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Thinking takes time.

The KFP exam is 3 hours and 30 minutes for 26 questions – about 8 minutes per question.  That’s not much time.  

You may argue that we do not manage a consultation in 8 minutes – and we very rarely do.  But the KFP is not an entire consult – it is a segment of it to assess your clinical decision-making skills.   It is devoid of the ‘chit-chat’ of the consult, the additional paperwork and the ‘by the way’ additions to the presenting complaint.  However, the KFP is not exempt to the clinical and cognitive biases that occur in decision-making – and it is this fact that influences the timing during the exam.

You might remember some of my previous blogs around clinical reasoning.  Type 1 reasoning or ‘pattern-recognition’ is fast, intuitive and based on ‘gut-feel’.  Type 2 thinking (hypothetico-deductive) is slow and analytical.   The tricky thing is, the KFP tests Type 2 thinking.   So how do we speed up a slow and analytical process?   We use a plan.

Let’s look at a case:

Ethan Edwards, aged 3 years, is brought in by his mother as when he woke up this morning she noted him limping.   He has no other medical history and is fully vaccinated.  On examination his is afebrile and winces when you move his right hip.  There are no other abnormal examination findings.

Question 1:  What are the most likely diagnoses for Ethan’s presentation?   List five (5).

Now time yourself, how long does it take you to generate a list of differentials?   And how how long after generating the list, do you sit and rack your brain in case there are any more?   And how do you know if any are missing?

Why not use a surgical sieve to make it quicker?

  • V: vascular – ?
  • I: infective – septic arthritis, reactive arthritis, viruses
  • T: traumatic – joint trauma
  • A: autoimmune – Juvenile Rheumatoid arthritis
  • M: metabolic
  • I: iatrogenic – Drug reaction e.g. serum sickness from Ceclor
  • N: neoplastic – osteosarcoma, leukaemia
  • C: congenital – haemophilia
  • D: degenerative – Congenital Hip Dislocation
  • E: endocrine/environmental – Non-accidental injury
  • F: functional – child is pretending!

You have way more than five, so use the additional key features such as absence of temperature and other examination findings to narrow it down.   Feel free to comment on the post to list your thoughts.

Question 2:  What other features would you seek on history?  List five (5).

For each of the diagnoses, list an important historical feature that will rule in or out the diagnoses.   Again you have another list with way more than the required five answers, so pick the best ones to answer the question.

Question 3:   Additional history is unremarkable.  What further investigations would you do exclude serious causes of Ethan’s presentation?  List four (4).

Go through your differentials, pick the serious ones, list the key investigation for each and you have your answer list!   I encourage you to share you answers by commenting on the post.   If you’d like some help, here’s a great Reference:  RCH – The acutely swollen joint.  If you think in algorithms not patterns, your answers will demonstrate your thinking process.    Look at the questions on the left (the historical features) and how they relate to the differentials on the right.

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It may take a little longer at the beginning of the question to generate a broad differential list, but if you take the time to do this, the rest of the answers are already prompted and more likely to be correct.  Importantly, if you don’t have time to check them, that’s OK, as they are more likely to be correct in the first instance.

Using clinical reasoning techniques takes practice so that they become automated.  In the KFP it’s a good idea to allocate 7 minutes/question, then you will have around half an hour to tidy up your answers and check for over-coding, abbreviations etc. 

Rechecking answers is not for rethinking answers – this should be done in the first instance!

If you’d like more examples of the above, Clinical Reasoning Compass is on online module containing clinical reasoning lessons, KFP-style quizzes, and detailed answers with clinical reasoning approaches so that you can practice.

Please feel free to comment on the post to share your thoughts and answers – what a great way to practice the process!

 

 

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