I was going through some SAQ answers with some Registrars yesterday, and there were a few points that came up that I thought I’d share. When writing your answers, there are a few things you can do to make your writing more efficient, to get more information on the page in the allocated time, to sound more confident/consultoid, and hopefully get a better mark.
1) Label or Brand the case & situation at the start
Labelling the situation gives you a clear idea at the start of what you’re dealing with. By labelling I mean giving a brief one-line statement that defines the problem. The idea is to define:
a) What category the patient/situation falls into: Eg Paeditiric, Obstetric, Neurosurgical, Infectious diseases, Psychiatric
b) What is the nature of the problem? (may be the same as above): Eg Infectious diseases, trauma, medico-legal…
c) What is the nature of the situation? Is it an emergecy, a critical incident, a medical error, a consent and capacity issue, or something else entirely.
Some situations will only require 2 of the above descriptors. But you can see that labelling a “paediatric, neurosrugical emergency” or a “critical incident involving a minor who is also a psychiatric patient” paints a bit of mental picture, you can start to visualise the situation from the very start, and this will help you get some structure to your answer as well, as you have a clearly defined path to go down.
NB: This technique is also VERY useful in the SCE section of the oral exam.
For Example (don’t put the bits in brackets in your answer – they are for illustration only):
A 40yo female lawyer presents with abdominal pain and PV bleeding. She is 24 weeks pregnant with an IVF pregnancy. Outline your management.
This clearly ridiculous question could be labelled as: “This is an Obstetric (pregnant patient) and potential neo-natal (potential premature delivery) emergency, with potential medico-legal ramifications (patient is a lawyer with a “precious baby”).
A 6yo boy presents with fevers, a purpuric rash and a GCS of 9. He has just returned from school camp. Outline your management.
A label for this could be: “This is a paediatric (6yo patient) infectious diseases (with likely bacterial/meningococcal sepsis) and public health (multiple exposures) emergency”.
Labelling or branding patients/situations takes practice. I’d encourage you to go back over some of your written questions/answers, and just try re-writing the first sentence a few times to practice getting your label right.
2) Prioritise your differential diagnosis
This is a tricky one. As the ED people, we nearly always want to know what will kill the patient if we miss it, and focus our management strategy around that. Starting your DDx with “what’s most serious” shows that you are safe, because you won’t miss the serious/life threatening condition that may kill the patient. However you need to balance this against “what’s most common”. You don’t label every kid with a fever question “A paediatric infectious diseases emergency, must exclude meningococcal sepsis”, because depending on the other information given, this may show a complete lack of perspective. Sometimes you may need to do 2 lists, one titled: “most serious”, the other “most common”, or you may need to mesh the two together. Generally the questions with the critically ill or sick sounding patients need the “most serious” list, and the well-patient scenarios are OK with the “most common” list (as long as you make it clear that you wouldn’t miss the “most serious” stuff as well).
3) Be confident, but not cocky
Nobody likes that arrogant doctor that struts into a room and starts barking orders at people, do they? We’ve all met that person, and personally I find people like that offensive, they are often impolite to the nurisng staff, and are often wrong in their clinical judgement and management. They are also often concrete in their thinking and won’t change course when presented with evidence that they should. Pride comes before a fall, so don’t be that guy/gal in my resus room, please. HOWEVER: as ED Consultants, you often need to be decisive, quick thinking, and confident in your ability to make a diagnosis and rapidly implement the correct treatment. This involves a combination of knowledge (you need to know the facts), experience (ie you’ve seen it before), and decisiveness (make a decision, and move forward), BUT ALSO flexibility (the ability to acknowledge when you’re wrong and change your plan based on new information), and co-operation (working in a team and taking multiple players opinions into consideration). This is a tricky one for your written answers, but have a think about that fine line between confident and cocky, and if you are starting to get near the line or cross it, back off a bit!
4) Remove wishy-washy qualifying statements/words
Compare the following statements:
“may consider giving IV fluid, depending on signs of shock”
“Titrated N.saline boluses: End points: resoration of perfusion, PR < 100, SBP > 100”
“possibly send to theatre depending on whether or not bleeding continues”
“Theatre if: chest drain > 500ml/hour for 2 hours”
“ICU Consultation, posisbly surgical referral if pain continues”
“Immediate ICU and Surgical attendance to ED”
You can see how all of the second sentences are more authoritative, more definitive, and don’t sound wishy-washy. Personally, if my 6yo kid has meningococcal speis, I don’t want you to “refer them to peads & I.D.”, I want you to kick some ass and get the flipping Paediatrician and ID Consultant down there NOW! That’s a bit melodramatic, but can you see the point. Remove un-necessary qualifiers from your answers like: “may”, “consider”, “possibly”, and replace them with definitve statements of what you will DO, not what you MIGHT DO.
If there are variables, you can replace qualifiers with short “If x, do y” statements:
“Theatre if: bleeding persists”
“Inotropes if: un-repsonisve shock after 60ml/kg”
“Detain in ED if: lacks capacity”
5) Use Point Form
This is probably one of the more useful tips, as it really can save a lot of time & writing effort. You’d be surprised how you can transform a paragraph of text into one statement followed by a list (with a bit of practice). Some question types lend themselves to point form, eg the resuscitation questions, others don’t. But I’d encourage you to start trying a few answers with bullet points, and see if you’re able to get the same information out in less words.
6) Re-write your answers
You shouldn’t re-write every VAQ or SAQ that you do, however I’d strongly encourage you to pick one from every session that you do, perhaps the question that you found most difficult, or scored the lowest on, and take half an hour to re-write it in a way that you think would get the best marks. Sometimes that will mean re-writing your opening statement 4 or 5 times, or having several goes at prioritising the DDx, or actually looking up factual content that you missed. I used to do this, and would re-write sentences thinking “how can I make the same point or get the same information out in less words”, and it would often take 2 or 3 goes until I’d made the point as succinctly as possible.
By taking the time to do this you are showing yourself what a “good answer” looks like, and spending time not just thinking about it, but actually doing it, will translate into better answers in your next session.
So there you have it, some tips for your written answers that I hope come in handy. If you have any other tips feel free to leave a comment below, or email me here.