Hi! My name is Daniel Lim Jhao Jian. Here is where I share my experience, knowledge and ideas. You are welcome to leave comments and follow my blog. You are free to copy anything from this blog. Please recommend this blog to your friends.

Friday 25 August 2017

Disasters in my 3rd year of MBBS

The second semester of my 3rd year of MBBS at NUMed consisted of the Long Term Conditions (LTC), Infectious Diseases (ID), Primary Care (PC), Mental Health (MH), Women's Health (WH) and Child Health (CH) rotations. At the end of each rotation, there was a MOSLER assessment where we had to see a patient, take a history from them, perform a physical examination, determine the differential diagnosis, plan their investigations and answer other relevant questions by the examiner.

The MOSLER had 4 domains of assessment which were Information Gathering, Technical & Procedural Skills, Communication Skills, and Clinical & Diagnostic Reasoning. In order to be able to proceed to the final examinations of 3rd year, we had to pass each of the 4 domains as well as Professional Behaviour in at least 4 out of the 6 MOSLER's. Otherwise, we would fail the entire 3rd year.

The MOSLER had always been the assessment that I feared a lot. I felt that the Information Gathering, Technical & Procedural Skills and Communication Skills domains were not too difficult. The only domain I found very difficult was the Clinical & Diagnostic Reasoning, because it required a lot of studying as well as application of knowledge in a clinical scenario. In the end, I passed all domains of the ID, PC, MH and CH MOSLER's, but not the LTC and WH MOSLER's.

My failures in the LTC and WH MOSLER's were my greatest disasters in 3rd year of MBBS. They were indications that I was at a real risk of failing 3rd year, which definitely caused me a lot of stress. Now that I had successfully passed 3rd year, it feels so much like a miracle. I will always remember the mistakes that I made in the MOSLER's so that I won't repeat them in the future. Here, I am going to write about what happened during my LTC and WH MOSLER's.


Soon after I began the LTC rotation in January 2017, I started doing revision for the LTC MOSLER. At that time, I had the assumption that only conditions that were within the LTC learning outcomes would be tested in the MOSLER, so I only revised those conditions. There were only 15 conditions in the learning outcomes, so my revision was quite relaxed. By the end of January, I had finished 2 rounds of revision.

Then, I had 5 days of holidays for Chinese New Year. On the day after I came back from the holiday, my senior told me that the LTC MOSLER would not necessarily test on conditions within the LTC learning outcomes, instead any chronic conditions that we had learnt during the FoCP last semester could be tested as well. This worried me greatly because I had not revised those conditions.

I quickly finished my 3rd round of revision for the conditions in the LTC learning outcomes. Then, I started revising all other chronic conditions learnt in FoCP, and I managed to finish the 1st round of revision on 6 February 2017. I was planning to do a quick 2nd round of revision on the next 2 days. My LTC MOSLER was scheduled on 9 February 2017.

On 7 February 2017, I was supposed to have self-directed learning in the morning according to the timetable. However, as soon as I woke up on that morning, my friend messaged me to inform that I need to meet the lecturer on that day for the LTC MOSLER. Even though my MOSLER was supposed to be on 9 February 2017, the lecturer wanted to do it earlier.

I immediately panicked because I wasn't prepared to do the MOSLER on that day. Even though I just finished my 1st round of revision for all FoCP chronic conditions, I felt that it wasn't sufficient and that I needed a 2nd round. I decided to explain to the lecturer that I wasn't prepared to do the MOSLER on that day, hoping that he would allow me to do it on the original date of 9 February 2017.

However, the lecturer's response was that I had known that my LTC MOSLER would be on that week so there was no excuse for me to be unprepared. He insisted that I must do the MOSLER on that day, so I had no choice but to proceed with it. The patient in the MOSLER had abdominal pain at the right-upper quadrant, fever, vomiting and lethargy. He had a history of diabetes.

During the discussion part of the MOSLER, I gave the differential diagnosis of Hepatitis and Cholecystitis. However, the lecturer immediately said that both my diagnosis were wrong. He asked for another diagnosis and gave me the clue that it was related to diabetes. I had no idea at all, so I tried answering Diabetic Nephropathy and Diabetic Neuropathy. Obviously, both were wrong.

Eventually, the lecturer told me that the correct diagnosis was Diabetic Ketoacidosis (DKA). He then asked me a few more questions about DKA. I had not revised anything about DKA, because I had assumed that it is an emergency acute condition instead of a chronic condition so it won't be tested in the LTC MOSLER. As a result, I was unable to answer any of his questions, except for one.

In the end, the lecturer let me pass the Information Gathering, Technical & Procedural Skills and Communication Skills because I still performed reasonably well in those domains, but as expected he gave me a fail for the Clinical & Diagnostic Reasoning domain. I also failed the Professional Behaviour because I was rough when examining the patient. I was really disappointed about that.

The worst thing was that, later on that afternoon, during the bedside teaching session with another lecturer, we clerked a patient with DKA for the first time. Even though it was a different patient, his symptoms were very similar to that of the patient in my LTC MOSLER. If only my MOSLER was done just one day later, I could have passed the Clinical & Diagnostic Reasoning domain.


After the MH MOSLER on 3 May 2017, I had passed the Information Gathering, Technical & Procedural Skills and Communication Skills domains in 4 MOSLER's. The only domain where I still needed to pass one more time was the Clinical & Diagnostic Reasoning, since I failed it in the LTC MOSLER. I decided that for the WH MOSLER, I would focus entirely on the Clinical & Diagnostic Reasoning and ignore the other domains. I was planning to start my revision on 8 May 2017 which was the first day of the WH rotation.

However, I fell sick one day before of the start of WH rotation. Because of my sickness, I was unable to revise at all. It took me about one week to recover from my sickness. When I began my revision at that time, I was already left behind by quite a lot. I struggled to catch up with my studies. Because of that, I was unable to engage actively in the teaching sessions, which gave the lecturers a bad impression on me. WH was really difficult due to the fact that there were a lot of topics to cover.

Throughout the WH rotation, I hardly clerked patients in the hospital, except when required by the lecturer, because I felt that it was no longer important since I already passed those domains in 4 MOSLER's. I only cared about doing revision to pass the Clinical & Diagnostic Reasoning domain. Even though I knew that making the correct diagnosis requires taking a good history, I had the assumption that there would be 'error carried forward' in the MOSLER, where I just had to make a diagnosis based on the information I obtained from the patient.

One week before the WH MOSLER, there was a new update for my favourite video game Clash of Clans (the Builder Base update), which was one of its greatest update in history. The update was teased way back in March, but it was ultimately delayed until that time. I just couldn't resist my temptation to try out the long awaited update. This affected my revision for the WH MOSLER to a certain extent.

My WH MOSLER was on 30 May 2017. After all my efforts in doing revision, I felt that I was fairly well prepared for the WH MOSLER, but I was still quite nervous as it was the most difficult MOSLER. My patient in the MOSLER had bleeding in early pregnancy. At once, I thought of the differential diagnosis of miscarriage, ectopic pregnancy and molar pregnancy. I felt rather relieved because it seemed to be an easy case.

When taking the history from the patient, I mostly focused only on the bleeding and I did not attempt to explore further. I was not serious in the history taking because I did not find it important (as I mentioned earlier) and I already had the differential diagnosis in mind. I was also quite rushed and I showed little empathy to the patient who was feeling quite sad because of the miscarriage. Then, I poorly performed the physical examination on the patient due to my lack of practice.

From the history, I figured out that the patient most probably had an incomplete miscarriage since she underwent an evacuation, and I gave that as my first differential diagnosis during the discussion part of the MOSLER. I was able to answer most of the questions by the lecturer fairly well. I felt that I should be able to pass at least the Clinical & Diagnostic Reasoning domain, which was all I wanted.

The lecturer gave me a fail for Technical & Procedural Skills which I had expected. He also told me that I could not pass Information Gathering, Communication Skills and Professional Behaviour due to poor history taking, rushing and lack of empathy. Then, much to my disappointment, he told me that as a result of my poor history, I failed the Clinical & Diagnostic Reasoning as well. He said that the patient had a fever which I did not enquire about, and that the actual diagnosis was septic miscarriage instead of incomplete miscarriage.

I tried to make an appeal for the Clinical & Diagnostic Reasoning domain, on the grounds that I was still able to make a reasonable diagnosis based on what I got from the patient. However, I was told that I failed because of my poor history taking which prevented me from making the correct diagnosis, and that there was no such thing as 'error carried forward' because all the domains of the MOSLER were viewed as a whole.

I was extremely disappointed by the outcome of the WH MOSLER. No student in NUMed had ever failed all domains in a single MOSLER. I thought back of the whole incident and tried to identify all the factors that contributed to my failure. During the CH rotation, I made sure not to repeat the same mistakes. In the end, I was able to pass all domains of the CH MOSLER and with that, I could proceed to the final examinations for 3rd year.

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