Talk the talk

Talk the Talk

Posted 01/11/19

In theatre, about to do a lap chole…

Me: Tell me the complications of gallstones.

Final year med student: Well… err… pancreatitis… inflammation…

Me: No.

I ask med students this question all the time (I do lots of lap choles – what else are we going to talk about?) and nine times out of ten I get an answer that starts out like the above. This is fine if you’re in your second or third year. This is not fine if you’re in your final year. You haven’t learnt “exam talk” and you need to. “Exam talk” is how you show your examiner that you know your stuff. You tell them what they need to hear in a professional manner that screams, “I’ve done this before, I’ve thought about this, I know what I’m talking about, move on to the next topic please.” If you don’t master exam talk, you will not sound convincing. Your examiners will have to pull things out of you. It will be hard work for them. Examiners don’t like hard work. Make things easy for them. Learn exam talk.

Classify, classify, classify.

Rule number one of exam talk and where my final year colleague fell short above. Classifying your answers or your presentations of patients is key. It gives your answer structure which, a) helps your examiner understand how you are thinking, b) helps you not to forget things and c) will help you answer questions which you’ve not come across before.

There are lots of ways to break down or classify what you’re talking about. It will almost certainly depend on the topic – e.g. are you presenting a patient or are you talking about the complications of gallstones – but it may also depend on how you like to think about things or whether there tends to be a set structure for that particular topic that the examiner is expecting to hear. For example, in the case of the complications of gallstones, there’s well-known anatomical classification that the examiner will be expecting to hear:

The complications of gallstones can be classified according to their anatomical location, either in the gallbladder, in the biliary tree or in the bowel.

In the gallbladder, complications include: biliary colic, acute cholecystitis and empyema, chronic cholecystitis, mucocele, chalangiocarcinoma and Mirizzi syndrome.

In the biliary tree, complications include: obstructive jaundice, pancreatitis and ascending cholangitis.

In the bowel, gallstones can cause gallstone ileus.

Complications of a surgical procedure is another common question to be asked:

Complications of a surgical procedure can be general, such as pain, infection, bleeding and scaring which are common to most procedures, or specfic. Specific complications may be early, such as x, y or z, and late, such as a and b.

Some of these time definitions are slightly arbitrary and no one is going to hold you to them too rigidly. Broadly, early complications occur within hours or days where as late complications develop in weeks, months or years. For inguinal hernia repair for example, specific early complications might include haematoma or urinary retention and late complications would include chronic pain and recurrence.

So, if asked the complications of open inguinal hernia repair, I might say:

The complications of open inguinal hernia repair include general complications that are common to most surgical procedures such as pain, infection and bleeding, and complications that are specific to this procedure. Specific complications may be early, such as post-operative urinary retention and haematoma, or late, such as hernia recurrence and chronic pain.

Common things are common and important things are important

I could go on discussing how to classify things but I think you probably get the idea and they’re well-described elsewhere. “Symptoms sieves” (e.g. TIN CAN BED DIP POG… Trauma, Infection, Neoplasm… google it) can be useful to classify causes for symptoms, presentations or pathology, particularly if you haven’t previously thought about it – e.g. what are the causes of neck pain? However, a word of caution when using these and/or other mnemonics: they can trap you into reciting an order that doesn’t prioritise the common and important. The causes of anorectal bleeding are a good example. It’s best not to start your answer with trauma and infection. Instead, you should say something along the lines of:

Common and important causes of anorectal bleeding include perianal conditions such as haemorrhoids and fissure-in-ano, colorectal cancer, diverticular disease and inflammatory bowel disease. Rarer causes include, trauma, infection, iatrogenic (e.g. surgery or endoscopy), angiodysplasia and brisk upper GI bleeding.

Yes, there are more, but the examiner doesn’t care because I gave them 95% of the causes of anorectal bleeding in one line. Some symptoms or presentations are just so common in medical practice that you have to have this kind of structured, rapid fire answer ready to go. By all means use your symptom sieve for the rarer causes but please give the common and important causes first.

If you’re asked for the causes of acute pancreatitis, do not begin by talking to me about scorpions. Or if you do, be prepared to tell me which type of scorpions cause pancreatitis and the relevant pathophysiology. I want to hear something along the lines of:

The common causes of acute pancreatitis are gallstones and alcohol. Rarer causes include trauma, steroids…

You’ve got to front load your answer with the common and important causes. Fortunately, the GETSMASHED mnemonic for acute pancreatitis is excellent because it does precisely that. Once the examiner has heard the common and important causes, the rest is just icing on the cake and they may just interrupt you to move on to something else.

Give me more

So there’s two key rules for exam talk – “classify, classify, classify” and “common things are common and important things are important”. There are a few more but they’ll be fodder for another post.

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