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Strategies for the MCCQE Part II
Excerpt

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.
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Pathology Review and Practice Guide
Excerpt

INTRODUCTION

 

Knowledge is the foundation of excellent pathology practice and excellent outcomes on exams. This book helps build that foundation in a comprehensive yet concise format. It is a solid reference for practicing pathologists, and provides excellent preparation for the US and Canadian pathology exams.

 

The US and Canadian pathology exams differ in format: the US exam is entirely written and multiple choice; the Canadian exam has a written and an oral component, and the written component is entirely short answer.

 

For this reason, the exam strategies discussed below cover different formats, and the book itself includes short answer questions and multiple choice questions.

 

GETTING READY FOR THE EXAM

 

A Structured Study Plan

 

In addition to reading cases, a structured study plan should include a thorough and systematic reading of Robbins and Cotran Pathologic Basis of Disease and of a surgical pathology textbook (either Sternberg's Diagnostic Surgical Pathology or Rosai and Ackerman's Surgical Pathology). Pay particular attention to definitions, fundamental terms, and concepts. Make lists and tables for comparison and grouping. Focus on subspecialty books during your rotation of that subspecialty. When it is closer to the time of the examination, go over old examination questions and collections of images to help you objectively assess your knowledge and your weaknesses.

 

Group Study

 

If there are more than 3 people writing the examination, it can be helpful to get together regularly to go over old examination questions, slides, gross images, and so on. As a group, go over a chapter or a topic in Robbins and Cotran Pathologic Basis of Disease and brainstorm possible questions on the areas you think are important.

 

Literature Review

 

Glance over the last 3 years of the American Journal of Surgical Pathology. This should be sufficient to keep you up to date on this field. Advances in Anatomical Pathology has some very good review articles that can help you quickly update your knowledge on specific topics. You also need to be aware of any new tumor classification systems in the most recent editions of World Health Organization publications.

 

Practice Exams

 

In the 3 months before the examination, try to systematically gain exposure to all subspecialty experts in your department. Trust yourself and your program. If the resident training committee thinks you are doing well, and you did well on your department exams, you will do fine on the pathology exam.

 

HEADING INTO THE EXAM

 

In Canada, you must bring a microscope to the exam. In the US, you can bring your own microscope, but microscopes are also supplied.

 

If you bring a microscope, also bring a slide, a back-up light bulb, and a filter. Use the slide to adjust your microscope.

 

If you have to travel to a different time zone for the exam, consider arriving 2 to 3 days early to avoid jet lag. No matter where the exam is held, give yourself at least a day to become familiar with the examination venue and your route to the venue.

 

Know your examination schedule well. Get to the site at least 15 minutes early to allow time for preparation, sign-in, going to the washroom, finding your seat, and so on.

 

TAKING THE EXAM

 

The Basics

 

Before you begin taking the exam, enter all pieces of required information on your answer sheet. If you forget to enter your name and ID number, your results may not be scored. Do not bring personal electronic devices into the examination room. Do not communicate with fellow examinees while the exam is in progress. Do not comment about the wording of questions in your answers.

 

Strategies for Unknown Lesions

 

First, try to categorize the lesion as neoplastic or nonneoplastic.

 

Nonneoplastic lesions can be classified as congenital, inflammatory, or infectious.

 

Neoplastic lesions can be classified as benign or malignant. Malignant neoplasms can be primary or secondary. Most neoplasms can be further classified into the following 3 subcategories based on cell lineage or origin: epithelial (carcinomas), stromal (sarcomas), and hematopoietic (lymphomas, leukemias).

 

Strategies for Multiple Choice Questions (US)

 

- Anticipate the correct response while you read the question. If you see the response that you anticipated, circle it and then check to be sure that none of the other responses is better. If you do not see the response that you expected, use the following strategies to eliminate responses that are probably wrong:
- Responses that use absolute words, such as "always" or "never," are less likely to be correct than ones that use conditional words such as "usually" or "probably."
- "Funny" responses are usually wrong.
- If you can identify more than 1 correct response, "all of the above" is the correct answer. "None of the above" is usually an incorrect response, but be very careful not to be trapped by double negatives.
- The longest response is often the correct one.
- A response that repeats key words that are in the body of the question is likely to be correct.
- If you have no idea of the correct answer, choose response b or c. Response a is least likely to be correct.

 

- If you cannot answer a question within a minute, skip it and come back to it later.

 

- Transfer all responses to the answer sheet at the same time, once you have marked all questions on your exam. Make sure that you have filled the appropriate bubbles carefully in pencil.

 

- Take the time to check your work before you hand in the answer sheet. Trust your instincts and try not to change your original answers.

 

Strategies for Short Answer Questions (Canada)

 

- Bring at least 2 pens.

 

- There are about 30 questions divided by groups and each question has multiple parts. You have 3 hours to answer them. Pace yourself appropriately.

 

- Glance through the questions and answer the easy ones first.

 

- Read the entire question before putting down your answer.

 

- Write legibly. Use bulleted lists and tables.

 

- Provide the number of answers that are asked for. If you provide 5 answers when 3 are asked for, only the first 3 will be marked.

 

- Write down the most important answer first. If a disease has multiple histologic features, write down the most common feature first.

 

- Do not leave any questions unanswered.

 

Strategies for Examining Slides and Images

 

- Make sure your microscope works well before the examination starts.

 

- For the US and Canadian exams, you have about 2 minutes to examine each glass slide, and about 20 seconds to provide your answer and pass the slide to the next candidate.

 

- Both the US and Canadian exams also include screen-based images for showing virtual slides, and gross pathology, forensic, and other images.

 

- Pace yourself appropriately:
- The US exam has a 3.5-hour session for examining about 50 glass slides and 25 virtual slides, and a further 1.75-hour session for screen-based images.
- The Canadian exam has a 2-hour session for examining about 50 glass slides, and a 90-minute session for examining 40 to 60 screen-based images.

 

- Provide 1 answer only to each question unless otherwise specified.

 

- If you cannot make a satisfactory diagnosis, provide the best answer you can, and move on. Do not leave any questions unanswered.

 

- Remember "common things are common" and the answer is most likely straightforward. You do not need to rack your brain looking for "rare birds."

 

- For the Canadian exam, do not write lists of differential diagnoses, and write legibly but quickly.

 

Strategies for Oral Examinations (Canada)

 

- Be professional. Dress professionally and act professionally. Look at the examiners with a level of confidence. You have studied hard and prepared yourself well for this day. Accept that you will be a bit nervous, which is expected and appropriate.

 

- There are 5 to 6 cases to examine in 1 hour. Each case will have 1 or 2 slides with age, gender, and site information. The materials could come from surgical cases, autopsy, or cytology. After reviewing the cases, you will be examined by 2 examiners for 1 hour.

 

- Make notes while looking at the cases: summarize histologic features, differential diagnoses, and diagnosis; note answers to anticipated questions. Take the notes with you into the examination room. You can also make notes during the oral exam to organize your thoughts.

 

- The oral examination usually starts with "describe what you see and give a differential diagnosis," followed by "describe how you would work this case up." Do not jump to the diagnosis right away even if you are confident with your diagnosis. Do not be panic when you cannot get a definitive diagnosis. A structured approach with a differential diagnosis is usually what the examiners are looking for.

 

- Be patient. Wait for the full question to be asked before answering. Think and organize your thoughts before answering. It is fine to ask for clarification or for the question to be repeated if you do not completely understand the question.

 

- Be honest. When you do not know the answer, say, "I do not know," or "I will look it up," or "I will show it to someone else." Do not guess wildly. Do not ramble wildly. You will be interrupted if you ramble.

 

- Be independent. Do not expect feedback or comments on how you did during the exam. Do not be misled by inadvertent feedback, or the behavior or attitude of the examiners.

 

- Take hints from your examiners. If they ask you whether you have anything else on your differential or any other stains you would like to order, it means you are missing something. If they ask whether you are sure, it means you are probably wrong. Do not argue with or question the examiners.

 

AFTER THE EXAM

 

- You have done your best. Do not contact your examiner to see how you did.

 

- In the US, you receive your results through PATHway from the American Board of Pathology.

 

- In Canada, the exam board stratifies candidates into pass, borderline, and fail groups. For all borderline candidates, the exam board reads final in-training evaluations reports (FITER) and considers scores on all components to make the pass/fail decision. Exam results are usually available within 1 week.

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