Assessment of Shortcomings of Candidates in the Fellowship of College of Physicians and Surgeons (FCPS)-II (Board/Exit) Examination: A Qualitative Analysis of Dermatology Candidates’ Short and Long Cases With Suggestions for Improvement

Background Clinical examination is the final step for the assessment of a candidate in the Fellowship of College of Physicians and Surgeons-II exam and several stressors are associated with it. After a certain level, the stressors and myths related to this exam increase the chances of poor performance. This study aimed to identify the shortcomings of candidates’ short and long cases with suggestions for improvement. Methodology This qualitative research with a thematic analysis approach was conducted at the College of Physicians and Surgeons of Pakistan, Regional Center, Lahore. The data were collected from 20 examiners who assessed 88 candidates’ short and long cases of dermatology through observation and cross-questioning. Results The major themes that emerged with more subcategories were poor history taking, poor examination, and poor time management while updated knowledge, rationalization, and enhancement of presentation skills were also highlighted in long cases. The major suggestions to improve the short and long cases were to focus on the command given, maintain the privacy of the patient, and improve training. Conclusions This study highlighted many major shortcomings the candidates showed while performing the long and short cases which may facilitate the forthcoming candidates to avoid these weaknesses by following the suggestions for improvements.


Introduction
Most medical students and even candidates appearing in board exams consider some aspects of their medical education stressful, especially while appearing in the final exit exam which is considered a gateway to their career.The medical exam not only declares a candidate pass or fail but also determines the direction of his/her future and leaves a long-lasting effect on him/her [1].
Clinical examinations are considered stressful not only due to their difficulty but also because of the unpredictability of the type of cases students have to handle, patient's reactions, and their own performance [2].
In addition to the struggle to meet their own set values, today's candidates also have to satisfy the demands of their parents and society, which adds to further stress and anxiety [3].In the domain of education, a high level of anxiety is often experienced by students during performance-related activities such as exams [4,5].
Although some level of anxiety among students is essential to achieve success in exams [6], excessive anxiety can have an adverse effect on their performances [5].Importantly, in students, a high level of anxiety could have an impact on working memory, reasoning abilities, self-esteem, academic performance, and achievement [7].Anxiety in students can affect their physical and psychological characteristics causing panic attacks, which make them go blank during exams, nervous, palpation, and could even cause stomach 1, 2 1 upset [8].
Given the low pass rate of the Fellowship of College of Physicians and Surgeons Pakistan (FCPS)-II exam on the first attempt, this study aims to identify and highlight the shortcomings of candidates appearing in FCPS-II dermatology clinical exam during short and long cases and explore strategies to overcome these shortcomings.The findings may help postgraduate residents appearing in exams and direct them toward success.

Materials And Methods
This study aimed to identify the shortcomings of candidates in short and long cases in FCPS-II dermatology clinical exams and to explore the suggestions for improvement of shortcomings in short and long cases.
A thematic analysis approach was used for this study conducted at the College of Physicians and Surgeons of Pakistan, Regional Center, Lahore, after the end of the FCPS-II clinical dermatology exam.The 88 candidates of the FCPS part-II clinical exam along with 20 examiners were the study sample.
These candidates appearing in this clinical exam as a final step of their examination had already completed their five years of training in dermatology and passed their written exam.These candidates were assessed by 20 examiners of FCPS-II from all over Pakistan.The examiners evaluated candidates using both subjective and objective measures, employing a performance checklist for each task in both short and long cases.After the exam, examiners were provided with questionnaires to address the shortcomings of candidates and offer suggestions for improvement.
In short cases, candidates had 10 minutes to examine an unseen patient according to the given instructions, and after the permission of the examiner, they could proceed to the relevant systematic examination to reach a differential diagnosis.After completing the examination, the candidates briefly described the findings and clinically correlated with the differential diagnosis.Each candidate was cross-questioned by a set of two examiners and evaluated for the four short cases likewise.
In long cases, the candidates had one hour which is usually the most decisive step toward the success of the candidate.In the first 30 minutes, candidates took a detailed history; completed the cutaneous, general physical, and systematic examination; and drew a differential diagnosis.In the next 30 minutes, the candidates had to present a case summary and defend their case with the relevant examination.After the case presentation, the candidates were cross-questioned by a set of two examiners, especially regarding management and recent advances.

Results
The results revealed that there were some common mistakes the candidates made during the long and short cases.The major themes that emerged with more subcategories were poor history taking and poor examination while updated knowledge, rationalization, and enhancement of presentation skills were also highlighted in long cases.The major suggestions to improve the flaws of the long case were to focus on these weak areas.In short cases, the identified flaws were a lack of reasoning to examine a candidate during a short period.Some overlapping themes that emerged in short cases were poor history-taking skills, handling patients like tools and not as humans, and poor time management.Suggestions were given to improve these target areas.
Candidates in the exam showed several weaknesses in their short cases, as shown in Table 1, the most important among them being the method of clinical approach.Another major issue was the vain attempt to define the lesions without accurately identifying and describing them, where the candidates failed to identify the gross findings.Examination of certain body parts such as axillary lymph nodes, hand web spaces, and trunk sections was usually ignored, not only demonstrating a lack of emphasis but also failure to detect the most important diagnostic features.These drawbacks in the clinical methods not only led to incomplete patient assessments but also inaccurate diagnoses.On the other hand, the candidates showed a dangerous tendency to keep to a narrow-minded approach that even the examiners' instructions or hints did not broaden their viewpoints.Such a deficiency prevents them from the possibility of brainstorming other diagnoses and changing the tactic to new facts.In light of the referenced drawbacks of the short cases, some primary proposals of solutions were made by the examiners, in pursuance of the positive change, as shown in Table 1.Candidates should first have an essential requirement to sharpen their abilities with practical experience.Besides the regular training sessions, partial practice in handling outpatient department patients will also be beneficial.Second, every candidate is advised to do mock exams often during their training time.These mock tests, on the other hand, serve as a great arena for candidates to practice real situations and diagnose various diseases and the nature of the feedback, which can improve their clinical skills and boost their confidence.
In this exam, the candidates had numerous flaws while performing long cases, as shown in Table 2. Poor history-taking skills which include forgetting to ask about past medical history, gynecological history, Dermatology Life Quality Index, family history, and systematic approaches were some of the key issues that were overlooked.A lack of expertise in scrutinizing important things during history taking was a skill that was lacking.In addition, the examination methods uncovered the basic flaws, i.e., the candidates were poorly skilled in clinical examination and there were situations where they skipped systematic examinations.This flaw caused the inefficiency which, in turn, led to a lack of fluency and methodical ways, demonstrated in the incomplete medical examination of a patient.Moreover, candidates started to behave robot-like and their empathic abilities were weakened with poor bedside manners; hence, they were not able to connect with patients on compassionate grounds.These deficiencies alluded to the fact that the quality of clinical skills as well as the empathetic approach of the candidates in long cases need great improvements.To deal with the described deficiencies, several suggestions have been offered in Table 2. Initially, the usefulness of up-to-date information is emphasized while dealing with patients of different types and searching for relevant, recent literature.Updated knowledge is a key factor that dermatologists must have to be informed about the current trends and new developments in the dermatology field.Furthermore, rationalization and uniformity are emphasized as the keys to examining patients.Candidates should follow a logical order of investigation and an individualized management system, ensuring the use of protocols to improve their approach.With these, candidates should also work on improving and sharpening their skill set through practice sessions that are specially designed for presentation skills, time management, and shortcomings.Preparation of a 12-minute history taking is recommended as well as the practice of detailed case presentations widely to improve their general clinical performance.By way of these recommendations, candidates will be able to make their way toward an advanced and efficient strategy in long cases, resulting in their expertise in the field of diagnosis and patient management growth.

Flaws in long cases
The major themes of shortcomings in both short and long cases supported by more statements are shown in Table 1 and Table 2, respectively.

Discussion
In this article, we present the first comprehensive evaluation of the shortcomings observed in candidates by the examiners during the clinical assessment of the FCPS-II exam, which is similar to a board/exit exam.Examination of the candidates during a viva voce or observation is a subjective task and leads to uncertainty and ambiguity.To reduce this stress, candidates should start their preparation with the exam viewpoint which may enable them to focus on the key areas of assessment.Candidates may prepare by completing their syllabus and assessment pattern of the exam by attending different types of training, demonstrations, and case presentations, and, most importantly, by updating their knowledge about the latest advancements in the field.
Although appearing in the final step of the exam after clearing the written test is stressful, candidates need to learn that if they handle patients with care and empathy, then it might be possible that the examiner may overlook knowledge gaps.The results of this study also showed that many candidates mishandled patients, which was noticed by the examiner.They were unable to show compassion toward their patients even though it is a crucial element in doctor-patient relationships [9].
The results of this study also revealed that candidates were unable to take proper medical history, physical examination, and proper diagnosis.To reach a logical diagnosis, all these key areas should be focused upon which usually leads to a systematic examination and appropriate diagnosis [10].Candidates usually stay up all night the day before the exam which makes them lethargic, drowsy, and inattentive [9].This inattention may hinder their ability to stay focused and follow the commands of the examiners, especially in short cases.
Results also showed that candidates ignored the important relevant areas of examination, i.e., lymph nodes and web spaces in hand examination.The skin is a complex barrier organ and is constantly exposed to various endogenous and exogenous factors that impact this balanced system, potentially leading to inflammatory skin conditions comprising infections, allergies, or autoimmune diseases [11,12].It was suggested to the candidates to minutely observe the skin conditions without missing any area in the physical examination.
The findings also showed that candidates were not willing to change their viewpoint about their patients' diagnoses even after being cross-questioned by the examiner.Such a rigid attitude toward diagnosis compelled the examiner to highlight that the candidates might have seen the patients before the exam.However, it was proved that some of the candidates accidentally had seen some patients in the local tertiary care hospital and they gave an inflexible diagnosis to those patients.If candidates show flexibility in their diagnostic point of view, it may avoid confusion and misdiagnosis which is usually the result of firm adherence to unreasonable rigid criteria.
Ignoring the given commands may affect the assessment of the candidates and show their rigidity, as was highlighted by the examiners in both long and short cases that the candidates used tunnel vision and were very rigid in their diagnosis.
Candidates also failed to defend the differential diagnosis they made during the exam which was an indication of knowledge gaps; therefore, the examiners suggested updating themselves through literature and simulated patients.It was also suggested that candidates attend more training in clinical dermatology than cosmetology workshops to improve their clinical diagnostic skills.It is supported by the literature that training improves the experience and diagnostic skills of a dermatologist [13].
Thus, this study highlighted many major flaws the candidates showed during both long and short cases which may facilitate the forthcoming candidates to avoid these weaknesses by following the suggested suggestions for improvements.

Study limitations
The study limitations include subjective appearance bias by the examiners, single-center data, and lack of sample diversity.Due to the limited existing literature on this topic, critical and constructive comparisons could not be made.Additionally, the absence of longitudinal data and consideration of confounders such as exam stress is another limitation.Future research should employ larger, diverse samples and standardized measurement tools for more reliable findings.

Conclusions
This study provides valuable insights into the shortcomings that candidates demonstrated during the FCPS-II dermatology clinical exam, which is an exit exam in dermatology.The study findings highlight the critical importance of thorough and timely preparation and a holistic approach for candidates undergoing viva voce or observational assessments in the medical field.Addressing these shortcomings and implementing the suggested improvements will undoubtedly contribute to more effective and comprehensive preparation by the forthcoming candidates.Thus, this approach will not only help the candidates pass the exam but will also make future consultants more proficient, accurate, and empathetic in clinical assessments of their patients, ultimately benefiting patient care and the overall quality of medical practice.However, it is important to acknowledge the study's limitations, thus underscoring the need for future research with broader and more diverse samples.
findings.Inability to identify and describe basic lesions.Omission of important relevant areas of examination, i.e., lymph nodes, web spaces in hand examination, and trunk examination willing to change their point of view about the diagnosis given to the patients even after discussion with the examiner No logical discussion beyond the known diagnosis.Not strictly following the command given Suggestions for improvements (short cases) Theme Description Need for upgraded knowledge Indicates the need for mock exams for practice Subcategories Description Statement examples Training mock exams Candidates were suggested to attend more training and exposure in outpatient departments (OPDs) in supervision Supervisors need to spend more time on candidate training in OPDs.Need to have frequent mock exams during training Description Poor history taking Comprises all the deficiencies in taking patient history Subcategories Description Statement examples Missing components of Candidates lack the skills to cover the major points while taking history Poor history-taking skills.Missing components of history, especially past medical history, gynecological history, Dermatology Life Quality Index, family history, and 2024 Zeeshan et al.Cureus 16(4): e58393.DOI 10.7759/cureus.thepatients and missed the important components of a flexible examination Poor examination methods (more acting than fluency, haphazard and not up to the mark.handle the patients with an empathic approach A robotic approach to history as if the patient was not a human but only a tool to pass the exam.Very few observed bedside manners to give a logical correlation of examination findings with diagnosing logically and practically managing the patient Clinical correlation of skin lesions was lacking.Poor rationalization regarding patient management (were more theoretical rather than practical) the inflexible diagnosis of patients made by the candidates Subcategories Description Statement examples Obstinate Candidates were so rigid in giving the diagnosis despite the change in the clinical 2024 Zeeshan et al.Cureus 16(4): e58393.DOI 10.7759/cureus.583934 of 7 conclusive approach picture because they had seen the same patient a few days ago in some local tertiary care hospital Fixed and firm ideas that they had seen the patient before the exam Suggestions for improvements (long cases) to update their knowledge through different sources Simulated patients are needed.Reinforce candidates to read the literature for updates on common diseases (for leprosy read more books rather than just Rooks') to rationalize themselves by using standardized procedures Uniformity of assessment (questions should be same for all candidates).Need to rationalize and individualize the management according to the patient to polish their skills in specific areas Frequent case presentations during training (detailed and relevant history taking and presentation should be frequently practiced during training since the beginning of the training).History taking should not last for more than 12 minutes (the candidate may ask important remaining questions during the examination)