Early Preparation for Professional III M.D

By Bro Muhamad Na’im a.k.a jacknaim (MD USM)

Since my juniors asking me on how to prepare for the coming professional III as they are

currently entering final year, i find that it is relevant to share this in this blog so others may

benefit from it as well.

It’s also a time convenient for me as i don’t have to reply it personally to everybody. Just

click on the link and it’s ready.

Though, i’m not really a best person to give this advice as i’m not truly a maniac in study. My

time are full with lot of activities and times for study are quite limited. But insha’allah, i will

try to give some tips.

To be honest, i do hope that in the future, there will be a Muslim juniors qualified to sit for

viva distinction and awarded with distinction. (sigh! It’s my dream to pursuit it but due to lack

of preparation, only manage to get B, but thanks to Allah!)

The key point is to make an early preparation and LOT of practice.

Clinical Part

Long Case 50%

OSCE I & II 20% Total: 100%

Short Cases 30%

Pass > 50

Borderline > 45

Fail <45

a. Short case

Each of you will be assign 3 cases either surgical based or medical based. Those who get

surgical based for short case will get medical based for long case.

You will be assigned 10 minutes for each case. You SHOULD spent 5 minutes on

examination, 2 minutes for presentation and 3 minutes for discussion with the examiner.

You may choose to do running commentary or present your finding after finish your

examination. For medical based especially internal medicine, it is RECOMMENDED that you

comment after finish examination.

They are two ways of presenting your finding for short case. One is to conclude first and give

detail or you can start from finding and conclude.

Based on my examination, i think this patient have right sided pleural effusion by evidence of

reduce chest expansion, reduce breath sound and stony dull on percussion. Other finding in

this patient includes (you comment on relevant positive finding from periphery to specific

region examination).

Or you can go another way a round.

For my style. I prefer to combine both method and draw a conclusion at the end of

examination. I found it more time consuming and you did not miss the finding. During my

exam, i was given surgical case which were Non union Right Tibia-Fibula fracture, Graves

disease and uterus larger than date. Believe me that i have more than enough time for two

earlier cases.

What i did is as follow. You can skip reading this part if find it too long and go to the

recommendation section because i’m just blabbering about my exam experience.

First i did an inspection and screen the patient. There i notice that patient is un able to walk

and something is not right with her right leg. So i give comment on that and inform the

examiner that i want to examine the right leg. So i proceed with specific inspection.

(shortening, false joint, scar, external fixator scar, deformity)

Then i did the palpation by comparing both leg. After finish the step, i explain my finding.

Next i proceed with movement and after finishing it, i stop and explain my finding to the

examiner.

Then i make a conclusion to the examiner that i think the patient was having non union of the

right tibia fibula probably secondary to complication of open fracture as evidence of present

of external fixator scar, mobile, pseudo joint, non tender, loss of bone continuation and no

evidence of infection.

The examiner the stop me and go for a discussion session. he ask me what investigation i

want to request. And i go bla bla bla and then he pull out the X-ray, ask me to interpret and

how to manage the case. He also ask about definition of non union, type of non union and

why non union occurs. After finish with management, he stop asking and we were waiting for

the bell to ring.

I did the same thing for the thyroid case. I did quick inspection and told the examiner that i

want to examine the neck. Then i specifically inspect the neck and present the finding to

examiner. Then i told examiner that i want to proceed with palpation. After palpation, i point

up my finding and then i go for auscultation, present the finding and finally percuss the

manubrium and present my finding.

Then i make my diagnosis and told the examiner that i would like to examine the periphery to

look for sign of hyperthyroidism. The examiner say no need and he just test me on theory

about what finding to look in periphery. Then he ask me about advise for the patient

(surgery), how to manage the patient in outpatient dept, how to prepare the patient for

surgery, complication of surgery and finally the question that i can not answer (difference of

primary and secondary hyperthyroidism and prevalence of secondary hyperthyroidism).

For the third case, i did not perform very well because of lack of practice in O&G cases.

However i did manage to find finding (more than two pole) and draw conclusion that it was a

multiple pregnancy. However the examiner want a diagnosis of Uterus larger than date and

we discuss about that. I only manage to reach the differential diagnosis and the bell rang.

Recommendation

- Practice early. Dont wait until study week because there will be a congestion of student who

want to examine the patient. It will bring discomfort to patient and waste your time too. So

form up your study group and look for patient to examine. (max no of person in study group is

5. The best is 3. But my study group consist of 7 person). The person in charge of finding the

patient MUST KNOW the finding and diagnosis of patient. You examine the patient while the

other friend act as examiner. Do it in exam format. Other friend will then ask question and

you must answer it as you were in exam. To benefit other, allow one more friend to do

examination in full format and for patient sake, the other three just appreciate the findings

only.

- Many doctors are friendly and helpful enough to help and teach you especially the trainee

lecturer. During our time, we make full use of them and be friend with them. They conduct a

free class for us during the weekend and also when we have free time during weekday. So, go

and befriend with them and arrange extra class with them.

- make use of HRPZ and District posting. Both of them are full with patient with good

findings.

- Clinic is a MUST to attend be it surgery, paed, medical, ortho.. they are heavenly place to

learn about short cases.

- For medical short case, make sure you finish reading the short case book written by Chu Nee

Kong. Trust me it’s REALLY BENEFICIAL.

- For surgical based, i don't have a good book to suggest. But trust me if you go to ward and

clinic, it is enough for you to pass because surgery cases are straight forward.

- Practice with your friends at any free time you have to polish you skill and to ensure that

your examination is smooth. My study group use to use marker pen to draw finding on skin,

use picture to practice describing. At each session, we will be commenting on our study mate

performance, what area to improve and also some hot and spicy critics to challenge them to

do better.

- I used to use imagination technique and mirror technique for practicing presentation. I use

mirror to practice presenting the finding and imagination technique to imagine flow of

examination. Close your eye, imagine what you want to examine, follow the step and practice

talking. Try it out!

B. Long case

- Take a look at this list and made sure you know in heart about the disease

http://jacknaimsnotes.blogspot.com/2010/04/common-medical-problems-for-clinical.html

also look at your logbook. Some case are nasty as well like lupus nephritis... take a look at

past year compilation to familiarize yourself with the common case in exam.

- Always look at guidelines by our ministry of health for management. In exam, they however

just want Outline or principle of management.

- Practice, practice and practice. One person will go and clerk the case as if you are in exam.

Only spent one hour with patient for clerking, examination and arranging your presentation

then spent another 30 mins with your colleague.

With patient:

15-20 min (history)

10 min (detailed physical exam)

10-15 min (arrange presentation)

10 min for thinking bout differential dx, ix, mx

remaining time to clarify history from pt

with friend:

Present for 15 minutes and another 15 minutes for discussion. Your friend will ask question

and discuss as you were in exam. To ensure that other benefit it as well. Make sure you write

back short history, finding, diagnosis of your patient together with discussion and photocopy

it for others.

- like what i mentioned in short case section, approach your lecturer or trainee lecturer or

doctor for you to practice presenting case and discuss about management. They know a lot.

- Ideally you should at least clerk one patient per day. That will make you a SUPERB student.

But for a lazy person like me, i found out that clerking one patient per week or per two week

is enough. The rest, i just flipping over the folder to see the history, ix and management. If i

need to clarify something then only i will ask the patient. THIS IS A BAD HABIT if you

want to score in your exam. To be honest, i stumble a bit during real exam where my time

frame goes hay wire. I miss lot of point during the exam.

- During exam, examiner will ask everything under the sun. Basically the mark for long case

are divided as follow

History: 20 mark

Physical examination: 20 mark

Differential diagnosis: 20 mark

Investigation: 20 mark

Management and discussion: 20 mark.

And as a GENERAL they will advance from one level to another level once they satisfactory

with you. If you stuck at any part, they will ask you very-very basic question including basic

anatomy, physiology, biochemistry or even basic science during matriculation.

Beware of what you called SIMPLE CASE as it may be a killer one for you. One of the

examiner told me that not many score on asthma case. I’m one of the example. I got a case of

7 years old Malay boy with mild AEBA secondary to chest infection with underlying mild

persistent asthma and atopy. He also have strong family history of atopy, asthma and living in

industry area. Other example of simple case that you must know by all of your heart including

diabetic foot, diabetes, tuberculosis, pneumonia etc.

Do not create finding or bluff them because each examiner are given template. If you do it

then they will make your life miserable.

Tips during presenting the case

- Greet the examiner and ask to sit politely.

- Put your clerking sheet on table in front you and you should sit straight. Do not hold

anything with your hand and DO NOT PLAYING with pen, tendon hammer as it is very-very

irritating.

-Examiner will ask you whether you have any problem or not during clerking the patient.

They will set their standard on you at this time. If you are having serious problem in clerking,

they will try to help you in other way.

- Be confident yet humble

- It is best you did not look at the paper at all. Or just minimize looking at the paper. Some

examiner wont even ask you to present full history, they just want summary, problem list and

positive finding that you find.

- Do not argue with examiner (they are always right)

- Present loudly and clearly. They wont punish you for the broken english as long as the

meaning are clear.

- Only one examiner will be dominant but do not forget about second examiner because they

will also give you mark. Look at them sometime and offer a smile.

- The time keeper wont give you mark but do not ignore them as they may offer you some

tips.

C. OSCE

There will be OSCE I and OSCE II but honesty i think it is just ONE PAPER because you

will sit for both of them at the same time with total station are 26 and each station is 5

minutes.

It is considered as a bonus for you to help you pass the clinical part if you can score it. And

there is no other way to pass it unless you did a lot of past year questions.

In my blog, i also post some of the OSCE questions and you may find it somewhere. I put the

example of the answer for the question but of course you need to double check it. I’m not an

expert too.

And, there are a lot of compilation question made by seniors. You can always look for it to

make your own answer scheme. When exam is around the corner, you dont have to trouble

yourself to read the whole book, just flip trough your own note and it is more than enough.

Apart from that, most of the procedure are common and can be seen in wards or OT like

inserting CBD, Ryle’s tube, Digital rectal exam, pap smear, suturing. However, each station

has it’s own scheme and what you did in wards may not be true (even though it’s working and

practical). Therefore, in order to know the correct step, go to the skill labs and ask help from

the staff there. They are willing to teach you the correct step and which aspect will be

rewarded points.

Sometimes, during sitting the exam, you will have a thought block. You find it very difficult

to recall an answer for the question. My suggestion is, close your eyes and take a deep breath

and recite some supplication (doa). Then try to answer it again. insyaALLAH!

If you still unable to recall until the bell rang then forget everything about the station. Just go

to the next station and focus. There’s no space and time for you to regret or cry. Sometimes,

there will be a moment when you suddenly remember about answer for the past station while

answering the current station. Block that thought and focus!

Theory Part

MCQ I&II (100%)

MEQ I & II (100%)

Total: 100%.

MCQ

You need to be really strong to face this paper. Imagine you have part 1 and part two. Each

paper have 100 questions (500 respons) and time given are two and half hour. Paper 1 at

morning and paper 2 at evening. Really stressful.

Basically for each question, they will be 5 respond. Respond a and b usually basic (anatomy,

physio, definition) and very easy. Respond c to e are clinical (management, symptoms,

investigation, findings). C is easy, D is moderate and E is DIFFICULT. So basically you will

have 3 easy respond, one moderate and one difficult.

The problem with MCQ is it is negative marking and it will be carry forwards. You will get 1

mark for right point and deduce ½ mark for wrong answer. if you did not answer, then no

mark will be given or deduce.

For me, basically i will answer the questions in three steps. Step one where i only answer

EASY RESPOND from question 1 till end. If i can not answer all respond, i will leave it for

second round.

For second round, i answer the moderate respond and try to understand further the question

that i left blank and try to answer it..

The final round is for me to decide either i want to answer the remaining respond randomly

(tembak) or leave it blank. It’s like a gamble round where i put away the knowledge and

depends on my judgment and luck. Here i use logic in answering the questions.

I’ve used this method since first year and in all end posting exam. From what i can say, MCQ

is DIFFICULT and i only manage to get B for the MCQ using this method. Probably there’s

something lacking in this technique.

Therefore, i suggest you made your own research and ask help from the lecturer regarding the

best approach to answer MCQ.

Preparation wise, you need to answer past year questions. You may get it in library or through

seniors. Try to answer it. For me, it is best to answer the mcq by putting the correct statement

and explanation regarding the question. For example

Regarding neonatal jaundice

a) Conjugated bilirubin is neurotoxic

b) Jaundice within 24 hours of life-physiological jaundice

c) Breast milk jaundice due to decrease production of milk in mother

d) Premature is at risk of severe jaundice

e) Hearing impairment is a complication

Rather than just ticking FFFTT to the question, you made your own notes like

a. False (Unconjugated bilirubin is neurotoxic and can cause death in newborns and lifelong

neurologic sequelae in infants who survive (kernicterus))

b. False (Jaundice appearing on day 1 or early day 2 of life is likely to be due to hemolysis

and if starting that early, blood group incompatibility between mother and baby is most

likely.) **Jaundice on day 1 tends to be pathological and require extensive medical attention.

C. False (Breast milk jaundice is a common cause of prolong jaundice due to unknown factor

in breast milk that interfere with bilirubin mechanism. It must be differentiated from breast

feeding jaundice which due to inadequate breasts feeding, no early breast feeding or addition

of water during feeding.)

D. True (The risk of significant neonatal jaundice is inversely proportional to

gestational age)

E. True (sensorineural hearing loss)

Try to do at least 5-10 past year MCQ per day together with the answer. The best way to save

time doing MCQ is by doing it together with your study group. Divide the question among

yourself and each member must be responsible to do their homework. Jot down the answer

nicely in a paper or re-type it and print it to everybody. During your study group, discuss it

thoroughly.

In answering MCQ, make sure you use standard textbook reference like Bailey and love

(surgery), Neelson (pediatric), CM or Harrison (internal medicine), Ten Teachers (O&G),

Appley or principle orthopedic (ortho). If you use internet, do not use Wikipedia. For me, it’s

rubbish nearly half of the time. At some time, it could be helpful if you can’t find any other

resources.

For me, i made use of google by typing anything i want and search it under header “Books”.

Or “Scholar”. You need to type specifically and you will get hundred of standard textbook

who offer free page for display regarding the topic that you want. You can jot down the

answer from that text book.

Or, make a habit to search the answer through journal. Usually i will use database pubmed,

springerlink, elsevier, BMJ and if i’m too lazy then i will just search info in the eMedicine.

It’s a little bit hard but you will be happy with the result. If everybody in your study group do

their job with high sense of responsibility, then you can finish one set of question in one day

only. Trust me!

MEQ

I dont know about others, but i found that MEQ is the most interesting paper in exam.

Because it’s challenging, more practical and need you to apply what you learn. The answer is

on the next page (but of course you can not see it).

The pattern of the questions are same every year and you can predict the answer. but of

course, you need to practice, practice and practice. Sometimes the answer is similar if you

made habit of reading case note in wards.

Try it out. Follow up the case note starting from patient first presentation, see what history did

doctor elicit, differential that they put, investigation, outline of management. And see how

they change the management once the result come back. It’s quite the same.

Plus, you also need to do past year collection as well to see the pattern of the question and

familiarize yourself with it. At the end of the day. It truly worth it.

My last advise

1) Make early preparation.don't wait until study week. During my professional I and II, i

usually use study week to rest. But during pro III, i have to struggle so hard because i did not

make early preparation. At the end, i just read seniors’ note and summary of the disease and

have to struggle until two days before exam.

2) take a good rest and do not worry to much. It will affect your performance. On the first day

of exam, i could not sleep at all at night. On the next morning (MEQ paper), i have to bring

Coffee each exam session because too sleepy. While others answering continuously, i have to

take a break few times to drink coffee.

3) form a study group and ensure all your group mate succeed. The only way to measure

whether your study group effective or not is that by having every body pass and not to have

top scorer while other fails.

4) Doa banyak-banyak. I use to pray like this. Just for sharing

Ya Allah permudahkanlah aku untuk menuntut ilmuMu, mengingatinya dan menyebarkannya.

Bantulah aku untuk menjadi seorang doktor agar aku tidak menjadi fitnah di atas dakwah

yang aku lakukan. Buka dan lapangkanlah dadaku untuk menjawab soalan peperiksaan,

tenangkan fikiranku dan permudahkanlah aku untuk mendapat idea bagi menjawab soalan

exam. Jauhilah aku dari lalai dan cuai semasa menjawabnya. Kurniakanlah examiner yang

baik dan berilah aku soalan dan kes-kes yang aku mampu untuk menjawabnya. Ameen!

Hope that will help you. Finally i would like to take this opportunity to thank my study group

mate who fight along side me in this very fierce battle. Alhamdulillah we all pass. It is a sweet

moment to have everybody pass. Thanks to Dr Adam Al Anas (study group leader), Dr

Huzaifah Mat Jan, Dr Hazwan Maznon, Dr Najman Ab. Wahid, Dr Ali Montazerri and Dr

Fauzi Wahab.

Thank also to the doctor who provide us (study group) with extra classes and teach us with

love.

Internal medicine: Dr Shahidi, Dr Siti Maryam, Dr Nazri Mustaffa, Dr Safarul , Dr

Pediatric: Dr Salmi, Dr Arzuar, AP Noraida.

O&G: Dr Husna, Dr Sham, Dr Shahaniza.

Surgery: Mr Osman (HKB), Dr Siti Rahimah, Dr Huzairi, Dr Amin,

Orthopedic: Dr Muhammad B. Paiman,

A&E: Dr Shaik Farid

Ophthalmology: Dr Azhany Yaacob

ENT: Dr Irfan

And of course other lecturers too.