‘Bull-dogging’ for the RACP exams

The Royal Australasian College of Physicians’ (RACP) Clinical Examination takes a full day and for medical registrars is the barrier between basic and advanced training, including subspecialty training. My experience was as an ‘examination assistant’ (or ‘bulldog’ in colloquial terms) for the candidates. I had been on my general medicine rotation and the consultant of my medical unit was looking for volunteers.

The clinical examination day comprises a morning and an afternoon session. Each session is comprised of two short cases and one long case. Short cases each take fifteen minutes. Candidates have three minutes before they enter the station to read one sentence which provides the name of the patient, presenting complaint and body system to examine. The candidate introduces themselves, examines the patient, presents their findings, is questioned by two examiners and walks out at the bell, remembering to wash their hands before they leave. In contrast to medical school OSCEs, candidates do not speak to the examiners while examining the patient. Instead they present afterwards, which is when they start scoring marks. My candidate asked me to signal him at six minutes (by tapping on my watch, coughing or clearing my throat) so he could spend the next nine minutes presenting and thus scoring marks. The examiners can also ask for investigations to be interpreted. For example, “What would you like to order for his murmur?” or, “You said ECG, tell us about this ECG and chest x-ray.” Fortunately, the short cases are assessed ‘blind’ by the examiners who have not examined the patients themselves. This is not so for the long cases.

For the long case, the candidate spends one hour alone with the patient. During this time, they take a thorough history, perform an examination, determine the patient’s medical and psychosocial issues and construct a management plan. After this, candidates have ten minutes before seeing the examiners. In these ten minutes, the candidate can think of potential questions and collect their thoughts. The long case assessment occurs over 25 minutes with two examiners. The candidate begins by presenting the case followed by non-stop questioning on anything from the history (“What were the circumstances of the fall you mentioned?”), physical examination (“What do you mean by nerve compression, what level?”), investigations (“How do you determine if the asthma is mild, moderate or severe?”), and management (“What if this person were to go to surgery?” or, “How might you educate this patient?”).

While the examination represents an artificial construct, particularly in respect to the short cases, the format does allow for assessment of a candidate’s ability to perform at a physician level, to analyse, interpret information and to deal with the inevitable dilemmas presented by real patients. “Under the pressure of the exam, candidates generally revert to their normal level of everyday practice,” says successful candidate Dr Luke Vos of Launceston General Hospital.

He advises budding physicians, “Preparation for clinical examinations really begins as soon as you enter physician training. The essential elements of history taking, physical examination, construction of a differential diagnosis and the establishment of a plan for the investigation and management of each clinical problem are skills you can continue to refine from day one. While somewhat daunting, a willingness to expose yourself to constructive criticism from colleagues and mentors will help improve your approach and can prove invaluable. The skills you develop in preparation for the clinical exams will continue to serve you throughout your career.”

From a bulldog’s perspective, I could see how medical school trains us for these types of exams, but also prepares us for days when we just need to remain calm and focused on the next patient. And given that the clinical examination fee was $3,780 this year, there was definitely good motivation to pass!

More information can be found at the RACP PREP Basic Training Program website: http:// / examinations/clinical-examination.