Prepared by Glenn Q. Mallari, MD, solely for the Future Diplomates of the PAFP Pampanga Chapter
DISCLAIMER: This reviewer was produced for the sole purpose of assisting the future examinees of the PAFP Pampanga Chapter in taking the diplomate examinations of the PAFP. The author makes no claims about accuracy of this reviewer as everything was culled from memory. In fact, the grammatical errors are the fault of my high school English teacher. He-he.
Always refer to your textbooks and CPGs for guidance.
Overview of Exams: Day One: Written, Day Two: Oral
The Diplomate Exams given last January 11 and 12, 2003, consisted of two parts, given on two consecutive days, The first part, the written exam, given on the first day, was divided into two sessions.
Day One: The Written Exam
The first session of the written exam, consisted of 150 multiple choice questions from the major subjects in Family Medicine- Internal Medicine, Pediatrics, OB, Surgery, EENT, etc, mostly on clinical applications of current Philippine Clinical Practice Guidelines, A collection of these guidelines can be found in a book called “Compendium of Philippine Medicine”, published yearly and given out for free by your friendly med reps. The answers to the test were written on a machine readable paper, which facilitated checking (results were out within hours). Each paper had a uniquely assigned number (e.g., 0064) to prevent fraud, and future examinees must ensure that all answer sheets are marked with the same serial number, which essentially is your ID number, because none of the examination papers come with your name on it.
During the exam, the Examiners were all watching us very closely and were very strict about making any noise during the test. “If you fart, you will be shot”, was one of the rules, honest. If you need to pee, an armed guard with a bomb detector will escort you. He-he again.
A sample questionnaire is as follows:
1) What is the “gold standard” in the diagnosis of CAP?
a) chest X-ray b) sputum CNS c) CT scan d) blood culture
Answer: D, (please refer to Current Philippine CPG)
2) A pregnant patient on her first trimester of pregnancy is diagnosed to have acute appendicitis.
The management should be:
a) wait until the second or third trimester b) give antibiotics c) immediate appendectomy d) watchful waiting
Answer: C
3) A 25-year-old patient comes to you with undescended testes. The condition you should be most concerned about at his age is:
a) impotence b) testicular cancer c) prostatic hypertrophy d) orchitis
Answer: B (please refer to your surgery or urology textbook)
4) The following is a risk factor for osteoporosis:
a) early menarche b) BMI of 28 c) smoking d) use of HRT
Answer: C (see CPG or Osteoporosis Guidelines)
5) You are presented with a 28-year-old male patient with CAD and hypertension. Your treatment goal, according to NCEP ATP III Guidelines would be:
a) LDL below 190 mg/dL b) LDL below 130 mg/dL c) LDL below 100 mg/dL d) LDL below 160 mg/dL
Answer: C (please refer to NCEP ATP III)*
Note: ATP III has since been updated (July 2004), so that in high-risk patients (i.e., previous MI, poorly controlled diabetes or HPN, etc), the LDL goal should be <70 mg/dL.
The update can be downloaded at : http://www.nhlbi.nih.gov/guidelines/cholesterol/atp3upd04.htm
Some questions can throw you off course or are downright crazy:
1) What is the antidote for the chemical warfare agent that Iraq imported in large quantities from Turkey recently, as published in a Newsweek article:
Answer: I honestly do not know up to now (who cares anyway?)
2) Ruffa Mae consulted you today because of breast pain. She said that her breasts become tender and painful a few days before she has her menses. What is the treatment?
Answer: Gamolenic acid
The second session of the written exam took place after a 15- to 30-minute break for merienda. Merienda consisted of juice, kakanin, and a sandwich that tasted really strange (probably grass cuttings from the UST Botanical Garden?). Anyway, I was probably too excited to eat.
The second written test consisted of another set of 150 questions taken from clinical applications of lectures given throughout the year by the Academy, a compilation of which can be found in the book published by the PAFP, called the “Proceedings”, and a few questions from the 4 quarterly journals of the PAFP during the past year. All answers were again written on computer-readable paper.
It must be pointed out that you must finish answering all questions within the allowable time limit, which is 2 hours per session. Time management is therefore extremely important as you will be under time pressure.
By late afternoon, the Examiners (all 15 members) met in session and decided what the passing mark would be.
A computer printout of successful examinees was posted outside of the examination venue (UST Medicine Building) after the meeting (around 4pm). A total of 49 examinees passed out of the 116 who took it (or 42% survived the first day).
Day Two: The Oral Exam
Those who survived the first day are asked to come back the next day for more punishment-the oral exams, or the Revalida, as it is called at UST. The Revalida consists of four cases, each of which must be finished within 15 minutes (there is a bell timer), for a total of one hour. Each “patient” is ensconced in a separate room, with an examiner silently and closely watching you and scoring points, and the passing mark, I was told, was 75 points, This means that you must score perfectly in at least three cases to be able to pass and be called a Diplomate.
Each room or station is independent of one another. The four stations are:
Station I- Clinical reasoning-Tasks: Chief complaint(s), HPI, Focused PE, Differential Diagnosis, Final Diagnosis
Station II- Diagnostic Reasoning and Procedure- Diagnosis, 3 most important lab procedures, interpret lab/ancillary procedures, evaluation of clinical skills (i.e. proper way to do tourniquet test)
Station III- Diagnosis and Management, Tasks: Formulate Appropriate Management-Therapeutic, Preventive. Explain the rationale for the management
Station IV- Communication skills and Family Medicine Principle, Genogram, Family Cycle, Staging of Family Cycle, Discuss Family medicine Principles
The simulated patients have been previously coached on what to say and to respond to your questions, even feign pain to your palpation. You are given, however, certain “tasks”, which you must do, in order to score points. This must be emphasized because a lot of examinees fail because they did not finish the tasks (written on a piece of paper) in the allotted time allowed, even though they arrived at the correct diagnosis.
Indeed, some of the examinees (29 of them) who took the oral exams were second-timers, or examinees who passed the written part but failed the oral exams.
The key to success in the oral exam is to be conscious of the given “tasks” at all times, because no matter how much you say during the Revalida, you will not earn any point unless you accomplish the tasks assigned for the given “case”.
To illustrate:
First Case:
The first case was a patient with left flank pain. To arrive at a correct diagnosis, you must ask the usual things we ask any patient with the same symptom who consults us at our clinic- when and how did it start? Did you have any fever, dysuria, diarrhea or vomiting? Does the pain radiate to any other part of your body (In this given case, the patient said the pain radiated to the ipsilateral scrotum)? Have you had the same symptoms before? (Patient said yes) Have you ever been diagnosed to have urinary stones before? The patient answered yes. Have you undergone any X-rays or ultrasounds procedures? The patient pulled out a set of IVP X-rays (remember, he will not show you anything until you ask for it). The correct diagnosis in this case was very straightforward, although I did not say it yet at this point. It was, you guessed it, ureterolithiasis, left, with secondary hydronephrosis of the left kidney (pain due to renal colic).
PE findings: (+) CVA tenderness, left; no organomegaly, (+) direct tenderness, left flank and hypogastrium, normoactive bowel sounds.
Tasks:
1. Diagnosis/Impression
2. Differential Diagnosis (give at least five)
3. Lab procedures you will request in order to confirm your diagnosis ( routine urinalysis, KUB ultrasound, creatinine, IVP, or if the patient can afford it, high-speed spiral CT scan); optional: urine CNS, CBC, BUA (uric acid stones), stone analysis for any stones passed out, etc
4. Treatment: ESWL (best), open surgery, basket extraction, etc
Second Case:
The second case was a patient with 8–10 pus cells in her urinalysis. Typhidot test was IgG negative, IgM positive, E. histolytica cysts in her stool exam, moderately dehydrated. From history, the patient was fond of eating food sold by street vendors.
Tasks:
1- What is your diagnosis?
2- Interpret the lab findings and give the basis for your interpretation. Answer: UTI (basis: 8 pus cells in routine urinalysis is considered the cut off point for UTI; Typhoid fever (IgM positive and IgG negative on Typhidot test means an acute infection), amebiasis.
3- Give 5 possible causes for anemia in this patient
4- Issue a prescription and a plan for follow up (remember, this is Family Medicine, so you must always be holistic in your approach to treatment and prevention of recurrence of the diseases in this patient).
Third Case:
The third case was a patient with the following lab findings: CBC: HgB 14.2, Hct=53, WBC=6,300, platelets= 65,000
Tasks:
1- How do you do a proper Tourniquet test?
2- Do it on the patient, describe, and explain step-by-step
3- How do you monitor a patient with a suspected Dengue? What would you request for lab work-up and what are the expected findings? Answer: CBC, Hct, actual platelet count; a 20% rise in Hct in 24 hours and a progressively decreasing platelet count would point to a diagnosis of Dengue. Other tests: Dengue Immunochromatographic test, etc.
4- Interpret the lab findings in this patient. Answer: Elevated Hct, normal HgB, thrombocytopenia (defined as a platelet count of less than 100,000)
5- Differential Diagnosis for Dengue
Fourth Case:
Oh yes, that darn Genogram…
The most difficult case was supposed to be the easiest. On the table you will see on a piece of paper a Genogram. Our case was about an obese 37 year-old woman with diabetes. She had an infected wound on her leg that was seen by an orthopedic surgeon who recommended immediate amputation. The patient belonged to a blended family (she has two children out of wedlock) and four children by her present husband, two of whom are adults and very close to her emotionally, Her husband is a carpenter with a monthly salary of 15, 000 pesos. Both she and her husband are of limited education.
Tasks:
1- Demonstrate Your Communication skills and show how, step by step, the proper way of informing her about her disease condition (talk in Tagalog) and the need to amputate her infected leg, taking into consideration her limited education. finance, family resources, and understanding about her disease condition.
2- How would you treat this patient? (Do a holistic approach- patient education, lifestyle medication, diet, exercise, weight reduction, meds must fit into family budget, enrollment into lay diabetes education programs in hospitals and clinics, etc, etc, etc, etc) All these things you must accomplish in 15 minutes. The majority of examinees I think crashed and burned in that room. Oh well….
The odds:
What are the odds? 42% passed the written exams (49 out of 116 hopefuls) during the January 2003 Diplomate exams. Of those who took the orals, 72% made the grade. I learned that 29 other examinees from last year who failed the orals joined us during the second day. Historically, only about 30 to 35 examinees make it to Diplomate status every year. As of February 2005, there are about 800 Diplomates and Fellows, among almost 7,000 members of the PAFP.
The key is preparation… preparation… preparation. Praying wouldn’t hurt either.
Some other reviewer pointers:
Surgery-Acute AP, Inguinal Hernia, undescended testes, Breast CA, staging,
BPH- what part where prostatic cancer arises from
Infectious disease- Lost of questions on Hepa B, Hepa A, Hepa E,
Interpretation of hepatitis B profile results, HIV, Typhoid (Typhidot test),
Meningococcal meningitis (treatment and prophylaxis), pneumonia, Community Acquired Pneumonia (see updated CPG) possible etiologic agents in CAP in certain ages and populations, with varying risk factors
Pediatrics- Bronchitis, Bronchiolitis, Immunization Schedule, Protein malnutrition, Kwashiorkor, physical characteristics of those patients with specific forms of malnutrition, fluid replacement therapy, dehydration, Idiopathic thrombocytopenic purpura (ITP)
IM- thyroid, Thyroid nodules, thyroid function test, Tests for thyroid function and in hyperthyroidism, thyroid storm, Congestive Heart Failure, Osteoporosis, ABG in a patient with severe dyspnea for several hours, CAP treatment and stratification according to CPG, Dyslipidemia, NCEP ATP III, risk stratification in ATP III based on patient lipid profile, previous MI or CVA, etc, Obesity-WHO and Asia-Pacific Classification, Hypertension, Atrial Fibrillation, Osteoporosis- risk factors; SLE, exudates, transudates, pleural effusion, why it occurs (pathophysiology), TB; better read up on JNC VII Hypertension Guidelines, American Diabetes Association CPG (updated every January of every year)- downloadable from their website (ADA.org), or if you are nice to me, I can give you a copy on CD.
OB- EDC computation, H. mole, pre eclampsia, preventive OB (Folic acid, Fe), Pap’s smear
Family med- Family Cycles, Family Types (lots and lots of questions here, but not very hard if you had read and memorized the handout from the PAFP)
Please ask Dr. Vic Valencia for other pointers as he might have other subjects and questions I may have missed (there are a lot!) My excitement had clouded my recall, as you may guess. You might also want him to do an endoscopic exam on your stomach before you take the test because stress ulcers can kill. Humingi na lang kayo ng discount kay Vic.
Suggested reading materials and references:
1- Compendium of Philippine Medicine (must be number one on your list), 5-minute clinical consult (for quick reference)
2- Proceedings,
3- PAFP journals,
4- Handout from the PAFP on Family Medicine (Introductory Course)
5- Latest textbooks
6- NCEP ATP III
7- Merck Manual Centennial Edition
8- Stedman’s Medical Dictionary
9- ADA diabetes CPG
Note: Please check with the PAFP main office about your status and eligibility for the Diplomate exams next year. Update your CME record by sending certificates of CME activities you’ve attended. Pay any back dues. Check if you missed attending a required course, because this can prevent you from taking the exams. One of the required courses is the QA course (quality assurance course). Please bring a passport size picture (your own, of course, not GMA’s). You are also required to brush your teeth and take a bath a least a few days before the exams. Also change into fresh underwear because they will check before you can enter the examination room. Dr. Rudy Gutierrez, one of the nicest people around, has extra underwear that you can borrow. Also, no pets are allowed inside the examination site, without exception. He-he. Pregnant examinees get extra10 points for effort. Joke again, he-he.
The Proceedings book is published sometime around October of every year, call the main office about this. If you are missing a copy of the quarterly-published PAFP journals, you can get a few spare copies for free from the secretaries of the main office, if you are nice to them and they like your face.
Lastly, I wish you all the best and good luck!
Remember:
“We all have the capacity for greatness, not fame, for greatness is measured in service to fellow men.” - Martin Luther King, Jr.
For any concerns or questions, get in touch with:
Glenn Q. Mallari, MD, DPAFP
President, PAFP Pampanga Chapter
email address: drglenn88@yahoo.com
or visit the Mallari FamilyCare Clinic website at : http://drglenn.familydoctors.net
