meq/l Bilirubin (serum)* Neonates (conjugated) 0-10 μmol/l mg/dl (total) μmol/l mg/dl Adults (conjugated) 0-5 μmol/l mg/dl (total) 3-22 μmol/l mg/dl Bleeding time (Ivy) < 5 min < 5 min Calcium (serum)** Total mmol/l mg/dl Ionized mmol/l mg/dl Calcium (urine) < 6.2 mmol/d < 250 mg/24h Carcinoembryonic antigen (CEA) (serum) < 3.0 µg/l < 3.0 ng/ml CO 2 (total)** mmol/l meq/l Chloride (serum) mmol/l meq/l Chloride (urine) Infant 2-10 mmol/d 2-10 meq/24h Child mmol/d meq/24h Adults mmol/d meq/24h Cholesterol (serum)** < 5.2 mmol/l < 200 mg/dl Cortisol (plasma) AM nmol/l 6-23 μg/dl 4 PM nmol/l 3-15 μg/dl Creatinine (serum) μmol/l mg/dl Creatinine (urine) Males mmol/d g/24h Females mmol/d g/24h Creatine kinase (CK, CPK) - Males (race dependent) IU/L U/L Females (race dependent) IU/L U/L Erythrocytes (RBCs) - Children** x /L million/mm 3 Males x /L million/mm 3 Females x /L million/mm 3 Ferritin (serum) μg/l ng/ml Follicle-stimulating hormone (FSH) (plasma) Males 1-10 IU/L 1-10 mu/ml Females, premenopausal IU/L mu/ml Females, postmenopausal IU/L mu/ml Glucose (fasting) (plasma or serum) mmol/l mg/dl Growth hormone (hgh) (serum, adult) fasting 0-10 μg/l 0-10 ng/ml Hematocrit - Newborn % Children** % Males % Females % Hemoglobin (Hb) - Newborn g/l g/dl Children** g/l g/dl Males g/l g/dl Females g/l g/dl High density lipoproteins (HDL) (recommended range) > 0.91 mmol/l > 35 mg/dl INR Iron (serum) - Males μmol/l μg/dl Females 5-29 μmol/l μg/dl Iron binding capacity (serum) (TIBC) μmol/l μg/dl Lactate dehydrogenase (LDH) (serum) - Adult IU/L U/L Child IU/L U/L > 60 years old IU/L U/L *Test values are method dependent **Test values vary with age ***Test values are diet dependent.../over

8 Tests SI Units Traditional Units Leukocytes - Total x 10 9 /L ,000/mm 3 Differential: Neutrophils x 10 6 /L /mm 3 Lymphocytes x 10 6 /L /mm 3 Monocytes x 10 6 /L /mm 3 Eosinophils x 10 6 /L /mm 3 Basophils x 10 6 /L 15-50/mm 3 Low density lipoproteins (LDL) (recommended range) < 3.4 mmol/l < 130 mg/dl Luteinizing hormone (LH) (serum) Males 1-9 IU/L 1-9 IU/L Females (follicular) 2-10 IU/L 2-10 IU/L (mid-cycle) IU/L IU/L (luteal) 1-12 IU/L 1-12 IU/L (postmenopausal) IU/L IU/L Magnesium (serum) mmol/l mg/dl Magnesium (urine) mmol/d meq/24h Mean corpuscular volume (MCV) fl µm 3 Osmolality (serum) mmol/kg mosm/kg Osmolality (urine) mmol/kg mosm/kg Oxygen (arterial saturation) 94-99% 94-99% Parathyroid hormone (PTH) ng/l pg/ml Partial thromboplastin time (PTT) See aptt See aptt pco 2 (arterial) mm Hg mm Hg ph (arterial) Phosphatase, alkaline (serum) IU/L U/L Phosphate - Adults mmol/l mg/dl Children mmol/l mg/dl Platelet count x 10 9 /L 150, ,000/mm 3 po 2 (arterial) mm Hg mm Hg Potassium (serum) - Newborn mmol/l meq/l Infant mmol/l meq/l Child mmol/l meq/l Adult mmol/l meq/l Potassium (urine)*** mmol/d meq/24h Progesterone (serum) (adult) - Males nmol/l ng/ml Females (follicular) nmol/l ng/ml (luteal) nmol/l ng/ml Prolactin (serum) - Males 1-20 μg/l 1-20 ng/ml Females 1-25 μg/l 1-25 ng/ml Prostate specific antigen (PSA) µg/l ng/ml Protein (serum) - Total 60-0 g/l g/dl Albumin g/l g/dl Protein (urine) mg/d mg/24h Prothrombin time (PT) 9-12 sec 9-12 sec Reticulocytes x 10 9 /L 25,000-75,000/mm 3 Sedimentation rate (ESR) 0-15 mm/h 0-15 mm/h Sodium (serum or plasma) mmol/l meq/l Sodium (urine)*** mmol/d meq/24h Specific gravity Sperm count x 10 6 /ml 20, ,000/mm 3 Testosterone - Males nmol/l ng/dl Females nmol/l ng/dl Pregnant females nmol/l ng/dl Thrombin time (plasma) < 17 sec < 17 sec Thyroid-stimulating hormone (TSH) (serum) - Adults miu/l miu/l -Term infants: (0-1 day) 1-39 miu/l 1-39 miu/l (1-4 days) 1-17 miu/l 1-17 miu/l (2-20 weeks) miu/l miu/l (21 weeks to 20 years) miu/l miu/l Thyroxine (T 4) (serum)** nmol/l 5-12 μg/dl Thyroxine, free (FT 4) (serum)** pmol/l ng/dl Transaminase (serum) -- AST (SGOT) 7-40 IU/L 7-40 mu/ml ALT (SGPT) 5-35 IU/L 5-35 mu/ml Triiodothyronine (T 3) (serum) mmol/l ng/dl Triglycerides mmol/l mg/dl Urea (plasma or serum) mmol/l see Urea nitrogen Urea nitrogen (BUN) (plasma or serum) see Urea -23 mg/dl Uric acid (serum) (enzymatic) μmol/l mg/dl *Test values are method dependent **Test values vary with age ***Test values are diet dependent TMCE