Wednesday, December 24, 2008

Understanding the patients on Part 4

"Ten of the case management stations will have standardized patients..." – from the National Board Part 4 PDF

One of the unique aspects of the National Boards Part 4 Exam is the manner in which the patients are utilized on the exam. 
In the past, when state boards were the only way to get licensed as a D.C., patients were simply a body that you used to perform your procedures and set-ups. Boards could just as easily used a mannequin instead!
On Part 4, the patient's role, and how you need to treat and handle them is different from state boards, and your proficiency exams in school.
Understanding their role, and how they affect your objectives will be essential to your success on the exam.

What is the patient's job, and what will they do?
"... have been carefully trained to simulate a given condition."  – Part 4 PDF

The Part 4 Exam of the National Boards is a standardized exam. This means that the test questions are the same, no matter whether you take the exam in New York, Dallas or Los Angeles. The patients on Part 4 are also "standardized". In other words, the possible responses you can get from the patients, will also be the same.

The patients are not just a live body for you to perform your exams on, but also to interact, respond and react as an actual person would. This is important because your ability to elicit their responses, both physical and verbal, will be crucial to your diagnosis and your score.

The patients will be normal (that is, have no actual condition), but they are trained and scripted to play or simulate a clinical condition or disease. This means they have been instructed to provide positive (or negative) responses to any procedure that you are asked to perform, and only those procedures. If you do a procedure that is not listed, you will get no points, and you will get a non-response from the patient.

Keep in mind that whatever procedure you do, there are things a patient can fake. They might complain of things such as pain, or numbness, or demonstrate a decreased range of motion. If they complain of pain with Dawbarns' test, you might suspect sub-acromial bursitis. If they have no pain, you can rule out that diagnosis.

However, there are a lot of things a patient cannot fake: such as pallor, jaundice, or papilledema. Since a patient cannot fake abnormal pulsations, if you are asked to palpate the abdomen, you can definitively rule out aortic aneurysm as their simulated condition! You may get a finding of pain, but that would suggest a different condition.

So keep in mind, whatever you do, you are always looking for some response from the patient.

Also, the patients have also been scripted to give you additional or background information about their condition, if you ask follow-up questions (and only if you ask). The examiners are not just grading you on HOW you perform a procedure and if you are able to elicit or recognize the response from the patient, but also whether you ask the pertinent questions. So performing Gaenslen's test and getting the patient to say it reproduced their complaint would be only part of your objective. You might also need to get the patient to reveal they have progressive stiffness of their back, and restricted deep breathing. These questions (and others) would allow you to recognize they are simulating ankylosing spondylitis.

Finally, even though the patients are standardized, not every examinee will walk out of the room with the same information. This is because not every examinee will perform the exams effectively, or interact and acquire information from the patient like they should. The patients are instructed to only give information if you ask the questions. So if you don't ask, you lose!

Always ask follow-up questions with your procedures.

What is the Board looking for?
"Examinees will be evaluated on their ability to perform these procedures within the context of a specific case, and their ability to elicit all necessary clinical signs and symptoms from the simulated patient  for each of the procedures demonstrated." – Part 4 PDF

Finally, the Board also grades you on your doctor-patient interaction and communication. They want to see whether you treat the patient in a professional manner, and with dignity, and respect. In other words, did you explain what you are doing to the patient? Did you make sure the patient was comfortable, and express concern and empathy for their problem? Did you talk and treat the patient like you care about them as a person? Or, did you ignore the person and handle them like they are just a body?
On occasion, the Board might give you a patient who is uncooperative, or antagonistic, or apprehensive. In situations like these, the Board wants to see how you would handle a real-life situation.

Treat the patient as if they are real.

So on the ten case management stations of Part 4, always keep in mind these critical rules:
1. The patients are trained and scripted to play a clinical condition.
2. Perform all procedures with the objective to get a positive (or negative) response.
3. Ask follow-up questions to get or confirm your diagnosis. If you don't, you will not get an answer and lose points.
4. Treat the patients as if they are real; with respect, and as though they really have the condition (be gentle with a whiplash!)

If you keep these rules in mind and follow them, you will maximize the points for the case management, and get the findings for your diagnosis.


  1. hey dev, was wondering about your reference to Dawbarns test. Isn't it positive if the pain is relieved upon abduction of the arm or you feel a click under your hand?? thanks -v. snider

  2. First of all, love the picture of you with a 'tash.
    Second, on your X-ray $$ page, you have a few terms that I have some question on.

    ~ "sunburst appearance" is labeled as hemangioma. Isn't this associated with osteosarc?
    ~ "candle flame" is a Paget's shin... but is the difference between that and "candle wax appearance" for DISH the location?
    ~ Does "whiskering" have to appear at the SI joint?

    I cant find you on AIM and I dont even want to associate myself with twitter. Hope this finds you well!

  3. Thanks, That's my Porn star look.
    1 Yes the sunburst periosteal rx is for osteosarcoma, but also hemangioma. I can't tell you where, but that is straight from Yocum. I doubt you'll get that.

    2. Candle flame is for pagets of long bone. It is seen internally. The candle wax, or "melted wax" is for DISH and that is anterior to the spine.

    3. Whiskering can occur anywhere enthesopathies occur; in psoriasis of the fingers, or heel or SI. Reiters, and AS give whiskering too.

    4. Twitter? hater!

    5. Do the tests. They will not be up past tomorrow night.


  4. Dr. Batungbacal I have a question about scores. How does one lose 400 points on the board exam (i.e. just doing the ortho tests without communicating this to the patient, not doing the exam bilaterally,etc.)? I also heard the boards give points for asking the patient questions after performing the ortho test but 5 minutes is not enough time to carry all these activities out. I just want examples to get an understanding for scoring on the brink. I also wanted to know if messing up just on one of two technique moves in a station is significant to one's score?


    Chiro student

  5. Chiro Student,

    This question, (how they grade), is a rather complicated and in depth issue to answer in an email or a post. I actually have plans to publish a series of blog articles in the future, but for now will try to answer your questions.

    First I am in a small minority who feels they are NOT looking for you you do all the tests bilaterally.

    Yes, asking questions before during and after the ortho tests is important! I don't have the time or space to put all the evidence here, but I will give you a few examples.

    Here is the first, immutable fact. The patient is trained and scripted to respond physically and verbally during the exam. But to get the responses, you must perform the tasks and ask the questions.

    Asking questions is essential to the Post stations. In other words, sometimes it will be difficult to make a diagnosis without their response. For example: Last year one station had several ortho/neuro tasks (related to the SI region) to perform on a 21 year old male. The people who just performed the tasks failed. The people who performed the tasks found out the patient had stiffness and thought it was AS. The people who also asked additional questions found out he had a history of chlamydial infection and heel pain KNEW he had Reiter's. So the questions had a direct impact on the Post station. I always say, your success on the Post is directly related to your effectiveness on the PRE (or SPE) station.

    Is there a point value to asking questions on the Pre (SPE)station?

    We are 99% certain it is. In the past, we have asked students to pay attention to the examiner even after they have completed the tasks and are sitting down, talking to the patient. We have many people who told us that they were still being graded.

    One good example: One person told us that on one station she had finished the tasks with plenty of time but was uncertain of the patient's diagnosis. She said the examiner took her grade sheet and placed it upside down in the completed/graded pile. She decided she had nothing to lose so she stared asking questions. When she asked about "unexplained weight loss", not only did the patient say "yes" (giving her the diagnosis), but the examiner actually grabbed her grade sheet from the stack gave her the point(s). That one question not only helped her on the Post station, but clearly had an impact on her Pre (SPE) station.

    Yes, 5 minutes is not a lot of time for some, but it is enough time to perform the tasks efficiently and still ask the questions. (This is one small reason why I feel performing the tasks bilaterally is nonsense).

    In answer to your last question; No, you cannot fail the exam because of a couple set ups on technique. Remember, the scores from the 3 sections are combined into one grade. So if you blow one section, you can still pass if you do well in the others.

    Technique is worth maybe 10-15% of your overall score. And as further evidence, I know of a few who failed the technique section, but still passed exam. (This comes from people who passed the exam but requested a breakdown of their scores).

    Considering the space and time limitations here I hope that helps. It usually takes me a few days in the live class to fully convey all the evidence and rationale behind the grading and strategies.

    Good luck on you results!

  6. Just proving I got into the whole blog action.......thanx Dev!!!

  7. Getting ready for Part 2retake chiro prac and part 4 in sept/nov. I'm so glad I found this blog will be taking to you about your upcoming classes for those test. Nothing more motivating than having to work at grocery stores until you can get in to practice. Just wanted to express my apreciation for your efforts. Bless you!

  8. I hear you! It helps to have a little "real world" motivation behind you.

    Feel free to contact me if you have any questions.