Samson Handbook of PLAB 2 and Clinical Assessment

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SECTION 1

Guide to Samson Handbook of PLAB 2 and Clinical Assessment

ABOUT PLAB 2 (old PLAB 2)

Professional and Linguistic Assessment Board (PLAB) part 2

The PLAB test is the main route by which International Medical Graduates (IMGs) demonstrate that they have the necessary skills and knowledge to practice medicine in the United Kingdom.

PLAB part 2 is an Objective Structured Clinical Examination (OSCE). It consists of 17 OSCE stations. Of these, one is a rest station and two are pilot stations. Very rarely there may be only one pilot station.

This leaves 14 active clinical scenarios or stations which will contribute towards the results.

REST STATION:

A 5-minute rest station is part of the exam, during which a candidate has no clinical scenario or task to tackle. The rest station can fall at any point in the exam; at the beginning, in the middle or at the end.

The main pitfall to look out for here is to avoid thinking excessively about any mistakes you might have made in the previous station(s). Try to maintain a positive and composed attitude.

PILOT STATION:

A pilot station is one where the GMC checks whether a station can be used in future examinations. Pilot stations are usually new scenarios.

The marks for pilot stations will not count towards the final results. It is, however, difficult to know which one is a pilot station. Therefore, the candidate should try not to approach any station casually because even scenarios that appear for the first time can end up being active stations.

There will be 16 candidates sitting an exam in one batch and there are usually three batches in a day:

The 9 a.m. batch, 11 a.m. batch and the 2 p.m. batch, which comes to a total of 48 candidates sitting the PLAB 2 exam each day.

Candidates are usually given a particular time to come for the exam. Usually, candidates sitting the exam at 09:00 a.m. are asked to come at 08:00, the 11 a.m. batch will come at 09:00 a.m. and the 2 p.m. batch will come at 10 am. The times are usually specified in the candidate’s PLAB 2 booking confirmation email. It is advisable NOT to come later than the specified times. Candidates who come in after the stated time might not be allowed to sit the exam.

Each station lasts five minutes. An additional minute is allocated to read the scenario before the candidate enters the cubicle. There are 17 rooms or cubicles and each candidate will be placed outside each room before the exam starts.

When the exam starts, candidates will be moving from one cubicle to the next, following each other until all the 17 stations are completed. Therefore, some candidates might have the rest station as their first station.

ONE MINUTE READING TIME:

A minute is allocated to read the scenario while standing outside the rooms. This time must be used very well. It is advisable NOT to use this time to think about the mistakes made in previous stations but to concentrate on the current station.

You are encouraged to read and understand what the task requires and think of how to begin the station i.e. does the patient know about all the information given in the question or do I need to inform him? What will be my opening phrase?

If you feel that there was not enough time for you to read everything in one minute, there is a copy of the same question inside the cubicle. You can read the task again once inside the cubicle but remember the 5 minutes will have already started and therefore you will be using your precious 5 minutes.

On the other hand, it is pointless to start performing a task which you did not understand very well. Therefore, it is better to read the task again, even if it means using some of the five minutes.

THE FIVE MINUTES:

After one minute of reading the task outside the cubicle, you will be asked to enter the station. You will meet the examiner inside the cubicle, who will check your name and candidate number on your badge. The badge will be provided by the GMC on the day of the exam upon arrival. You will be expected to wear the badge for the entire duration of the exam.

The examiner will usually take their time to write your candidate number as it is important for them to know who they will be examining. By the time you start the real task you will have spent about 30 seconds of the five minutes, especially if you read the task again inside the cubicle.

When there is 30 seconds remaining to finish the task, you will hear a reminder bell: "The task is 30 seconds remaining". This is called the 4:30 bell.

Therefore, you lose about 30 seconds in the beginning taken partly by the examiner and partly by you as you walk into the cubicle. So the actual time left to perform the task is approximately four minutes.

It may sound little, but if you understand the task and do only what it asks of you, there is enough time. In fact, in most of the stations, you will manage to give the patient all the information required and still have time to spare. There are, of course, some stations which will be difficult to complete due to the time factor, but you are not always expected to finish the task, especially in counselling stations.

At the end of the five minutes, you will hear a bell telling you to move on to the next station.

During the five minutes, you will not be provided with pen and paper to write anything down. You should keep all the information in your head. The only time you will be provided with pen and paper is in scenarios where you are required to explain a procedure to a patient and drawing may help the patient to understand better e.g. when explaining hemicolectomy with primary anastomosis, ectopic pregnancy, open ovarian cystectomy, vasectomy etc. But you will NOT be provided with pen and paper in all stations where you are required to explain a procedure or an operation.

It is therefore important to check in each station if you have been provided with these. If so, failure to use them may result in scoring low marks and possibly not passing the station. However, if you are not provided with pen and paper, you do not need to ask for them.

The rule is therefore: if provided with pen and paper and you do not use them, it is a mistake.

The other stations where you will be provided with pen and paper are Mini Mental State Examination (MMSE) and Insulin dose calculation. In these two stations you are always provided with pen and paper because you need to write things down.

You can view the candidate briefing video by following this link:

www.gmc-uk/doctors/plab/osce/briefing.asp-gm/osce briefing video.

AFTER THE EXAM:

Usually after the exam, you will feel bad and hopeless. A feeling that you are worthless, you failed to perform or a feeling like you have been robbed.

Most of the time you will not know whether you have passed or not. In fact, you will be convinced that you have failed. But the results will surprise you; "We are pleased to tell you that you have passed the PLAB 2 exam."

Usually people who feel that they did very well after the exam end up being disappointed when the results come out as a fail. Though not everyone who feels like this fails the exam.

The reason for this is that, if you concentrate on making the simulators happy, you might not be happy with your performance in the majority of the stations.

Those candidates who focus on telling the patient as much information as they can, tend to be happy with themselves for having delivered all the information they wanted. But the examiner is not only looking for knowledge, he is also looking for patient-doctor interaction.

PLAB 2 RESULTS:

You will be told on the day of your exam when your PLAB 2 results will be out. It usually takes 10-14 days.

FEEDBACK IF YOU PASS:

You will not be given any feedback if you pass the exam. You will receive this phrase via email: We are pleased to tell you that you have passed the PLAB 2 exam.

FEEDBACK IF YOU FAIL:

You will receive the station breakdown. i.e. which stations you passed and which ones you failed. Also you will be told of your overall score (please see marking system section). You will NOT receive an explanation as to why you failed the station(s).

LOCATION:

The PLAB 2 exam is only held in Manchester, England. You will need to book a hotel close to the GMC Manchester building. We would recommend that you arrive a day before the exam and visit the place where the exam will be held to avoid getting lost in the morning. Remember you might not be allowed to sit for the exam if you arrive late.

The address of the GMC Centre in Manchester is 3 Hardman Street, M3 3AW.

BOOKING THE PLAB 2 EXAM:

You can book the exam online via My GMC online account. You can only book the PLAB 2 exam after passing the PLAB 1.

FREQUENTLY ASKED QUESTIONS:

1. What documents do I need to take to the PLAB 2 exam?

You will be required to take two types of documents on the day of your exam: booking confirmation email/letter and proof of identity.

Only one of the following documents will be accepted as proof of identity and it must be an original copy:

•Your passport

•Your UK immigration and nationality department identification

•Your home office travel document

•Your UK driving license

•Your EU identity card

If you forget to take any of the above listed documents or if your document does not bear your photograph, you will be allowed to take the examination but you need to take the correct form of identification as soon as possible.

•Other documents required for registration include the following (after passing PLAB 2):

•Your primary medical qualification certificate

•Your IELTS test report form

•Your certificate of good standing (this must be within three months from the date of issue at the time of presentation)

•Evidence of internship

2. What skills are covered?

The following skills are covered in PLAB 2 exam skills:

i. Clinical examination

ii. Practical skills

iii. Communication skills

iv. History taking skills

v. Diagnostic and management skills

vi. Good medical practice

The PLAB part 2 covers everything a UK-trained doctor might expect to see on the first day of Foundation Year Two (FY2).

3. What are the components of the exam?

You will be assessed on four main skill areas in the OSCE:

•Practical skills e.g. checking blood pressure, taking a cervical smear, performing venepuncture etc.

•Communication skills: e.g. explaining a diagnosis, investigations and treatment, communicating with relatives, breaking bad news etc.

•History taking skills e.g. diarrhoea, wheezing, vaginal bleeding etc.

•Examination skills e.g. hip examination, abdominal or cardiovascular examination etc.

4. What does a typical PLAB 2 scenario look like?

Here is an example of candidate instructions:

This station tests your ability to take a history and reach a likely diagnosis.

Mr. Brown is a 45-year-old man who has come to A&E with right knee pain. Take a relevant history and suggest a likely diagnosis to the examiner.

This station will last five minutes.

5. How does the actor respond?

The actor receives what we call actor instructions on how to respond when asked by the candidates. These include the presenting complaints, past medical history, allergy history etc.

The simulated patients usually act as naturally as possible. In fact you feel as if you are talking to someone who really does have a medical problem.

6. Why did I not meet the requirements for passing the exam?

May be because you have passed less number of stations (fewer than nine) or you have not reached the cutoff point. You need to fulfil both criteria in order to pass the exam.

7. How will I get the results?

You will receive an email.

8. Will I get feedback if I pass PLAB 2?

You will not get feedback; you will only be told that you have passed the exam.

9. How much time is required to prepare for PLAB 2?

If you decide to attend our course, then you need four to six weeks to prepare for the PLAB 2 exam. This is only true for those who are fully committed to taking the exam.

10. How many times can I attempt PLAB 2?

You have a maximum of four attempts to pass the PLAB 2 exam. If you fail all four attempts, you will need to go back and start from PLAB 1 again. If your IELTS has expired, you will need to start from the IELTS (the IELTS certificate is valid for two years).

11. What is the pass rate for PLAB 2?

The pass rate varies between 64-71%.

12. Is there a dress code?

Generally, it is advisable to dress formally for both female and male doctors but you are advised to be bare below the elbow with no watches, bracelets or rings. You should, therefore, not wear a jacket or put on a tie. You need to look smart, so that the actors may feel like they are speaking to a real doctor.

13. How is the exam marked?

Each station has a number of objectives, for example; past history, technique, diagnosis, relevant differential diagnosis, treatment etc.

The examiner will grade each objective A, B, C, D, or E.

The examiner also gives a judgement of fail, borderline or pass.

The grades A-E are then translated into marks, i.e.

A = 4

B = 3

C = 2

D = 1

E = 0

Whatever grade you get in each objective will be translated into marks and then multiplied by the percentage (%) i.e. weighting.

For example, if a candidate had the following marks:

(10%) Introduction = A

(40%) Explaining & advising = C

(10%) Diagnosis = D

(40%) Sympathy & empathy = E

the scoring would be as follows:

A = 4 x 10% = 0.4

C = 2 x 40% = 0.8

D = 1 x 10% = 0.1

E = 0 x 40% = 0

So your total marks in this station would be 0.4 + 0.8 + 0.1 + 0 = 1.3.

If the pass mark for this station were 2.0, then these marks would mean that this candidate had failed this station.

The overall mark does not count towards you failing or passing.

The GMC uses the borderline marking to set the standard to pass the exam. So each station in the exam has a pass mark.

14. How is the pass mark worked out for each station?

In each station, the examiner also grades candidates as fail, borderline or pass. These judgements do not count towards you failing or passing the exam.

The overall examiner’s judgement is used to determine the pass mark for future candidates.

What counts towards you passing or failing the exam are the marks you get for each objective.

The GMC takes the mean scores of previous candidates who were judged borderline in each station to work out the pass mark for each station.

15. What is a borderline performance?

A borderline performance is that of a minimally competent candidate. You are said to be minimally competent if the examiner thinks that your performance is safe and he is generally satisfied but he/she still has some concerns.

AFTER PLAB 2

16. How long does the PLAB 2 result take to come out?

It takes 10 – 14 days for the PLAB 2 result to come out.

17. What should I do after the PLAB 2 exam?

Most people stay in the UK to process their registration and apply for jobs.

18. How long does it take to get a job?

At the moment most people are able to find a job within 3 months after passing PLAB 2 exam, but this time period may change from time to time.

19. What if I fail?

If you fail you can re-sit as soon as possible. You need to pay the GMC fee again.

20. What type of registration will I apply for after the exam?

You can apply for one of the two types of registration:

•Provisional registration

•Full GMC registration

If you have done an internship in your country, you will get full GMC registration, which means you can apply for any SHO, registrar or consultant jobs, depending on your experience.

If you haven’t done an internship, you will be offered provisional registration, which means you can only apply for Foundation Year One jobs (house jobs).

My recommendation is that it is better to come to the UK after doing a house job (internship). This is because with full GMC registration, you have a far greater chance of getting a job than with provisional registration. What determines whether you will get full registration or provisional registration is not the PLAB 2 exam. It depends on whether you have done your internship or not.

21. What is a clinical attachment and how can I apply for one?

A clinical attachment is an observership. This is when international medical graduates are given a chance to shadow fellow doctors in the UK hospitals to learn how the NHS works. If you have got GMC registration this can be a hands-on experience. The other reason you need a clinical attachment is to have UK references.

22. When should I do a clinical attachment?

You can do clinical attachments either before or after PLAB 2.

In general, clinical attachments can be done at any time, even before you do the PLAB test.

23. Does a clinical attachment help with the PLAB 2 exam?

The advantage you will have by doing a clinical attachment first before the PLAB 2 exam is minimal. In my opinion, there is no need to do a clinical attachment in order to prepare for PLAB 2.

24. How can I apply for a clinical attachment?

You need to apply to different hospitals via human resources. It is better to send your CVs to different hospitals, as only a few will reply to your request.

25. Are clinical attachments free?

Most hospitals charge a fee of £200-£500 for clinical attachments, but there are a few hospitals that offer free clinical attachments.

26. How do I show proof of accommodation when I come for the PLAB exam?

If you book our course, we will provide you with a letter that you have booked accommodation with us.

LIFE IN THE UK

27. Where do I stay while doing the course?

Our accommodation is 5-10 minutes away from the centre by bus. The accommodation is in a safe area and our accommodation manager is always around for your safety.

28. How much is the cost of living in London?

Accommodation costs around £100-£140 per week.

Food depends on what you eat; it may cost anywhere from £20-£50 per week.

Transport by bus is around £30 per week.

These are only estimated figures and they may change depending on where you live in London.

WHY PEOPLE FAIL THE PLAB 2 EXAM

Obviously different people make different mistakes. But there are common mistakes, which are observed in most candidates.

1. Lack of respect for the exam

"I have done many OSCE exams like this in my life."

You might have done many exams in your life but you have not done the PLAB 2 exam.

This exam is different from all other exams, mainly due to time constraints, the accuracy demanded, and also perfect preparation by other candidates. You need to give yourself the best chance.

Find a PLAB training centre that will give you individual attention and guide you properly. SAMSONPLAB academy will give you all you need. You might already have the knowledge, and all you need is proper guidance and awareness of the exam itself.

It is a simple exam if you keep it simple. Be surrounded by positive study partners. It is not uncommon to find a group of candidates who were studying together all failing the exam, or a group of candidates studying together who all passed the exam. Positive influence is very important.

2. Not having enough time for preparation

We advise that you do the course at least four to six weeks before the exam date. However, if you only have a little time, you can do it in fewer weeks. It will just mean that you have to work extra hard. I have seen many people doing the course two weeks before the exam date and passing the exam. Everyone is different, of course, but my recommendation is that you do the course at least six weeks from the exam date.

You might have children, work or commitments, which prevent you from attending the course. I understand life is not only about PLAB. But if you want to pass PLAB 2 you have to compete with everyone.

Attend the course early, either via our online services or in person.

3. Not doing the mock exams

When you attend our course, you will get enough knowledge on every topic that may come up in the exam.

The mock test will help you develop presentation and communication skills. This is equally as important as having knowledge. By attending the mock, you will improve your approach to the patient and your bedside manner.

You will start using more of the words like sorry, please, thank you, unfortunately, I am afraid to say, I am really sorry, etc.

In the UK you must use these words as often as possible. And the mock test is the time when you can improve your bedside manner. You could be rude and not realise it, hence the usefulness of doing the mock tests.

The mock tests will also help you improve time management.

During the mock tests, you need to listen to the feedback given to you by the examiners. This is what will help you improve. Even if you fail the mocks, do not worry. The idea is to learn during the mock and pass the real exam.

Do not expect to pass all the mock tests.

HOW TO USE THIS BOOK

This book is divided into different sections, i.e. medicine and history counselling, paediatric history and counselling, surgery history and counselling etc.

Each of these sections is divided into topics. The topics are either based on the presenting complaint or diseases, such as headache, dizziness, palpitation, chest pain, epilepsy, multiple sclerosis etc. In turn every topic is divided into scenarios. The scenarios contain the candidate’s instructions, the patient’s information, the examiner’s prompt and the model answer. There could be more than one scenario for each topic.

It is advisable to practice in a group of three so that one person can act as a patient, the other as the examiner and another one can be the candidate. You should then exchange roles.

As a patient you need to simulate the symptoms given in the questions.

If you are playing the role of the examiner, you should check the examiner’s prompt and the model answer to correct your colleague’s mistakes.

Sample marking sheets have been provided at the end of each section to help you understand what examiners are looking for. Look at the examiner’s prompt to see what type of questions the examiners might ask you.

The PLAB 2 exam is not only about what you do but also how you do it. Therefore paying attention to things like empathy, fluency and how you listen to the patient are all very important if you are playing the role of an examiner.

THE NEW PLAB – SEPTEMBER 2016

The GMC has announced changes to the PLAB exam. These changes come into effect in September 2016 for both PLAB parts 1 and 2.

PLAB 2 exam is changing from September 2016 to reflect real life situations, which involve encounters between doctors and patients. The new exam will test candidates in mock consultation settings that will more accurately reflect how doctors apply their knowledge and skills in real life. This will ensure that only those with good level of knowledge and skills are permitted to practice in the UK.

This book reflects the new changes that will be implemented from September 2016. The scope of this book will continue to change as PLAB changes.

The new PLAB 2 OSCE exam will have 18 stations in total and each station lasting 10 minutes. Candidates will have two minutes to read the task and eight minutes to perform the task. The new scenarios will be longer and will contain more patient information.

A detailed feedback will be provided on the candidate’s performance to help candidates prepare for re-sits. The feedback will cover each area of exam scenario.

The new PLAB test will include assessment of wider ethical values and principles in Good Medical Practice, e.g. maintaining patient’s confidentiality, respecting patient dignity and values, etc.

There will be more scenarios such as:

Couplet stations: these stations use information identified at one station to inform actions at the next station.

High fidelity simulator stations: these stations test the candidate’s ability to deal with abnormal signs and acutely ill patients. The SIMMAN scenarios are already in effect but they will now contain more patient information and examiners will have more time to interact with the candidates to assess their knowledge.

Professional stations: these stations assess candidate’s ethical principles.

Handover stations: these stations assess candidate’s ability to assimilate information and prioritise patient’s needs.

Pass mark: The GMC will change the way they set the pass mark from the current method which uses the results of those candidates judged to be borderline to a new method known as borderline regression. This means on the day, the GMC will use the results from all the candidates to set the pass mark for each scenario.

New Limits: The candidate will be expected to pass the written and practical parts of the exam within a maximum of four attempts at each. There will also be a new limit in which to apply for a licence. Successful candidates must be granted registration with a licence to practice within two years of passing the test.

COMMUNICATION SKILLS

VERBAL COMMUNICATION SKILLS

Communication is a means of exchanging information and thoughts between individuals by means of speech, signals or writing. In medical practice, communication between a doctor and a patient is mainly via speech and body expressions.

It is important that the doctor possesses the ability not only to understand the body language of the patient but also to demonstrate appropriate body language himself in response to the patient’s behaviour or situation.

Non-verbal communication skills such as facial expressions, posture, gesturing, silence and emoting are important components of a doctor’s everyday life. If you say something which your body language is not expressing, it may be perceived as being rude or unsympathetic. It is therefore difficult to imagine a very good doctor who possesses poor non-verbal communication skills.

As doctors, we deal with patients who most of the time are not in a normal mood. They are either sad (e.g. a patient with depression) or very happy (e, g mania, or being discharged home).

Well, it is self-explanatory. If all was well, then they would not have come to hospital. Therefore, a doctor with poor non-verbal communication skills will experience problems in medical practice.

No wonder the GMC places considerable emphasis on communication skills during the PLAB 2 exam. In fact, there are more diseases which are incurable than curable. Therefore support, empathy and good customer service skills are becoming more and more important.

The PLAB 2 exam is therefore your chance to show the examiner how you would do things in real life and demonstrate your excellent bedside manner. You have a greater chance of passing the PLAB 2 exam with excellent communication and interpersonal skills only than with excellent knowledge only.

This means that candidates who have poor non-verbal communication skills have a higher risk of failing the PLAB 2 exam.

How do I express verbal and non-verbal communication skills?

It is simple; the tone of your voice should change depending on what you are talking about with your patients. Maintain eye contact throughout the consultation. While speaking to the patient, your body should be moving slightly rather than sitting still. Many people do move their heads when talking, to stress the main points in their conversations.

Your facial expressions and body posture should also change to suit the circumstances. For example, some people may think that keeping quiet is the same thing as listening. If a patient is talking, you need to be able to express either some body movement (e.g. nodding of the head) or responding with some words that show your attention, for example you can try saying "yes or I understand or uh huh or ok" while the patient is speaking. This will usually encourage the patient to talk more.

But you have to be careful as well that you do not ‘overdo’ some of these things. Some candidates keep repeating the same thing over and over e.g. ok, ok, ok. This, too, is not very good. We need to find a balance.

You need to try and maintain eye contact with the patient at all times. Some candidates find it difficult to look at the patient during the consultation. Instead they look left or right from time to time. This is not good. Eye contact is a sign of confidence and respect for the patient.

Similarly, during a physical examination of a patient, if you need to ask a patient a question, you need to look at the patient’s face - meaning that you need to stop your examination momentarily and continue after the patient has answered your question.

Failure to do these things will result in misunderstanding between you and your patient.

Check if the patient knows what is going on

In the PLAB 2 exam, just like in real life, it is important to clarify with the patient how much he/she knows about his condition or if anyone has been there to explain things to them. Do this at the beginning of each consultation so that you can determine the starting point.

For example, you can try as follows:

Hello. Are you Mr Brown? My name is Dr Smith. I am here to talk to you about your condition and to explain how we will be managing you further. Has anyone been here to explain what is going on with you? Or Has anyone been here to explain the results of your investigations?

In the PLAB exam, just like in real life, you should always consider the possibility that the diagnosis or the investigations have not been explained to the patient.

It is better to start explaining the investigations or diagnosis to the patient and then be told by the patient that they are already aware of the results/diagnosis, than to assume that the patient knows about it. Imagine that happening in a diagnosis of cancer.

Such errors in the PLAB would probably result in failing the station. This is in fact a critical error that should be avoided not only in PLAB but also in real life.

Before you start your consultation you need to ask patients what they would like to know.

For example… "So, Mrs Jones, before we start, do you have anything on your mind that you would like us to discuss?"

This allows you to know the patient’s expectations.

The following are the objectives which examiners usually use to assess communication skills.

1. Initial approach or introduction

Here are the questions to consider under this section:

•Do you introduce yourself clearly and explain your role within the team?

•Do you explain the purpose of the interview?

•Do you consider patient safety issues, including checking the patient’s identity?

•Are you polite and professional with the patients, treating them with sensitivity and respect?

•Do you check the starting point? i.e. finding out how much the patient knows about what is going on?

The doctor is expected to introduce himself or herself by their surname but he/she may wish to be called by their first name.

The doctor is expected to check the identity of the patient by calling their name or by asking them how they would like to be addressed. And it is expected that once someone has told you how he or she would like to be addressed, you stick to that name.

For example:

Doctor: "Hello. Are you Mrs Smith? Nice to meet you. My name is Dr Jones. I am one of the junior doctors in the department. How would you like me to call you?"

Patient: "Sarah."

The common mistake of most PLAB 2 candidates is that after being told by the patient that she would like to be called Sarah, they start calling her Mrs Sarah. Do not do this. Sarah is her first name. The first name cannot be used in this context.

2. Checking for patient understanding

In this section, you should consider the following:

•Do you invite questions?

You need to stop from time to time to allow the patient to ask questions and to check that the patient is following your explanation. For example "Have I made myself clear? Is there anything you would like to ask me?

•Do you speak at a pace and detail which the patient can follow?

It is better to invite a question and answer it, than rush through every point about a particular disease.

There is usually not enough time to cover everything in 5 minutes, so it is important to try and answer the patient’s concerns and add a few important points if time allows.

3. Explaining and advising

You need to speak at a pace which is comfortable for a patient to follow.

Refrain from using jargon and medical terms.

If you use phrases which your body language does not support or express, you will lose marks.

You should be able to show doctor-patient interaction.

Examiners are looking for real interaction between you and the simulated patient and not memorised phrases, which are fired at a patient in the hope that you will cover all the points.

PLAB 2 is about demonstrating your bedside manner with the patient and that your medical practice is patient-centred.

You can demonstrate that you are practising patient-centred medicine as follows:

•When explaining treatment to the patient, you need to offer the available options. Give the advantage(s) and disadvantage(s) of different treatment options and advise the patient on which method of treatment you would recommend, and why.

So do not impose treatment on a patient, even if you feel that this is the best treatment available. Rather, give the patient information about the available treatment options (include advantages and disadvantages) but let them decide upon suitable treatment for themselves.

For example:

Mr Brown, from what you are telling me, most likely you have a condition called heart failure. Heart failure is a condition in which your heart is not functioning (pumping) properly. Have I made myself clear? Is there anything you would like to ask?

What we need to do:

It would be better for you to stay in hospital so that we can keep a close eye on you. Would that be a problem? We will then do some further investigations like blood tests and a scan of your heart. We will also start you on water tablets, which will help remove the excess fluid in your body, which is causing swelling of your legs. How do you feel about that?

Answering difficult questions

It is important not to give false reassurances to the patient.

Here are some of the common difficult questions:

After an operation, a patient can ask: "When can I go home? Or Where did I get this infection? or Will you cure this infection?".

This type of question can all be answered in a similar manner: It is a difficult question to answer and there is no harm in admitting to the patient that you do not have an exact answer to the questions.

As a junior doctor, it is also important to know when to say, "It is a difficult question to answer" and when to say, "I am not quite sure about the answer to that question, I will consult my seniors and get back to you with an answer."

You should only tell the patient, "It’s a difficult question to answer," if you feel that, even after consulting your seniors, they would not be able to give the exact answer either.

For example, a patient with an MRSA wound infection, asking, "When can I go home?" is definitely a difficult question to answer, because determining how long it takes to clear the MRSA infection would be difficult, even for seniors. They may just offer you an estimate.

It is also important to know that the scenarios are set at the level of Foundation Year Two. So you should be able to answer most of the questions. You cannot keep saying, "I will consult my senior." The examiner would like to hear your advice and management plan. So even if you say you will consult your seniors, you will not gain any marks and you risk failing the station.

The best approach is to explain your likely management plan to the patient and at the end you can simply say, "I will also consult my senior for a second opinion."

There are times when consulting a senior is important, as you need to show the examiner that you know your limits as a junior doctor.

But do not consult seniors by rot as this will demonstrate that you do not have adequate knowledge to manage scenarios which would normally be managed by a junior doctor at the level of Foundation Year Two.

4. History taking skills

You need to be able to ask questions relevant to the presenting complaint. You will get two types of history taking scenarios:

1) Take a history and give the diagnosis to the examiner : In these types of questions you need to take a full history and in the last 30 seconds you give your diagnosis to the examiner. Usually the examiner will stop you at the 4:30 bell to ask for your diagnosis and the reason behind it. The examiner may also ask you, How would you confirm your diagnosis?

2) Take a focused history and discuss management with the patient or with the examiner : In this situation, you need to take a relevant history, get the diagnosis and discuss the management. In this type of scenario you should take a history of the presenting complaint and any other relevant history like past medical history , drug history and allergy history .

If you take too lengthy a history, you may not have enough time to discuss management with the patient. Usually, when the question says take a history and discuss management with the patient, you need to leave more time for management than just 30 seconds.

In history taking stations, you should ask yourself the following questions:

•Do you make good use of open-ended questions?

•Do you use open questions repeatedly to obtain further information?

•Is your balance of open and closed questions effective so you can obtain precise information while still maintaining an effective rapport with the patients?

•Do you obtain a clear picture of the effect of the symptoms on the patient’s life? i.e. effects of the patient’s symptoms on their social life and occupation.

•Do you pick up on the patient’s concerns and fears and explore these sensitively but thoroughly?

How do you start off history taking scenarios? You can start as follows:

a) How can I help you?

b) What brings you to hospital today?

c) I understand that you have been having headaches. I am sorry to hear that. Can you please tell me more about your headaches?

If you use option a) or b), you could follow this up by another open-ended question like: "Can you tell me more about you headaches?"

If you find some positive history from the patient but you are unable to follow up with further questioning, you will lose marks.

You should be able to elicit all the positive history from the patient.

You should also reach the diagnosis or reasonable differential diagnoses.

When you tell the possible differential diagnoses to the examiner, you need to give the differential diagnoses which are relevant to the given history. The differential diagnoses should be mentioned in the order of the most likely diagnosis to the least likely. However, do not include very weak differential diagnoses, as you will lose marks for doing so.

You are also expected to explain to the examiner the reasoning behind your diagnosis.

5. Making an accurate diagnosis, planning investigations and management

•Here you need to be able to differentiate between common conditions, important conditions and rare ones.

•When deciding on investigations, do you remember the basic, important investigations before embarking on more invasive tests?

•Can you develop a clear management plan for a patient?

Examiners would like to hear your management plan, so you need to be able to outline the plan to the patient.

Do not just say "I will consult my seniors".

Getting the diagnosis from the history alone is not always possible. There are times when you are almost 100% confident about the diagnosis, but there will be times when you will have 2 or 3 differential diagnoses, each of which could potentially be the correct diagnosis.

The question will tell you whether you have to give the diagnosis to the examiner or to the patient.

In situations where you need to give the diagnosis to the examiner you must give your opinion. You should not say:" I am not sure of the diagnosis" or keep quiet when asked by the examiner.

If you do not give your diagnosis to the examiner, you will lose marks or fail the station.

However, if you are talking to the patient and you are not sure of the diagnosis, it is ok to tell the patient that you are not sure of the diagnosis, but there are a few things which could present in a similar manner. Add that you will do further investigations and you will come back with more answers.

In cases where cancer is NOT the likely diagnosis, you can tell the patient what type of possible causes you have in mind.

For example, where a patient presents with testicular pain and where testicular torsion is the likely diagnosis, the likely diagnosis could be explained as follows:

"… from what you are telling me, it’s likely that you have a condition called testicular torsion. This is a condition in which the testis twists around itself and the blood supply is cut off. But it could also be other things, like infection or inflammation of your testes. We will need to examine you and perform some tests to rule out other causes.

If examination or investigations confirm that this is testicular torsion, you will need to go for an emergency operation to………………Would that be ok with you?"

From the above example, we can see that if you have a diagnosis of higher index of suspicion from the history, you will need to tell the patient the likely diagnosis and how you would manage it.

But do not alarm the patient unnecessarily with a serious diagnosis. If you have a high index of suspicion of cancer, you need to wait until the diagnosis is confirmed before you can tell the patient he or she has cancer.

It is not a good thing to tell the patient: I think you may have breast cancer.

In this case, it is better to say: It is difficult to say definitely the cause of your symptoms. There are a number of things which can cause your symptoms, but it is necessary to do the investigations as soon as possible so that if you need treatment, there will not be any delay.

If the patient asks you about the possibility of cancer, you will need to answer the question, but at the same time you have to refrain from giving false information/reassurance.

For example:

Patient: "Could it be cancer, doctor? "

Doctor: "Unfortunately, cancer is one of the things that could cause this type of symptoms but, as I said, there a few other things which may present with similar symptoms. We need to do investigations as soon as possible so that if you need treatment there won’t be any delay".

6. Building and maintaining a relationship

In this section you need to think about your verbal and non-verbal communication skills. Here are the points to consider:

•How do you make it clear to the patient that you are interested in what they have to say?

•How well do you really listen?

•Do you explore their feelings sensitively?

•Do you interrupt the patient while he/she is talking?

•Do you ask the patient how the symptom or disease has affected them at home and at work?

•Are you able to demonstrate both verbal and non-verbal (facial expression, voice tone and body position) emotions to your patient?

•Do you try to be as helpful as possible to your patient?

7. Providing accurate information

Here it is important that you understand the task very well, as patients will ask you questions on the information provided in the scenario. These types of questions aim at testing your understanding of the tasks.

You are also expected to provide your own information to the patient. It is not acceptable to give false information to the patient. It is better to apologise to the patient and admit that you are not sure of the answer to their question, and that you will go and find out and get back to them.

NON-VERBAL COMMUNICATION SKILLS

This includes the following aspects:

(I) What you wear

(II) Your body language:

A – The way you sit

B – Hand movements

C - Touching

(III) Head movements and facial expressions

(IV) Eye contact

(V) Verbal communication

A – The tone

B – The loudness of your voice

(VI) Common Behavioural Syndromes in PLAB-2

(I) WHAT YOU WEAR ON THE DAY

1. It is required that you wear nothing below the elbow i.e. wear a short sleeve shirt or fold your long sleeves. This goes both for male and female doctors.

2. You need to wear nice trousers or a skirt. Wearing jeans or mini-skirts is unacceptable. High shoes, trainers or boots should also be avoided.

3. Basically, you should be formally dressed in a suit but without a jacket and with nothing below the elbow.

(II) YOUR BODY LANGUAGE

A – The way you sit

1. You need to sit at least a distance of one and a half metres away from the patient, which is neither too far away nor too close. It is usually advisable to leave the chair where you find it when you enter the cubicle in the exam unless it is obviously very far or very close. Most of the time it will be placed at a suitable distance.

2. Women should sit with their legs together and men with their legs slightly apart, but not too wide apart.

3. Do not lean too far forward or sit too relaxed, leaning back in your chair. Neither of the two looks very professional.

B – Hand movements

It is advisable for everyone to sit with hands held together and placed on the thighs.

Alternatively, you can move your hands slightly during the consultation to accompany your body language, but excessive hand movements may give the wrong impression.

Do not place your hands in between your thighs or sit on your hands. This makes you look unconfident in front of the patient and does not leave a good impression.

C- Touching patients

This can either be in the form of shaking hands with a patient or touching patients in order to express empathy. Avoid touching patients on the back, shoulder or face. You can express your empathy by touching the patient on the hand.

The best thing is to avoid touching patients at all, because your touching could be misunderstood.

You can shake hands with patients but be aware of cultural differences, especially female patients. Never hug patients you do not know.

(III) HEAD MOVEMENTS AND FACIAL EXPRESSIONS

There must be some slight head movements along with your verbal communication skills. Do not sit with your head still, staring at a patient.

You need to show some sort of facial expression, depending on the situation. This could include putting on a smile or showing some facial expression if you are stressing a point. But do not have a mask-like face.

They say every face tells a story:

1. Are you touched by the information given to you by your patient? Let it show on your face.

2. Are you happy because your patient is getting discharged home today? Congratulate him and seem pleased.

3. Do you want your patient to stay in hospital but he/she does not want to? Show its importance by your facial expressions and the tone of your voice.

4. Are you reassuring the patient about something they should not be worried about? Show confidence so that they can trust you.

5. Are you treating a patient with an acute emergency? Your urgency, your tone, your facial expression should all show that you are under the influence of adrenaline, trying to save the patient.

6. Do you want to encourage your patient to give you more information? You need to be able to nod your head or make some sounds which will encourage the patient to continue giving you information.

In summary, your voice and your body language should all go with the patient’s emotion and the information you are talking about.

(IV) EYE CONTACT

It is important that you maintain eye contact with the patient throughout the consultation. However, this does not mean that you keep staring at the patient constantly with eyes wide open, without a break. This might scare your patient and he/she may find it difficult to relax.

What I mean by maintaining eye contact is that you look into the patient’s eyes most of the time, but with a relaxed face. Once in a while it’s ok to look to the side.

Do not look at a task all the time. If you need to read the task again, apologise to your patient, "Please give me a moment, I need to have a look into your notes, is that ok?"

Moreover, do not keep looking at the floor, or left and right every now and then, or this will be taken as a lack of confidence.

You need to show honesty, confidence, respect and concern on your face for the patient.

Try to look confident. Confidence means speaking loudly enough so that the patient can hear you, and maintaining eye contact.

In short: Confidence = Voice up + Eye contact

PLAB 2 is difficult in that it asks for two things at the same time; knowledge and acting. Most PLAB 2 candidates do not pay much attention to the acting part. In fact in my experience most people fail PLAB 2 due to poor non-verbal communication skills. When you are taking a history from the patient, do not close your eyes or look up to the ceiling while you are trying to recall the differential diagnosis or any information. This would result in a poor overall grade because you are losing out on professionalism and bedside manners.

The General Medical Council has clearly stated that they have checked your knowledge in the PLAB 1 exam. PLAB 2 tests how you would perform in real life. Therefore, never undermine acting.

The simulators in the PLAB 2 exams are usually not real patients but they do act their roles very well, so that you will feel as if you are talking to a real patient.

As a doctor you also need to act your role very well, so that they can feel that they have been speaking to a very friendly, sympathetic, respectful and knowledgeable doctor.

(V) VERBAL COMMUNICATION SKILLS

1. You need to be able to use empathetic phrases like:

i – I’m afraid to say…

ii – Unfortunately, the results include bad news…

iii – I am sorry to say that we found out that you have a condition called …

For example:

You have just told the patient that he has diabetes and the patient is asking…

Patient: "Really, doctor, do I have diabetes?"

Doctor: "Yes, you do."

This type of answer makes the doctor sound insensitive.

It is better to be more sensitive by answering like this: "Unfortunately, all the results we have done show that you have diabetes" or

"I am sorry, Jane, but that is what is causing your symptoms. I am really sorry that I have to tell you this."

2. You need to be able to speak loud and clear so that the patient can follow. Do not speak so low that the patient cannot hear you.

Do not shout, either; this may offend the patient (he/she is not deaf).

Remember, you need to show some confidence (loud speech plus good eye contact).

Do not show that you are fed up with repeating things to your patient. If the patient did not understand, it is your fault. It means that you did not make it clear.

Therefore, do not say: "I told you before…."

Rather say, "I am sorry I did not make it clear, basically what you need to do is…"

3. Deliver the information in an organised way by sign posting before moving to a new section. When explaining things to a patient, try to divide information into sections. After each section check that the patient has understood by inviting questions from him, e.g.; " Have I made myself clear, or do you have any questions ? or Is there anything you want me to repeat ?"

For example:

Past medical history: I now need to ask about your general health…

Social history: Now, I need to ask you a few questions about your social life…

4. Do not fall into arguments with the patient.

This is a common problem for some doctors.

For example:

Doctor: Do you have any medical problems?

Patient: No

Doctor: Are you taking any regular medication?

Patient: Yes, I take lisinopril for high blood pressure.

Doctor: But I asked you before, Mrs. Brown, if you have any medical problems, and you said no. Now you are saying you have hypertension.

Patient: Sorry doctor, I forgot.

Doctor: Can you please give me the correct information because I need to give the correct diagnosis to the examiner!

NEVER act like this, either in PLAB 2 or in real life.

COMMON PLAB-2 BEHAVIOUR SYNDROMES

Introduction

This section talks about common mistakes made by many doctors. I have written this so that those who read this book can learn not only medical knowledge but also how to improve their communication and social skills. Outlined in this section are mistakes I have been observing in most foreign-trained doctors for the past seven years of my experience with PLAB.

The comments and behaviour styles outlined here are not to be misunderstood for racism or to be taken personally. This section has been written to help those who fail the exam and yet do not understand why they have failed certain stations.

To be specific, this book has been written for the future PLAB candidate. This book will help you avoid the common mistakes. I must say, I made some of these mistakes during my PLAB 2 preparation myself.

Some mistakes are commonly observed in people coming from certain backgrounds, but that does not mean that other doctors cannot make similar mistakes. Read about these mistakes, avoid them in the PLAB 2 exam but do not take it personally.

1. Housewife syndrome:

This problem is common in Asian female doctors who moved to the UK 10 -15 years ago. They have remained as housewives for a long time and now they want to get back into medicine. They have not been communicating with people frequently and consequently they have lost interpersonal skills. The second problem is that, they also do not have enough time to prepare for PLAB 2 because of child care problems. The biggest problem is that they have lost social skills on how to interact and communicate with people.

Solution: If you find yourself in this situation, try to have different study partners to help you learn and get back your social skills. Do not rely on Skype partners; face-to-face practice is very important for you to improve body language and regain your confidence.

It is very important to do all the mocks and get feedback on your verbal and non-verbal communication skills. Attending all the mocks might be a problem due to lack of time, but if you attend the course early you can manage to do the mocks over the weekends. If you are determined, you can easily overcome this. It is also important to highlight that not everyone who has been a housewife for 10 years will have this problem. It is common, but not with everyone.

2. Married man syndrome:

Husband and wife decide to take the PLAB exam at the same time. Having done the course together, they tend to continue practising together. For some unknown reason, husbands tend to perform worse in the PLAB 2 exam than their wives. There could be different reasons for this:

A. Husbands find it difficult to learn from their wives.

Probably as men we are too arrogant to learn from a woman. But as far as communication skills are concerned, women are usually better than men.

B. Lack of interaction with other doctors.

For some reason, husbands tend to be quiet most of the time and well-behaved. Why? I do not know - maybe he wants to show his wife that he is well-behaved, and avoid an argument at home. Unfortunately, you need interaction for PLAB 2.

Solution: Husbands should try to learn from their wives if appropriate, and also try to have other study partners, whether male or female, for a change. But it is probably better that you continue studying with your wives, because you are together most of the time, so it will be easier to monitor the progress of your studies. However, once in a while, studying with other partners might be helpful.

3. Serious man syndrome:

A good number of male doctors tend to have problems with expressing their emotions. They tend to sit quietly with no smile. As a result, when talking to a patient they find it difficult to build a rapport with the patient.

This type of candidate tends to have A mask-like faces and monotonous speech. Mask-like face means lack of facial expression (emotions) and monotonous means lack of change in voice tone (poor use of voice). Their history taking tends to sound like an interrogation.

Solution: Try to learn from other doctors. Sometimes it is very helpful to watch others perform a counselling station. Try to observe different people practising. This is the best way for you to see what you are doing wrong. Avoid having a study partner who has the same problem as you.

4. Pressure of speech syndrome:

Doctors in this category tend to speak very fast without checking for the patient’s understanding.

Solution: It may be difficult