2018 FRACP Clinical Examination

Transcription

1 2018 FRACP Clinical Examination New Zealand Instructions to Candidates Adult Medicine and Paediatrics and Child Health

2 Preamble The Clinical Examination is designed to test clinical skills, attitudes and interpersonal relationships. The clinical skills include history taking, physical examination, interpretation of findings, construction of a diagnosis or differential diagnosis, method of investigation and general management of patients. As you have already passed the Written Examination any detailed discussion in the Clinical Examination will be directed to testing clinical skills. Questions testing your factual knowledge will be at a level appropriate to making adequate management decisions in the case being discussed. Eligibility have 24 months of certified training by the end of the training year in the year prior to the Examination be in an accredited training position or an approved interruption in training completion of all PREP requirements comply with the limit on the number of examination attempts and other requirements for progression through training, which are detailed in the Progression through Training policy have paid all associated training fees. Trainees with outstanding training fees will not be eligible to sit the examination unless they have made an application in writing to the Honorary Treasurer requesting special consideration. The Progression through Training Policy states that you must be in an accredited training site and be completing requirements even if you have completed 36 months of Basic Training Application Form You will be ed the closing date for applications 1

3 Dates The dates Clinical Examination will be held are: Paediatrics and Child Health May 2018 Adult Medicine June 2018 Clinical Examination candidates should not assume that their own examination will be at the same time as other candidates from their hospital or city. Venues The Examination will be held in the following locations: Adult Medicine Whanganui Hospital Hawkes Bay Hospital Palmerston North Hospital Kenepuru Hospital Nelson Hospital Christchurch Hospital Dunedin Hospital Southland Hospital Paediatrics and Child Health Wellington Hospital Christchurch Hospital Waitakere Hospital Botany Superclinic Candidates will not be examined in their own hospitals and candidates should be prepared to travel to a different city. The College will try to advise Clinical Examination candidates of their allocated venue with as much prior notice as possible. Please note that due to unforeseen circumstances, these venues may change at short notice. 2

4 Proof of Identity Candidates must have with them proof of identification (e.g. a passport, a photo driver's license or hospital photo identification card) as this will be checked upon arrival at the Examination. Format of the Clinical Examination The Examination format will require candidates to be examined on two long cases and four short cases. The structure of the Examination will allow this to be done within two examination cycles (morning and afternoon) on the one day. In each cycle, each candidate will be examined on one long case patient and two short case patients. In one cycle the long case will be seen before the short cases, while in the other cycle the long case will follow the short cases. Each candidate will be examined during these two cycles by at least four pairs of examiners. Each case will be scored independently, and the candidate's final result will be determined by the aggregate mark. Long Case Assessment You will be allotted 60 minutes to take a history, examine and develop a management plan for the patient. Aids for physical examination may be taken into the patient's room but printed material (including textbooks, notes, MIMS or other drug compendia) proforma sheets, electronic devices (including recording equipment and mobile telephones) are not permitted. The aim of the restrictions is to make the Examination as fair as possible for all candidates. A candidate who takes in unauthorised material may be disqualified from the Examination. Paediatric candidates may take normal percentile or similar charts into the patient's room. Results of urinalysis ± rectal examination will be provided to you. You may not begin writing any notes until you enter the examination room Candidates in the paediatric examination will not be allowed to send parents or guardians out of the room to be alone with the patient during the long case assessment. You will have 10 minutes to prepare your discussion and move to the examiners' room following your history taking with the patient. You will spend 25 minutes discussing the patient with one team of examiners. The examiners are instructed to place emphasis on the accuracy of the history and findings on examination, attitudes to clinical problems, possible diagnosis, investigations required and their appropriateness, overall interpretation, and approaches to management. Your assessment should therefore be directed accordingly. You will be examined by two examiners. On occasion, a third examiner may be present but will act only as an 'observer' during your examination. You may expect one examiner to lead in the discussion, usually followed by the second; although variations to this may occur. It should be noted that excessively lengthy case presentations are inadvisable and may be interrupted. 3

5 Candidates are reminded that all patient records, including their notes about patients, should be treated confidentially. All notes regarding patients must be left with the organisers at the examination for destruction. If you know the patient you are seeing in the examination please inform the staff onsite immediately. College staff and Local Organisers go to great lengths to ensure that the patients you will examine are not known to you. However there remains the possibility, for whatever reason, that a candidate has seen a patient before. Failure to inform the staff of a prior knowledge of the patient could be seen as a breach of the Academic Integrity in Training Policy Short Case Assessment Each of your short case examinations will last for 15 minutes. This part of the Examination is designed to assess your technique of physical examination, your ability to elicit physical signs and your ability to interpret and place appropriate significance upon your findings. As part of your assessment of the findings you may be asked to comment on relevant diagnostic tests (e.g. X-rays, ECGs) and/or nominate appropriate investigations. The introduction given to you by the examiners has been standardised beforehand and is designed to be accurate, short and directive. You will also be given a 2 minute introduction sheet outside the examination room to review for 2 minutes before entering. These sheets were introduced at the 2008 examination which the candidates found very useful. The sheet will state the patient s name, age and sex and task. You will be examined by two examiners. On occasion, a third examiner may be present but will act only as an 'observer' during your examination. There will be up to ten minutes between the two short cases in each cycle. Required For trainees of the College, the standard required includes the breadth of knowledge, aptitude and skills sufficient for the management of general medical or paediatric patients to enable you to enter advanced training. You are required to pass at least one short case and one long case in order to pass the exam. If you do not meet this requirement you will fail regardless of your final score. Quality and Safety s In order to maintain appropriate health and safety standards during the conduct of the Examination, examiners and candidates must both ensure that they wash their hands prior to, and after, carrying out any physical examination. 4

6 You may be dealing with patients with infectious diseases and you are advised to take the appropriate precautions. A supply of clean disposable pins will be supplied for neurological examinations (for both the long cases and the short cases). You will not be permitted to use your own pins unless they are disposable. Case Selection A broad range of cases is selected for the Examination, however candidates may be asked to examine similar systems on patients selected for their examination. Examiner Review of Patients Examiners will have taken a history from, examined and identified relevant issues for discussion for each long case patient, prior to each cycle of the Examination. This is done without the aid of patient notes or prepared histories to enable a more accurate appraisal of the patient's ability to give a clear history and of the accuracy of signs. Short cases are also assessed 'blind' by the examiners prior to each cycle. Examination Day Timetable One Half of Candidates Other Half of Candidates Morning One long case followed by two short cases 9.20am 11.50pm Two short cases followed by one long case 9.35am 12.20pm Afternoon Two short cases followed by one long case 2.15pm 5.00pm One long case followed by two short cases 2.00 pm pm Most hospitals will provide light refreshments during the course of the Examination cycle, however Candidates are responsible for provision of their own lunches (unless the examining centre is remote). All candidates should arrive at the examination site by 9.00am 5

7 Number of Examiners Each team is made up of at least two examiners and each candidate sees at least four pairs of examiners. At each hospital venue, there may be additional examiners allocated to teams. Therefore a 'team' may consist of more than two examiners, however, only two will actively examine you and determine your score. Where this occurs, the third person is called an 'observer' to differentiate them from the 'examiners'. Equipment for the exam The following equipment is considered appropriate for candidates to use in the Examination and it is advised that each candidate brings this equipment to use: Blank paper/cards and pencils/pens (candidates must bring their own stationery and it will be checked before the examination begins) Stethoscope (These must not be electronically augmented unless the candidate has obtained specific permission for medical reasons). hand-held ophthalmoscope (not a pan-ophthalmoscope) Red topped hat pin or equivalent for visual field testing Auroscope Pocket torch Tape-measure and/or ruler Tendon hammer Single-use spatulas Tuning forks (128 and 256 Hz) Hand-held visual acuity chart(s) Cotton wool. Single-use neurological examination pins for testing sensation Pre-printed picture for higher centres testing (*) A blank form for undertaking a screening mini-mental test (*) Props such as a jar, key and shirt-sleeve with button for hand function testing (*) Toys for distraction and testing of development (*) Growth Charts (*) (*) - some items are more relevant to either the adult or paediatric examination. Candidates are not allowed to bring in references, mobile phones, smart watches or other data storing/sharing devices whether written or electronic. If a candidate inadvertently brings any of these or any other equipment not considered acceptable to the Examination, they must declare this to an Examination Coordinator who will take the item(s) for safe keeping until the Examination is finished. 6

8 Preparation for the Examination Regular clinical activities in the hospital will prepare you for clinical examination of patients. In most hospitals the Director of Physician/Paediatric Physician Education (DPE) and members of other College training committees will often assist trainees by discussing the Clinical Examination and undertaking 'long' and 'short' cases at practice sessions. Pre-Examination Contact at Examination Sites In the past, there have been occurrences of candidates approaching their Examination hospitals after receipt of their allocation letter to obtain information regarding examination case selection or the types of cases in which a hospital specialises. As a result, the Clinical Examinations Committee has developed an official statement. Candidates should be aware that: Any attempt to gain information pertaining to possible examination cases from staff organising the Examination at their allocated hospital may be perceived as providing them with an advantage and may lead to disqualification from the current Examination; Attendance at practice cases or examinations at their allocated hospital, after notification of allocation, is not permitted and failure to comply may lead to disqualification from the current Examination. See the Academic Integrity in Training policy for more information Please note you may go to the outside of the hospital the day before the examination to ensure that you know where to go. However out of respect for the site and the staff who are working please do not go in and ask to look at the rooms where the examination will take place. Candidates with medical conditions or disabilities The Clinical Examination Committee aims to provide candidates with optimal examination conditions in which they can perform to the best of their ability. There are some limits on the adaptations that can be made to the examination without compromising the process or the conditions for other candidates. It is the decision of the candidate whether or not to present for the examination and candidates must decide if they are well enough and adequately prepared to sit the examination. Impaired preparation cannot be considered as a reason for any special treatment. All candidates must reach the defined standard to pass the examination. Candidate marks cannot be adjusted to allow for medical conditions or disabilities. The pass standard cannot be adjusted to allow for medical conditions or disabilities. Supplementary examinations are not offered for candidates who suffer from illness or other personal difficulties that may have impaired their preparation for, or performance in, the examination. 7

9 Permanent or long standing medical conditions or disabilities If you have a permanent or long standing condition that may affect your ability to participate normally in the examination you may be eligible for special assistance during the examination. For example you might require additional time to move between examination rooms; need to sit for some of the short case segment; or need additional equipment or aids. You must notify the Basic Training Unit at least three months before the examination or at the time of application of this examination if known. You must indicate the type of assistance you require and attach a detailed medical certificate showing: a description of the medical problem or disability; the duration of the medical problem or disability; the medical practitioner s professional opinion about the effect of the medical problem or disability on your ability to perform in the examination and the assistance you require. Medical conditions or other personal difficulties arising in the lead up to the examination If you develop a medical condition or other circumstances affect your ability to participate normally in the examination in less than the three month notice period, you must notify the Basic Training Unit immediately and provide the required medical documentation. Where possible, modifications to the examination can be made. Other options for candidates also include, withdrawing from the examination (you may be able to receive a partial refund of the fees and not have an Examination attempt counted for this year) or rescheduling your examination until later in the examination week. This will only be possible if vacant spaces are available. It is not possible to offer candidates the option of being examined in the supplementary examination as there are many years when no supplementary examination is held. Candidates should only present for the examination if they consider themselves to be well enough and adequately prepared to sit. Medical conditions or other personal difficulties arising on the day of the examination If a medical condition or other personal difficulties prevent your attendance at the Examination, you must notify the Basic Training Unit immediately. Medical documentation and/or statutory declarations must be submitted within the next 48 hours. If you are unwell on the day of the examination you must decide if you are well enough to sit the examination. Once you commence the examination the attempt will be counted. If you are feeling unwell on the day please notify the Local Examination Organiser at your exam site. Please note that candidates who are unwell in the lead up to, or on the day of the examination will not be offered a supplementary examination on this basis. 8

10 Procedural problems during the examination If you consider that there has been a problem with the process of the Examination, you must ensure that the examiners are made aware of this on the day. Any problems during the short case examination (e.g. patient is out of the room for several minutes using the toilet) will be obvious to the examiners. In the long case examination, the examiners will ask you at the start of the case presentation if there were any procedural problems. If the examiners forget to ask, you should bring any problems to their attention. Where possible, examiners will take any procedural problems into account during the conduct of the case or in their marking. If you do not make them aware of any concerns with the examination process, the examiners will be unable to assist you in this way. If you have concerns that you did not bring to the attention of the examiners, you must notify the Basic Training Unit in writing immediately after your examination. This should occur by the close of the next business day after your examination. No notifications of procedural problems will be accepted after this time. Procedural problems that have been documented by the examiners or notified to the Basic Training Unit by candidates will be reviewed at the Clinical Examination Committee meeting. Procedural problems are only reviewed for candidates whose marks indicate a fail. If your marks indicate a fail result and there was a significant procedural problem that may have negatively impacted your performance AND it was not possible for this to be taken into account by the examiners on the day, the Clinical Examination Committee may offer you a supplementary examination. Please note that: A supplementary examination is the only remedy available for a procedural problem. The Clinical Examination Committee cannot amend a candidate's mark, nor the total mark required to pass the examination. Candidates please note the following important points: 1. Candidates who have made contact about perceived procedural difficulties in the examination after the closing date. It is important to note that nothing can be done at this late stage. It is too late to consider a supplementary examination and no adjustment can be made to the marks. Procedural difficulties must be notified to the College by the closing date. 2. Candidates who have made contact with requests that they be allowed to pass because their score was close to that required for a pass. Clearly this is not possible. The pass standard is fixed and candidate marks cannot be adjusted. Candidates who get close to a pass mark should take encouragement from the knowledge that most candidates in this circumstance improve to the point of gaining a pass mark in subsequent examinations. 3. Candidates who have queried that their mark in a particular case does not seem to match the points indicated by the examiners on the visual analogue scales on the feedback sheets. Candidates should note that the individual domains do not contribute equally to the final mark. In some cases certain domains are given more weight than 9

11 others by the examiners. For example, missing one very important physical sign in the short case may lead to a fail mark for that case even if the candidate performed well in the other domains of the case. The only situation where candidates may find it helpful to contact the Basic Training Unit after the results have been released is if they believe the marks in their individual cases do not add up to the total mark. In this circumstance the mark may be recalculated. The processes of special consideration allows an applicant to present additional information relevant to a decision, and to ensure that the Examination Committee has had the opportunity to receive and consider all relevant information. Reconsideration and review processes apply only to decisions of the Examination Committee (e.g. whether to offer a partial refund of fees or if an attempt at the examination is counted). Examination results cannot be altered by these processes. See the College website for information regarding the College s Special Consideration Process Please note that Clinical Examination results are not subject to the Reconsideration, review and appeals process. Procedure in the Case Misadventure Travel to allocated Examination Site Occasionally candidates have experienced unanticipated difficulty travelling to their allocated examination site. This may be because of inclement weather, vehicle breakdown or some other factor. It is important that as far as possible candidates allow for redundancy in their travel arrangements to take account of these unforseen difficulties. If despite such forward planning some extraordinary travel circumstance prevents a candidate from travelling to the examination or the extraordinary travel circumstance is such that it is likely a candidate s performance would be significantly impaired because of it, the candidate must inform a member of the College staff (see contact details at the end of this document) as soon as possible prior to the day of examination. Depending on availability of space it may be possible for the candidate to be examined at an alternative more accessible site. Failing that the candidate should endeavour to travel to their allocated examination site and inform the College representative at the site of the extraordinary travel circumstances providing corroborating evidence when available. It may still be possible to rearrange matters to accommodate the candidate at the allocated site. Misadventure Preventing Attendance at the Examination before the Exam is underway. Where an illness or misadventure prevents attendance at the Examination, the College Education Officer must be contacted prior to the commencement of the Examination ( ). For weekend examinations, examinations@racp.org.nz and contact details will be automatically supplied. 10

12 Deadlines for Special Consideration Ideally applications for pre-exam special consideration should be made at the time of application Pre-Examination Special Consideration Requests Close Examination Day Special Consideration Requests Close Technical and procedural issues Paediatrics and Child Health Adult Medicine Friday 6 April 2018 Friday 20 April pm Tuesday 29 May pm Tuesday 19 June 2018 Results Paediatrics and Child Health 31 May 2018 Adult Medicine 21 June 2018 Results will be ed to you. Feedback Examiners complete a form designed to provide feedback to candidates in order that they may learn from the clinical examination experience. The feedback form for individual candidates is filled out immediately after each case. Examiners only have a short time to do this. The feedback sheet does not provide a list of pass/fail points. It should not be used as a means of disputing the basis of an unsatisfactory performance. It cannot and will not be used as a means of remarking a candidate s performance. Candidates who are successful in their attempt at the examination will be posted a copy of their feedback sheets after the full duration of the clinical exam process. Candidates who are unsuccessful in the Examination will have a feedback session with a person of their choosing (usually a supervisor) to discuss their performance. The feedback sheets will be given to the candidate at this session to provide information which may assist preparation for re-examination. Case summaries will be provided to the feedback person and must be destroyed following the feedback session. It is the responsibility of the candidate to arrange this interview time. Candidates may also wish to invite a support person to attend this session. 11

13 Number of Attempts Limits on the total training time allowed and the number of examination attempts are specified by the Progression through Training policy. The revised policy will be implemented from 1 January Transition arrangements are in place which may be relevant to trainees sitting the Written and Clinical Examinations in You can view your examination attempts to date on the Basic Training Portal. For more details please see the Progression through Training policy Withdrawal from the Examination (By-laws 6 and 7 as they relate to the Clinical Examination) 6) Candidates who withdraw their applications will be entitled to the following refunds: If withdrawing before the closing date a full refund of the fee. If withdrawing from the Clinical Examination after the closing date, but not later than 14 days before commencement of the Clinical Examination a refund of 50% of the fee. If withdrawing from the Clinical Examination after 14 days before the commencement of the Clinical Examination no refund. 7) Candidates who fail to appear for any component of the Examination will forfeit the fee for that component unless because of exceptional circumstances the Chairman of the Board directs otherwise. These fees are retained to cover the administration costs that have been incurred up until the time of the withdrawal. In exceptional circumstances the Chair of the Clinical Examinations Committee, in consultation with the Honorary Treasurer, may waive the penalty fee. Both patients and examiners provide their services on a voluntary and unpaid basis. 12

14 Fee (GST inclusive) Clinical examination fee $3, The Examination fees are reviewed annually by the Board. Overseas Trained Physicians (OTPs) Physicians/Paediatricians trained overseas and applying for Vocational Registration through the New Zealand Medical Council may be asked to undertake the Clinical Examination as part of the assessment process. Applicants who are required to successfully complete the Clinical Examination must do so within their period of probationary vocational registration with the NZ Medical Council. OTPs will not be identified as such during the examination Completion of Basic Training Eligibility for entry into Advanced Training is contingent upon Completion of 36 months of satisfactory basic training Passing both the Written and Clinical Examinations Completing PREP requirements If you have NOT completed 36 months of satisfactory* basic training at the time of passing the Clinical Examination, you WILL BE directed to complete further training before you can apply for the advanced training program. *Where satisfactory includes completing PREP requirements Contact with the College All queries regarding the Examination should be directed to the Basic Training team. Telephone

15 Appendix 1 Criteria for Assessment of Performance in the Long Case Assessment Domains Level of Performance History Examination Synthesis and Priorities Impact of Illness on Patient and Family Management Plan Exceptional Performance Much Better than Expected Exceptional attention to detail Highly sophisticated interpretation Mature understanding of complex issues Sophisticated interpretation of the history Focuses on key issues Shows maturity in extracting difficult information Highly mature, systematic, wellstructured completion of complex examination Actively seeks subtle signs that might enhance diagnosis Superior organisation of difficult examination Very sophisticated and intelligent synthesis Mature and competent arrangement of interactive problems Identifies all major and minor problems Very careful prioritisation which includes a long term view Recognises social impact of disease Highly sophisticated, well balanced and complete understanding of psychological and social aspects Shows mature understanding of subtle, difficult, or intimate aspects of patient s functioning Demonstrates balance when discussing issues and sophisticated use of external social support Sophisticated management plan incorporating all therapeutic options Mature anticipation of prognosis Ability to adjust management plan for different outcomes Superior construction of management plan, including long term impact Highly developed and discriminating use of investigations Mature recognition and interpretation of inconsistent results Better than Expected Emphasis on appropriate details Appreciates subtleties Interprets significant aspects of the history Includes important relative negative signs Appreciates significance of more subtle signs Confidently identifies essential problems Shows maturity in recognising lesser issues Shows persistence in exploring subtle psychological issues, or issues that impact on the patient or family Proposes appropriate management plan with good understanding of social impact lifestyle and psychological aspects of disease Good use of discriminating investigations Accurate interpretation of results Expected Complete and accurate history Minimal need to clarify details Timely and well structured Some interpretation Correctly identifies all important physical signs Identifies all key problems Arranges problems in order of priority Understands patient s physical and psychological functioning in relation to disease Appreciates impact of treatment and prognosis on patient and family Proposes an appropriate management plan for the major issues Provides a sensible, balanced approach to investigations Interprets investigations appropriately Recognises important side effects of proposed treatment Short of Expected Poorly organised Omission of some key issues Need to clarify important details Omission of some important physical signs Problems poorly prioritised Significant problems undervalued Fails to recognise some important aspects of the disease on patient or family Misses some aspect affecting functioning or reaction to illness Lacking confidence and including some errors in arranging a management plan Erratic and non-discriminatory use of investigations Errors in the interpretation of tests Lacking some appreciation of complication of treatment Well Short of Expected Omission of many key points Inaccuracies or lack of detail Repetitive, poorly structured Need to spend substantial time in clarifying details Many significant signs not recognised Poor understanding of significant problems Requires substantial prompting Poor understanding of the impact of disease on patient and family Shows little concern about psychological aspects Inappropriate or poorly directed management plan Poor understanding of useful investigations Inability to interpret investigations Major inability to appreciate side effects of treatment Very Poor Performance No clear structure Focused only on single problem Minimal detail Minimal attention to detail with the examination Most key management issues unidentified No attempt to establish priority Impact of disease not explored at all, or unable to be discussed Poorly directed management plan without regard to major issues Very poor ordering of investigations without regard to expense or potential complications No attempt to interpret investigations No understanding of side effects of treatment 14

16 Appendix 2 Criteria for Assessment of Performance in the Short Case Assessment Domains Level of Performance Exceptional Performance Approach to Patient Meets expected standard Examination Technique Fluent and accurate and within time Makes adjustment to routine when appropriate Examination Accuracy Correctly identifies all signs found by examiners Interpretation of Physical Findings Establishes a most likely diagnosis on basis of examination and includes discussion of difficult signs Discusses alternatives at consultant equivalent Discussion of Investigations Thorough interpretation of investigations, including integration with physical examination Recognises areas of doubt and discusses at consultant equivalent Much Better than Expected Meets expected standard Fluent and accurate and within time Makes adjustment to routine when appropriate Correctly identifies all essential and desirable signs Establishes a most likely diagnosis on basis of examination, considers all likely alternatives Correctly interprets investigations, integrates with examination findings without prompting, at a mature level Better than Expected Meets expected standard Fluent and accurate and within time Makes adjustment to routine when appropriate Correctly identifies all essential and most desirable signs Identifies most likely diagnosis and provides a reasonable differential diagnosis based on physical findings Correctly interprets all major findings Expected Introduces him/herself to the patient Shows respect for patient as indicated by preservation of patient s modesty, seeking permission for sensitive aspects of examination e.g. groin palpation Recognises and modifies examination when painful Undertakes systematic examination of required area or system, without unnecessary duplication Demonstrates confidence in the examination Completes assigned task in appropriate time Detects all essential signs Reports significant negative findings Does not find major signs that are not present Provides appropriate interpretation of signs Recognises inconsistencies in interpretation and findings Provides sensible priorities in diagnosis Discusses appropriate alternative diagnoses Accurately interprets and recognises major findings in investigations Integrates investigations with examination findings Short of Expected Less than expected standard Unduly rough, clumsy or causes pain without adjustment or apology Expected components not completed May require prompting to proceed with appropriate examination Misses essential signs Fails to look for or mention important negative findings Not confident with a diagnosis List of differential diagnoses poorly developed Unable to consider alternative explanations for findings Requires more than minor prompting to reconsider options Does not offer appropriate investigations Misinterprets or is unable to integrate investigations with examination findings Well Short of Expected Less than expected standard, requiring examiners to intervene Very slow and requires substantial prompting and guidance Misses essential signs Finds abnormalities that are not present Fails to look for important negative findings Unable to suggest a reasonable diagnosis May advance incorrect diagnosis inconsistent with signs Requires substantial prompting Unable to reconsider additional information which may alter diagnosis Unable to use investigations to assist in diagnosis Inappropriate dependence on investigations Very Poor Performance Inappropriate and insensitive approach to patient Slow examination not completed in appropriate time Cannot perform appropriate examination of system Misses all essential signs Finds abnormalities that are not present Fails to look for important negative findings Unable to suggest a reasonable diagnosis Unable to interpret the physical signs elicited Unable to suggest reasonable investigations Misinterprets information provided 15