1: What worked well.

As always the integrated way in which you have organized the sessions giving tips of how to tackle the different situations in the exam

The addition of Dr A , Dr S is invaluable adding in to your experience it gives us hands on what to expect

2: What can be improved?

I think its time if we increase the number of sessions per week as to cover more ground as time flies

3: How to improve it?

Either we can have 3 sessions per week or we can increase the timing of the sessions

4: What is the optimum number of participants in a session?

6 to 8

5: What time suits you best?

Currently for me the second half is suiting me better as I get done with all the other stuff before hand

6: What specific ‘topics’ would you like covered in different stations?

Not very confident in the musculoskeletal department in the clinical stations

If you have any topics related to that

Abd the ever sore Development

As of now I haven’t jot down the specific topics but will update you as we go along

Dr MF – Pakistan. 27 November 2020

I would like to give my feedback for the autumn sessions.

First of all, I thank you for the opportunity you gave me to attend your sessions. 

It was really useful, the way it is being done, enabling us to participate & present our views on an individual basis, helping us to understand, to  commit mistakes,  the way it was corrected by expert senior examiners, never to let us down but to encourage us always to study more & to practise more while attending ur classes. 

Previously I was not at all focused in my exam preparation,  but your course really streamlined me to prepare & to look forward for your classes. 
The current timing suits me.

I have not attended the course from the start , so really look forward to attend a full course in future. 

Dr DT Kuwait 29 November 2020

Thank you for participating in the session today.

It was the first session of discussing the clinical extended station of the examination.

We got an update on the timeline of the station. Four minutes to read the information and watch the universal cues for the candidate, 10 minutes with the role player taking the history in which you would be given a warning at six minutes, remaining time with the examiner six minutes summarising and examine discussing the examination and then three minutes of management discussion.

Our session today was of a three month old baby who had been brought to accident and emergency for cough and poor feeding. Universal queues were of a chest x-ray, skull X-ray and CT of the brain. Dr P & Dr Y role played the mother very well.

Universal cues were not adequately interpreted and signs were not picked up. This lead to the confusion in the history.

We later discussed the cues, signs and how the history can be improved and focused. Examination of an infant with suspected injuries was explained by Dr Aloke.
Learning points are:

• Watch the cues VERY carefully to pick up signs. Very unlikely to give Normal cue.
• Use the 4 minutes to wisely – it is a long enough time – but it flies.
• Adjust your questions to address the cue findings.
• Systematic approach to history and examination.
• Have a ‘plan’ of how to interpret CXRs and common scans.
• In Extended clinical station – ‘Any’ condition / pathology can be presented
• Follow the cues – they are key guide to history
• Gentle handling / examination of baby. Say it.
• Time management is important. Get to the point – quickly.
• “I want to know…” vs “I am trying to understand ..”.
• General ‘keep’ of child and weight are very important signs to note.

If there is anything else I have missed or to add a comment

MRCPCH Clinicals Online working together to reach your goalwww.mrcpchonline.org

Anil Garg

Thank you for participating in the session today.

I would like to thank Dr Siba especially for taking us through common scenarios one may encounter during the exam related to gastroenterology.

We discussed coeliac disease, inflammatory bowel disease with Crohn’s and ulcerated colitis, functional abdominal pain and constipation.

The learning points are:

• Communication – ‘Given task’ may not be the sole reason to talk to role player
• Check out for hidden cause of why new treatment is required or is being refused
• Functional abdominal pain can occur along side Organic pathology
• Faecal transplant?
• Be confident in ‘refusing’ further investigations as an option of managing functional symptoms
• Exam oriented study is essential for MRCPCH
• Prepare to answer questions appropriately
• Explore hidden concerns
• Bio Social medicine – HEADSS
• Keep an open mind

Add your comments or anything I may have missed.
Anil Garg

Advice from Dr H on clinical examination…

Today I did one scenario as candidate. It was short neuro clinical station.

Task was: Motor examination
Universal cue given were shown in video: waddling gait, positive gower sign obviously clear.
Diagnosis was very clear Proximal myopathy and most likely DMD.
Went through steps and sequence like introduction, request permission, asked for pain and  building rapport.
First look for Dysmorphic features, support, wheel chair, orthotic support. Wt & ht, well or ill.
After that confusion started – shall i have to request gait by asking heel walk and toe walk although waddling gait clearly given in clue?
However i asked for heel and toe walk. Gower sign was shown in clue. Then did tone, power and reflex verbalisation.
Dependent clue: was given tone reduced, power grade 3 in hips both side and 4 in both knee and ankle.
Reflexes preserved in knee while absent in ankle and babinski.
Did back examination and upper limb only tone  then times finished 6 minutes.
I couldn’t finish Upper limb power and reflex examination.

Presented the case as 8 year old child looks smaller for age would like to plot in appropriate chart.
There is waddling gait, decreased tone in lower limb, calf pseudohypertrophy and reduced reflexes
Consistent with LMN lesion mostly DMD, D/ D offered SMA type 3  but need to check tongue fasiculation.
Spina bifida  but no back scar and no wasting on both legs so unlikely.
Then Discussed investigation like Gene study, Creatinine kinase, muscle biopsy.
Need to do Respiratory, and CVS  Examination as it affects (cardiomyopathy, and chest infections).And supportive management MDT which include physio, genetic and parental education.
Problem which i noticed is how to skip or cut short phrases which needs to be asked in question or what part we can minimise of examination technique when we verbalise so that it can be finished in 5 minutes as here i could have skipped heel and toe walking as clear waddling gait.
I was practicing with a candidate and noticed above mentioned hurdles so sharing with u.

Thanks for wonderful session today

COMMENT: WHAT WAS THE TASK? CANNOT BE JUST MOTOR EXAMINATION.

Leave your feedback & comments:

Thank you for participation in the session today. Dr Alok discussed three common scenarios in the respiratory system which you could come across in the exam and are also important in the day-to-day management as a paediatrician.

The cases were:

• Cystic fibrosis – diagnosis and initial management,
• 25 week preterm with IVH, Chronic lung disease, mild developmental delay with acute respiratory distress
• 5 year old with eczema and undiagnosed asthma

There were key learning points:

• Focused history needs to be focused – do not spend your time on unnecessary details
• Think of 3 common differential diagnosis based on initial information provided
• Ask questions accordingly – do NOT think of rare conditions
• Respiratory system in NOT only below the Clavicles – consider nose and nasopharynx (ENT) too.
• Blocked nose or obstructive sleep apnoea cause considerable symptoms
• Blood spot test: screening vs diagnostic
• Lot of practice is needed

It is good to note that our time of ‘examination’ is decreasing – Dr Freda completed a respiratory examination in little over 5 minutes – well done.

Add any comments or points I may have missed.
Anil Garg

Many thanks for your regular feed backs. Another very useful session as always .

Thanks a lot to Dr Aloke for his very useful questions , I hope the examiners are that kind too to give us cues.Never expected a Bronchiolitis to be  in exam so it was an eye opener as well. So in this exam we have to sort out our devises and connections as well as college will not accept any excuse on our part.(sorry about disruption in between the session everyone) Hope we will get better with time. Fingers crossed .
Best wishes – Maria. 20 Nov 20

The task was: Bhad 6 yrs old has come for a FU visit. Please examine his eyes.

Dr Sound & Dr Shis took the hot seat.  Verbalizing the examination part was stressful and took a little longer but there was definite improvement in the time taken compared to previous sessions.

There was a ‘tendency’ not to believe the signs they had elicited and then to put them in a unifying diagnosis.

Learning points:

• Read Eye examination.
• Be organised – as in other system Inspection, Palpation, Percussion and Auscultation
• Divide eye exam: Vision – acuity and field, Extra ocular muscle, Fundoscopy
• Test EACH eye separately
• Fix head when checking eye movements
• Define 6 extra ocular muscle movements when checking

It was good to note the improvement but there is still a significant way to go.
Add your comments or any points I may have missed.

Anil Garg

The sentiments are in Hindi – my apology to some of my friends. It was sent to me and I had to keep it and share. One day I will attempt translating it …

सर्जन बनते शोहरत मिलती, derma में आरामRadiology में धन-दौलत, obstetrics में कामना.

सुख-चैन ना पैसा देखा, ना ही लोगों की सुनीसब्जेक्ट तो पूरे 19 थे,फिर paedia ही क्यों चुनी?

तो बंधु अपनी Paedia का सीधा सादा हिसाब हैये महज़ सब्जेक्ट नहीं, मेरे बचपन की किताब हैहर पेशेंट के अंदर मैं एक ‘छोटे शिव’ को पाता हूँरोज़ मैं अपनी ‘परछाई’ पर मंत्रमुग्ध हो जाता हूँ

Paediatrics in not just a subject – it is my childhood’s book. In every patient I see a little me. I am enchanted by the image.

पहले दिन जो तुम्हें देख कर रोता है, चिल्लाता हैछठवे दिन पे वो ही बच्चा पीछे पीछे आता हैजो राउण्ड पे माँ दादी के आँचल में छिप जाता हैमेरे जाते ही वो माँ के गाल नोंच खा जाता है

One who on first day would cry on seeing you …. by 6th day is following you around. He who hides in grandmother’s lap – comes out to play with mother after I leave.

दो टॉफी के लालच में दो इंजेक्शन लगवाता है”मैं स्ट्राँग हूँ” बोल बोलकर आँसू बड़े छिपाता हैवार्ड में बैठा बैठा अपने नित नये मित्र बनाता है’इस सिस्टर से करूँगा शादी’ ऐसे प्लान बताता है

देख खिलौने बाकी बच्चों के जब जी ललचाता हैफिर तो भैया पकड़ के जिद वो लोटपोट हो जाता हैI.C.U. में मौत से कैसे लड़ते हैं सिखलाता है’उम्मीदों को नहीं छोड़ना’ ये अहसास जगाता है

One who will create havoc on seeing another’s toy … In ICU does teach us how to fight Death and keep our hopes alive.

ये मासूम सा चेहरा पहले अपना भी तो होता होगा डाक्टर होने से पहले मैं ‘डाक्टर’ नाम से रोता होगा Pediatrics बस इन्हीं पलों का बेशुमार खजाना हैबच्चों के संग बच्चा होने का माकूल बहाना है..!

Dr HR has said .. Yesterday session was very good.

Only conflict was how examiner take my question about sign shown in video?For example clubbing was seen and if i ask clubbing is there or not ?Examiner may say failed to pick up sign.

The conflict is Consuming your time unnecessarily. My suggestion is you can say “Can I confirm Clubbing I noted in the image” Examiner will say “Yes” – of you are correct. This will not take more than a few seconds.

Another example There was No dysmorphic features but if i ask is there any dysmorphic features or not?Examiner may take it on another way that i didn’t pick up that face is normal or he may take to off track by asking what abnormal features are u looking for(Dysmorphic features too is big list!!).

Again – mention – “I would like to confirm – Child looks Normal and has NO dysmorphic features” Examiner: Yes / NO.

3rdly There was pansystolic murmur in video and if i ask which type of murmur than Examiner may take it as candidate dont recognise common murmur and asking non essential generic questions.
So how to ask when some signs already shown in video or photo as clue is dilema still.That question should not throw off track or giving wrong image like candidate failed to identify given sign.

You CANNOT ask which type of murmur. You should only ask for location and maximal intensity and radiation – if appropriate. Murmur characteristics will be presented in the discussion along with other information gathered.

Please note the above are my suggestions only and reflect what I would expect from a candidate. Examiners do vary to a degree as you might have noticed in our sessions.

Look forward to your comments and questions

Anil Garg

Thank you for participating in the session today. It was a first for us all.

We practised verbalizing the 4-6 minutes of actual clinical examination.

It was hard work. Dr S and Dr V took the hot seat and performed will, considering it was the first time. Others also had a ‘go’. Talking through different parts of the full exam: General physical observation, Palpation and Auscultation. As a group we know it all.

Learning points are:

• Picturize the whole situation
• Have a working differential from initial information and cues
• Introduction, Hand hygiene, Permission.
• Ask about pain from ‘role player’ / examiner
• Describe what you want to check and get information on
• Be careful of describing your examination technique
• Right sequence of proceeding and specific questions
• Practice Binary questions – a sign is present or Not
• Do not beat around the bush
• Summarize in a few sentences – remember Examiner has given you the ‘findings’.
• Practice, Practice, Practice to cover the whole in 5 minutes.

add a comment or any points I may have missed.
Video of the sessions will be available.

Anil Garg