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Clinical decision-making 

Get familiar with the clinical decision-making case and question types you will see on the MCCQE Part I.

Overview

The clinical decision-making (CDM) component of the exam consists of 38 case descriptions, followed by one or more questions, which assess problem-solving and decision-making skills in the resolution of a clinical case. You may be asked to:

  • Elicit clinical information
  • Order diagnostic procedures
  • Make diagnoses
    OR
  • Prescribe therapy

Your decisions should reflect the management of an actual patient.

In total, you will be presented with 65 to 75 questions related to the 38 CDM cases. Questions are either in a short-menu or write-in format. The CDM component includes pilot questions, also called pre-test items, which are scored if they perform well psychometrically. The standard maximum time allotted for the CDM component of the exam is 3.5 hours.

All cases and questions are presented in a single block. You may navigate freely between all CDM questions. You may flag questions and return to those questions at any point during the CDM portion of the exam. Certain test items will have pictorial material, such as photographs, diagrams, radiographs, electrocardiograms, and graphic or tabulated material. If relevant to the case or question, you will be presented with the normal lab values directly in the CDM question.

Points are not deducted for incorrect answers. However, you will receive a score of zero on a question if you exceed the maximum number of allowable responses or select a response that is considered harmful or dangerous to the patient. See below for advice on how to answer CDM questions.

You are only able to submit the examination once, when you have completed your CDM component, are ready to submit, or when your allotted time expires. Once you have submitted your examination, you cannot go back to change your answers.

Tips on clinical decision-making

The following video features tips that will help you understand and prepare for the CDM component. It explores time management, question instructions, scoring and scenario details for CDM questions.

Note that the graphical elements in the video are not representative of the examination.

Play Video

Short-menu questions

A short-menu question is similar to a multiple-choice question (MCQ). However, instead of presenting a list of 3 to 5 possible answers like an MCQ, a short-menu question typically offers a list of 6 to 30 options. You may be asked to select only one of these options, select up to a specified number, or select as many as are appropriate.

Note that the majority of questions are worded in the plural; e.g., “treatments,” “diagnoses,” etc. Even when you are asked to select “treatments,” there may be only one correct answer.

To select an option, click on the text of that option. You may deselect an option by clicking on it a second time. Each time you select or deselect an option, the total number of options currently selected for that question is displayed.

Write-in questions

A write-in question asks you to type in your answer. To ensure that your write-in answers receive the maximum credit possible, follow these rules:

  1. Record only one response in each of the boxes provided. If a question instructs you to “List four diagnoses,” four boxes will be provided, one for each response. Typing more than one response in a box may result in you being given a score of zero if you exceed the maximum number of allowable answers for that question.
  2. Be specific. For example, “thyroid disease” is an unacceptable diagnostic response when “hyperthyroidism” is the correct diagnosis.
  3. If you are asked to list drugs or medications, use generic names. Read such questions carefully to determine if you are also required to specify the route of administration and dosage.
  4. Word your responses carefully. Correct answers typically consist of single words or short phrases. You may type responses for common tests as their respective acronyms or short forms. However, you should ensure that they are clear and do not have more than one meaning. There are no penalties for spelling errors, given that the response provided is clearly indicative of the response intended.

How to respond to questions

The instructions for each question are different and must be followed. For example:

  1. Some questions specify the exact number of responses to be typed in or to be selected (e.g., “Indicate only one”). If you exceed the number of responses specified, you will be given a score of zero for the entire question, even if your responses include the correct answer(s).
  2. Some questions place an upper limit on the number of responses to be typed in or selected (e.g., “Select up to six”). Do not exceed that number. Furthermore, you may not need to select or list up to that number either. For example, a question instructs you to “Select up to six” answers. However, the correct answer may only consist of three or four responses. If you guess to build your answer up to the permitted number of responses, you run the risk of selecting some of the wrong responses. If you select inappropriate investigations or treatments that could harm the patient, you will be given a score of zero for that question.
  3. Some questions leave it to your judgment to select as many responses “as are appropriate.” What you deem to be the “appropriate” number should only be dictated by what you would do in the actual clinical situation. You should not be tempted, for example, to provide an excessive number of responses in an effort to ensure that you have included the correct response. The scoring keys for this type of question:
    1. Set limits on the maximum number of acceptable responses, as an excessive number may imply that you are over-investigating a patient.
    2. Penalize inappropriate response.

In either case outlined above, a score of zero will be given.

CDM write-in questions –
What counts as one answer?

The MCCQE Part I CDM component includes questions where you will need to provide written answers. At times, you are asked to list up to a fixed number of responses. To offer extra guidance and to prevent you from exceeding the maximum allowable responses, please see Examples of what counts as “one” answer and what does not count as “one” answer. You will have access to these examples on exam day.

CDM example

Case 1
A 13-year-old girl has a three-month history of intermittent diarrhea, weight loss, and muscle weakness despite an increased and voracious appetite. She has also experienced intermittent palpitations. Her parents report that her school performance has declined over the past few months. She also gets upset easily and is unable to concentrate well. Her sleep pattern is irregular. Physical examination detects a mild tremor of the fingers with the arms outstretched. Her palms are moist. Her blood glucose level is 4.5 mmol/L.

Use the information above to answer the following questions.

Question 1
What is the most likely diagnosis?

List up to three
1.
2.
3.
________________________________
________________________________
________________________________
Answer:
Hyperthyroidism (Graves’ disease) – 1 point

Listing more than 3 answers – 0 points
NOT ACCEPTABLE – Listing “Thyroid disease” as an answer

Question 2
Which initial investigations will you order at this time?

Select up to three answers
    1.  Colonoscopy
    2.  Endoscopic retrograde cholangiopancreatography
    3.  Erythrocyte sedimentation rate
    4.  Jejunal biopsy
    5.  Psychometric testing
    6.  Rectal biopsy
    7.  Serum 17 a hydroxy progesterone level
    8.  Serum beta-HCG
    9.  Serum electrolytes
  10.  Serum Insulin level
  11.  Serum T4 and T3
  12.  Serum vanillyl mandelic acid levels
  13.  Sweat chloride
  14.  Urine estradiol
  15.  Urine homovanillic acid levels
Answer:
Selecting Serum T4 and T3 – 1 point
Selecting more than 3 answers – 0 point
Selecting Serum beta-HCG and Serum electrolytes and Serum T4 and T3 – 1 point

Physical examination

  • Vital signs
    • Includes blood pressure, heart rate, respiratory rate, temperature, oxygen saturation (BP, HR, RR, Temp, SaO2)
  • Airway assessment
  • Breathing assessment
  • Circulatory assessment

Hematology

  • International normalized ratio (INR) and partial thromboplastin time (PTT)
  • Complete blood count (CBC) and differential
  • Type and crossmatch

Biochemistry

  • Cardiac enzymes
    • Includes creatine kinase and troponin I or troponin T (CK, TNI or CK, TNT)
  • Electrolytes
    • Includes sodium, potassium, chloride and bicarbonate (Na, K, Cl, HCO3)
    • Does not include glucose
  • Folate
  • Follicle-stimulating hormone and luteinizing hormone (FSH and LH)
  • Free triiodothyronine (FT3)
  • Free thyroxine (FT4)
  • Immunoglobulins
  • Lipids or Lipid profile
    • Includes low-density lipoprotein, high-density lipoprotein, total cholesterol, triglycerides (LDL, HDL, Chol, TG)
  • Liver enzymes
    • Includes aspartate aminotransferase, alanine aminotransferase,
      γ-glutamyl transferase, alkaline phosphatase, bilirubin (AST, ALT, GGT, ALP, bili)
  • Liver function tests
    • Includes bilirubin, INR, albumin
  • Renal function
    • Includes creatinine, estimated glomerular filtration rate (eGFR), urea nitrogen (BUN)
  • Thyroid function
    • Includes thyrotropin (thyroid-stimulating hormone) (TSH) only
  • Vitamin B12

Urine

  • Urinalysis
    • Includes urine routine and microscopy

Microbiology

  • Urine culture and sensitivity
  • Lumbar fluid analysis
  • Gonorrhea and chlamydia

Medications and lifestyle

  • Diet and exercise
  • Calcium
  • Vitamin D

Imaging

  • Computed tomography (CT) of the abdomen
  • CT of the pelvis
  • Ultrasonography of the pelvis
  • Ultrasonography of the abdomen
  • Airway, Breathing, Circulation (ABCs) (counts as 3 answers)
  • Blood work, including CBC, electrolytes, BUN, creatinine and glucose (counts as 4 answers)
  • Calcium and vitamin D (counts as 2 answers)
  • CT of the abdomen and pelvis (counts as 2 answers)
  • Electrolytes, BUN, creatinine (counts as 2 answers)
  • Erythrocyte sedimentation rate and C-reactive protein (counts as 2 answers)
  • Folate and vitamin B12 (counts as 2 answers)
  • FSH, LH, estradiol, progesterone (counts as 3 answers)
  • Hepatitis A, B, C (counts as 3 answers)
  • Iron, ferritin, total iron-binding capacity (counts as 3 answers)
  • Magnesium, calcium, phosphorus (counts as 3 answers)
  • Thyrotropin (thyroid-stimulating hormone), FT4, FT3 (counts as 3 answers)

Incorrect answers*

  • Chem-7 is incorrect unless specified
  • Iron studies is incorrect unless specified
  • Extended electrolytes (or extended lytes) is incorrect unless specified
  • Thyroid profile is incorrect unless specified

* These are examples of terms that do not have inherent meaning and are therefore incorrect. However, if candidates indicate what they mean by these terms (for example, by adding it in parentheses), then they should be scored accordingly:

  • Extended electrolytes (magnesium, calcium, phosphorus) = counts as 3 answers
  • Thyroid profile (TSH and T4) = counts as 2 answers
  • Thyroid profile (TSH, T3, and T4) = counts as 3 answers
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