Clinical Problems in Dentistry: 50 Osces and Scrs for the Post Graduate Dentist

By John Laszlo

Clinical Problems in Dentistry 50 OSCEs and SCRs.

This book gives both an understanding and an approach to pass both MFDS and MJDF exams. Detailed cases from real patients will enable the postgraduate dentist to gain an appreciation of the standards required and the professional behaviours expected from a successful candidate.

Building the basic OSCE into the SCR, this is the only book aimed at both the MFDS and MJDF exams.

Starting with Exam Expectations, the following fi ve chapters of subject-based questions cover: Medical Emergencies, Medical Matters, Ethical Examples, Clinical Cases and ends with Procedural Problems.

Written in line with the 2013 GDC Standards, this text should prove to be useful, not only for those preparing for the MFDS and MJDF exams, but for all members of the dental team who wish to use Clinical Problems in Dentistry for their CPD requirements.

Clinical Problems in Dentistry has been content evaluated, edited and reviewed. It should prove to be a valuable addition for the modern dental professional’s reading.

Key Features:

1. Mandatory Core CPD areas covered.
2. Focus on communication and non-technical skills for the exam and the clinic.
3. Additional information from the OSCE to the SCR level for each question.
4. Citations and references provided for further reading.
5. Easy to read, detailed studies of patients, describing them as people and not just clinical cases.

• Language: English
• Publisher: Xlibris UK
• Release date: Nov 11, 2013
• ISBN: 9781493119769

John Laszlo

John Laszlo BSc Hons BDS MFDS RCS(Ed) MJDF RCS (Eng) Member of the Faculty of Dental Surgery and the Faculty of General Dental Practice. The Royal College Surgeons England.

Book preview

Copyright © 2013 by John Laszlo.

All rights reserved. No part of this book may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the copyright owner.

Rev. date: 11/05/2013

To order additional copies of this book, contact:

Xlibris LLC

0-800-056-3182

www.xlibrispublishing.co.uk

[e-mail]

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Contents

Preface

Chapter 1 Exam Expectations

Introduction

The Exam Structure

The MFDS Themes

The MJDF OSCEs

Preparation for Exams

Failure

Exam techniques should reflect clinical ones.

The Four Clinical Domains

Exam Domains in Greater Detail

1. Information Gathering

2. The Candidate to Actor Interaction

3. Conveying Information

4. Clinical Issues

Key Elements of an OSCE Consultation

Unpalatable truth and dishonesty

Giving and Taking in the Examinations

Relevant Information in the OSCE

History Taking in the OSCE

Communication and Empathy

Empathy Is Not…

Breaking Bad News

From the Theatrical to the Practical

Words and Language

The Marking Scheme for the Examinations

Don’t Memorise Anything in This Book

References for Exam Expectations

Further Reading for Exam Expectations

Chapter 2 Medical Emergencies

Introduction

References Medical Emergencies Introduction

Further Reading to Medical Emergencies Introduction

Medical Emergency 1

Background Information

Introduction

The Steps Towards the Answer

Post-Emergency Care

Further Notes to Medical Emergency 1

Prevention

References to Medical Emergency 1

Medical Emergency 2

Background Information

Introduction

Patient with Difficulty Breathing

Responding to This Medical Emergency

Points to Note

Common Causes of This Medical Emergency

Further Notes to Medical Emergency 2

References to Medical Emergency 2

Further Reading to Medical Emergency 2

Medical Emergency 3

Background Information

Introduction

Answers to This OSCE

Signs and Symptoms You Will See

An Emergency Presentation of This Condition

The Importance of a Medical History

Document Your Findings

Further Notes

References to Medical Emergency 3

Further Reading to Medical Emergency 3.

Medical Emergency 4

Background Information

Introduction

Answers to this Medical Emergency

Heresy or Orthodoxy: An Examiner’s Comment

Facts to Consider

Adult Basic Life Support

References to Medical Emergency 4

Medical Emergency 5

Background Information to This Question

Please Take Note of Patient Notes

Introduction

Further Notes on Medical Emergency 5

Recognition of the Clinical Signs

References to Medical Emergency 5

Medical Emergency 6

Background to This Emergency

Introduction

Procedures to Follow

Further questions and answers about this emergency

Further Considerations of this Medical Emergency

Additional Details.

Anaphylactic Reactions Initial Treatment

References to Medical Emergency 6

Medical Emergency 7

Background Information.

Introduction

Beginning a Difficult Consultation

Procedures to Follow

Point to Note

Further Notes to this Medical Emergency.

Adult Choking Treatment

Paediatric Choking Treatment

References to Medical Emergency 7

Medical Emergency 8

Background Information

Introduction

Answers to this Medical Emergency.

Three Questions

Further Notes to this Medical Emergency.

References to Medical Emergency 8

Further Reading

Medical Emergency 9

Background Information

Paediatric Basic Life Support

Introduction

The Procedures in This OSCE

Public Expectations

Paediatric Basic Life Support

References Medical Emergency 9

Medical Emergency 10

Background Information

Introduction

The Devil is in the Detail

The First Procedures to Follow

From Angina to Cardiac Arrest

Further Notes

Adult Automatic External Defibrillation

References to Medical Emergency 10

Further Reading on Medical Emergencies

Chapter 3 Medical Matters

Introduction

Medical Matter 11

Background Information

Introduction

Medication Lists in the Exams

First Thing to Do

Medication and Side Effects

ASA Grading of the Patient

The Answers

Prescribing

Treating

Further Notes to this Medical Matter.

References to Medical Matters 11

Further Reading

Medical Matter 12

Background Information

Introduction

Developing Your Answers

Reasons for the Answer

A Lack of Information

Further Notes to this Medical Matter.

References to Medical Matters 12

Further Reading

Medical Matter 13

Background to This Case

Approach to the subject

Medical and Social Considerations

Answers to this Medical Matter.

Management Options

Treatment Options

Further Notes to this Medical Matter.

References to Medical Matters 13

Medical Matter 14

Background Information

Introduction

Structured Answers

Medication history

History Taking

Bleeding Tendencies:

Cirrhosis and Caput Medusa

Clinical signs of liver disease

Further Note to this Medical Matter.

References to Medical Matters 14

Medical Matter 15

Background Information

Introduction

Initial Answers.

Further Answers.

Clinical Recommendations

Further Note to this Medical Matter.

References to Medical Matters 15

Further Reading

Medical Matter 16

Background Information

Introduction

The Complaint

Answer to this Medical Matter.

Intra-Oral Signs

The Differential Diagnoses

The Case Management

Pain Questionnaires

References to Medical Matter 16

Further Reading

Medical Matter 17

Background to the Case

Introduction

Answers

Further Note to Medical Matter 17.

References to Medical Matters 17

Further Reading.

Medical Matter 18

Background to the Case

Introduction

Answers to this case

Appropriate Questions

A Revealing Clue

Continuing the Dialogue

Going After the Details

Further Answers

Specialist Tests

Definitive Treatment

An Important Clinical Consideration

References to Medical Matters 18

Further Reading

Medical Matter 19

Something to Wake You Up

A Re-introduction

Answers to This Medical Matter.

Chewing Over the Information

The Deficiency State

Clinical symptoms and signs

Critical Differences

Management Answer

Further Notes

References to Medical Matter 19

Medical Matter 20

Background Information

Just As a Reminder

Introduction

Formulating and Presenting Your Answers

The Answers to This Medical Matter.

More Answers

The Pause

Don’t Learn the Reference Intervals

Further Notes : Anaemias in Real Life

References to Medical Matter 20

Further Reading for This Medical Matter.

Medical Matter 21

Background Information

Introduction

Answers

Consider the Capacity then Consent.

Cervical Lymph Nodes

Silver Linings

Further Notes to This Medical Matter.

References to Medical Matter 21

Further Reading

Medical Matter 22

Background Information

Introduction

Answers

Further Notes to this Medical Matter.

References to Medical Matters 22

Further Reading

Medical Matter 23

Background Information

Introduction

Answers

Metabolic Considerations

References to Medical Matter 23

Further Reading

Medical Matters 24

Background Information

Introduction to the Case

Answers

Points to Note

References to Medical Matter 24.

Further Reading

Medical Matters 25

Background Information

Explaining and Describing

Introduction

Answers to This Medical Matter

Clinical Signs in Introduction

Access to Information

Further Notes to This Medical Matter.

References to Medical Matters 25

Further Reading

Chapter 4 Ethical Examples

Introduction

Where Do Ethics Belong?

The Hidden Curriculum

Serving the Profession

Ethics in the Exams

The 2013 GDC Guidelines

Consideration of These Oaths

References to Introduction Ethical Examples

Ethical Example 26

Introduction

Answer

Parental Responsibility

Closing Statements

Further Considerations

The Legal Aspects

References to Ethical Examples 26

Further Reading

Ethical Example 27

Background Information

Introduction

Answer

Further Notes to This Ethical Example.

The SPIKES Protocol

White Patches and Smoking

Management of the White Patch

References to Ethical Examples 27

Further Reading

Ethical Example 28

Background Information

Introduction

Sharps injuries

The Answers

Further Notes to This Ethical Example

References to Ethical Example 28

Further Reading

Ethical Example 29

Background Information

Introduction

Point to note

Answers

Further Notes to This Ethical Example.

References to Ethical Examples 29

Further Reading

Ethical Example 30

Background Information

Introduction

Considerations in Your Answers

The Answers

Further Notes to This Ethical Example

References to Ethical Example 30

Chapter 5 Clinical Cases

Introduction

Clinical Case 31

Introduction

Points to Note

The Answer

The Medical History

The Dental History

Determining the Nature of the Problem

The Dialogue in This Clinical Case.

Discussion of Solutions

Further Notes to This Clinical Case

References to Clinical Case 31

Further Reading

Clinical Case 32

Background Information

Introduction

Non-Accidental Injury

Answer

Child Abuse and the Exams

Dental Trauma

References to Clinical Case 32

Further Reading

Clinical Case 33

Background Information

Introduction

Answer

Testing Required

Management of the Condition

Further Notes to This Clinical Case

Diagnostic Features

References to Clinical Case 33

Further Reading

Clinical Case 34

Background Information

Introduction

Answer

Additional Radiographic Findings

Further Notes to This Clinical Case.

Parallax views

References to Clinical Case 34

Further Reading

Clinical Case 35

Background Information

Introduction

Answers

1. The First Steps to Take

2. The Early and Intermediate Treatment

3. Those Who Should Be Notified

4. Possible Complications Arising

5. The Management of Complications

Further Notes to This Clinical Case

Five Rules of 5’s.

References to Clinical Case 35

Further Reading

Clinical Case 36

Background Information

Introduction

Points to Note

Answers

1. The Brief set of Histories Relevant to This Patient

Points to Note

2. Explain the Options for Treatment

3. Common procedural complications and answers

Further Notes to This Clinical Case.

The Risks from Extraction

References to Clinical Case 36

Further Reading

Clinical Case 37

Background Information

Introduction

Answer

1. Greeting and Opening the Consultation

2. Open Questions and Body Language

3. Reflecting Back to the Actor/Patient

4. The Histories

5. Candidate’s Considerations of the Complaint.

6. Giving an Explanation

7. The Specific Problem

8. Initial Treatment

9. Further Specialist Treatment

Further Notes to This Clinical Case.

Further Reading to Clinical Case 37

Clinical Case 38

Background Information

Introduction

Answers for Clinical Case 38.

Point to Note

Concerns with Pre-Medication.

Points to Note

Points to Note

Points to Note

Further Notes to This Clinical Case.

References to Clinical Case 38

Further Reading to Clinical Case 38

Clinical Case 39

Background Information

Introduction

Answer

Beginning the Consultation

Focusing on the Issues

Points to note

Providing Answers

Advice and Explanations

Further Notes to This Clinical Case

References to Clinical Case 39

Further Reading

Clinical Case 40

Background Information

Introduction

Answers for Clinical Case 40.

Overall Prognosis

Further Notes to Clinical Case 40

References to Clinical Case 40

Further Reading

Clinical Case 41

Background Information

Introduction

Answers to Clinical Case 41.

Point to note.

Further Notes to Clinical Case 41

References to Clinical Case 41

Further Reading to Clinical Case 41

Woody’s Work 42

Background to This Case

Dealing with the Anxious Child

Introduction to the Case

Answer for Woody’s Work.

Explanations

Radiography and Explanations

Figures from canine studies

Ectopic canines guidelines

1. Leave and Observe

2. Deciduous Canine Extraction

3. Permanent Canine Extraction

4. Canine Transplantation

5. Exposure and Alignment

Patients don’t really care how much you know…

. . . As long as they know how much you really care.

Intranasal Sedation

Further Note about Woody

References about Woody’s Work

Some of Woody’s Work.

Clinical Case 43

Background Information

Introduction

Answers to Clinical Case 43.

Jollying the Patient Along

Key Skills + Core Chores

Surgical Sieves

A Patient-Centred Consultation

Further Notes to Cinical Case 43.

The journey is more important than the destination.

References to Clinical Case 43

Further Reading to Clinical Case 43

Clinical Case 44

Background Information

Introduction

Answers to Clinical Case 44.

Minor Matters.

Point to Note

Points to Note

Dental Record Retention

Further Notes to This Clinical Case.

References to Clinical Case 44

Further Reading to Clinical Case 44

Clinical Case 45

Background Information

Introduction

Clinical Case 45 Part 1: Answers

Two Heads Are Better Than One

Pemphigus and Pemphigoid

Zebras, Fascinomas and Zebromas

Nervous revision

Further Notes to Clinical Case 45 Part 1

References to Clinical Case 45 Part 1

Clinical Case 45 Part 2

Brown Envelope—Pink Paper

Answers Clinical Case 45. Part 2

Simple Questions but No Easy Answers

Breaking Bad News

Further Notes to Clinical Case 45 Part 2

A Ticket to the Zoo

References to Clinical Case 45 Part 2

Further Reading to Clinical Case 45 Parts 1 and 2

Chapter 6 Procedural Problems

Introduction

The Story So Far…

Important Developments

References Introduction Chapter 6

Procedural Problem 46

Background Information

Smoking Cessation

Introduction to Procedural Problem 46.

Answers to this Procedural Problem.

Addictive Behaviours and Fears

Does the Patient Need Help?

The Importance of a Medication History

The Treatment Ladder

Further Notes to Procedural Problem 46.

The First Words Last

References to Procedural Problem 46

Further Reading to Procedural Problem 46

Procedural Problem 47

Background Information

Introduction

Answers to Procedural Problem 47.

A Socratic and Not a Didactic View

Audit Topic

Audit Methods

Further Notes to This Procedural Problem.

References to Procedural Problem 47

Further Reading to Procedural Problem 47

Procedural Problem 48

Background Information

Introduction

The Answer

Pascal, Patients, and Papillomas

Further Notes to This Procedural Problem.

References to Procedural Problem 48

Further Reading

Procedural Problem 49

Background Information

Answers

Points to Note

Why We Need the Guidelines

Sharps! Points to Note

Safety Legislation in Dentistry

Further Notes to This Procedural Problem.

References to Procedural Problem 49

Further Reading to Procedural Problem 49

Procedural Problem 50

Background Information

Procedural Problem 50 Part 1

Introduction

Answers Part 1

Further Note to Procedural Problem 50 Part 1.

References to Part 1

Procedural Problem 50 Part 2

Introduction

Answers Part 2

Current trends

Manufacturing methods

Chemical composition

Consent Concepts

Consent Components

Consent 10 Commandments

References to Part 2

Further Reading

The End… (of the Beginning)

Essential reading for Beryl Murray Davies.

Preface

In the second decade of the Internet, our patients are living longer. Despite outward appearances, many are chronically ill. Advances in care pathways and modern medical treatments allow them to live robust lives. Patients, families and carers now effortlessly access electronic information and attend their appointments with a surprising degree of familiarity of the conditions they have and the treatments they wish to have.

In the advent of the digital age, in response to information now in the hands of our patients, technologies were developed for clinical training with the surgical professions seeking refuge in simulation from the onslaught of widely dispersed information freely available to all. Anatomical knowledge was taken from the cadaver to the computer, dissection being demoted and digisection promoted. Vast tracts of the training syllabus were deposited in digital… dot… domains in the progressive modernisation of clinical careers.

In addition to the above developments, patients with specific signs are no longer invited to attend for student clinical examinations. Professional actors recruited into OSCEs have replaced them. These days, dental students are asked to assess symptoms that an actor speaks about, rather than examining signs a patient suffers from.

Today, with electronic information being readily available, there is a fundamental question whether there is a need for a book such as this. When contemplating this project last year, the advice given by Professor St John Crean of the Faculty of Dental Surgery, RCS England was; there is still a need for the clinical textbook. In contrast to evolving electronic media, the textbook is a preserved specimen, only fading ink and yellowing pages mark the passage of time.

‘When treating patients have a warm heart and warm hands’ were words given in St Andrews by Dr David Sinclair. It was my good fortune to receive his wisdom and a privilege to meet (now) Professor Sinclair and reflect on that advice, when after the passing of nearly 25 years we met once more, this time at the Faculty of Surgical Trainers annual meeting in Birmingham in 2013.

That his words stand and have served so many so well in the clinic, is a good indicator that books and words frozen in time espousing warmth and humanity still have a place in clinical education. While the Internet is comprehensive and prone to mistakes, a book can concentrate and filter information, consistently condensing it into a form useful for the examination candidate and the practicing clinician.

Whereas the Royal Colleges now use actors in their clinical exams, I have based this book on real people: my patients. It was the advice and example of one patient Mr Barry Harvey that set the writing process in motion. This book contains just about everything I have learned about the MFDS and MJDF exams. Although it is the work of a single author (and I own all the mistakes), some of the very best people freely gave their opinions, advice and support to this project pushing it to completion:

The two Mariannes: Laszlo and Lehmann BA (Fribourg). Mrs Michelline Brannan MA (Oxon) BN. Mr Roger Farbey MBE, Helen Nield and staff of the BDA library, London. Dr Adrian Bercu. Fribourg, Switzerland. Mr Alex Leslie LLB and his staff of Radcliffes Le Brasseur, London. Mr Robert Francis QC. Serjeant’s Inn Chambers, London. Mr B Westbury, Mr S Henderson and staff of DPL, London. Professor St John Crean, Faculty Dental Surgery Royal College Surgeons, England. Dr Maria Hardman Clinic 95, Oxford. Mr Randy Smith, Miss Kay Benavides and Miss Carla Cobar, for their effort and energy in bringing this to print. All of my patients and colleagues for their appreciation, faith and trust.

Your comments, criticisms and corrections are expected and they will be accepted.

In this, the 600th year of the founding of my Alma Mater: St Andrews, Scotland’s first university, I now remember one of Scotland’s finest daughters: Miss Jane Haining. I am moved to write her lasting words:

There are mountains on the road to heaven

Jane Haining was a true Christian, a teacher and a healer. She perished in Auschwitz in 1944, giving her life caring for others. She was prisoner 79476. This book is dedicated to her memory and to those below, Olim Cives. I learned from them all, their words, wisdom and lives are written into this book.

Elizabeth Laszlo 4074003.

Reverend Dr Jorg Rades.

Dr Imre Laszlo MD Ph.D

Dr Asif Omar Qureshi BSc. MD.

Michael Vogel 65316

Anna Sotto

Dr Gustav Milan Braun MD FACS.

Dr Michael Norman Wood BDS FDS RCS (Ed).

1

Exam Expectations

Introduction

The aim of the Objective Structured Clinical Exams (OSCEs) in Part 2 of both the MFDS and MJDF and the Structured Clinical Reasoning (SCRs), Part 2 of MJDF, is to test your clinical competence. On entering these exams with a realistic prospect of passing, you will be expected to demonstrate contemporary evidence-based clinical knowledge delivered with appropriate professional behaviours.

The level of your abilities for the MFDS and MJDF examinations should be equivalent to that of any dentist working in primary dental care or secondary hospital care with two years’ post-qualification experience. You will not be assessed to the level of a specialist for the MFDS or MJDF, but you will be expected to demonstrate a level of communication skills, clinical knowledge, understanding, and management of common conditions seen in dental patients to a level beyond that of an undergraduate dental student.

In these examinations, although you will not be expected to demonstrate the knowledge and skills of a specialist, you should not forget that specialists mark your performance in the clinical scenarios presented to you.

Many of you will be attempting these exams to mark completion of your foundation training and will have up-to-date knowledge both readily to hand and fresh in your minds from your undergraduate days and postgraduate tutors. Some of you will have taken one or two years’ break from study in between completing Part 1 of the MJDF and now wish to complete Part 2 of MFDS, before Part 1 expires. The time limit is set at 5 years between parts 1 and 2 of these exams.¹

In doing so, you will benefit from reciprocal intercollegiate arrangements, ensuring equivalence for Part 1 of the exams. So you can take a short cut across the exams from MJDF, Part 1, to MFDS, Part 2, and save an hour or two of examination time in the process. A few of you will be taking the longer way round and stay within one track of either MFDS for the Scottish Colleges or MJDF in the English College.

Having completed both exams myself, I do not know if there are advantages to be gained by cutting across the tracks. It may well be that what you gain in time to complete this key aspect of your postgraduate training you might potentially lose in the subsequent stages of your career because there was a core component that was never learnt, revised, or examined.

Taking short cuts to save on the time spent taking exams could potentially mean the foundation upon which you will build your career may not be as sound as a candidate who completes all necessary steps in one track or both tracks together and therefore has all core components in place in the foundation of their careers.

Those of you from outside the UK, the Middle East, Europe, and USA and further afield will be taking these exams to demonstrate your clinical skills are worthy of recognition by your collegiate peers in the UK. You will be rewarded with membership by examination, then election to your chosen college after passing all parts for the diploma of MJDF or MFDS.

In addition to all of you who are newly qualified keen, aspiring hospital specialists, there will be a few of you who are older candidates from general dental practice who for one reason or another have only now just returned to study with renewed enthusiasm and confidence. You will be attempting these Part 2 OSCEs and SCRs for the first time, having never experienced Objective Structured Clinical Examinations as an undergraduate. For you, there will be the open curriculum to learn and a hidden curriculum of new phrases and communication techniques, of which the younger candidates will have gained experience in their undergraduate days. Learning the facts and figures needed for the OSCEs is one area to master; the other is learning about the best way to convey your knowledge to the actor and the examiner in the brief time allocated in the exam.

An interesting aspect of the OSCEs is the actor portraying a patient has a say in your assessment too. Actors are asked to comment on your presentation, and ultimately if you cannot perform in the OSCEs to the standard both the examiner and actor expect, you will not pass the exam.

Your decision to study for the MFDS and MJDF will undoubtedly improve your clinical skills. In the exam itself, demonstrating your enhanced knowledge and a deeper understanding of dental problems beyond the level required for your undergraduate exams is not easy, but it is achievable. More than anything else, it is a worthwhile exercise that benefits your patients and yourself with a sense of professional pride when your efforts are recognised with an exam pass and the award of your diploma.

The background of those who take and pass these exams is wide. Candidates from all over the world come to sit these exams in the UK. From the UK itself, there is a huge range of candidates preparing for the exams. There are recently qualified dentists in their early twenties who sail through all parts of the MFDS and MJDF at their first attempt. There are older candidates too. One middle-aged candidate who returned to study after several career breaks and having not picked up a dental textbook in nearly twenty years eventually passed the MFDS after five attempts. If you are taking more attempts than this or if you know of anyone who is taking more attempts than this, or thinking of giving up after failing, please let me know and I will send a copy of this book. Not only is this book more cost-effective than another failed exam attempt, with collegiate support and good luck we will make on the way, we might guide you towards the success that has eluded you.

In 2012, I attended the BDA (British Dental Association) Conference in Manchester to listen to the candidates who had recently passed the MJDF. These newly qualified speakers were part of a presentation supported by the Royal College of Surgeons, England, Joint Faculties of Dental Practice and Dental Surgery. These young dentists were invited to discuss their experience of the MJDF and why they chose to undertake these exams.

The first speaker said it gave him a sense of achievement, the second announced to the audience he wanted the letters after his name, while the third speaker told me (privately) he needed to get ahead of the competition to get his place in specialist training.

If those reasons were really true, then the aphorism ‘the only thing worse than finding out your best friend from dental school has died is finding out they did better than you’ might apply here. If that was true, then we would all be doing these and any other exam, just so we could do better than our best friend from dental school before we see our last patient and shuffle off to that great clinic in the clouds.

Wouldn’t we?

In putting yourself through these exams, you have shown a commitment to dentistry and a commitment to caring for your patients. Just by attempting these exams you are doing better, but not better than your best friend; you are doing better than if you decided not to continue with your studies at all.

So I guess doing these exams is a way of marking your progressive improvement as a dentist.

Oh, and by the way, before we get on to the exams themselves, just because the UK GDC (General Dental Council) does not presently consider the MFDS and MJDF to be registrable qualifications² do not let this odd decision put you off doing the exams. If this GDC decision is a reason for not studying to become a member of a Royal Surgical College, then what an own goal against: your profession and your place in your profession that would be. In the bigger scheme of things, don’t forget the GDC is limited to regulating the practice of dentistry in the UK. On the other hand, the MFDS and MJDF carry significant cachet and gravitas from the UK and from the Surgical Colleges around the world to wherever candidates who have studied and passed these exams are benefitting their patients in the practice of dentistry to a higher standard than if they had never contemplated these exams in the first place.

The Exam Structure

OK, with your motivation to continue studying and with whatever reason you are fuelling your desire and determination to complete your MFDS and MJDF, I guess we can now get on to the exam itself.

In the MFDS, there is no requirement to treat or to actually physically examine the actors who will represent patients with common clinical conditions. In various exam questions, actors will portray the relatives of patients who have endured certain clinical situations and you will conduct a dialogue with them.

In the MFDS, there are currently no medical emergency OSCEs; this is the preserve of the MJDF. At several MFDS exam sittings, I have seen anxious candidates in their last remaining minutes before being ‘condemned’ to entering the examination room, nervously looking through textbooks on how to deal with medical emergencies for an exam where there are no medical emergency questions!

Of course, the decision not to include medical emergencies in the MFDS may change in time, so do be aware of the regulations and requirements for the college you will be sitting your exam in. Do not unnecessarily stress yourself and lose time in revising a subject you will not be examined on.

In contrast to the MFDS in the MJDF, there are questions specifically dealing with medical emergencies; these may have actors representing patients or relatives of patients. There are also the procedural and practical medical emergency OSCEs with no actors but resuscitation manikins. In these OSCEs, you must demonstrate competence in dealing with any one of the medical emergencies presented.

Out with medical emergencies, there are further practical questions that do not have actors present. In those OSCEs, you need to demonstrate competences in a clinical technique or event, e.g. taking a biopsy or dealing with needle stick injuries. With two years of clinical work or more behind you, hopefully you will have plenty of experience of the former while little if any of the latter.

It is not the purpose of this book to teach you how to become technically competent in the clinical areas of your work. Only after practice, practice, and practicing again for all the hours you have and possibly some you think you might not have, will you become a competent practitioner in the clinical skills on which you will be examined. Rather, this book presents questions from cases that commonly occur in dental practice based around those OSCEs regularly found in both the MFDS and MJDF exams.

In your exam, in all MFDS and certain MJDF OSCEs with actors, an introduction with information about the case and the patient is presented to you in a booklet (which you must return at the end of the exam). In the two or so minutes you have before entering each OSCE and the ten or so minutes at the rest stations between active OSCEs, you will have time to note down and highlight any areas you feel are relevant to the exam question. During the examination with the actor, you can refer back to information you have written in the booklet.

In the MFDS and MJDF exams, you are given a comprehensive and clear briefing before you enter the examination room. The only thing you have to watch out for is that you are at the correct page for the correct OSCE. If you are unsure, then ask a member of the examination staff.

On the day of your exam, you will see administrative staff of the Surgical Colleges in attendance. In addition to their quite intensive workload, they do a first-class job in calming anxious candidates. You can rely on them to make sure you are at the right page, the right station, at the right time, and that you are all right.

The rest is up to you and all the hard work you will be putting in between now and your exam. For now there are three essential points you should note:

First, in these exams both your ability to communicate and your clinical knowledge will be examined.

Second, your understanding of the clinical problem the actor portrays, how you propose to manage this with any potential issues developing or background factors you uncover is at the heart the OSCE.

Third, the ability to demonstrate your clinical skills and competencies under exam conditions and not under clinical conditions is the key to passing both MFDS and MJDF.

The MFDS Themes

In the MFDS OSCEs, four clinical themes are examined. Depending on the theme of the question, a different emphasis is placed on these areas when assigning marks for the candidate’s performance:

1. Taking a history. This can be a medical, a dental, or a social history taken from the actor.

2. Explanations. These are a diagnosis, a prognosis, and the available options for treatment. If the actor agrees to one of the options you mention, then explaining what the procedure entails for them with the benefits and the risks involved will be expected from you. The advantages and disadvantages in proceeding or not proceeding with your options must be given in balanced terms.

3. Investigations. The results of any previous investigation or test should be interpreted and then communicated to the actor. In the OSCE, such test results will be given to you in the exam handouts and these are also provided in the introduction to each case.

4. Managing Patient Concerns. The enquiries or concerns of the actor representing a patient or their relative need to be addressed in the OSCE. Such exam questions frequently deal with consent issues: consent for a procedure, the management of a nervous patient or relative (most likely the parent of a child), encouraging or motivating the actor portraying a patient to take an appropriate course of action or to undergo some form of treatment. Lastly, management could mean informing the actor or patient of a course of action that is needed but which is neither ideal nor expected, such as giving test results or the breaking of bad news.

At present, the MFDS has a defined theme order from OSCE No 1 to OSCE No 10 as follows:

OSCEs 1-2: History taking.

OSCE 3: Investigations.

OSCEs 4-6: Managing patient concerns.

OSCEs 7-10: Explanations.

Please note this order may change in the future.

The MJDF OSCEs

In the MJDF exam, there will be a mix of the above themes with practical skills OSCEs, including (as mentioned above) the medical emergencies. The skills station OSCEs will cover the entire range of dental clinical activities. The only real preparation for the practical MJDF OSCEs is as stated above: to practise, practise, and practise every day while in clinic.

While you practise the clinical skills necessary for the MJDF, do not neglect to keep your theoretical—and evidence-based knowledge up to date. In many ways, some of the MJDF OSCEs are as much an exercise in multitasking as they are a test of your clinical competencies.

In contrast to the MFDS in the MJDF, there is no defined order determining the type of OSCE that will appear. So after completing a practical question, you may enter a medical emergency and then a dialogue question and so on.

Preparation for Exams

On one revision course a while ago, I met a candidate who had decided to take several months’ break from work to concentrate on the exams. On balance, this isn’t a great idea for several reasons:

1. You will not have an income and the exams do cost money.

2. You will not be in practice dealing with patients.

3. Your clinical skills might become degraded with absence from the clinic.

4. You will not be regularly practicing the techniques needed to pass the skills OSCEs in the MJDF.

5. In taking this amount of time off, you will be isolating yourself from your colleagues professionally, academically, and perhaps socially too.

Taking a week or even a month off before the exam and getting some rest is a good idea. Taking several months off is a bad idea.

Do carry on working and develop good professional relationships with your patients. Treat every patient as if you were being examined in an OSCE. By doing so in addition to giving them the best standard of care, you are also mentally preparing yourself for your exams. In doing so, I cannot see any harm in letting your real-life patients know you are studying for your postgraduate exams. I did.

Most will be quite pleased to know they are in the care of a dentist studying for higher qualifications.

From experience, I can tell you that patients are more than supportive, forgiving, and accepting when things do not go as well as expected or you have to give them your bad news. Patients are also very good at giving feedback too. However, if you want the support and feedback from your patients, you have to let them know what you are studying for and why you are studying for these exams.

Let’s not forget it is important to let your patients know when you will not be in the clinic to look after them. Don’t just abandon them when you will be at a revision course or sitting your exams.

Failure

If you do not pass an exam, patients are so supportive and do give you encouragement, feedback and insight from their perspective too. One candidate told me that the best words of advice received after failing did not come from a tutor or colleagues but came from a patient:

‘Och dinnae wurry aboo’ it. Dinnae gee up gee it an aer’ go. Ahll ah ways come ti yee wi mah nashers.’

(Do not worry about this failure; do not give up and give it another go. I will always come to see you with my teeth.)

For some of you now entering an exam your preparation comes after failure. Joining a study group will help to highlight the areas you need to concentrate on more and the areas where you have already reached the required standard to pass. Attendance at and learning with a study group is an efficient use of your time and can consolidate your approach to the exam.

Exam techniques should reflect clinical ones.

In working towards the MJDF, remember there are practical OSCEs too. So when you write out a patient’s prescription or are suturing your patient’s sockets, if you are in the mindset: that you are working under exam conditions, when sitting the MJDF exam, it won’t feel at all odd, for example; to be talking to the practice biopsy pad you are suturing and asking it in front of an examiner:

‘This won’t take too long. You will let me know if you are in any discomfort?’

If you don’t do this in the exam, then the examiners will probably think you don’t do this in real life either and you treat your patients with the same lack of respect you give to the practice pad. Do let the examiners know you would check the medical history, have used both topical and local anaesthetic, so there will be no pain or discomfort while you cut and suture and remember to place a tissue orienting suture for the histopathologist too.

Do not forget to advise that you will take the sutures out (if necessary) and give the results of the sample you have taken in one to two weeks time.

The Four Clinical Domains

In both the MFDS and MJDF exams despite the differences previously outlined, the assessment of the candidate is broadly similar. There are four domains on which both the examiner and the actor will mark you, and these are your abilities to do the following:

1. Gather relevant and necessary information. You need to demonstrate the clinical skill to exclude the improbable and concentrate on the possible information relevant to the OSCE.

2. Interact with the actor. How well can you relate to the actors? In my experience, there is a wide variety of actors, just as there is a broad range of patients. For some actors, their not being on the red carpet to the Oscars and having to settle for the blue carpet in the OSCEs is almost an unbearable insult to their talent. In contrast, other actors are very kind and considerate, wanting to do everything to help you pass, sometimes to the consternation of an examiner trying in vain to control the actor with a hard stare (nice use of body language).

3. Convey information. Nothing impresses the examiners more than simple things said simply. Please do not pluck the most complicated wordage out of your preconscious mind to convince the actor and the examiner you really know what you are talking about. You really will not convince them of anything. Speech is silver, silence is golden.

Use the power of the pause³ and allow the actor time to speak. Actors in the main love the sound of their own voice, so do not deprive them of the pleasure. After all, that is what they are getting paid for. This pause will give you time to put a few choice words of your own into the OSCE.

4. Deal with clinical issues. There isn’t any getting away from the fact you have to know your facts and you have to attend the exam with all the facts in your head not in your mobile phone. Guidelines change and the Internet is a good source of accessing the information needed in your revision. However, whatever else you do in the exam, please do not tell the actor to look up the data they need on the Internet and leave it at that. Rather advise them of reputable web sites to access information, e.g. NHS Choices, Cancer Care UK, Resuscitation Council UK. If doing so, you must cite the data, the source and the date you accessed it.

Homework, Information, and Consent

1. In the real world, with real patients, I always give them homework to do. This usually involves looking up something or other on the Internet or reading an NHS Patient Information Leaflet I give them.

2. Web addresses of something they ought to know are a good source of information, and my patients go online before we meet again in a week or so and come back with questions.

3. If they have not done their homework, then the patient will not know the facts, and therefore, the consent process might not be valid.

In-cranio is better than in-silico

In contrast to the real world in the MFDS and MJDF, you will not be meeting with the actors again (unless you are coming back for the re-sit). So in an exam, telling the actor all the information is available online, when you don’t know the answer (even though some 85% of patients have access to the Internet⁴), might not get you many marks from the examiners. For these exams, you are not allowed to take any electronic device into the exam. Nor can you realistically rely on last minute knowledge chaotically crammed into your short-term memory bank for recall if needed. In an OSCE, candidates who utilise this method of revision often present a mass of jumbled facts in a tangled knot and in doing so end up breaching one or all of the four clinical domains listed above. Although we have moved from the days of in vivo examinations with real patients to in vitro practical simulations, to pass these examinations, a substantial amount of data has to be well learnt and systematically processed in order to be dispensed efficiently and appropriately when needed.

In the exams, there will be a marking schedule to note down the results you achieve in the four OSCE domains, you will be assessed as being competent or not competent, and your grades will be added together. As mentioned above, depending on the theme of the exam question, a different emphasis or weighting will be attached to each of these OSCE domains.

Exam Domains in Greater Detail

In 1994, Chambers⁵ first noted the issues of competencies and their importance in dental training. If we go through the exam domains again in more detail, by knowing what is expected of you, your ability to achieve competence in the domains can be achieved through focused revision.

1. Information Gathering

In the OSCE, you should be able to recognise and react to concerns raised by the actor. For example, these concerns can be about the appearance and the function of dental work.

When taking a history, you should have an understanding of background social issues facing the patient portrayed in the OSCE. These might include any past or future events likely to impact on the decisions any patient or dentist engage in and when deciding on the best treatment option to pursue. In the OSCEs, you need to have an appreciation for factors that might not be presented in the introduction. You will need to gather relevant information to build as full a picture of the patient’s background as possible.

With regard to the MFDS and MJDF, a candidate who is not competent does not gather relevant information and does not appreciate those factors that are relevant but hidden.

You have to ask the correct question to uncover information which is not written in the introduction, which might influence dental treatment. Only through appropriate questioning in the history taking will you be able to uncover these factors. A favourite in the exam is the forthcoming wedding or other life-changing event, which the actor is planning but has not told you about at any time until you ask about it.

In essence, you should be able to take a focused, elegant, and precise history from the actor. You should be able to get the actor to provide you with the information needed to come to a correct diagnosis and use any relevant data that is provided in the introduction to assist in this process.

2. The Candidate to Actor Interaction

The competent candidate will show appropriate concern and empathy for the actor and the role they are playing.

Developing a rapport with your actor is important. I have thought about this interaction domain a lot in the past few months. After discussing this with my senior colleagues, we kind of thought that if you have an actor acting and a dentist going along with this, then the dentist has to be kind of acting a little bit too. So this domain is about acting with the actor. The candidate who can’t act a little will not develop a rapport and will probably fail this domain.

In essence, you will be able to be courteous and welcoming to the patient being played by the actor. One MJDF revision course organiser summed it up:

‘In the exam you get marks for being a human being.’

Be sensitive, show empathy, and be able to assist the actor in the telling of the story they wish to portray. From your time in the clinic, you will have gained significant experience of non-verbal communication skills, so use them.

Also, be aware of the actor’s questions, doubts, and fears, while showing respect for the ideas and expectations of the patient being played by the actor in the OSCE.

Do not forget the patient played in the OSCE has a right to autonomy and confidentiality too.

Acting and acting up

Please do not over-egg the pudding or corpse the actor out of your OSCE; it is so easily but inadvertently done. Before sitting my MFDS a while back, I did think about taking some acting classes (on the recommendation of a friend and colleague). For those candidates who do not feel confident, then this is a worthwhile option; there is no shortage of ‘resting’ (i.e. currently unemployed) actors who give classes. Attending these classes is cheaper than getting your practice in during the OSCE.

3. Conveying Information

The competent candidate will give clear explanations and provide options that are appropriate solutions for the problems portrayed. When giving the options, start with the simple things, and before moving to the next option, ask if the actor has any questions. Use this opportunity to clarify any misunderstandings. Give the actor the information in lay terms about what each option means and what it involves. The comparative costs should be borne in mind too. While you don’t need to specifically give a cost to each option, it is immensely helpful to give relative costs, i.e.:

‘Option one is less expensive than option two, and we will move to option three, the most expensive, which involves more work than the first two choices you have.’

This is probably all you need to say, and if the actor then asks for finite costs, you can possibly say that definite costs will be provided in a treatment plan.

The candidate who cannot give a structured set of options from simple to complex with relative costs is not competent. Using technological terms and jargon is not acceptable.

The use of jargon

If you find yourself using jargon, as I have done, then say to the actor or your patient:

I am sorry, we dentists do tend to use our own language, what I mean is… (try to use clear terms to explain, then finish by asking). Does that make it clearer for you?’

The response of ‘Yes, you have explained that very well. I would like to ask you about…’ is the actor’s way of telling you that you are back on track and the examiner can move along without marking your performance in an adverse way.

In conveying information, in addition to financial costs, there is another cost in terms of the time needed for you and the patient to complete an agreed treatment plan. In the information gathering domain, any time constraints imposed by social obligations will play a part in the options you and the actor will choose to follow. From this, you can see that clinical domains and social domains interact and cannot be treated in isolation.

In essence you will be able to explain a problem, explain the options, and then negotiate with the patient a solution they are happy to accept; that is, you will gain consent from the patient being portrayed in the OSCE.

You will be able to use appropriate language and clinical skills to deliver information about treatment outcomes both good and bad to the actor. Checking the actor’s understanding at each stage of the information delivery process is a significant part of the conveying information domain.

4. Clinical Issues

In having all the facts in hand, you should realise the limitations imposed upon you by your level of experience and legislation.

One issue to be addressed is referral to a specialist for complicated treatment options. In referring a patient, you need to be able to explain why you need to do so. Any further investigations providing information that will guide treatment or open further options need to be mentioned. The candidate who does not accept the limitations in their clinical abilities and does not appreciate the clinical issues is not competent in this domain.

While the domain of candidate to actor interaction is a bit nebulous and subjective, the domain of clinical issues is not.

Clinical issues are not so much about not knowing what you don’t know; it’s more about knowing the limits of what you do know.

Although changing continually, for the time being when you sit your clinical examination, accept that clinical issues are cast in stone and you have to be clear about what you can and cannot do within the rules of dentistry in the UK.

For the older experienced candidate who will not have too much difficulty developing a rapport with the actor, the candidate to actor domain should not be too difficult, but the clinical issues domain may prove to be bothersome if you have not read the latest guidelines.

Implants in the actor’s head

Some candidates for the MJDF have been placing implants successfully for many years; however, do remember the following:

The level of your abilities for the MFDS and MJDF examinations should be equivalent to a dentist in primary dental care or secondary hospital care with two years’ post-qualification experience.

So even if you have lots of experience in this area and a postgraduate diploma too, referral to a hospital specialist is the preferred route for the actor and certainly not the casual or cavalier:

‘Here is my business card. I can give you a great set of cheap abutments tomorrow and have you fitted up with a nice dazzling-white film star smile in a few days. I’ve been doing patients for years now, with very little bother, and as I’ve met you here today I’ll give you a great price too… How does that sound? Any questions? No? Good, here I’ll just scribble a few things for you to sign with a deposit to pay today, OK?’

Rather, it is more appropriate to explain something along the following lines to the actor:

‘Although I do have experience of placing implants, I feel that a referral to my senior hospital colleague for treatment planning and advice in the first instance would be an appropriate option. I would be happy to write the referral letter, to give you a copy and provide you with any further information. I would like you to have options and to make the correct choice with your dental treatment from one of these options. Please do ask me if there is anything you are unsure about.’

In essence, you will be able to devise an effective evidence-based treatment plan, arrange follow-up, and review the dental care where indicated. A range of treatment options needs to be discussed with the patient.

This should include and start with preventive care. Sensible use of your resources with time available for the treatment should be considered in your discussions guiding the actor towards the most appropriate dental treatment for ‘their patient’. In presenting your options in the examination, you will be aware of the current legal and social frameworks and the constraints these and evidence-based guidelines impose on your treatment planning and treatment options.

Key Elements of an OSCE Consultation

You will see that the above four domains overlap and should not to be dealt with in isolation from each other. The OSCE clinical consultations of the MJDF and MFDS will include the following key elements essential to any dental consultation in real life:

1. Taking a history from the actor. This will be the medical, dental, and social histories from which you will be able to derive all relevant data to provide options and shape your treatment plans.

2. Explaining findings to the actor. This could be the data from test results or explaining the findings of a radiograph, i.e. saying to the actor:

‘This is your X-Ray and this is what we have found.’ (Note use of term X-ray and not radiograph.)

3. Explaining a diagnosis to the actor. This is an explanation in lay terms of a condition they are portraying. In addition to the diagnosis, you will have to explain the prognosis. In other words, given the information you have and the knowledge of the condition the actor is portraying, can you explain how their care will progress and the disease will regress? Lastly, what do you intend to do with the actor in a proposed plan of action?

4. Planning the treatment for the actor. Using both the facts you have read from the introduction and those you have learnt from the history taking from the actor, together with the skills you have acquired in your clinical training, how will you form and present a suitable plan of treatment?

Simple plans presented simply work best

Please remember that an elegant treatment plan with simple effective solutions proven to work from clinical evidence is a more appropriate answer in these exams and in real life than a complex experimental solution with inherent risks of failure and limited chance of success.

5. Discussing options with the actor. These are the appropriate solutions to deal with the case as presented. You will have questions to answer, and these could range from the perfectly sensible to the implausibly risible.

For example, one question that seems to work its way into the OSCEs is whether: ‘Silver fillings cause cancer, yes or no? Can you replace them all with white ones please?’

Whatever else you do, keep a straight face and give evidence-based answers, citing where necessary publications to support the choices you give.

6. Explaining a treatment procedure in detail to the actor. If you have experience of the treatment in question, then great; this type of OSCE is a gift. If not, then pretending you do just won’t work in the OSCE. With certain treatments, although you might not have the experience, you will probably have sufficient knowledge to assist the actor in coming to a decision on whether they will proceed with a course of action or not.

In the OSCE, explaining the complexities of a treatment in lay terms is all that is required.

7. Giving the information needed for consent. This really just follows on from the previous section on explaining a treatment. Consent is a legal and clinical concept that is dynamic, and we will return to consent in detail in the cases of Chapters 4 and 6. For now, please know this:

Consent is a principle of clinical law and ethics.

Before any competent patient undergoes treatment, permission to treat must be obtained. The times of imposing dental treatment on patients have long gone with the ‘trust me I am the dentist’ approach to care.⁶ In the exams and in real life too, the patient has the final word on whether a proposal becomes a plan and a plan becomes an action resulting in dental treatment.

8. Motivation of an actor portraying a patient. This is a somewhat subjective area, and only through experience will you learn those techniques that work and those that might not in any given clinical situation. In the examinations, you should only use those techniques learnt in behavioural sciences and accepted by your colleagues and the profession as a whole. The patients represented by actors do come with their own modes of overcoming fear of the dentist or developing strategies to motivate themselves to accept dental treatment.

Some of these are inappropriate, e.g. taking an excessive level of alcohol or other substances before attending. In the exam and in real life, you will be able to identify these behaviours and deal with them appropriately.

9. Breaking bad news to the actor. This could be anything from telling the actor you lost the biopsy sample on the way to the hospital to telling the parent of a child you or one of your colleagues took the wrong tooth out from their only child (yes, really).

Unpalatable truth and dishonesty

Best to tell the truth and apologise. Explain what you need to do to correct the mistake and carry on with the OSCE.

In real life and in the exams, telling things to the patients and actors that are not strictly the truth is dishonest. It is easier to tell the unpalatable truth early than having the truth dragged out of you under cross-examination.

10. Managing an emergency. This has not been a part of the MFDS OSCE syllabus, but it does regularly appear in the MJDF OSCEs and can be anything at all. So it is best to be up to date with all of the latest Resuscitation Council UK Guidelines on dealing with medical emergencies. The next chapter will cover these in detail.

Giving and Taking in the Examinations

Relevant Information in the OSCE

In the examinations, your ability to give information to the actor can only come after taking a history, using terms they can understand. This is another one of the keys to passing the OSCE or any clinical exam. The taking of a history combined with the practical elements of a clinical exam is interwoven in the practice of dentistry. However, in the MFDS and MJDF exam there is no actual physical examination of a patient as there are no patients; there are only actors. This makes for an interesting experience for a candidate who is used to both history taking and clinical-examining, often at the same time in order to come to a diagnosis.

In one diet of the MFDS exam, an actor with the most unbelievably bad breath was present in an OSCE, and this OSCE had nothing to do with halitosis. It became clear after a few questions in the taking of a history that the bad breath was an ‘incidental finding’. If faced with a situation like this, remember that such clinical signs are not part of the exam.

The discord candidates faced here was an examiner sitting in an OSCE seemingly oblivious to this clinical sign. Do not be tempted to enquire if the actor and examiner both have anosmia.⁷ As interesting a subject as anosmia is, it is slightly outside the domain of the MFDS and MJDF. In addition, do not ask if either you or the actor is at the wrong OSCE. Rather, concentrate on the taking of a history so you can deal with the theme and topic as detailed in the introduction.

Taking a verbal history is the only tool at your disposal. I suppose one analogy is if you are used to looking at the world with both eyes. Can you imagine closing one and then gathering up the information you need to walk about the street without either bumping into other things or other people or missing a sign or signal? It kind of works, but your depth perception is a little bit messed up until you can interpret what you see with your one open eye and then you can function quite well.

History Taking in the OSCE

Well, I think you might say the clinical questions in the MFDS and MJDF are like looking at the world with one eye shut. So until you sit your exam, get lots of practice in taking histories before reaching out to examine the patient. I attended one revision course, and one statement from this course stuck with me:

‘Three quarters of all diagnoses can come from a good history.’⁸

I do not know if this figure is precisely correct, where it comes from, or