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