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January 2007: Oral exam tests your decision-making skills

How do you maximise your potential marks?

How do you avoid common mistakes and turn a discussion?

What is the most efficient way to prepare for an exam?

How do you maximise your potential marks?

How do you avoid common mistakes and turn a discussion?

What is the most efficient way to prepare for an exam?

The oral module is the most memorable component of the exam. On the day everyone is nervous and so the best advice is to practise with your colleagues and trainer.

In the 2006 summer examination, 75 per cent of candidates passed this component.

The day should be approached professionally, so dress smartly as you would for an interview. You will be required to show your examination number and a valid photo ID (passport or driving licence) to the exam administrator before waiting in the lounge where refreshments are available. A senior examiner will be present to answer last-minute queries.

You will then be guided to your allocated examination room with several other candidates. You will be told which table you are meant to go to when the exam commences.

The examiners are working GPs, so think of them as your trainer/colleague and be prepared to engage in an interesting discussion about the dilemma presented.

The agenda for the examiners is to try and establish how much you know, and to allow you to do as well as you can. This naturally means interruptions and further questioning. They could ask you to expand on your answer, justify your reasoning, explain your options or the implications of your choice, or to consider what your medical defence organisation would say (the latter is a common retort to the standard candidate statement ‘I would ring my medical defence organisation for advice').

Format

There are two orals, both lasting 20 minutes, each with a different pair of examiners. The orals normally break down into five questions of four minutes length, although more questions could be asked if time permits. You will get a five to ten minute break between the two sessions.

The four examiners will mark you independently and then collate their individual scores, which range over a possible nine grades. They do not know how well you have done in other modules of the exam.

You can expect different styles of examiner, but do not be disheartened by the fact that they seem neither encouraging nor disparaging; the examiners are trained to keep their body language neutral throughout.

Abrupt interruptions and closure of a particular question should be expected. This is to ensure that you do not overrun and lose potential marks.

The examiners are trying to help you, as it is their job to push you to demonstrate your level of competence. You may feel as though you are being repeatedly pressed and that your answers are doubted. This is one reason why orals are a challenge; asking ‘why' continually after an initial answer will eventually stretch anyone.

Ignore any observers, and if you agree to the exam being videoed, do not worry, it is the examiners who are being assessed for quality assurance.

Try to stay calm and avoid fidgeting. By all means ask for a drink of water if this will help you.

What are the oral exams testing?

The exams test decision-making. If you break this down to a simplified management tool, you have to state and recognise the dilemma presented, check any missing information, assess the available options and the implications of each choice before prioritising them and making a decision.

Once a choice has been made it should be subsequently checked to ensure that it was the right one, and you should reflect on the whole process to see what you have learnt and how to improve in the future.

Clearly, there are more complicated decision-making models, but if you keep to these principles then you should find that you can obtain good marks.

You could consider the implications for you, your partners, your patient, their family, society, the local PCO, the primary health care team, the local community, your profession and so on. However, instead of just reeling off this list in response to a question, try and work through it with an example of an implication for each relevant stakeholder you have identified.

If you cannot get started with your answer, then explain why the question asked poses such a conundrum. These dilemmas are based on real life experiences and discussions the examiners have been involved in, and you can assume that there was no instant, obvious, or correct response at the time the event occurred; if there had been, the question would not have been used in the oral examinations.

If there is controversy about an answer, say so and explain why. You need to decide on a course of action and then explain and justify your decision. If you have a strong ethical view this is perfectly acceptable, but demonstrate awareness that other doctors may have different opinions.

It is best to adopt the attitude of a thoughtful GP guided by ethical principles. A moderate opinion is always easier to justify than an extreme view, but remember that there is no ‘ideal' answer set by the College for the dilemmas presented.

In order to ensure that the four examiners cover a wide range of defined areas, they will convene at the start and middle of the day to plan which questions will be used and to ensure that the questions do not overlap significantly. This has led to the development of a format where any oral question may be put into a grid of three areas of competence, with four contexts for each competence (see table 1, attached).

Ethics

Knowledge of an ethical framework is not enough to pass, you will need to be able to apply and justify an ethical argument. While the four principle approach of Beauchamp and Childress (autonomy, beneficence, non-maleficence and justice) is frequently cited,1 it may not always be helpful to an argument. There is often conflict, for example between the autonomy of the patient and the social justice of caring for the community. You may find that a dilemma becomes easier to interpret ethically if you consider the ethics of virtue, care and consequence, or a deontological justification. If you respond with something like ‘I could use the traditional Beauchamp and Childress approach here, but in this instance I think that the ethics of virtue are easier to apply because...', you will be off to a good start.

The examiners have follow-up questions, at different levels of difficulty according to a candidate's initial answer.

Preparation

The list of potential questions is almost endless, and examples are often documented on the Internet. You may find the example question above helpful (see table 2, below). Practise as many as you can, regardless of whether they are ‘hot topics'.

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You cannot revise for a specific question. Even if you could predict a stem of a question, you do not know where the examiner envisages it leading. If your answer is correct but not in the area the examiner has set, then do not be put off by an interruption such as ‘That is true, but I want to concentrate on the implications for the partner involved.' This is to ensure that your answer can be marked; otherwise a perfectly viable statement by you is wasted, as it cannot gain marks for the area the examiner intended to assess.

However, you can practise your technique. The best way to prepare is to get used to answering questions from a colleague, so that OICJ (options, implications, choice and justification of your choice) is easy and becomes second nature.

Above all, approach this module remembering that the examiners are all experienced GPs whose job is to challenge what you say in order to see how high a mark you can achieve.

Table1: Grid showing the three areas of competence tested Top tips

Practise answering questions with:
Options
Implications
Choice
Justification of choice

Remember that the College does
not set an ideal answer

Common mistakes
Lack of justification
Poor range of options
Lack of decision-making
Inconsistency
Inability to apply an ethical framework

Author

Dr Chris Elfes
BM, DRCOG, DCH, MRCGP
GP, Swanage, Dorset, GP trainer, MRCGP examiner, nMRCGP assessor

MRCGPtab2

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