Structured Orals

Timing

The oral component of the Examination of Added Competence in Emergency Medicine consists of three stations, each delivered by a single examiner, for a total of three independent stations; one 25-minute (triple case) and two 12-minute (single case) stations. The triple case station involves three sequential cases, delivered one after another. There is no triage component tested in that station.

At the beginning of each oral, the examiner will give you a written clinical scenario containing information about the patient presented as if you are just about to go see that patient. You should read the written scenario carefully out loud, after which the timer will be started. After that time, you may start writing out memory aids or patient assessment rubrics. The examiner will conduct your oral exam and score simultaneously as you proceed through the case. The examiner will prompt you through the exam to allow for efficient use of time.

Examiner Role

This examination is different from the Simulated Office Oral component of the Certification Examination in Family Medicine where the examiner plays the role of the patient. You do not need to act as you would in a regular doctor-patient interaction. The examiner will facilitate your progress through the case. Ask the examiner for the information you feel is important to determine how to care for this patient.

The examiner will provide you with answers to all questions about history, physical exams, investigations, consults, or any other relevant inquiry. The examiner will occasionally direct or redirect you to cover certain essential aspects of the case. Should the examiner say a certain aspect of the case is normal or non-contributory, you should accept this and move on to the next steps of your evaluation or management.

Marks for PROCESS of caring for patients

This is an examination of your medical PROCESS of caring for patients who present to the Emergency Department. You are being assessed on how you manage the patient, not just if you get the right diagnosis at the end. There are many points for identifying various facts that are used to arrive at a sound differential diagnosis and management plan, and much less for the specific diagnosis itself.

Try to verbalize as much of your thought process as possible. Summarize periodically. You may take notes as you proceed, perhaps to remember an item to follow up, but since time is limited, consider using your time to verbally communicate with the examiner about the patient scenario. There are no points given for notes written on your paper. Carefully describe the actions you are taking. Remember, the examiner can only score you on the things you actually verbalize.

Avoid a cookbook approach and instead follow lines of questioning, physical assessments and investigations that are tailored to the case at hand. In this examination, a good history is most essential, and the relevant physical exam and logical differential diagnosis are also paramount. Any further investigations and management are secondary to a solid assessment that reflects a good foundation in the overall process of care for emergency medicine. There are no negative points for wrong answers.

Interventions

In the cases presented to you, there will usually be nurses to assist you in the emergency department (ED), as well as the services of your hospital. You may delegate certain activities to other members of your team. Be very specific in the orders and interventions you require (e.g., “CT scan of the chest” is not the same as “CT pulmonary angiogram”). Monitor the ABCs and vital signs in an ongoing fashion as necessary to get a feel for the progression of each case. Ask for the results of your interventions and investigations when appropriate.

Interpretations

You may be shown some actual copies of test results of your investigations and then be asked for your interpretation of what is presented to do. Please do so carefully, but succinctly. Certain results may be normal. Most scenarios are practice-based and don’t focus on extremely rare or occult problems. If the final diagnosis is uncommon or rare, the key points are for how you get to the diagnosis, not necessarily for the management of the specific diagnosis. When listing your differential diagnoses, be complete but concise; mention the things you should be considering in this patient, at this time.

Be decisive in the way you conduct your evaluations and establish your setting so that you can gather the best information in the most efficient manner.

Disposition

Make certain to be direct and clear in your disposition of each case, ensuring each patient has a clearly articulated and transparent care plan that covers all the essentials and is well presented to your examiner. Ensure that each patient has a comprehensive plan that provides continuity of care, be it in-patient or as an out-patient. Remember to include family members or caretakers as well as primary care health professionals.

Interaction with others during the exam

The examiner is not allowed to give you any feedback on your performance. However, he or she will work with you during the exam to provide all the information necessary to manage each situation optimally.

You will be expected to be silent during the intervals between the oral examinations. Do not discuss the content of the oral examinations with other candidates, before, after or during the examination. Experience has shown that prior knowledge of the clinical content or case diagnoses of oral examinations has resulted in poorer performances than might otherwise have been expected. You will be best served in preparing for this oral examination by exploring a case-based approach with practice scenarios that reflect a similar process and structure.

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