What is a long case
The best analogy that has been put forward to me is that a long case is simply an organised discussion between two physicians. More specifically, a junior physician discussing the points of a case they have seen with their more senior colleagues. The patient belongs to the junior physician - they are in charge of the patient, and they take ownership of the management. As such, the ideal candidate will walk into the consultation with a view to 'owning' the patient, with a real desire and need to 'sort' out the most salient issues in a reasonable and well balanced manner.
In terms of the RACP examinations, the long case consists of three parts. the first part is where the candidate spends 60 minutes with a patient, effectively taking a history and examination (analogous to the initial consultation). The second part is where the candidate spends 10 minutes formulating their thoughts and management plan. The final part is where the candidate undertakes a mature discussion with two (or three examiners - one being a local observer learning to be an examiner). The final part consists of a 25 minute discussion. This discussion is split into the presentation of the history and examination, followed by a discussion of the issues raised throughout the initial consultation.
The examiner's always have a brief prior to the examination week - and that is to inform them that this is not an examination of knowledge. It is not sufficient that the candidate know the differentiating CD molecules of T cell lymphoma's. Rather, they are expected to have a mature, well balanced and reasonable discussion and management plan concerning the patient that has been presented.
The structure of presentation is broken down into the following steps.
1) Introductory statement
2) Medical History
3) Social History
4) Examination
5) Closing statement and issues.
In terms of the RACP examinations, the long case consists of three parts. the first part is where the candidate spends 60 minutes with a patient, effectively taking a history and examination (analogous to the initial consultation). The second part is where the candidate spends 10 minutes formulating their thoughts and management plan. The final part is where the candidate undertakes a mature discussion with two (or three examiners - one being a local observer learning to be an examiner). The final part consists of a 25 minute discussion. This discussion is split into the presentation of the history and examination, followed by a discussion of the issues raised throughout the initial consultation.
The examiner's always have a brief prior to the examination week - and that is to inform them that this is not an examination of knowledge. It is not sufficient that the candidate know the differentiating CD molecules of T cell lymphoma's. Rather, they are expected to have a mature, well balanced and reasonable discussion and management plan concerning the patient that has been presented.
The structure of presentation is broken down into the following steps.
1) Introductory statement
2) Medical History
3) Social History
4) Examination
5) Closing statement and issues.
Introductory statement
I have been told that some examiners will come to a conclusion about a pass or fail simply based on the opening and closing statements. Thus it pays to put extra time into perfecting this part of the discussion. An introductory statement should start of with a bang and place the patient in the context of their major illness. For example "A 64 year old male with the management problem of debilitating steroid refractory rheumatoid arthritis" does not pain the same picture as "A socially and geographically isolated, recently unemployed 64 year old male ex-carpenter with the management problem of debilitating, activity limiting steroid refractory rheumatoid arthritis". It should then lay the table of contents for your following discussion.
If you listen the discussions between two physicians, you will see that the introductory statement of a long case follows a similar, stereotypical structure to that in the introduction of a discussion between two colleagues. Here are a couple from my long cases (altered for confidentiality purposes).
" I reviewed Mr AB, a socially isolated, frail and cachectic 48 year old caucasian male, recently unemployed with the management problem of newly diagnosed metastatic adenocarcinoma of the oesophagus. This is in the context of moderate-severe asthma-COPD overlap syndrome, polycythaemia rubra-vera, significant and major depression complicated by alcohol, tobacco and marijuana dependence"
"I reviewed Mrs XR, a well-suported but dependent 89 year old widower with the management problem of progressive cognitive decline and intermediate risk acute coronary syndrome in the context of multiple cardio-metabolic risk factors including diabetes with micro and macrovascular complications, poorly managed hypothyroidism and progressive immobility secondary to polyarticular osteoarthritis"
" Mrs MC is a highly motivated but increasingly dependent 78 year old, morbidly obese female of portugese descent with the management problem of debilitating and activity limiting osteoarthritis, combined variable immunodeficiency syndrome complicated by bronchiectesis and polypharmacy. This is in the context of multiple cardio-metabolic risk factors including non-insulin dependent type 2 diabetes with multiple micro and macrovascular complications, sight threatening macular degeneration, and loco-regional carcinoma of the breast"
Essentially the introductory statement is intended to capture the examiner's attention, paint a vivid picture of the patient with the salient points that identifies to the examiner that the candidate has understood the major factors contributing to the patient's ill health (social and medical).
The introductory statement is of vital importance. I have been told that it is best to write out an opening statement verbatim. Time should be spent conceptualising this statement (and the closing statement) in the 10 minutes allocated after seeing the patient and before discussion begins with the examiner.
If you listen the discussions between two physicians, you will see that the introductory statement of a long case follows a similar, stereotypical structure to that in the introduction of a discussion between two colleagues. Here are a couple from my long cases (altered for confidentiality purposes).
" I reviewed Mr AB, a socially isolated, frail and cachectic 48 year old caucasian male, recently unemployed with the management problem of newly diagnosed metastatic adenocarcinoma of the oesophagus. This is in the context of moderate-severe asthma-COPD overlap syndrome, polycythaemia rubra-vera, significant and major depression complicated by alcohol, tobacco and marijuana dependence"
"I reviewed Mrs XR, a well-suported but dependent 89 year old widower with the management problem of progressive cognitive decline and intermediate risk acute coronary syndrome in the context of multiple cardio-metabolic risk factors including diabetes with micro and macrovascular complications, poorly managed hypothyroidism and progressive immobility secondary to polyarticular osteoarthritis"
" Mrs MC is a highly motivated but increasingly dependent 78 year old, morbidly obese female of portugese descent with the management problem of debilitating and activity limiting osteoarthritis, combined variable immunodeficiency syndrome complicated by bronchiectesis and polypharmacy. This is in the context of multiple cardio-metabolic risk factors including non-insulin dependent type 2 diabetes with multiple micro and macrovascular complications, sight threatening macular degeneration, and loco-regional carcinoma of the breast"
Essentially the introductory statement is intended to capture the examiner's attention, paint a vivid picture of the patient with the salient points that identifies to the examiner that the candidate has understood the major factors contributing to the patient's ill health (social and medical).
The introductory statement is of vital importance. I have been told that it is best to write out an opening statement verbatim. Time should be spent conceptualising this statement (and the closing statement) in the 10 minutes allocated after seeing the patient and before discussion begins with the examiner.
Medical History
If the case poses diagnostic problems, start with this making sure that you take great care into establishing chronology of symptoms, relevant positives and relevant negatives. Remember to use mnemonics such as SOCRATES for patients who present with pain - this will mean that you will not forget any salient points
For management problems, start with the most relevant. Often you need to ask the patient which specialist do you see most frequently, or what is your main pressing medical condition. For each condition take a detailed history. I use the mnenomic PIRMC to help remember the relevant features.
For management problems, start with the most relevant. Often you need to ask the patient which specialist do you see most frequently, or what is your main pressing medical condition. For each condition take a detailed history. I use the mnenomic PIRMC to help remember the relevant features.
- Presentation of problem
- What were the symptoms that led to the diagnosis, eg polydipsia and polyuria in diabetes, crescendo angina in acute coronary syndrome, progressive dyspnoea and dry cough in idiopathic pulmonary fibrosis
- Investigations that lead to the diagnosis
- Eg US and subsequent triple phase CT scan showing evidence for hepatitis, PET scan confirming metastatic disease, endoscopy confirming oesophageal carcinoma
- Risk factors
- Family history, smoking, previous chemotherapy for cancer's etc
- sun exposure for melanoma, cardiometabolic risk factors for ischaemic heart disease
- Management
- GP managed? Specialist managed? how often is follow-up?
- Include acute management steps - eg IV antibiotics
- Non-pharmacological management
- eg dietary modifications, physical activity
- Primary prevention
- endoscopic band ligation program for identified oesophageal varices
- Secondary prevention
- Surgical intervention
- CABG, AICD
- Complications
- Of disease
- Of Treatment
- classic = steroid related complications
Medications and Allergies
The majority of the medications should be presented alongside the medical history. Make sure additional medications are presented in this section. Do not forget allergies
Family History and Social History
The social history is arguably the most important aspect of the medical history. It gives context to the person, and it is the person who has the disease. As has been explained to me many times, the major reason for a candidate to fail a long case is if they havent considered the patient with the disease. That is, if a candidate knows the rigorous requirements for a liver transplantation but fails to recognise that this patients geographical isolation combined with their social instability and lack of supports, with entrenched fear of a health system that he has perceived to have failed him a number of times would make transplantation incredibly difficult, then it is clear that the candidate hasn't reached the maturity required to progress to advanced training. Here is a mnemonic that I used to remember some of the salient points of the social history. I make sure that I spend a significant portion of time covering these points. Remember that the examiner's often do not have time to take a detailed social history, and therefore expect that you have done so.
A: Advanced Care planning, Alternative and complementary medicine practices, Alert bracelets +/- vitacalls
B: Boarding (Home – modifications, steps, distance from appointments, distance to family, liveability), Barriers to making appointments (child care, affordability, distance, availability of care-giver)
C: Care-giver: Who is primary carer, carer stress, availability of carer, crisis plan if primary carer is sick
D: Depression (and other mental health states – self harm, positive and negative symptoms), Diet & Exercise (Meal size, frequency, snacking, calorie counting, knowledge of food), Drugs (Alcohol, Smoking, IVDU, marijuana etc), Driving (Licencing requirements)
E: Education (English literacy, level of schooling), Employment (Current status, job)
F: Finances (Primary source of income, welfare support, adequacy),
G: Goals (What patient expects to achieve) Gender identification (+/- sexual practices), General practitioner (regularity, home visits, availability, relationship)
H: Health promotion (healthy behaviours amongst close social contacts)
I: Ideas, Concerns, Expectations, Insight, Compliance
A: Advanced Care planning, Alternative and complementary medicine practices, Alert bracelets +/- vitacalls
B: Boarding (Home – modifications, steps, distance from appointments, distance to family, liveability), Barriers to making appointments (child care, affordability, distance, availability of care-giver)
C: Care-giver: Who is primary carer, carer stress, availability of carer, crisis plan if primary carer is sick
D: Depression (and other mental health states – self harm, positive and negative symptoms), Diet & Exercise (Meal size, frequency, snacking, calorie counting, knowledge of food), Drugs (Alcohol, Smoking, IVDU, marijuana etc), Driving (Licencing requirements)
E: Education (English literacy, level of schooling), Employment (Current status, job)
F: Finances (Primary source of income, welfare support, adequacy),
G: Goals (What patient expects to achieve) Gender identification (+/- sexual practices), General practitioner (regularity, home visits, availability, relationship)
H: Health promotion (healthy behaviours amongst close social contacts)
I: Ideas, Concerns, Expectations, Insight, Compliance
