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Key Features Exams

Published on Nov 18, 2015

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PRESENTATION OUTLINE

Key Features Exams

Answering the questions

critical steps

The KF exam focuses on critical steps in the resolution of a problem. If in doubt, you should ask yourself - "Of all the possible and reasonable steps in this case, what are the critical steps that must be present?"
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Be specific

In KF exams examiners look for key features, not general or broad comments. You need to highlight the specific features of the case. General comments are too broad or ambiguous for examiners to assign marks. The answers need to correspond to specific answers (and their synomyns) on their coding sheet.
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being specific

  • "investigate anaemia"
  • "advise lifestyle changes"
  • "start medications"
  • provide follow-up
  • refer
Examples:
"investigate anaemia", your answer could be "test for serum iron" (marks for serum iron);

"advise lifestyle changes", your answer could be "counsel smoke cessation" (marks for smoke cessation);

"provide follow up", your answer could be "review BP in 1 week" (marks for review of BP in 1-2 weeks);

"perform a full physical examination", your answer could be "examine the respiratory and cardiovascular system, and check for right and left heart failure" (marks for examining for left and right heart failure);

"refer", your answer could be "refer to a gastroenterologist for an urgent gastroscopy" (marks for gastroscopy);

"start medications", your answer could be "prescribe 1000IU Vitamin D supplement per day" (marks for Vit D supplement - 1000IU or equivalent a day)

"reassure", your answer could be "explain that gastroenteritis usually is self-limiting and will improve in 3-5 days" (marks for mentioning self-limiting with improvement seen from 3-5 days)
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Answer the question

You will only get marks for answering the question. This is a fundamental exam technique, but this is still a common mistake.

answering the question

  • "common", "most likely"
  • "important"
  • "next step", "immediate"
Be careful of key words like:

"Common", "most likely" - if you are asked for common problems, no marks are awarded for rare problems, eg. acoustic neuroma in patient with tinnitus will receive no mark as acoustic neuroma is a rare cause of tinnitus.
"Important" - if you are asked for important condition(s), this means important condition(s) that is (are) not to be missed. In other words, the more serious conditions should be listed, eg. space occupying lesions in young patient with a new complaint of headache is an important condition not to be missed, albeit an uncommon condition.
"next step", "immediate" - means literally what you would do next if this patient came to you with a particular problem, eg. for an unconscious patient in general practice, you would do DRSABC, not ask for more information from accompanying friends or family.
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Answering the question

  • be in phase
  • prioritise answers
  • maximum responses
Be careful to note which phase of the consultation the question relates to:

a management question will not award marks for further history or examination steps.
a question asking for procedural steps will not award marks for other management or physical examination steps.

You are tested on your ability to apply knowledge to making decisions in a specific clinical setting. You must demonstrate the ability to prioritise rather than list things from textbooks.

Note the number of responses available or allowed. If a question asks you to list 4 differential diagnoses, list your top 4 common possibilities for the patient - no less and definitely no more. You may not lose marks for listing less than the number allowed but you may not gain any marks either. You may score a "zero" for that question for listing more than the allowable number of answers.
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Read the whole case

then attempt the questions
Often there is more than one part to a question. Read the whole question and answer each part separately. If you are not sure of the first part of the question just move on to the next part(s). You may be able to answer these. Different parts to a question test different key features. You don't need to answer the first part before moving on the subsequent parts.
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Don't forget, context

Each KF question will explicitly state the context, especially when it is important. If the context is not explicit then one can assume the setting is an average urban setting. Common contexts to be aware of include: Aboriginal Community Controlled Health Services, remote Indigenous community, rural settings, regional towns, Emergency Departments (in small country towns) and on the roadside.
You need to pay attention to demographic and epidemiological information provided in the stem.
eg Treating acute otitis media with antibiotics may be appropriate in Aboriginal children in Central Australia but not in a different population and context.
eg Starting adenosine for SVT may be appropriate in a hospital ED setting in a small town but not in private general practice.
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Write Clearly

  • avoid abbreviations
  • check what you write
Take care with what you write down as your answer. If your exam is paper-based, take care with your hand writing. If the marker cannot read your scribbles then you cannot get a mark.

These days exams are done online. Thus take care with your typing, and checking what you write is also important. Although markers can accept minor typing mistakes, answers that are ambiguous cannot be awarded a mark. It is also better to avoid abbreviations because mistyping of abbreviations are more likely to lead to ambiguous or undecipherable answers. Further, not all abbreviations are widely used and accepted.

Examples:

SOB or SBO (easily mistyped when in a hurry)
IBD or IBS (S and D are next to each other on the keyboard)
mg (in lower case it is less likely to be read as Myasthenia Gravis)
IVF (intravenous fluids or in-vitro fertilisation)
PID (prolapsed intervertebral disc or pelvic inflammatory disease)
There are many more ambiguous abbreviations that you may not be aware of. So it pays to write the answer in full.
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Time yourself

Set yourself timing deadlines. For KF exams this is harder to do than MCQ exams where you can allocate about 60 seconds for each question. KF questions may have 1 to 3 parts each and each part may have different tasks (choose from a list, list answers and short answer questions) so it is difficult to allocate time evenly amongst the questions. Nevertheless you can count all the parts and allocate time to each and have time left to go over the questions once again before the end of the time allocation. If it is not possible to have spare time, then you need to have enough time to answer all questions at least once.

A suggestion is to have about 30 minutes spare out of a 3 hour exam to look over the answers especially those answers to questions you had difficulty with.

Order of answers

is not important.
The order of answers is usually not important. Do not waste time trying to order your answers. For example Airway assessment does not need to be before check for Circulation or Breathing in basic resuscitation.
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unnecessary information

There is no need to provide extra information. Write only in the box provided. In an online exam there will be a word limit in each field. If you go beyond the word limit you are definitely giving too much and/or unnecessary information.

For example when you are asked to list (differential diagnoses, immediate management steps) you do not need to explain what those items are, or when you would do them, or the conditions required before acting on them. If you feel you have to explain each item then you should reconsider the answer and/or provide the answer in another way.

For example:

rather than "check airway - look into the mouth", "airway" would suffice as a response
rather than "pericarditis is likely if there is weak pulse, low BP, soft heart sound and pain on sitting forward is relieved", "pericarditis" would suffice as a response
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Use all cues

  • irrelevant diagnoses
  • repeating information provided
  • remember patient demographics
  • remember context
Each KF problem provides relevant information for you to consider. There are positive information in the history and examination as well as important negative findings - all are relevant data. In some situations there are cues or prompts to guide you to particular answers. Therefore:

Don't order a test when it has already been done. The questions wants you to consider other tests
Don't give a diagnosis that is not common for a particular age group. You must deal with this particular patient with their specific issues
Don't give a diagnosis that is not relevant to the symptoms and signs provided. The questions test your decision making based on the available information.

Caution!

Choose as many items as appropriate.
When you are faced with this "opportunity" you must understand that there is a trick to this type of question. "Choose as many items as appropriate" does not allow you to choose all options - where you will get all the correct answers. Instead there will be options that are critical errors - errors in judgement that is unsafe for the patient. Therefore, the question is really about avoiding making critical errors in judgement. When facing this type of question, think "What choices shouldn't I make."
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to be mindful of,

  • But it is correct
  • Clinical judgement
  • Making assumptions
  • Gut feelings
but it is correct, but is it essential

clinical judgement influences by patient cues, environmental cues, internal cues (emotions) - clinical decisions are based on facts, clues not cues, context not environment

making assumptions - be careful not to add information or data that are not presented based on assumptions from past experience - Aboriginal patient and non-compliance

instinct and gut feelings - don't jump to using this technique too early. When you have nothing else use gut feelings.
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to be mindful of too,

  • Premature closure
  • Blind obedience
  • Heuristic thinking
premature closure - reliance on initial impression when more information may come to light eg information in the next question. Be flexible in changing your diagnosis for example.

blind obedience - reliance of test results, PHx, specialist reports eg RA in FHx does not mean the patient has RA when presenting with arthralgia

heuristic thinking - experience based thinking (stereotyping, common sense, rule of thumb) are short cuts. It is a problem when uncommon problems present with common symptoms eg URTI symptoms but HIV or legionnaire disease are not considered when there are obvious risk factors.
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