Internal Medicine

Instructions

Oral Portfolio Overview

Instructions for Examiners and Students

Expectations

The basic expectations of the student are essentially uniform across the third, fourth and fith year and are listed below. An equal degree of commitment to each case is expected from each year of study. The only variation is in their confidence, the degree to which they can bring prior experience to bear on the case, and the actual extent of their knowledge.

  • In third year, students’ knowledge is expected to be narrower, less deep and less confident and their reasoning less precise (although it should be sensible). It is also understood that they bring less experience to bear on each case.
  • Though investigation and management can and should form part of the third year assessment, the emphasis should be on the intepretation of the clinical findings and the clinical reasoning process which flows therefrom to a sensible differential diagnosis.
  • There is a more stringent expectation for fourth and fifth year students in terms of accuracy, extent of knowledge, and sureness in the process of clinical reasoning.. They are also expected to have more first-hand experience and greater facility with investigation and management.
  • The standard is assessed against the marking guidelines, at a level appropriate for each year of study. The essential yardstick is competence as a clinician. The portfolio exam must be seen as a clinical exam, albeit one conducted in the absence of the patient, and not a theory exam.
  • A biopsychosocial approach is expected. The student should have developed a sensible and comprehensive problem list which they can discuss and defend, and which contains relevant psychosocial problems in addition to a formulation of the medical problems.

An Extended Open-Book Exam

  • In essence the oral portfolio assessment is an exended open-book exam.
  • The student has had anything from a few days to 2 months to consider their case, to read extensively around it, to consult any book or resource they like, and to discuss the case with any fellow-student or senior clinician they like. They have also had plenty of opportunity to return to the case, think more about it, bring new knowledge and insights to bear on it or do additional study and discussion.
  • The assessment is made on the understanding that this opportunity for ongoing reflection and study was available and could and should have been utilised.
  • An essential condition however is that any additional reading, learning or discussion has been incorporated into a genuine deeper understanding of the case, potentially transferrable to other cases, and is just not appended as an “add-on”.

In the interview, the student can expect:

  • To have free access to their portfolio, so that they can remind themselves of the information therein, including any notes or observations they have made beyond the actual patient clinical details.
  • That all questions will relate in some way to the actual patient, even though the link may be indirect.
  • That they will not be subject to a random “viva” touching on areas of medicine not relevant to their case, with the exception that the high-performing student, having scored well on the patient, may be tested on the breadth and extent of their knowledge.
  • That they will not be expected to have memorised any case-specific information, such as clinical details, laboratory results or normal ranges.

In the interview, the examiner can expect:

The student to be comfortable discussing:

Regarding Clinical Findings

  • The patient’s clinical findings, their significance in general, and their specific significance in supporting the current diagnosis and excluding alternative diagnoses.
  • A discussion of possible clinical findings that might have been expected in the patient, but weren’t observed.
  • A discussion of possible clinical findings that might have supported reasonable alternative diagnoses.

Regardings Diagnosis

  • Evidence of the clinical reasoning that supported the actual diagnosis.
  • Evidence of the clinical reasoning that excluded alternative diagnoses.

Regarding Investigations

  • A list of the relevant investigations performed, with their results.
  • Knowledge of the normal range, and how the results compared with these. Memorisation is not required or encouraged, but the range should be recorded in the portfolio, and the student should be able to discuss the degree of deviation from normality, with an appreciation of significance for both diagnosis and severity.
  • An understanding of the relevant investigations, including the reasoning behind the use of the investigation and a sense of its appropriateness.
  • An understanding of other investigations which might have proved helpful in this patient, based on their reading.
  • An understanding of how alternative results or investigations in this patient might have directed the diagnosis in a different direction.

Regarding Severity of illness

  • Ability to discuss the severity of illness in the patient and how this was inferred from the clinical findings and investigations.

Regarding Management

  • A summary of how the patient was managed (monitoring, pharmacological and non-pharmacological management).
  • An understanding of the significance and appropriateness of each component of management.
  • An understanding of other aspects of management which might have proved helpful in this patient, based on their reading.
  • An understanding of how management might have differed given alternative diagnoses.
  • Not required in the earlier years is detailed pharmacological knowledge, including dosages, but there should be some concept of how each drug works at the class level.

Regarding Prognosis

  • A reasonable concept of the patient’s prognosis, expected complications and outcome.

Regarding course and follow up

  • A report of how the patient progressed on subsequent days, provided continuing follow-up by the student was feasible.
  • A clear understanding of whether the patient’s condition was static, improving or deteriorating.
  • Ability to discuss how changes in the patient’s condition could be and were inferred from clinical observations and investigations.
  • Ability to suggest appropriate responses to both improvement and failure to improve.