Structured Orals

The oral exam consists of three stations, each delivered by a single examiner; one 25-minute (triple case) and two 10-minute (single case) stations. At the beginning of each oral, the examiner will give you a case scenario containing information about the patient or patients. You should read the scenario carefully out loud and begin the exam. The examiner will be conducting the examination and scoring simultaneously as you proceed. The examiner will prompt you through the exam to provide an efficient use of time.

The examiner will occasionally direct or redirect you so as to cover certain essential aspects of the case, such as triaging your patients initially or obtaining specific information.

Try to verbalize as much of your thought process as possible. Carefully describe the actions you are taking. In particular, try to identify all sick and unstable patients early. Remember, the examiner can only score you on the things you actually say to him or her.

Similarly, ask your examiner for as much information and detail as you require to have a sufficient understanding of each scenario. Periodically, try to verbally summarize your impressions.

You may take notes as you proceed but since time is limited, consider using your time to communicate about the exam scenario.

Be very specific in the orders and interventions you require and remember that you may delegate certain activities to other members of your team. In the cases presented to you, there will usually be nurses to assist you in the emergency department (ED), as well as the services of your community hospital.

Monitor the ABCs and vital signs as necessary to get a feel for the progression of each case. Ask for the results of your interventions and investigations when appropriate.

Remember to proceed through each case as if you were actually there, interacting with the patient and staff in this community hospital ED. Avoid a cookbook approach but maintain a realistic and structured style throughout the exam. You will notice that the history is essential, the physical exam is important and any further investigations are tertiary to a proper assessment.

Also note that should the examiner say a certain aspect of the case is normal or non-contributory, you may chose to move on to the next steps of your evaluation or management.

When listing your differential diagnoses, be complete but concise; mention the things you should actually be considering in this patient, at this time. Try to focus on the overall assessment of the patient scenario, not a particular diagnosis.

Make certain to be direct and clear in your dispositions of each case, ensure each patient has a transparent care plan that covers all the essentials and is well presented to your examiner.

You may be shown some results of your investigations and asked for interpretation. Please do so carefully but succinctly. Certain results may in fact be normal. You will also appreciate that most scenarios are actually case-based and don’t focus on unusual or occult problems.

You will occasionally be interrupted by staff or patients who may request attention while you are evaluating other cases. Deal with each situation appropriately but remember to verbalize the thought process for each of your decisions in flow management.

Be decisive in the way you conduct your evaluations and establish your setting so that you can gather the best information in the most efficient manner. Do not hesitate to ask for any help required from your scenario to guarantee your best management of each case.

Ensure that each patient has a comprehensive plan that provides continuity of care, be it in-patient or as an out-patient. Remember to include family members or caretakers as well as primary care health professionals.

In closing, you should know that the examiner is not allowed to give you any feedback on your performance. However, he or she will work with you during the exam to provide all the information necessary to manage each situation optimally. You should also appreciate that obtaining the precise diagnosis is not always necessary to receive a passing grade. Rather, this is more often determined by an organized approach to problems and the logical development of appropriate investigations and management.

During the intervals between the oral examinations, do not discuss the content of the oral examinations with other candidates. Experience has shown that prior knowledge of the clinical content or case diagnoses of oral examinations has resulted in poorer performances than might otherwise have been expected. You will be best served in preparing for this oral examination by exploring this case-based approach with practice scenarios that reflect a similar process and structure.

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