How to Pass the AMC Clinical Exam. First Time Success Guide.

An AMC Part 2 Clinical OSCE Examination Study Guide

Imagine having spent 6 to 7 years of medical school and tens of thousands of dollars on examinations, tuition, and books in order to gain your first doctor job in Australia. Imagine doing well on all these other exams but failing in one final exam. And failing this exam is severely impacting your chances of gaining a job in Australia. If you are wondering what examination I am talking about, it’s known as the Australian Medical Council Part 2 Clinical OSCE examination. The AMC Clinical Exam has a reputation of being one of the most difficult medical assessment examinations, and one that International Medical Graduates (IMGs) frequently underestimate. This error has led to many candidates failing this examination. This situation is even more painful when you learn that the AMC clinical exam is in fact a straightforward examination to study for, and it requires nothing more than readily available medical knowledge, practice and organization.

Before diving into tactics and strategies. Here’s a brief overview of the AMC clinical exam:

• The AMC Clinical Examination is the second of two examinations that comprise the AMC Clinical Certificate. The AMC Clinical Certificate is a prerequisite for many IMGs in order to gain general registration in Australia.
• The AMC Clinical Exam is set at the standard of a final year medical student in Australia.

Play the AMC Clinical Exam by the rules.

The AMC clinical exam is like a game, you need to play by the rules. I have heard others say it is like a dance and you have to know the steps well.

The exam itself is set at the standard of a final year Australian medical student (and the AMC calibrates its exam questions against Australian medical schools). The exam, therefore, is quite “doable” with the appropriate preparation and understanding of its nature.

Many IMGs love the format of this examination. They get to interact with standardized patients and diagnose their problems. The play-acting element makes the AMC clinical exam quite interesting, but that doesn’t mean it’s easy to pass.

And even though you can take the AMC Clinical Exam again if you fail. Clearing it the first time around gets closer to your goal of a medical career in Australia.

Preparing for the Australian Medical Council Part 2 Clinical OSCE examination can be frustrating. You know it’s a graded pass or fail and that there is a low pass rate. It is expensive and takes a lot of your time away from other pursuits, so no one wants to deal with taking it more than once.

Here I have assembled the most important pieces of advice for International Medical Graduates who are thinking about or preparing for the Australian Medical Council Part 2 Clinical OSCE examination.

Format of the AMC Clinical Exam

The AMC Clinical Exam is a 3 hour and 20-minute examination. That tests for skills necessary for a doctor to work under supervised clinical practice. This is done using 16 different simulated clinical scenarios.

Most of the time, the scenario is pretty straightforward, you’re a physician meeting a patient in an office that is presenting with some sort of problem that you are asked to address.

A clinical encounter usually consists of a patient-centred interview, physical examination, sharing your clinical impressions and further workup required, and patient counselling and education.

The examination assesses your command of the spoken English language, measuring clarity, pronunciation, word choice, and how easily patients can understand your questions or statements. It also assesses your communication and soft skills, including how well you provide information to patients, whether you put them at ease, helped with making decisions, etc.

Last but not least, the AMC Clinical Exam assesses your clinical reasoning through data collection and data analysis by requiring you to take a focused history driven by a differential and conducting a focused physical examination.

You will deal mainly with role players and usually the examiner does not ask any questions but just observes your performance. There are sometimes real patients with, for e.g., rheumatoid features, cardiac murmurs, peripheral neuropathy, joint problems, liver symptoms but they are a rarity.

In general, the patients and examiners are very supportive and want to help you even though you might not believe this. So please listen to them carefully, they often try to give you valuable hints. On many occasions, there is a second examiner present who is there to assess the process of the examination itself and rotates through the stations. The examiner does not judge your performance, so please do not worry about their presence.

Textbooks for the AMC Clinical Exam

It is important to remember that the Australian Medical Council Part 2 Clinical OSCE examination assesses your knowledge of the most common diseases in Australia.

Australian Handbook of Clinical Assessment

Finding the perfect resource is crucial. The Australian Handbook of Clinical Assessment is by far the most important resource to passing this examination. It should take under 4 days to get through this book. This book includes detailed sample cases for the majority of cases encountered in Australia. It gives you a very comprehensive explanation of the examination process, has incredibly important hints for the different clinical areas with fantastic examples with detailed explanations of all aspects of the scenario.

Each chapter is prefaced with the most valuable explanatory notes which I encourage you to read thoroughly.

A great example is an introduction to “The Psychiatric Consultation” which covers in a very brief and precise way what you are expected to consider when examining a mental health patient. I recommend being aware of topics but working through them in a thorough way, realizing that a scenario can easily change.

For example, Right Lower Quadrant pain in a female patient might be appendicitis in one exam but could be ectopic, a twisted ovarian cyst, renal colic, or domestic violence in another examination.

You need to have a good understanding of the underlying issues.

The examiner will generally know very quickly if a candidate has just rote learned a case, and is regurgitating facts, but not demonstrating a thorough understanding of the case.

I believe that the publication of this particular book has allowed International Medical Graduates to understand the nature and requirements of this examination much better than ever before and it is really important to know about the expectations and to understand the importance of for example critical errors.

Key Components of AMC Clinical Exam Stations

Differential Diagnosis

Reaching a diagnosis involves the process of establishing a “differential diagnosis,” in which all possibilities for a patient’s symptoms are initially considered.

The possible causal factors are then narrowed down through a systematic collection of information, which makes some diagnoses more likely and rules out others.

The goal of differential diagnosis is to systematically collect information on the pattern of symptoms to allow you to accurately diagnose what is causing them. Knowing the key buzzwords for the prototypic cases is necessary to nail the diagnosis.

If in one station you are presented with a 40-year-old female patient with right upper quadrant pain who happens to be obese, you will right away think Cholecystitis. But there are still other diagnoses to consider in this scenario.

Having someone else quiz you on differential diagnosis tables or challenging yourself by covering up part of the information is useful. So I would recommend studying differential diagnoses from the very beginning of your preparation period, and follow up 1-2 days before you take the examination to keep them fresh in your mind.

History Taking

For history taking, it is useful to memorize a skeleton to structure your history-taking. It is generally expected that you cover every category, even if superficially, with every patient, just like in real life. Different categories will yield richer information with different patients. Here is an example structure:

• Chief Complaint
• History of Present Illness
• Review of Symptoms
• Past Medical History
• Past Surgical History
• Social History: Living Situation / Drugs-Alcohol / Sexual History / Smoking
• Family History
• Medications
• Allergies

All of this should be addressed with every patient and should be recorded in your notes, even if very briefly. This is the basis of the first part of the encounter.

Physical Examination

The best way to prepare for the actual physical examinations manoeuvres is to study with a partner. I recommend using the Oxford Handbook of Clinical Examination and Practical Skills to brush up on physical examination skills. A YouTube search will get you to what you’re looking for as well.

Study Partners and Flash Cards

I know of many International Medical Graduates who have tried to practice for the AMC Clinical Exam by using Skype or over the phone but the problem is that you do not get to interact face to face and in person with your study partner, and that’s what the AMC Clinical Exam is currently all about. Although it should be noted that the AMC is now establishing a virtual clinical examination.

If at all possible, rather than practising over a video chat or phone call, work on practice cases in person with other International Medical Graduates, family members, or friends.

Your live partner does not have to be a doctor, or even in a medical field, all you need is someone to practice with or on. This way, you can try out your communication and interpersonal skills before facing standardized patients during the actual examination.

Ideally, you have a third partner who can keep time and give feedback about issues like time management and communication skills.

I suggest practising AMC Clinical Exam long cases with a partner at least twice, and then create flashcards for all the cases.

Include the patient’s name, age, primary complaint, and vital signs on each of these cards, shuffle them and practice again.

Since you won’t know which specific cases will show up on your AMC Clinical Exam, shuffling the flashcards simulates a random selection process, which is similar to what you’ll experience on your examination day.

Also, if you don’t perform well in a certain case then put the corresponding flashcard in a different batch. Ideally, you should organize a real trial exam of a number of cases in a row with your partners, in order to simulate the actual AMC Clinical Exam.

Try to get as real and authentic as possible. For example, hang the stem to the station on the wall or a door and pretend that you come into the examination room. It helps you to understand the pressure of the exam and to learn how to put a bad performance behind you.

Time Management for the AMC Clinical Exam

It is important to time yourself while practising. You cannot perform well if you don’t know how to stick to the time limits. You might think you are going to do okay even without practicing with a timer, but in reality, on the day of the examination, you will be too nervous and stressed to even think about time.

But if you have practised all of your cases with a timer then your brain will be much better at managing the time for you. Therefore you will have one less problem to worry about, which will enhance your performance.

Be aware that sometimes there will be a bell ringing during the exam and the examiner might interrupt you after 4 minutes to say “Please move on to your next task” or “It is time to move on to your next task”.

The Importance of Empathy in the AMC Clinical Exam

As funny as this may sound, remember that being “human” gets you points in the AMC Clinical Exam.

Empathy is something many medical associations feel is lost in patient encounters in the new generation of doctors and is something the panel wants you to demonstrate to your patients.

When you practice before your examination, remember to flex your empathy muscle and make sure your “patient” feels heard and supported.

Practice PEARLS in each of your patient encounters: Partnership, Empathy, Apology, Respect, Legitimisation, and Support.

What To Do A Few Days Before The AMC Clinical Exam Day

The AMC Clinical Exam can be tough if you haven’t developed the stamina for it.

To prepare for the real thing, I suggest selecting 16 sample cases from amongst the ones you find most difficult and practice performing them a few days before the examination.

Do this with the same time limits and allotted breaks that you would face on the examination day so they can stay fresh in your mind.

Simulating the actual exam will give you a really good idea of how rough the exam day is going to be. This will also, allow your brain and your body to adjust and make you more ready and energetic on the day of your AMC Clinical Exam.

Relying on too many study resources will just leave you overwhelmed. The only primary resources I believe that you need are mentioned in this post.

We are all different and will experience different emotional and physiological responses to the examination stress, which also influences our social and family environment. Many candidates exhibit symptoms of anxiety or sometimes even depression which needs to be addressed possibly with a referral to a counsellor.

A healthy balance of mind and body is important and can be supported by relaxation techniques, massage, physical fitness exercises, etc.

If you’re travelling to the AMC Clinical Exam interstate, allow sufficient time to familiarize yourself with the location of the examination centre. Make sure to have a relaxing evening before the examination day, that might include a massage, a romantic dinner, a walk on the beach, a concert, or whatever tickles your fancy.

Do not study on that day, what you haven’t learned by then would not be something you would catch up with tonight.

What To Do On The Day Of The AMC Clinical Exam

On the day of your AMC Clinical Exam, you should have a good breakfast. Pamper yourself, put your favourite make-up on, dress up a bit, wear loose clothing, most of us start to get very nervous and to sweat a bit and no doubt you’ll feel uncomfortable if you have tight-fitting clothes on with a sweat stain under your arms.

Try to stay calm and remind yourself that these patients are only actors and they are not sick. The AMC provides all the necessary tools. However, you might have to ask for them and then the examiner will produce them for you. In some stations, things are on the desk and you just have to grab them and it is surprising how often a candidate will not use the provided things, such as cotton wool for sensory testing, etc.

However, remember to bring the following items to the examination centre:

• Confirmation notice
• Unexpired Primary Identification bearing your name, photo, and signature
• Comfortable professional clothing
• Clean white lab coat
• Standard Non-Enhanced Stethoscope

The following items are not permitted in the AMC Clinical Exam:

• Electronic devices such as beepers, recorders, watches, cameras, cell phones and other devices
• Study materials: any type of notes, reading materials and study summaries
• Other medical equipment

Carefully Read the Stem of Every AMC Clinical Exam Station

While reading the stem, every word has a meaning.

If the stem mentions that a male patient is an abattoir worker, this can be an extremely important fact that. For e.g., he might suffer from Zoonosis, a disease transmitted by working with animals.

If the stem says that a female patient is on tamoxifen, she probably has or had breast cancer.

If you are not sure about any aspect regarding the stem, you will have an opportunity to ask the examiner for clarification. The scenarios are usually single topic stations, so the main diagnosis will be apparent fairly early on.

If, for example, it seems to be a case of cholecystitis, try to demonstrate an organized, structured, and focused approach, honing in on the main problem. However, keep an open mind and talk about differential diagnoses as well, because you might just think it is “cholecystitis” but in reality, it might be pancreatitis or something else.

This becomes especially important if the patient or the examiner makes comments like: “Dr. last time I had cholecystitis, it felt quite different.”

Prick up your ears and rethink if the patient is trying to give you a hint that this case is something different.

Occasionally, one station can contain two separate issues. For example, a paediatric case might be complicated by a parent with a psychiatric or social problem and you might be expected to cover both topics.

If you deal quite well with the paediatric component but ignore the parent’s drinking problem you could still be at high risk of failing the station.

In summary, in most stations, you should have a good idea about the task and a well-structured plan of approach in your head at the end of the reading time.

How to Approach the Patient in the AMC Clinical Exam

Demonstrating good communication skills, empathy and patient-centredness is an important component of the AMC Clinical Exam. To open the encounter with the patient, I would like to recommend the GRIPS approach:

G: Greet the Patient

R: Build a Rapport with the Patient

1. Introduce yourself and state your position as a doctor
2. Ensure Privacy
3. Social Courtesy

In simple words, greet the patient, smile, and introduce yourself, state your purpose, ensure the patient is comfortable and make good conversational history.

(Note: Prior to COVID-19, it was generally a good idea to offer to shake the patient’s hand. I would advise against doing this now. Instead, look for a bottle of antibacterial liquid and make a deliberate show of using good hand hygiene).

Here’s a basic outline:

1. Knock on the Door Before Entering the Room
2. Enter the Room
3. Clean your Hands
4. Introduce Yourself, “Hello Mr / Ms ______. My name is Dr ____. I’ll be taking care of you today. What brings you in?”
5. Patient: “ABC”
6. You: “Is there anything else you wanted to address today?”
7. Patient: “ABC”
8. You: “That sounds very important. I’m glad you came in today. Could you tell me more about ABC?”

History Taking in the AMC Clinical Exam.

When taking a history be mindful of your body position, sit upright with an open stance towards the patient, but not too close, and relax, that way you appear more confident. Keep your back straight, lean forward a little bit, and keep your arms relaxed in your lap or on the desk. Try to be super nice to your patients but don’t be fake. It is really important to form a doctor-patient relationship, this is why eye contact and smiling are essential.

Relax your facial muscles and smile (but not in breaking the bad news stations). Speak, not too fast, avoid being monotonous, and don’t be too loud. Use a moderately pitched, soft voice. It is very useful to ask one or two non-medical-related questions during some of my patient encounters. Show genuine empathy and build rapport, for example, by asking about kids’ names, education and how they like their job where appropriate.

If, for example, your patient is a retired music teacher, ask her what type of musical instruments he/she plays or which instrument is his/her favourite.

Just by asking these simple questions, your patient will feel much more comfortable for the rest of your encounter and they might even give you a few hints here and there.

Let the patient speak as much as possible, and use as few questions as you can. “Could you tell me more about the pain?” ends up being much more efficient than “Did the pain radiate anywhere?”.

Although of course if it’s an important question and the patient has not elaborated you can be more specific.

Where appropriate, you can ask how an issue has affected someone’s life. This can lead to appropriate referrals that will help a patient be compliant with treatment.

Try not to interrupt the patient although you might have to interrupt if the patient goes on and on. If they use terms that you don’t understand, ask them for an explanation. Continue to work your way through the skeleton as above. Make sure you’ve covered all of the elements mentioned above before you move on to the exam.

Summarize your understanding of the history of the present illness and ask if there is anything he or she would like to add. This reinforces to patients that you are listening to what they are saying. It’s perfectly appropriate to finish with a few quick and direct questions.

Before commencing your physical examination at each AMC Clinical Exam station, encourage the patient to ask questions whenever possible. They are there to help you and might put you on the right track or give you clues in which direction to go.

You might ask the patient “Now if it’s okay with you I would like to do a few physical examinations to help me narrow down my diagnosis, but before I proceed is there anything that you feel might be important that you would like to mention?” or “Any questions you want to ask me?” or “Anything else you want to tell me?”.

Some patients will give you a few hints but others will not, which is fine because this question only takes a few seconds to ask and it can help you if you have somehow missed asking something very important.

One important thing in the history station is to respond to the patient’s complaints. For example, if he or she has got pain, you could ask the examiner to provide painkillers, or if the patient has photophobia you might offer to dim the lights in the room.

If the patient is forgetful or confused, they will likely answer your questions by stating, I don’t know or I can’t remember. In such cases, ask your patient, “Is there anyone who knows about your problem, and may I contact him to obtain some information? “ If the patient doesn’t know the names of their medications or is taking medications whose names you don’t recognize: Ask the patient if they have a prescription or a written list of the medications. If not, ask them to bring their list with them as soon as possible.

If the patient is hard-of-hearing, face the patient directly to allow them to read your lips. Speak slowly, and do not cover your mouth. Use gestures to reinforce your words. If the patient has unilateral hearing loss, sit close to the hearing side. If necessary, you can also write your question down and show it to them.

If you encounter a crying patient, allow them to express their feelings, and wait in silence for them to finish. Offer them a tissue, and show empathy in your facial expressions.

With the current pandemic situation, it’s probably best to avoid reassuring gestures such as placing your hand lightly on the patient’s shoulder or arm.

Don’t worry about time constraints in such cases? Remember that the patient is an actor and that their crying is timed for a certain amount of time. They will allow you to continue the encounter in peace if you respond correctly. If the patient is angry, stay calm and don’t be frightened. Remember that the actor is not really angry, they are just acting angry to test your response.

Let the patient express their feelings, and inquire about the reasons for anger. You should also reasonably address the patient’s anger.

For example, if the patient is complaining that they have been waiting for a long time, you can validate their feelings by saying, “I can understand why anyone in your situation might become angry under the same circumstances. I am sorry I am late. The clinic is crowded, and many patients had appointments before yours.”

Reassure the patient that now that it is their turn, you will focus on their case and take care of them.

If the patient is anxious, encourage them to talk about their feelings. Ask about the things that are causing the anxiety. Offer reasonable reassurance. You can also validate the patient’s response by saying, “Any patient in your situation might react in this way, but I want you to know that I will do my best to address your concerns.”

Performing a Clinical Examination in the AMC Clinical Exam.

Before you touch the patient, wash your hands with soap and dry them carefully. Make sure your hands are warm, so rub your hands together if they are cold.

Similarly, rub the diaphragm of your stethoscope to warm it up before you use it. Do not auscultate or palpate through the patient’s gown.

As you proceed, be sure to ask the patient’s permission before you uncover any part of his or her body (eg, is it okay if I untie your gown to examine your chest? or can I move the sheet down to examine your belly?).

You may also ask patients to uncover themselves. But you should expose only the area you need to examine. Do not expose large areas of the patient’s body at once.

After you have examined a given area, cover it immediately. If the patient refuses to let you physically examine them, don’t push.

What to do if a Patient Refuses a Physical Examination.

A patient in severe pain may initially seem unapproachable, refuse a physical examination, or insist that you give them something to stop the pain first. In such cases, show compassion for their pain. Say something like “I know that you are in pain.” Offer help by asking, if there is anything you can do to help them feel more comfortable?

It’s good to ask if the patient has taken any painkillers in the past few hours and if they are allergic to any painkillers before you prescribe any.

Then ask the patient’s permission to perform the physical examination first then offer painkillers next. If the patient refuses, gently say, “I understand that you are in severe pain, and I want to help you. The physical examination that I want to do is very important in helping determine what is causing your pain. I will be as quick and gentle as possible, and once I find the reason for your pain and to reach the diagnosis, I should be able to give you something to make you more comfortable.”

If the patient still refuses to cooperate, skip the physical examination or manoeuvre, and document the fact they declined the exam.

Conducting the Physical Examination.

During the physical examination, always examine the heart and lungs, even if very briefly.

Then move on to examining the system of interest to the chief complaint, eg abdomen, shoulder, neurologic, etc.

In other words, the exam should consist of listening to the Heart and Lungs + “The system of interest” depending on the chief complaint.

You can examine a body part that the patient says hurts.

Be gentle, do not poke too hard, apologize or say something nice as you do it, and do not repeat a painful exam manoeuvre.

If you see a scar, a mole (nevus), a psoriatic lesion, or any other skin lesion or bruise during the physical examination, you should mention it and ask the patient about it even if it is not related to the patient’s complaint and think about abuse as a possible cause.

When doing a physical examination, it’s often easy to get wrapped up in thought and not explain what it is you’re doing. Thus, you should show and describe that you’re performing a particular exam.

For example, if performing an abdominal exam and observing the patient’s abdomen, an out-loud statement of “Your abdomen doesn’t look distended, and there doesn’t appear to be any bruising” may earn valuable points as an alternative to simply staring at their abdomen for a few seconds.

Please note that you cannot do the following physical examinations in the AMC Clinical Exam:

• rectal
• pelvic
• genitourinary
• inguinal hernia
• female breast
• corneal reflex examinations.

If you believe one or more of these examinations are indicated, say them to the examiner.

Physical Examination in the Online Version of the AMC Clinical Exam.

During the online format of the examination, you cannot perform a physical examination but you have to ask the examiner for the findings.

Please use the same approach.

Firstly tell the patient that you will ask the examiner for the findings and then be pleased to the examiner and it does not hurt to say “Thank you” at the end.

Regarding the vital signs, the examiner will normally provide pulse, blood pressure, respiratory rate, oxygen saturation, and temperature but you should always specifically ask for them.

However, if you suspect a possible difference in e.g. blood pressure in the right and left arm, or if you expect an orthostatic or if there is a chance of coarctation of the aorta, you will have to specifically request the specific corresponding findings like blood pressure in right and left arm, blood pressure while lying and standing and radial as well as femoral pulses.

You need to realize that the examiner will only give you findings if you specifically ask. For example, it is pretty useless to ask “What are the findings on inspection of the abdomen?” or “Are there signs of liver failure?”, the examiner most likely will respond “What are you looking for?” This wastes a lot of time.

Please ask straight away “On inspection, I am looking for distension of the abdomen.” The answer will be “It is” or “it is not.”

Ideally, you should tell the examiner at the same time why you are performing an examination and what you expect to find and what the underlying problem could be, e.g. “I am looking for tenderness in the right iliac fossa over the McBurney’s point to confirm or exclude likely appendicitis.”

After the physical examination, you must “close” the encounter with some kind of compassionate statement that acknowledges the patients’ frustration by sharing what you think might be going on, and some of the tests that you will order:

• “I’m so sorry you’re dealing with this back pain, it sounds frustrating”
• “After hearing about your symptoms and doing the physical examination, I’m going to go over what I think might be wrong and what we can do to further figure it out.” This is a good indication of your intent to transition.
• “I’d like to order a few tests to address the most likely cause.”
• “Thanks again for your time. I’m very glad you came in today to get this taken care of.”
• “Do you have any other questions or is there any other aspect of your health care we haven’t already discussed?”

If you don’t have time for a full mini-mental status exam, at least ask patients if they know their name, where they are, and what day it is.

Note Taking

During note-taking, do not make up history or physical examination findings. Only write information that you obtained. Note any pertinent positive or negative history or physical examination findings. Note the diagnostic tests that you recommend and make sure these directly address your differential. Do not order unnecessary tests that you cannot justify. Do not order invasive or expensive tests if you can achieve the diagnosis with a less invasive and/or less expensive test.

Phone Cases

The AMC Clinical Exam will also include one or two phone cases, where a patient or a patient’s relative calls you with certain symptoms.

As with other encounters, patient information will be given before you enter the examination room. Once you are inside, sit in front of the desk with the telephone, and push the speaker button by the yellow dot to be connected to the patient.

Do not dial any numbers or touch any other buttons. You are only permitted to call the patient once. Treat this as a normal encounter and gather all the necessary information. To end the call, press the speaker button above the yellow dot.

As in the paediatric encounter, there is no physical examination. Here’s a basic outline:

• Take a focused but thorough history.
• Express empathy and use patient-centred communication skills.
• Decide if the patient’s concern can be addressed over the phone or if the patient needs to come into the clinic or the Emergency Department to be seen in person.
• In general, if the patient expresses pain, fever, wound redness or discharge after a procedure or surgery, then they likely need to be seen in person and examined.
• When in doubt, ask the patient to come in to be seen. If you think that the patient needs to be seen in person, do not let them talk you out of it such as by saying it is too late at night, or that transportation is difficult, this is likely a distractor. So apologize for the inconvenience, explain to them your differential and why it is important to be assessed in person.

Management and Counselling

You should be able to establish a probable or even definite diagnosis after a proper interpretation of the history. Make sure you have a systematic approach and plan your approach to physical examination, investigations and management:

• What would be the three most likely differential diagnoses?
• What would be important to concentrate on in physical examination and investigations to confirm or exclude diagnoses?
• Were there other important factors or risks in the patient’s history supporting one of the diagnoses over another?
• How do you explain the diagnosis and differentials including prognosis and possible complications to the patient?
• What is the most appropriate management for the main and other differential diagnoses, including lifestyle, counselling and prevention?

Often the diagnosis is clear very early, so tell the patient what you suspect it is in lay language and terms the patient understands. Ask the patient if they know the diagnosis and what they know about it.

If the patient seems hesitant to accept your diagnosis or advice, be prepared to change your mind if the evidence doesn’t support your diagnosis. This is very much a patient-centred examination and it is always appreciated if you draw a picture, a diagram or a decision tree as there are pen and paper on the desk to make your explanations clearer for the patient and the examiner and you can always add that you will give them a hand out to take home so they can remember what you said.

Investigations

Regarding investigations, it is not a good idea to ask for “Complete Blood Count, Electrolyte Sedimentation Rate, C-Reactive Protein, Urine Electrolytes, Liver Function Tests, etc.”

It is best to be specific and indicate to the examiner the relevance of why you order the test, what you suspected and what the test results would mean for either diagnosis or management and treatment.

Show perspective rather than ordering irrelevant and unnecessary tests!

For example, don’t just order a complete blood count in a patient with a suspected chest infection. It is much better to focus on the white blood cells count to exclude leucocytosis.

Order simple investigations first, especially office tests if applicable, and more complex investigations like CT and MRI will come later.

The most valuable office tests are the urine dip-stick, urine pregnancy test and finger prick for glucose.

Do not order unnecessary tests that you cannot justify.

Do not order invasive or expensive tests if you can achieve the diagnosis with a less invasive and/or less expensive test.

You should also explain to the patient the diagnostic tests you are planning to order. In doing so, you should again use lay language and terms.

For example, we need to run some blood tests to check the function of your liver and kidneys, or you need to have a chest x-ray and a CT scan of the head.

You might further explain the latter by saying, The CT scan is a form of x-ray imaging that gives us clear images of sections of the body.

Specific Types of Patients You May Encounter in the AMC Clinical Exam.

If you encounter a reserved, unemotional, or upset patient, remember that this is by design. Continue to engage the patient despite their difficult attitude. One of the best ways to do this is to describe your observation and ask them about it: “I see you are angry, would you like to talk about it?”, or “You seem quiet, is something bothering you?”

If you encounter a patient who uses drugs, alcohol, or tobacco, you will not have time to counsel them on each issue, although you should address them directly. One possible way to do this is to say supportive words such as “I’d like to spend more time with you to discuss this. Will you be back in 3-4 weeks so we can discuss it then?”

Wrapping Up With the Patient.

Always state the plan in layperson terms and if the patient is comfortable with the plan moving forward. Don’t use medical jargon, but simple language.

Sometimes you may want to use a medical term like “Subarachnoid Haemorrhage” to demonstrate your knowledge to the examiner. But you also have to explain in simple terms to the patient, i.e. that this is the space between the skull and the brain or ask the patient if s/he understands what you are talking about in the examination. The patient most likely will answer “Yes, I have heard that term before”, so there is no time wasted.

Explain the treatment options including both pharmacological and non-pharmacological options.

Explain red flags e.g. Hypoglycemia & Hyperglycemia in Diabetes & what to do if they happen.

Always ask for their understanding and if the patient has any questions. Don’t be too firm in your advice to the patient, rather present options. It is the patient’s choice what they are comfortable with.

Don’t be sucked in to say “Oh, yes, you definitely should have a hysterectomy” for example in menorrhagia. It is only one option of a range of management possibilities.

Make sure the patient understands the options available to them clearly.

If the patient does not accept your advice, e.g., Jehovah’s witness refusing to have a blood transfusion or have their children immunised, all you are expected to do in such a situation is to accept their point of view but to explain the issues and consequences to the patient.

In rare circumstances, you might have to refer to a guardianship board.

If the patient cannot pay for certain tests or treatments that may not be covered by Medicare, reassure the patient by saying, “Not having enough money doesn’t mean you can’t get treatment.” You might also add, “We will refer you to a social worker who can help you find resources.”.

The comment of “Don’t worry” does not go down well with the patient because even it is a trivial problem, the patient would be worried and they would think that you just don’t understand their chief complaint which is not a good start to develop a doctor-patient relationship.

Make Appropriate Referrals

Never forget that you’re acting as an intern or a junior medical officer. Don’t hesitate to ask for help or a second opinion from a senior doctor. At least mention that you would ask or check with them if you’re unsure. In some stations, it’s important to refer the patient to a specialist.

But. do not refer a patient to a senior doctor without explaining to the patient exactly what will happen. It is a mistake to try to get out of a situation by saying “I’ll refer you to the orthopaedic surgeon.”. You have to be quite specific about why and what will happen there.

Follow Up

Hand out a reading material they can take home so they can remember what you said.

Always provide a safety net by arranging a follow up often the next day, but maybe a few days or weeks later.

Be willing to reassure if indicated and medically possible and do not hesitate to arrange admission to the hospital if indicated.

Everything counts from your attitude, manner, voice, to your language. Don’t end the consultation in a way that patient feels more confused, threatened, without an option, or not being taken care of.

If time constraints dictate that you choose between a thorough physical examination and an appropriate closure, give priority to the execution of proper closure with:

• Initial diagnostic impressions.
• Initial management plans:
• Need for follow-up tests
• Ask the patient if they have any other questions or concerns.

Failing Some Stations

Most candidates fail a few stations, so be prepared for that.

Often there is one scenario that you might not know much about at all and you soon think that you have failed that station.

Remaining calm in unexpected or difficult circumstances is the key to surviving stations or even the rest stations. You may never know that you will still pass that station even if you don’t know much or you feel so bad.

It is extremely important not to think about it any longer, once you have moved past that station, clear your mind, forget about it, put it behind you and concentrate on the next station and believe in yourself. Even if a candidate fails the examination, it is not a disaster. A wise man said: “Failure is only a word, not a sentence.”

One Last Word of Advice

The last and the most important advice that I can truly give you is PRACTICE, PRACTICE, and PRACTICE.

The only way to pass this exam is to prepare well. The preparation time required will depend on your medical knowledge, your communication skills and how familiar yourself to the Australian healthcare system.

You may know every little detail in your book. But this is worthless if you cannot perform well. So please make sure not to rush and take as much time as necessary to practice a few times before you schedule your examination.

The Aftermath

Just a reminder that you also should look forward to your life after the examination and that means finding a job. Remember you need to have all your paperwork ready for provisional registration with the Medical Board of Australia.

The most common hold-ups are lack of current language certificate as it has to be within the last 2 years and the certificate of good standing from medical authorities in every country where you have been previously and currently registered. It happens regularly that International Medical Graduates are delayed or refused registration because of some aspects of the paperwork being missing.

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