11.3  Written Examinations

Clinical Reasoning in Examinations

  • While the focus of this book is practical exit examinations, there is significant overlap of with the material and techniques tested in written examinations. Strong clinical reasoning and management plan formulation makes passing practical examinations much easier, and indeed many candidates fail the practical examination not due to inadequacies in their examination technique, but instead in their clinical reasoning. It is therefore prudent to discuss these techniques in this book

Manage the Specific Patient Presented

  • In any scenario requiring management, the examiner is testing your application of knowledge, gained in training and through study, in that particular scenario. A detailed summary of all the material studied with respect to the patient’s problem(s) is unhelpful and provision of this will not receive a passing grade. Instead, the examiner is trying to ascertain if, when presented with that patient in your solo clinic, you could adequately manage their presentation. It is essential to concentrate on the following aspects of the particular patient:
  1. Clinical uncertainties
  2. Multiple diagnoses, and their interaction
  3. Medical history
  4. Occupation
  5. Driving requirements
  6. Social history, responsibilities and limitations
  7. Barriers to compliance
  • For example, a question may present a patient with keratoconus and ask you to discuss your treatment plan. The correct answer will be very different for a 35-year-old pregnant female who drives commercially and a 20-year-old man with an intellectual disability and low visual requirements. Your answer must demonstrate you understand these differences and can treat the patient presented

Using All Available Information

  • Written examination questions are prepared long in advance and are reviewed and edited many times before they are finally used. All information given is specifically chosen. No extraneous information remains after this editing process. It is very rare for misleading, irrelevant information (a “red herring”) to be given. Therefore, if you make a specific effort to use every piece of information given in the question, you will pick up on the aforementioned patient specifics and give a better answer
  • Some commonly ignored information in the questions, which alters management, are listed below:
  1. Gender
  2. Ethnicity
  3. Medications and comorbidities
  4. Occupation
  5. Specific visual acuity (with reference to driving and perhaps aviation standards)

Give A Balanced Answer

  • This examination is testing whether you are safe and competent, not brilliant or brave. Given the choice between two management options, it is usually safest to pick the “boring” option. If you could give your answer at a meeting and attendees would fall asleep then you are on the right track. Be the “grey man” – neither cavalier nor cowardly, without error of inclusion or exclusion – and the examiner will, by default, pass you

Time Management

  • You must be ruthless with your time management in written examinations. After months of study you will often know much more than can be included in an answer in the given time. The best answers are often quite short and to the point. Spend time brainstorming during reading time, then start the question by refining your plan for your answer, before starting to write. Leave a minute to review your work. Once the time for a question is up, move on
  • Once you are comfortable with your ability to turn plans into full answers, you can quickly cover past questions by only formulating the answer plan (in the allotted time)

Red Flags

  • Often questions will contain a “red flag” component – a critical diagnosis or treatment that must be considered or implemented, as failure to do so will blind or kill the patient. Sometimes these red flags are obvious, but scour every question for subtle red flags and mitigate these risks
  • Some common “red flags” include:
    • Pregnancy (with treatments contraindicated in pregnancy)
    • Giant cell arteritis (in any patient over 50 with acute vision loss or diplopia)
    • Intraocular tumour (when the fundus is obscured)
    • Aneurysmal third nerve palsy (in any patient with acute onset non-esotropic diplopia or ptosis or mydriasis)
    • Horner’s syndrome (in any patient with acute onset miosis or ptosis)
    • Intracranial tumour (in any patient with disc swelling or headache)
    • Myasthenia gravis (in any patient with acute onset variable diplopia or ptosis)
    • Serious systemic illness, for example malignant hypertension, presenting with ophthalmic symptoms
    • Non-accidental injury (in any paediatric patient with signs of trauma)


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