Clinical Examination. Australia Guidelines for Candidates

Transcription

1 Clinical Examination Australia Guidelines for Candidates

2 Contents 1. Preamble Applications Requirement to Sit the Clinical Examination and Number of Attempts Dates Venues for Examinations Proof of Identity & Dress Standard Stationery and Equipment Conduct of the Clinical Examination... 3 a.) Long Case Assessment... 4 b.) Short Case Assessment... 4 c.) Standard Required... 5 d.) Quality and Safety Standards... 5 e.) Case Selection... 5 f.) Examiner Review of Patients... 5 g.) Examination Day Timetable... 5 h.) Number of Examiners Supplementary Examination Preparation for the Examination Pre-Examination Contact at Examination Sites Procedure in the Case of Illness or Misadventure... 7 a.) Illness/Misadventure on the Day of the Examination... 7 b.) Illness/Misadventure Preventing Attendance at the Examination Withdrawing from the Clinical Examination Results Feedback Examination Assistants Fees Overseas Trained Physicians (OTPs) Reconsideration and Review Processes Appendix 1:Criteria for Assessment of Performance in the Long Case Appendix 2: Criteria for Assessment of Performance in the Short Case ii

3 1. 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. Success in the Written Examination is a pre-requisite for entry to the Clinical Examination. You have therefore already satisfied the College that your cognitive skills meet the required standard. Detailed discussion in the Clinical Examination will therefore be directed at testing clinical skills. Questions testing your factual knowledge will be at a level appropriate to making adequate management decisions in the case being discussed. 2. Applications There will be two application deadlines for the RACP Clinical Examination. Refer to the RACP website for the application opening and closing dates: Eligible applicants will be advised of the closing date via . Please note that candidates must adhere to the relevant closing date. Applications received after the relevant closing date will not be considered under normal circumstances. Late applications must be accompanied by an explanatory letter with supporting documentation (where applicable) and will incur a late fee in addition to the exam fee. Acceptance of late applications and a place in the Clinical Examination is not guaranteed for applications received after the relevant closing date. All documentation should be forwarded to: The Chairman Clinical Examination Committee 145 Macquarie Street SYDNEY NSW Requirement to Sit the Clinical Examination and Number of Attempts All candidates sitting the Clinical Examination, including OTPs, must have current medical registration with AHPRA. OTPs can obtain a 2 week temporary registration. All candidates who apply to sit the Examination are encouraged to take into consideration their preparedness for the 2013 Clinical Examination. As part of its commitment to quality training and education that produces medical specialists displaying the highest standards of knowledge, skills, and professionalism, the RACP s Progression through Training Policy comes into effect on 1 January This policy has been designed to ensure trainees meet each required standard before progressing through to the next stage of training. Trainees registering to sit the Clinical Examination are encouraged to consider the requirements of the policy, and where applicable, take into account the number of attempts at sitting the exam remaining to you. The Progression through Training Policy states that trainees must pass the Clinical Examination within five attempts. A transition period for the introduction of a limit to the number of attempts at the Clinical Examination ensures that every trainee will have at least two or more attempts at the Examination after 1 January

4 The following table outlines the number of attempts candidates have as of 1 January Number of unsuccessful attempts as at January Number of remaining attempts as at January 2013 Remaining attempts may be used at the trainee s discretion without a time limit. Trainees who are unsuccessful after five attempts at the Clinical Examination will neither be eligible to continue training, nor to apply for entry into Advanced Training. 4. Dates Refer to the RACP Clinical Examination website: for all dates relating to the Clinical Examination cycle. It is anticipated, at this stage, that all candidates will be accommodated during the July/August period. Candidates should not assume that their own Clinical Examination will be at the same time or location as other candidates from their hospital or city. A Supplementary Examination, if required, will be held soon after the main examination. 5. Venues for Examinations Candidates will not be examined in their own hospitals. Candidates should be prepared to travel to a different city which, in most cases, will mean a different state. The College will try to advise Clinical Examination candidates of their allocated venue with reasonable notice. In the event you are allocated a hospital where you work, or have worked at in the past, you must advise the College as soon as possible. 6. Proof of Identity and Dress Standard Candidates must bring with them proof of identification (e.g. a passport, a photo driver s licence, or hospital photo identification card). This will be checked upon arrival at the Examination. Please dress in an appropriate and professional manner for the Examination. This is not a day for casual clothes; neither is it necessary for candidates to invest in an expensive suit purely for the Examination. It is important that you are comfortable and can examine your patient easily in the clothes you are wearing. 7. Stationery and Equipment Candidates must bring their own stationery for use during the Examination e.g. clipboard, blank manila folders, blank cards or paper and pens/pencils. Pre-printed/written templates or reminders are not allowed. Candidates are required to bring their own equipment to the Clinical Examination. The rationale for standardisation of acceptable equipment includes fairness to all candidates and to ensure, as much as possible, that the clinical signs a candidate may elicit will match those obtained by examiners, who will likewise use standard equipment. 2

5 The following equipment is considered appropriate for candidates to use in the Examination. It is advised that each candidate brings the following equipment: 1. Blank paper/cards and pencils/pens 2. Stethoscope (These must not be electronically augmented unless the candidate has obtained specific permission for medical reasons). 3. Standard hand-held ophthalmoscope (not a pan-ophthalmoscope) 4. Red topped hat pin or equivalent for visual field testing 5. Standard auroscope 6. Pocket torch 7. Tape-measure and/or ruler 8. Tendon hammer 9. Single-use spatulas 10. Tuning forks (128 and 256 Hz) 11. Hand-held visual acuity chart(s) 12. Cotton wool. 13. Single-use neurological examination pins for testing sensation 14. Pre-printed picture for higher centres testing (*) 15. A blank form for undertaking a screening mini-mental test (*) 16. Props such as a jar, key and shirt-sleeve with button for hand function testing (*) 17. Toys for distraction and testing of development (*) 18. Standard Growth Charts (*) (*) - some items are more relevant to either the adult or paediatric examination. Candidates are not allowed to bring in references, PDA, mobile phones, or other data storing / sharing / recording 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. A candidate who takes in unauthorised material may be disqualified from the Examination. A candidate found with a recording device, including a mobile phone, will be automatically failed. 8. Conduct of the Clinical Examination Candidates will 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 in each case will be determined by the consensus mark. 3

6 a.) NB: Long Case Assessment i) 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 (refer Item 7) but printed material (including textbooks, notes, MIMS, or other drug compendia), pro-forma sheets, and electronic devices are not permitted. The aim of the restrictions is to make the Examination as fair as possible for all candidates. Medication lists, and results of urinalysis / rectal examination will be provided to you when relevant. ii) You will have 10 minutes to prepare your discussion and move to the examiners room following your history-taking with the patient. iii) 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 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. Candidates are reminded that all patient records, including their notes about patients, should be treated confidentially. Following the Examination, candidates must ensure that their notes regarding patients are destroyed appropriately, or left with the organisers at the Examination. b.) NB: Short Case Assessment Each of your short case examinations will last for 15 minutes. This part of the Examination is designed to assess your physical examination technique, 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. Candidates will be provided with a written introduction to the short case before entering the examination room. This introduction will contain the patient s name, the relevant body system and sometimes the dominant clinical problem or symptom. The introduction given to you by the examiners has been standardised beforehand and is designed to be accurate, short, and directive. 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 10 minutes between the two short cases in each cycle. From 2013 candidates are required to successfully pass at least one of the four short cases in order to pass the overall examination. 4

7 c.) d.) e.) f.) g.) Standard Required For Trainees of the College, the standard required includes the breadth of knowledge, aptitude and skills sufficient for the management of general medical patients to enable you to enter Advanced Training. To assist those Basic Trainees who are preparing for the Clinical Examination, the Clinical Examination Committee (CExC) has made available the criteria it uses for assessment of performance in the long and short cases (Appendices 1 and 2). The CExC recognises that Trainees have their own way of taking a history, performing an examination, and preparing for the Clinical Examination. These reference tables are provided to assist Trainees to understand the criteria used by the examiners in judging their performance, and should not be interpreted as support for a particular method of history-taking and examination. It should also be noted that not all of the assessment domains will be applicable in every case. Quality and Safety Standards 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 before and after carrying out any physical examination. Alcoholic hand gel may be provided outside of the patient rooms. Many candidates choose to bring their own supply. Using the gel before entering the room can save time during the examination segment. Clean disposable pins should be used for neurological examinations (for both the long cases and the short cases). Please ensure that pins are disposed of appropriately. 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 Prior to each cycle of the Examination, examiners will have taken a history, examined and identified relevant issues for discussion for each long case patient. 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 an appropriate history and of the accuracy of signs. Short cases are also assessed blind by the examiners prior to each cycle. Examination Day Timetable The following table represents the typical Examination day schedule for Adult Medicine and Paediatrics candidates. While all hospitals try to adhere to the schedule, individual variation may occur. Candidates will have a 10 minute break between their two short cases in both the morning and afternoon sessions. 5

8 Adult Medicine Morning Afternoon One Half of Candidates One long case followed by two short cases Two short cases followed by one long case 8.50am to 11.20am 1.50pm to 4.30pm Other Half of Candidates Two short cases followed by one long case One long case followed by two short cases 9.10am to 11.50am 1.30pm to 4.00pm Paediatrics Morning Afternoon One Half of Candidates One long case followed by two short cases Two short cases followed by one long case 9.50am to 12.20pm 2.50 pm to 5.30 pm Other Half of Candidates Two short cases followed by one long case One long case followed by two short cases 10.10am to 12.50pm 2.30pm to 5.00pm Information will be provided to candidates on catering facilities available. Most hospitals provide light refreshments during the course of the Examination cycle. Candidates are reminded that they are responsible for providing their own lunches. h.) 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, additional examiners are allocated to teams to allow for the smooth running of the Examination in case illness or misadventure befalls an examiner. 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. 9. Supplementary Examination A small number of candidates may be offered an opportunity for re-examination at a Supplementary Examination where the format will be identical to that of the earlier Examination. The Supplementary Examination is offered rarely, and offered only where there has been procedural misadventure during the course of the Examination. In the case where a Supplementary Examination is offered, an additional application form, with payment details, will be forwarded to the applicant for completion. If you are offered a Supplementary Examination and, for any reason, you are not available at the time of the Examination, the right to the Supplementary Examination will be forfeited. 10. Preparation for the Examination Regular clinical activities in your hospital should be the best preparation for your Clinical Examination. In most hospitals, the Director of Physician / Paediatrics Education (DPE) and members of other College training committees will often assist Trainees by discussing the Clinical Examination and arranging long and short case practice sessions. 6

9 11. 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. 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. Failure to comply may lead to disqualification from the Examination. 12. Procedure in the Case of Illness or Misadventure a.) Illness/Misadventure on the Day of the Examination Where an illness or misadventure on the day of the Examination impairs performance, candidates should inform the Local Examination Organiser on the day of the Examination. Where candidates consider that there has been a problem with the process of the Examination, they must ensure that the examiners for that case have been informed. Any problems during the short case examination (e.g. patient leaves the exam room for several minutes to use the toilet, take a phone call etc.) will be obvious to the examiners. In the long case examination, the examiners will ask candidates at the start of the case presentation if there were any procedural problems. If the examiners do not ask, the candidate should inform the examiners. Where possible, examiners will take any procedural problems into account during the conduct of the case, or in their marking. Requests for special consideration must be submitted with supporting medical documentation and a letter from the candidate s Director of Physician / Paediatrics Education (DPE), where appropriate. Refer to the RACP website for details of the closing date for requests. If you are able to submit your request earlier, please do so. Requests received after the closing date will be not be considered. For information regarding the College s Special Consideration Process, refer to the College website at: It should be noted that special consideration cannot lead to an amendment to the candidate's mark, or the total mark required to pass the examination. Special consideration, where there has been a procedural misadventure during the exam, may occasionally lead to the offer of a supplementary examination. Please note that while the Clinical Examination Committee sympathises with candidates who suffer illness or misadventure in the lead-up to the Examination, impaired preparation cannot be considered as a reason for special consideration if the candidate chooses to proceed with the Examination. Candidates should only present for the Examination if they consider themselves to be adequately prepared to sit. 7

10 b.) Illness/Misadventure Preventing Attendance at the Examination Where an illness or misadventure prevents attendance at the Examination, you must contact the Assessment Unit at the College on Medical documentation or statutory declarations should be submitted to the College immediately. All documentation should be forwarded to: Assessment Unit The Royal Australasian College of Physicians 145 Macquarie Street SYDNEY NSW Please ensure you provide your mobile number as this will be supplied to the Local Examination Organiser at your centre in case they need to contact you on the day of the Examination. Please inform the Assessment Unit staff if you prefer not to do this. 13. Withdrawing from the Clinical Examination Notification to withdraw from the Clinical Examination must be given in writing and all documentation should be forwarded to: Assessment Unit The Royal Australasian College of Physicians 145 Macquarie Street SYDNEY NSW The following refunds are applicable: Refund Nil 50% 75% Details If withdrawing from the Clinical Examination within 14 days of the commencement of the Examination. Candidates who fail to appear for the Examination will also forfeit their fees. If withdrawing from the Clinical Examination after the closing date but not later than 14 days before the commencement of the Examination. This refund may be granted under extraordinary circumstances where a candidate is able to provide persuasive reasons as to why they are unable to present to the Examination. The application must be accompanied by a supporting letter from the Trainee s Director of Physician / Paediatrics Education (DPE), along with medical documentation, where appropriate. 100% If withdrawing before the closing date. 14. Results Results of the Clinical Examination will be available on the College Website. Refer to the RACP website for details of when the result will be posted. Candidates will receive information on how to access their results with their allocation letter. All candidates will be notified of their result by mail. 8

11 15. Feedback Examiners complete a form recording each candidate s performance, immediately after each case in the Clinical Examination. This record includes the examiners agreed physical signs and priorities for examination, as well as the trainee s performance in the domains of interest. These records are used to provide feedback to trainees. This is delivered by interview with a member of the National Examining Panel (NEP) for unsuccessful candidates; or by mail to successful candidates. The NEP member uses the information contained in the examiners report forms and his/her experience with the examination to assist unsuccessful candidates to improve their performance in a subsequent examination. The feedback is provided to trainees purely to assist them in recognising areas of relative strength or weakness. Trainees who are unsuccessful in the Examination will be informed in the letter containing their results of the name and telephone number of the NEP member with whom they may discuss their performance. It is the responsibility of the candidate to arrange this interview time. Candidates may also wish to invite their Director of Physician / Paediatrics Education (DPE) to attend this interview. This may be useful in planning means of improving areas of weakness. Unsuccessful candidates should contact their assigned NEP Member shortly after receipt of their results letter, as candidate feedback is not retained indefinitely. Feedback to unsuccessful candidates is provided through interview, to ensure that the comments recorded by examiners are appropriately contextualised and of optimal value to the trainee. Written feedback will not be sent directly to unsuccessful candidates. 16. Examination Assistants Examination Assistants will be present on the day. The Assistants will escort you to the examination rooms and generally ensure that your examination proceeds as efficiently as possible. They will sit in during your presentation of the long case and during your short case segments. Assistants should remain unobtrusive in the background, and should be prepared to assist you or the patient during practical tasks, e.g. gait or hearing examinations. They should not communicate in any way with you during the period you are with the examiners. They should not assist you with timekeeping. Please do not ask them to do so. It should be noted that Clinical Examination candidates are not permitted to act as Examination Assistants during any part of the Examination period in the year in which they are sitting for the Examination. 17. Fees Refer to the RACP website for the Clinical Examination fees. The Examination fees are reviewed annually by the Board. 18. Overseas Trained Physicians (OTPs) All candidates sitting the Clinical Examination, including OTPs, must have current medical registration with AHPRA. OTPs can obtain a 2 week temporary registration. All OTPs who are required to complete the RACP Clinical Examination as part of their application for specialist recognition will sit the same examination format as Basic Trainees. 9

12 OTP candidates for the Clinical Examination will be examined on two long cases and four short cases, over the course of one day in the Clinical Examination cycle. The pass standard will be that expected of a candidate who has completed the Basic Training Program of the College. The Examination will be in general internal medicine. There will no longer be an exit level long case in a candidate s particular specialty. The short cases for Adult Medicine will no longer be in a modified format (i.e. mini cases) and will be the same as those used for examination of Basic Trainees. The College strongly recommends that the OTP should contact his/her local Director of Physician/Paediatrics Education (DPE) to participate with local trainees in preparation activities for the Examination. 19. Reconsideration and Review Processes The processes of reconsideration and review allow an applicant to present additional information relevant to a decision, and to ensure that the Committee has had the opportunity to receive and consider all relevant information. Reconsideration and review processes apply only to decisions of a Committee. Examination results cannot be altered by these processes. For information regarding the College s Special Consideration Process, refer to the College website at: If you have any queries please contact the Assessment Unit in Education Services of the College. Telephone: or assessments@racp.edu.au 10

13 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 Exceptional attention to detail Highly sophisticated interpretation Mature understanding of complex issues Highly mature, systematic, well-structured completion of complex examination Very sophisticated and intelligent synthesis Mature and competent arrangement of interactive problems Highly sophisticated, well balanced and complete understanding of psychological and social aspects Sophisticated management plan incorporating all therapeutic options Mature anticipation of prognosis Ability to adjust management plan for different outcomes Much Better than Expected Standard Sophisticated interpretation of the history Focuses on key issues Shows maturity in extracting difficult information Actively seeks subtle signs that might enhance diagnosis Superior organisation of difficult examination Identifies all major and minor problems Very careful prioritisation which includes a long term view Recognises social impact of disease 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 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 Standard 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 Standard Complete and accurate history Minimal need to clarify details Timely and well structured Some interpretation Correctly identifies all important physical signs Identified 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 Standard 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 Standard 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 Appendix 2: Criteria for Assessment of Performance in the Short Case Assessment Domains Level of Performance Exceptional Performance Approach to Patient Examination Technique Examination Accuracy Interpretation of Physical Findings Discussion of Investigations Meets expected standard Fluent and accurate and within time Makes adjustment to routine when appropriate Correctly identifies all signs found by examiners Establishes a most likely diagnosis on basis of examination and includes discussion of difficult signs Discusses alternatives at consultant equivalent Thorough interpretation of investigations, including integration with physical examination Recognises areas of doubt and discusses at consultant equivalent Much Better than Expected Standard 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 Standard 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 Standard 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 Standard 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 Standard 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