Medical Student Exams

The medical students had their exams this week. The written exam was on Friday. On Monday, the third-year students took their clinical exams, and on Tuesday it was the fifth-year students.

The clinical exam consists of three parts:

1. The Long Case: The student is assigned to a patient in a ward bed. She or he is given 1 hour to take the history and perform a basic physical exam, and compile a differential diagnosis. Then the examiner, one of the consultants, approaches the student at the patient’s bedside, and the student presents the patient. The consultant questions the student throughout – either to clarify a statement, or to ask for more detail, or to simply quiz on that particular topic. Then the student does a complete physical exam in front of the examiner, stating the relevant findings. At the end, the student is asked for the diagnosis, and then the differential diagnosis. The examiner has 30 minutes for this portion.
2. The Short Case: After the Long Case, the student moves onto the next patient to which she or he is assigned, where the consultant is waiting, having finished the Long Case with the prior student. The consultant tells this student the basic details of the patient’s history, and then asks the student to do a complete physical exam. At the end, again the student has to state the diagnosis and the differential diagnosis. This is 20 minutes.
3. The Viva (pronounced Vye-vah): A large tray of many medical instruments and tools are present on the table, such as a speculum, an IV cannula, a bottle of normal saline, Oxytocin, oral contraceptives, a ring forceps, et cetera. The examiner chooses (or has the student choose) an item, then asks the student “What is it, and how is it used?” As the student speaks, the examiner asks more details, and can go in any direction with it, and eventually the instrument itself can become irrelevant. The discussion may focus on only one instrument, or may incorporate several instruments. The Viva lasts 20 minutes.
   

It was very interesting to watch the exams. I have particularly enjoyed here how the physical exam becomes so much more important in the absence of basic diagnostic tests (eg. diagnosing anemia based on pallor in the conjunctivae and palms, palpating hepatomegaly and splenomegaly).

My favorite part of the exam was the viva. I thought it was very creative, and a very nice way to quiz students. There was such a wide range of questions that could be asked, and all were clinically relevant, and could have been learned on the wards.

Dr. Mugyeni conducted the Viva for the third-year students. He is a sympathetic man who smiles often, although he can be firm when teaching. He encouraged me and Joseph, the postgraduate who was there, to chime in with questions. He usually used the instrument to start, and then asked several questions surrounding the subject. Sometimes his question was confusing in the wording, and I could see the student hesitate. He wouldn’t realize the confusion, but sometimes Joseph or I could clarify.

For the fifth-year students, Dr. Wasswa conducted the Viva. He is an operatic man, with a definite stage presence and a lot of drama in his speaking. He punctuates his sentences with volume and by bulging his eyes out. It is quite funny when you are watching, but surely quite scary when you are the anxious medical student in the spotlight.

For Dr. Wasswa, the tray of medical instruments was a mere table adornment. I saw him use it only once, when he handed a student a vial of Depo-Provera. The rest of the time, he picked a topic and just started asking questions.

The questions were often vague, and sometimes designed to have only a wrong answer. For example, if he asked a student what he might find in a clinical scenario, and the student said something like “The patient might have ruptured membranes, or vaginal bleeding,” Dr Wasswa would bellow “Doctor! You want the patient to have ruptured membranes or vaginal bleeding! That is terrible! You are a truly bad doctor!” He also had a tendency to close his eyes as the student spoke, so that you might think he had fallen asleep, then suddenly he would bulge his eyes and shout “CORRECT!!”

Martin, the postgraduate who was with Dr. Wasswa, is a very nice, empathetic soul. Sometimes when a student could not get an answer, Dr. Wasswa would sit there and just stare at the poor thing, and you could cut the tension with a knife. At one point, Martin couldn’t handle the tension anymore and just burst out with an answer.

The funniest part was when he was asking a student about gestational diabetes, and the answer was “Insulin”. The student could get it. Dr. Wasswa picked up a pack of syringes with needles off the tray, tore one away from the pack, and began to fiddle with it. He tapped himself on the cheek, twirled it in from of his face and held it straight up. Still, the student could not get it. Dr. Wasswa finally gave up.

As a side note, the women who participate in the Long and Short Cases are all real patients in the wards. They are approached and asked to participate, and they invariably agree. The women are astoundingly tolerant of all of this, sitting through each extended review of their personal medical history, complaints, and descriptions of their bodies (“The abdomen is distended and uneven. It moves with respiration. There are striae and a linea nigra.”) with patience and a bemused expression. At the end, snacks and sodas are purchased for them. Also, in order to prepare the ward for exams, the patients who are not chosen to participate (and who are not so sick) are cleared out of the postpartum ward and wait outside all day. I found it remarkable.