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A guide to understanding and managing performance concerns in international medical graduates

Appendix B. Exam support guidelines

Last revised: 19 May 2020

It is not uncommon for IMGs to struggle with passing exams such as the AMC and FRACGP. There are many reasons for this, but generally they relate to the IMG’s:

  • particular circumstances (personal, family and social)
  • constraints on their practice
  • limited exposure to a broad range of presentations (including chronic disease)
  • approach to study
  • professional isolation and lack of educational support from someone experienced.

The following is a suggested approach when providing support to an IMG who has failed one or more segments of the RACGP exam:

  • Identify the reasons behind the IMG’s failure.
  • Analyse the exam results.
  • Formulate an action plan.


Consider the following when exploring the reasons for failure.

  • Study:
    • Allocated time for study – Was it dedicated, regular time or ad hoc?
    • Study methods and resources used – often, a limited number of resources is used. Consequently, the IMG lacks depth and breadth of knowledge.
    • Did anything, such as health issues, personal problems, family or financial concerns, interrupt their study plan?
    • Do they have a study partner or study group? How do they study with their partner or the group? How effective is that study? Sometimes study partners have poor approaches to study, and the required support and guidance is therefore not available.
    • Do they have a supervisor in practice? Are they receiving in-practice teaching? Do they have a more experienced colleague with whom they can discuss clinical cases and ask questions? Having someone experienced who can act as a mentor is of great benefit.
  • Exam technique (particularly important with the KFP and OSCE)
  • Exam stress and negative attitudes to assessment
  • Language (reading and comprehension, typing skills)
  • The scope of their clinical practice (and how this compares with the RACGP’s ‘Competency profile of the Australian general practitioner at the point of Fellowship’):
    • The practice type and location – Is there pressure to conduct shorter consultations? Are they travelling long distances to and from work?
    • Hours of work – Is there pressure to work long hours, thus impacting on study time?
    • The range of clinical presentations that they see – What kinds of presentations are they not seeing?
  • To what degree has their study plan been informed by the RACGP’s ‘Competency profile of the Australian general practitioner at the point of Fellowship’ and the Curriculum for Australian General Practice 2016?
  • What do they believe are their strengths and weaknesses?


Current and previous exam results (particularly if a breakdown of the marks is available) can provide useful information with respect to areas of weakness, as well as informing a learning and study plan.

Consider:

  • What is the fail margin? How does it compare with previous fail margins?
  • Compare the scores for AKT, KFP and OSCE.
  • Are there any patterns or discrepancies with respect to the areas of strength and weakness?
    • What do these discrepancies suggest?
    • Was there difficulty with one particular segment of the exam over another? What does this suggest?

The KFP and the OSCE are the components that generally cause more difficulty: the KFP because of issues with clinical reasoning and the OSCE because of weak clinical skills and communication skills in particular.

There may be difficulty with both of these components because of insufficient clinical experience and exposure to a broad range of presentations.


Having explored the reasons for failure, all the issues should be listed according to the following headings:

  • Clinical knowledge and its application
  • Clinical reasoning
  • Clinical practice
  • Exam technique
  • Study
  • Other

From this, an action plan for preparing for the next exam may be prepared. It is important:

  • to not keep doing ‘more of the same’
  • that a variety of study resources is used
  • to find someone more experienced who can act as a mentor.

Clinical knowledge and its application

Core topics (such as diabetes, hypertension, heart failure) require depth of knowledge. It is not appropriate to rely solely on John Murtagh’s General practice for study. Other texts and sources of in-depth knowledge must also be used.

Clinical guidelines are available on the RACGP and other websites. Knowing guidelines off by heart does not necessarily equate to being able to apply them in practice. This is where clinical experience, application of knowledge, shared decision making and communication skills are important.

John Murtagh’s General practice is useful with respect to:

  • being familiar with common problems, red flags, masquerades and what should not be missed
  • problem solving with respect to the common presentations (refer to Part 3 – Problem solving in general practice).

The RACGP check and gplearning modules are very useful because information is presented with reference to clinical cases and contexts.

Areas of confidence or strength should be revised so that the knowledge remains fresh.

Clinical reasoning

Many factors impact on clinical reasoning, including knowledge and its application, the ability to problem solve and clinical experience (time in practice as well as breadth of practice).

Other aspects of clinical reasoning, which often aren’t highlighted, are the ability to:

  • apply the general to the specific
  • problem solve in a new context
  • present and discuss the decision with the patient (this enhances confidence and is also part of shared decision making).

Clinical reasoning is facilitated when there is structure to the consultation and a process for problem solving. Clinical practice entails the management of patients who come with a particular presentation within a specific context. No two contexts (or patients) are the same. In the consultation, information is gathered (history, examination, investigations) and simultaneously processed as regards its meaning and value and what further information may be required. The importance that is placed on individual pieces of information influences decision making and the relative importance of each piece of information is contextual. KFP questions and OSCE cases test clinical reasoning and must therefore be approached as if managing a real patient in practice rather than as a textbook case.

Case discussion is one way of improving clinical reasoning. The following guidelines will make the case discussion more meaningful:

  • Don’t just discuss ‘interesting cases’. Discuss undifferentiated presentations and cases where more thinking is required in order to problem solve.
  • Don’t make assumptions and be wary of making invalid interpretations.
  • Only use the information at hand.
  • Ask: What would happen if …
    • the parameters of a case were changed (eg age, gender, severity of symptoms, comorbid conditions)?
    • test results came back normal/abnormal?
    • the patient’s condition worsened?
    • other symptoms developed?
  • Information gathering – an appropriate list of differentials should always be generated with every presentation. In order to do this, it is necessary to think about what information is required to rule in or out each differential with respect to:
    • history-taking
    • physical examination
    • ordering of investigations.
  • Consider red flags, masquerades and things that shouldn’t be missed.
  • Investigations – differentiate between:
    • first-line, second-line and routine tests
    • screening and diagnostic tests; tests that assist with diagnosis and tests that assist with management
    • necessary and unnecessary tests (don’t order a test if it will not affect decision making).
  • Prescribing – Therapeutic Guidelines, Australian medicines handbook, Australian Prescriber and NPS MedicineWise are all good resources.
  • Management:
    • should be tailored to the individual (ie the person and the context)
    • should include shared decision making
    • should be separated into immediate (what must be done now), short term (in the next few days), medium term (in the next few weeks or perhaps few months) and long term.

The following articles provide guidance for getting the most out of case discussion:

Clinical practice

This is perhaps the most difficult issue to address, particularly when it is not realistic or not possible to change practice or even to get experience with a broader range of presentations within the same practice. Helpful alternatives include:

  • case discussion and role-play of clinical cases with an experienced GP or medical educator – cases taken randomly from a day’s consulting are an excellent source of material for discussion (including cases from an experienced GP’s day)
  • direct observation of consults by an experienced GP or medical educator
  • observation of an experienced GP in their consulting.

Exam technique

Exam practice is useful for identifying issues with exam technique. There are many resources available for AKT and OSCE practice; however, resources for KFP practice are limited. The principles of the KFP examination are critical to understand and practise with good quality cases/questions is key. Poorly written cases/questions only serve to confuse and generate negative attitudes.

Study

In formulating a study plan, the following should be considered:

  • preferred learning methods
  • dedicated, regular study time (no interruptions)
  • study partner or study group (face to face or Skype/FaceTime)
  • a realistic timeline (What will be done and when? – so that everything is covered, while at the same time allowing for revision)
  • prioritisation of study topics.
On the last point:
  • Uncommon and rare presentations do not justify detailed and extensive study. However, common problems require a high level of detailed knowledge and understanding. The difficulty is in deciding which topics to prioritise. The article by Georga Cooke et al (Common general practice presentations and publication frequency) is a useful guide in this respect (refer to Resources list).
  • Study topics can be grouped into ‘short’ and ‘long’ topics according to whether they require less or greater amount of study. When time doesn’t allow for an in-depth session on a common problem, it may be more advantageous to cover, for example, three or four uncommon conditions that will each take only a small amount of time.

Other

The IMG should be encouraged to address factors such as personal and family concerns that contributed to previous exam failure or that may affect future performance. The aim would be to minimise, as much as practicable, anything that may act as a distraction to study and remaining focused in the lead-up to the exam as well as during the exam.

Exam anxiety is another issue that is best addressed earlier rather than resorting to ‘quick fix’ measures at the last minute.

 

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