ABOUT THIS RESOURCE

This resource helps you prepare for the Medical Council of Canada’s clinical skills exam, the MCCQE Part II, and equivalent exams in other countries, such as the USMLE Step 2 in the United States.

It aims to offer a concise, strategic approach to the exam, based on common entities as the likely targets for the exam and the practical limits of what standardized patients can play.

THE CLINICAL PRESENTATIONS IN THIS RESOURCE

The clinical presentations in this resource come from the objectives for the exam set by the Medical Council of Canada (MCC). (The MCC publishes its clinical presentations online under its “medical expert” objectives: use the search term Medical Council of Canada medical expert in your browser.)

The resource unpacks each clinical presentation in a series of standard sections.

MCC PARTICULAR OBJECTIVE(S)

The MCC outlines a particular focus for most of its clinical presentations, which this section summarizes.

MCC DIFFERENTIAL DIAGNOSIS WITH ADDED EVIDENCE

The MCC lists causal conditions for each clinical presentation, which are presented in this section as an edited and expanded differential diagnosis.

The differential diagnosis is edited (lightly) to exclude uncommon entities.

It is expanded to describe the common presentations of the remaining entities (except where, occasionally, these entities are self-explanatory and need no expansion).

So, this section presents the common clinical evidence for the common entities in the MCC’s list of causal conditions.

The MCC notes in each clinical presentation that its list of causal entities is not exhaustive. These lists do, however, show the MCC’s priorities for the exam—which is why this resource follows them closely.

STRATEGY FOR PATIENT ENCOUNTER

This section describes the elements likely to shape a patient encounter for each clinical presentation, including the likely scenario and the likely tasks. The tasks can include history, physical exam, investigations, or management. Most clinical presentations could engage any of these tasks, so generally this part covers all of them each time.

In clinical presentations where the MCC identifies emergency management as the focus, the resource unpacks steps for emergency management.

This section also sometimes includes “pearls”: particular advice gleaned from experience in clinical practice.

HOW THIS RESOURCE HELPS YOU OVERCOME COMMON CLINICAL-EXAM ERRORS

The Medical Council of Canada reports several common clinical- exam errors, including:

• not recognizing urgent presentations
• peppering patients with closed-ended, yes-no questions
• not listening for, or looking for, evidence to rule out differential diagnoses
• counselling patients with rote, directive, generic information

This resource helps you overcome these common errors by:

• summarizing the MCC’s objectives for each clinical presentation, which highlight when urgent presentations are at issue, and unpacking steps in emergency management where relevant
• modelling open-ended questions
• clarifying diagnostic goals for history taking, physical exams, and investigations
• modelling approaches to counselling that target the particular situation of patients and enable them to make their own, informed decisions

EXAM BASICS

EXAM FORMAT

You can read about the format of the MCCQE Part II on the MCC’s website.

The exam takes place over 2 days and involves a series of encounters with standardized patients. An examiner is present during each encounter (you should ignore the examiner, except when the examiner speaks to you).

The first day has 8 14-minute encounters.

The second day has 4 6-minute encounters combined with 6-minute reading or written-answer tasks (the encounters may come before or after the reading or written-answer tasks).

Any clinical presentation can form the focus of either kind of encounter.

The use of standardized patients places some strategic constraints on the exam. For example:

• Only people age 16 and older can play standardized patients. So, in pediatric cases, the patient will likely be an adolescent, a child absent on some pretext (leaving the parents to discuss the concern), or a simulated neonate.
• Psychiatric disorders are easier to simulate than disorders with physical symptoms, which increases the likelihood of a psychiatric disorder on the exam.

OVERALL GOAL: FIND EVIDENCE, USE EVIDENCE

Your overall goal is to gather evidence, and use this evidence to focus on what is relevant and useful to the individual case at hand.

READ THE CASE INSTRUCTIONS CAREFULLY

Each patient encounter begins with a set of written instructions that describe a scenario and specify the tasks you need to perform.

You have 2 minutes to go over these.

• Glean context from the instructions. For example, they may contain laboratory test results, or information about the patient’s age or occupation, which may be relevant to the differential diagnosis.
• Do only the tasks specified by the instructions.
• If an instruction says to “assess” a patient, start by taking a history. Do a physical exam only if warranted by the evidence.

ALWAYS TAKE THESE FIRST STEPS

Always:

• Introduce yourself to the patient.
• Ask the patient for consent to interview and examine them. Be aware that consent may depend on culturally sensitive care, which the patient may not clarify until you ask.
• Offer the patient a chaperone for the encounter.
• Wash your hands.

USE HISTORY TAKING TO HELP THE PATIENT TALK

Standardized patients have information to tell you that is designed to narrow your differential diagnosis. Use open-ended questions, as opposed to yes-no questions, to let the patient talk.

And then listen.

MAKE NOTES SPARINGLY

You will be supplied with a pen and paper at the exam (you’re not allowed to bring your own). You can use these for notes during history taking, but keep your focus on your patient.

Make eye contact with the patient as they talk. If you take notes, be strategic—for example, sum up distinguishing symptoms or red flags with single words.

TALK YOUR WAY THROUGH PHYSICAL EXAMS

Describe your procedures and findings as you perform a physical exam, including normal findings. This allows the examiner to understand your process.

Always:

• Obtain the patient’s permission to conduct a physical exam.
• Drape the patient appropriately.

FOCUS ON RELEVANT INVESTIGATIONS

Order investigations that narrow the differential diagnosis, based on evidence from the scenario instructions, the history, and/or the physical exam. Don’t order every possible investigation.

TAILOR MANAGEMENT TO THE PATIENT

Provide next steps and information that target the situation of the particular patient. This means you need to ask the patient for relevant details about their situation, such as work, recreation, and dietary routines. Think of these details as a way to begin a conversation with the patient about changes to their routines that could help them.

LISTEN FOR REDIRECTION WHEN YOU’RE STUCK

There may be times that you blank on a scenario, or nerves get in your way. If you are seriously off track, the examiner may try to redirect you. Be aware of attempts at redirection and adjust your approach accordingly.

If you draw a blank on history taking, remember that you can always ask about medications, allergies, family and personal medical history, and the psychosocial impact of the presenting problem.

PREPARE FOR PARTICULAR CHALLENGES

PATIENTS WHO REQUIRE CULTURALLY SENSITIVE CARE

Any patient encounter may engage the need for culturally sensitive care. When you ask permission to interview and examine a patient, a refusal from the patient may stem from this.

When a patient withholds consent, engage in a straightforward, respectful conversation about the patient’s expectations for care.

For example:

• Express confidence in your ability to help the patient.
• Describe specific procedures and investigations you may need to perform in the context of the patient’s case.
• Ask the patient how to proceed with their permission (e.g., by providing a same-sex doctor).
• Do your best to meet the patient’s expectations while protecting the patient’s health and safety.

PATIENTS WHO ARE RELUCTANT TO TALK

Some standardized patients may show reluctance to talk, to test your ability to elicit information on sensitive topics. In these situations:

• Acknowledge the patient’s reluctance to talk (e.g., “It seems like you are having some difficulty talking about your health concern.”)
• Offer empathy and reassurance (e.g., “Some problems are hard to talk about. It’s okay to feel unsettled. I want to help you, not judge you.”).
• Express confidence in your ability to help the patient.
• Show your ability to listen respectfully: allow the patient to talk at their own pace.

ABUSIVE PATIENTS

Some standardized patients may be angry. In these situations:

• Remain calm.
• Acknowledge the patient’s anger.
• Express confidence in your ability to help the patient.
• Ensure your safety and the safety of others. It may be appropriate to assess for homicidal ideation (e.g., “When someone is as upset and angry as you are, they sometimes think about harming others. What thoughts have you had about harming others?”). Seek an emergent admission to a psychiatry ward in the case of homicidal ideation.
• Offer clear next steps. For example, state that you need the patient to answer some questions, so you can better understand their situation.

NONCOMPLIANT PATIENTS

The health concerns of some standardized patients may stem from noncompliance with prescribed medications.

For example, uncontrolled diabetes can contribute to a variety of presenting problems, such as incontinence, hypertension, and diplopia. Patients may have uncontrolled diabetes because they are not taking their medication, due to forgetfulness or financial constraints.

In any noncompliant patient, seek the reasons for noncompliance.

• In forgetful patients, discuss possible strategies to help with compliance. For example, how could they set up reminders for themselves? How well do they cope with day-to-day tasks in general? What family or friends could they call on for assistance? In patients who are not coping and who do not have social supports, consider community supports such as home care services.
• In patients who cannot afford their medications, express empathy and seek details about the patient’s situation. Consider referring the patient to social service agencies, which can help with financial assistance and skills such as budgeting.

DISSENTING HEALTH-CARE PROFESSIONALS

The exam may test your ability to manage conflict with other health-care professionals who disagree with your decisions about a patient’s care. Use evidence to negotiate these situations:

• Take a position based on evidence, and defend it calmly and rationally.
• Offer to monitor the patient’s situation and revisit your decisions as the evidence warrants.