Examination for Different Audiences

For Medical Students

What It Tests

An examination has a purpose, and the purpose changes what is done and what is recorded even though the knee is the same.

In an examination for assessment the purpose is to demonstrate competence, so completeness and narration matter more than efficiency.

In a clinic the purpose is a decision, so the examination is targeted at the decision and the record has to support it.

This page is about that difference, because a trainee taught only the assessment version performs the wrong examination for twenty years afterwards.

How It Is Performed

For an assessment, run the full sequence, say what you are doing, and state what you would do next. 4.1.4 covers the sequence.

Expect to be stopped. An examiner interrupting is usually moving you on rather than correcting you.

Do not skip the parts that feel obvious. Exposure, the other side, the hip and the neurovascular check are the marks most commonly lost.

And do not perform a test you cannot interpret. A candidate who demonstrates a manoeuvre and cannot say what a positive means has shown less than one who did not attempt it.

MRCS Level

How It Is Performed

The viva and the OSCE reward a different examination from the clinic, and both are legitimate.

In an OSCE the examination is a performance with a mark scheme, and the sequence is the scheme. Narrate, be systematic, and finish with your next step.

In a viva the examination is described rather than performed, so the ability to say why a test is done at a given flexion angle matters more than the hands.

In a clinic the examination is subordinate to a decision, so a complete examination that does not address the decision has not done its job.

The common thread is that the record is the same in all three. What changes is the emphasis, never the honesty of what is written down.

How Good It Is

Examination performs differently in these settings, and the difference is mostly about the patient rather than the clinician.

An examination subject in an assessment setting is usually comfortable and cooperative, so laxity testing works as described.

A clinic patient may be sore, anxious and guarding, and every test that depends on relaxation performs worse. The pivot shift is the clearest casualty. 4.10.6 covers it.

A patient under anaesthetic is fully relaxed, so laxity testing performs at its best and the findings are not comparable with anything recorded awake. 4.10.10 covers the difference.

So the same test in the same knee produces three different results in three settings, and a record that does not say which setting it came from is hard to use.

FRCS Level

How Good It Is

At this level two further audiences appear and both change the examination substantially.

The operating list. A pre-operative examination exists to confirm the plan and to find the thing that would change it, so it is targeted and it is recorded in the terms the operation will be judged against.

The multidisciplinary meeting. An examination presented to colleagues has to be reproducible by them, which means grades with endpoints and angles rather than impressions. 4.1.8 covers the record.

A teaching audience changes the examination too. Demonstrating a test on a patient is a clinical act performed for someone else's benefit, which needs the patient's agreement and needs the demonstration to stop when they have had enough.

Where It Misleads

The audience can corrupt the examination, and the corruptions are predictable.

An examination performed to confirm a plan finds what it expects, which is the strongest reason to examine before reading the imaging and before settling the plan.

An examination performed for a meeting can drift towards findings that are easy to present rather than findings that matter, and rotational laxity is harder to present than anterior translation.

A teaching demonstration repeats provocative tests on a patient who is already sore, so the fourth repetition is both less informative and less kind.

And an examination performed for a report carries an incentive the clinician may not notice. The remedy is a record written the same way whoever is going to read it, which is the only defence that survives scrutiny.

Fellowship Level

Where It Misleads

The audience that most distorts examination in referred practice is the referrer.

A patient arrives with a diagnosis attached, and the examination is then performed to confirm or refute someone else's conclusion rather than to assess the knee. Both of those are narrower than the job.

The discipline is to examine before reading the referral in full, which is administratively awkward and is the only way to get an uncontaminated examination.

A second distortion is the expert audience. An examination described in a fellowship or consultant setting is pitched at people who will recognise a pattern, which encourages pattern language and discourages the plain record of what the knee did.

The plain record is what the next clinician needs. A note that says the knee had grade two anterolateral rotatory instability is a conclusion; a note that says what translated, at what angle, with what endpoint, and how it compared to the other side is evidence, and the conclusion can be rebuilt from it. 4.1.8 covers the standard.