Tuesday, 12 July 2016

The Chronic Liver Failure Lesson



Dr. BK (fictional name), when still a MBBS student, appeared for his first surgery ward posting clinical exam in 3rd semester in AIIMS, New Delhi. In the 3rd semester posting, it is expected that the student should know the basic clinical history taking and general physical examination.
Everyone was amazed when Dr. BK got 80% marks when the class average marks were in the range of 55 to 65%.
On enquiring it was found that Dr. BK was asked about the signs of chronic liver failure in exam, which he answered brilliantly. This one answer was enough for him to top the exam.
On further inquiry it was found that in the night before exam Dr. BK has specifically prepared the answer to the question, ‘what are the signs of chronic liver failure?’
So, how did Dr. BK knew before hand that he will be asked about the signs of chronic liver failure in exam and prepared accordingly.
Did he enter in a deal with the senior residents allotting the case to get a case of liver failure allotted to him? On enquiring it was found that the case allotted to him was not having liver failure and was randomly allotted to him?
Did he entered in some kind of deal with the examiner so that he will ask him about the signs of liver failure, no matter what the patient was suffering from and prepared accordingly? This was not the case as the examiner was quite fair and strict examiner.
Did Dr. BK consulted some psychic to tell him the question which will be asked in the exam the next day? No, nothing like this. 
So what was the answer to this mystery of preparing a specific answer in exam to get topper level marks?
On deeper investigation into the matter the mystery behind Dr. BK’s success revealed some interesting facts.
In the exam viva, when his turn came, Dr. BK presented the clinical history of the patient and answered the examiner’s question regarding it, similar to other students.
When it was the time for presenting general physical examination findings, Dr. BK also presented his findings of the patient's vital signs such as pulse rate, respiration rate, blood pressure and temperature similar to other students.
Now he came presenting the general signs of health regarding anaemia, jaundice, chest and heart, etc.
Normally, the students say, there is no pallor (for anaemia), no cyanosis (for breathing and heart failure), no raised JVP (for heart condition), no icterus (for jaundice, usually due to liver failure), etc.
Dr. BK, after saying, there is no pallor, no cyanosis, no raised JVP, no icterus, added, with a slight cockiness in his voice, “Sir, there are no signs of chronic liver failure in this patient’’.  This was expected as there was no liver illness in the patient allotted to Dr. BK.
The examiner was piqued by his confident statement, that “there are no signs of chronic liver’’. Usually in 3rd semester, students do not comprehensively know the signs of chronic liver failure, which can literally effect from head to toe.
With an aim to take Dr. BK a peg or two down, he asked, “And, what are the signs of chronic liver failure which you looked for in this patient?”
Dr. BK, replied, “Sir, starting from head, there is no loss or discoloration of hairs, no icterus, no loss of axillary (armpit) hairs, no gynecomastia (enlargement of breast in males)”… and so on till “no white, brittle toe-nails.”
The examiner was amazed at the depth and thoroughness of his knowledge and gave him 80% marks, while most students in his batch got 55 to 65% marks only.
Dr. BK knew before hand that, in the surgery exam he will be asked about anaemia, jaundice, etc. which he studied same as other students. In addition, in the night before exam, he had specifically prepared in great detail, the signs of chronic liver failure.
Usually examiner asks the details related to the patient’s illness and condition.
Even though, the patient was not having any liver illness, while presenting the general physical finding, his cockiness and confident statement, ‘that there are no signs of chronic liver failure in this patient’ was akin to waving a red flag in front of a bull.
The examiner could not avoid cross-examining his statement, which he replied with his thoroughly prepared answer.
This technique is forcing or leading the examiner to ask you some question which you are well-prepared.
It requires you to prepare in great details and beyond your expected level of knowledge, answer to some question, you will be likely to be asked in exam.
The question should be related to some point which you are going to be asked routinely, so that you can link the question to it. In this case, all routinely say, jaundice in not present, to which he linked, signs of chronic liver failure.
Make generalized statement, for which the examiner will demand details, to see if your statement is justified.
While making this generalized statement, there should be confidence and even a bit of cockiness in your voice and body language, so that the examiner take it as a challenge and ask you to justify your statement. Look the examiner in the eye when making your generalized statement.
Don’t give details until specifically asked for. For e.g. Dr. BK, could have told the details of signs of chronic liver failure without being asked, but he reserved it for next question.
So, with a little before-hand preparation, you will be able to force the examiner to ask you favourable questions, creating a good impression for you.
But beware, overconfidence and cockiness in general should be avoided in exams and interviews, to avoid antagonizing (angering) the examiner. This is a high risk to high reward game, and not all will be able to pull it off brilliantly.

(Based on true incident)
— ND
© Author. All rights reserved. 

DISCLAIMER: This article is intended only for fun purpose. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use of the information herein is at you one's own risk. Before trying to emulate or follow anything the reader is well advised to take into account ethical, moral, legal and other considerations. The author recommends that Medical Education should be of the highest ethical and moral level keeping in mind the interest of the patient as foremost and according to MCI and other Board’s norm. 
 
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