Medical Council of Canada

Clinical Decision Making

Clinical Decision Making

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 60 to 70 questions related to the 38 CDM cases. Questions are either in a short-menu or write-in format. The maximum time allotted for the CDM component of the exam is 3 1/2 hours.

All the cases and questions are presented in a single block. You may navigate freely between all questions. Certain test items will have pictorial material, such as photographs, diagrams, x-rays, 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.

Of the 38 CDM cases, eight are pilot cases that do not count towards your total score. While the pilot cases and questions are not scored, they are not identified as pilot cases in the exam. We encourage you to do as well as you can on every case and question.

You are only required to submit the examination once, when you have completed your CDM component and are ready to submit, or when your allotted time expires. Once you have submitted your examination, you may not 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.

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

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., “List 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:
  • Set limits on the maximum number of acceptable responses, as an excessive number may imply that you are over-investigating a patient
  • Penalize inappropriate responses

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

Short-menu questions

A short-menu question is similar to a Multiple-Choice Question (MCQ). However, instead of presenting a list of five possible answers like an MCQ, a short-menu question typically offers a list of 10 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.

Please 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.

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 will result in you being given a score of zero.
  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.

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, the following examples depict what counts as “one” answer:

  • Electrolytes including Na, K, Cl, CO3 (does not include glucose)
  • CBC and differential
  • Liver enzymes (includes AST, ALT, GGT, ALP, bilirubin)
  • LFT (bilirubin, INR, albumin)
  • Cardiac enzymes (includes CK, TNI, TNT)
  • Urinalysis (Urine R&M)
  • Urine Culture & Sensitivity
  • Vital signs (includes BP, HR, Temp, Sats)
  • Lipids (includes LDL, HDL, total cholesterol, TG)
  • Type & cross match
  • FSH/LH
  • Thyroid function (TSH only)
  • Immunoglobulins
  • Lumbar fluid analysis
  • Gonorrhea/chlamydia
  • Renal function (includes creatinine, eGFR, BUN/Urea)
  • INR, PTT

Please note, these examples are included on exam day, under candidate instructions, for you to reference at any time.

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 (Case 1)

What is the most likely diagnosis? List up to three.

  1. ________________________________
  2. ________________________________
  3. ________________________________


Hyperthyroidism (Graves’ disease) – 1 point

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

Question 2 (Case 1)

Which initial investigations will you order at this time?
Select up to three answers.



Selecting Serum T4 and T3 – 1 point
Selecting more than 3 answers – 0 points