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.

Summary

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.

Final preparation for x-ray

Finally finished the Part 4 Reviews and Florida! it has been a hectic 6 weeks of constant lectures. I still have a mini x-ray class tonight. I have had little time to post all I wanted to write.

I know, been totally remiss in updating this blog. Oh well, better late than never...

Regarding the x-ray exam: 

1) Make sure you know your radiographic signs. Know what the signs are for. At this point don't worry about what the signs look like, or how to identify them. The key is to know which answers are bogus and which are relevant to the condition.

2) Remember that history is key. The age and sex is important to note as you will be able to eliminate a few detractors. Obviously the history may be the most important clue to your answer.

3) Stick with the test-taking strategies that I covered in the Review. Decide which side of the equation you want to answer first. That will give you diagnostic leverage to the rest of the question.

4) Expect more "mainstream" conditions. Don't look for the oddball, low call conditions. Remember, the Board's objective is to test you on things "commonly encountered in practice". They are not out to trick you or test you on the bizarre. If you haven't heard the term, or don't recognize the condition, it is probably wrong. In other words, the answer is likely to be a fracture, arthritis or cancer, rather than something obscure like a Morquio's, or sickle cell anemia. 

5) Most important of all is to scan the choices first, don't scan the film. Don't look for something that is not there. Remember 2 of their answers are correct, so look for them. If it's not on a choice, it is not the correct answer.

6) Watch your time!

7) Start at the correct number on your scantron.

If you have any questions, please post it here and I will respond as soon as possible. I will be checking back several times a day over the next few days. 

I will appreciate your feedback after the test.

I will post few more thing up later over the next few days, so bookmark this page. 

Introduction

Well, I finally got around to starting a blog. I was always hesitant to do so since blogs seemed to be (for many) a bit of a soap-box to yell from.

I realized that the blog is perfect solution to a problem that I have had over my 25 years of teaching Board Reviews to Chiropractors.

I speak to hundreds of Chiropractic students and DC's each year, either to discuss their questions or concerns about the exam, or getting feedback about their experiences with the National Boards. The problem I had was this bottle-neck; relaying the information on to our students on a timely and efficient manner...

This site is the solution to that problem.

Now I can pass on information and the experiences of people who have taken the exam to those who haven't. I will be able to address any changes or trends of the Board. You can also ask questions, or post your experiences or insight to help others.

I am excited about the potential of this forum.

If you will be taking the exam, you might pick up that one tip that will make the difference in your test. And with your input, if you have taken the exam, we help others in their last hurdle for licensing.

So feel free to post your questions and comments. Or start another thread detailing your experience with the test