NZREX Clinical Handbook for Candidates 201 New Zealand

7/30/2019 NZREX Clinical Handbook for Candidates 201 New Zealand

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Protecting the public, promoting good medical practiceTe tiaki i te iwi whnui me te whakatairanga pai i te mahi e p ana ki te taha rongo

NZREX Clinical Handbook for Candidates

2010

Mid City Tower, 139-143 Willis Street, P O Box 11-649, Wellington, New Zealand

Telephone 0800 286 801, 64-4-384 7635, Fax 64-4-385 8902,www.mcnz.org.nz, [email protected]


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NZREX Clinical Handbook for Candidates December 2010

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Contents

Introduction 3

English language requirement 3

International English Language Testing System (IELTS) 3

Medical knowledge 3

Location and timing of NZREX 4

OSCE format of NZREX 4

Content and format of NZREX 4

Instructions to candidates 9

Communication 10

Professionalism 10

Management 10

History 11

Investigating 11

Clinical examination 11

Clinical reasoning 11

Pass mark 11

Examination result 12

Impairment 12

Appeal of examination process 12

Review of result 12

Privacy issues 12

Transferring between examinations 13

Withdrawals 13

False declarations 13

Late applications 13

Communication 13

After NZREX 13


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Introduction

The New Zealand Registration Examination (NZREX Clinical) was established by the MedicalCouncil of New Zealand (the Council) to assess overseas trained doctors, whose primaryqualifications are not recognised in this country, before they enter any form of clinical practice.

The goal of NZREX Clinical is to be a valid, fair, reliable and consistent assessment. The objective

of the examination is to ensure that candidates are competent to enter a period of provisionalregistration in New Zealand, during which time they will be further assessed.

To be eligible to apply for NZREX Clinical, candidates must satisfy the Council of their competencein English and medical knowledge by successfully completing the following prerequisites:

RequirementsDoctors applying to sit NZREX Clinical will be required to have achieved the minimum followingscores in the Academic Module of the International English Language Testing System (IELTS)within one examination: 7.5 in speaking 7.5 in listening 7.0 in writing 7.0 in reading

All NZREX clinical candidates must have attained their IELTS within the last: 2 years of the intended examination date for new NZREX candidates, or 5 years of the intended examination date for repeat NZREX candidates.

IELTS is the only English test approved by Council.

NOTE: The test of English as a Foreign Language (TOEFL) and Occupational English Test(OET) are not accepted by the Council as alternatives to IELTS.

Medical knowledgeNZREX Clinical candidates must have passed, within the last 5 years, one of the followingprerequisite examinations: United States Medical Licensing Examination (USMLE) Steps 1 and 2 (Clinical Knowledge) PLAB Part 1 Australian Medical Council MCQ.

If the time from when the candidate passed one of these examinations has expired past the 5 yearvalidity point, the candidate must sit or re-sit one of the possible prerequisite examinations.

Under the Educational Commission for Foreign Medical Graduates (ECFMG) rules, a candidate

may not re-sit a USMLE step once they have already passed it. However, if the result exceeds the5 year NZREX Clinical timeframe the ECFMG will allow NZREX Clinical candidates to re-sit theUSMLE Steps 1 and 2. If this is the case, the candidate must write to the NZREX coordinator at theMedical Council of New Zealand, including their full name, ECFMG number, and the dates thatthey previously sat the USMLE Steps 1 and 2. The NZREX coordinator will write to the ECFMGconfirming that the candidate wishes to sit NZREX Clinical and therefore needs to re-sit theUSMLE examination(s).


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Location and timing of NZREXNZREX is held either three or four times a year in Auckland. Council reserves the right not to holdan examination if there are insufficient candidate numbers. If this was the case, candidates wouldbe informed and moved to the next available examination date.Candidates must organise their own transportation and accommodation. Websites that can behelpful include www.tourism.net.nz, which provides good general information on accommodationand transport, and www.maxx.co.nz for Auckland bus services.

NZREX formatThe current NZREX examination is an Objective Structured Clinical Examination (OSCE) format of16 stations. This is a well established method of assessment that is used in many universities andpostgraduate medical colleges throughout the world.

NZREX contentNZREX assesses the following core competencies: the ability to safely undertake basic procedures and interpret laboratory results and other

clinically relevant data the candidates ability to take a medical history

the candidates ability to demonstrate appropriate physical examination techniques the candidates ability to demonstrate safe and appropriate clinical management.

Each organ system/domain will be tested in at least one station. The competencies that will betested are history (three cases), clinical examination (four cases), investigating (two cases),management (three cases) clinical reasoning (four cases). There will be at least one case on childhealth, one case on mental health and one case on womens health.

The following matrix strongly influences the topics for station design and selection in the NZREXexamination:

Communication (global)

Professionalism (global)Cardiovascular

HistoryClinicalExamination

Investigating Management Clinical Reasoning

Chest pain

Shortness ofbreath

Fall/collapse

Raised bloodpressure

Leg swelling

Low BP/Shock


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Professionalism (global)Respiratory



Cough

Shortness of breath

Cyanosis

Haemoptysis

Chest pain

Wheeze


Professionalism (global)Neurological



Headache

Visual disturbance

Dizziness/Vertigo

Confusion/Delirium

Weakness

Collapse/Fall

Tremor

Unsteady gait

Disturbedconsciousness

Seizures

Speech difficulty


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Professionalism (global)Gastrointestinal



Abdominal pain

Anorectal pain

Groin pain

Abdominaldistension

Altered bowel habit

Nausea/Vomiting

Abdominal mass

Difficulty swallowing

Jaundice

Haematemesis

Rectal bleeding


Professionalism (global)Genitourinary

History ClinicalExamination


Urinary retention

Abnormal vaginalbleeding

Genital discharge

Genital pain

Urinary frequency

Nocturia

Urinary incontinence

Leg swelling

Scrotal swelling


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Professionalism (global)Musculoskeletal



Joint pain

Joint swelling

Traumatic injury -bone

Traumatic injury soft tissue

Back pain


Professionalism (global)Pregnancy



Bleeding

Abdominal pain

Fever

Raised BP


Professionalism (global)Endocrine/Metabolic



Contraception

Weight loss

Weight gain

Lethargy

Infertility

Sexualdysfunction

High blood sugar

Low blood sugar

Collapse

Menstrualdisturbance


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Professionalism (global)Haematological



Lethargy

Pallor

Abdominalbruising


Professionalism (global)Oncological

HistoryClinicalExamination Investigating Management Clinical Reasoning

Breast lump

Neck lump

Enlarged lymphglands

Enlarged spleen

Enlarged liver

Pain

Terminal patient


Professionalism (global)Behavioural



Depression

HallucinationsAgitation/aggression

Substance abuse

Anxiety

Learning difficulty

Deterioration inintellect

Confusion


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Professionalism (global)Senses



Eye pain

Reduced vision

Ear pain

Hearing change

Facial pain

Oral pain


Professionalism (global)Other



Unwell child

Allergic reaction -medication

Allergic reaction -environmental

Fever

Skin rash

Skin - suspiciouslesion

Abnormallaboratory test

Number ofcases (totalcases = 16)

Up to 3 Up to 4 Up to 2 Up to 3 Up to 4

Instructions to candidatesIt is very important that you follow the instructions for each case. If the station requires you toundertake a clinical examination, marks will only be awarded for clinical examination. Spendingtime taking a history will reduce the time available to complete an examination and therefore maycompromise your performance in the station. There are 16 stations in total. Each station lasts for12 minutes. There is 2 minutes allocated for reading the station instructions, followed by 10minutes in each station.


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Communication (global)All stations require candidates to demonstrate communication skills expected of a recent medicalgraduate working in a New Zealand hospital. These could include breaking bad news to a patient,obtaining informed consent, explaining how to use asthma inhalers, communication with children,communication with family members, communication regarding medication etc. There will be astrong emphasis on culturally appropriate communication. This reflects the multicultural nature ofNew Zealand society and the special place of Maori in New Zealand society. All stations will

incorporate some degree of communication skills.

Examiners will be looking for demonstration of good listening skills. These would include activelistening, reflecting, clarification, choosing an appropriate level of medical terminology, bodylanguage etc. Incorporating the patients or familys own values and beliefs is considered anintegral part of good communication skills.

Understanding the presenting problem from the patients perspective (the illness) should be soughtin conjunction with information that allows an accurate medical assessment (the disease).

An often overlooked part of communication skills is the generation of a mutually agreedmanagement plan with the patient. This would include a discussion on what treatment options areavailable with the advantages and disadvantages of each.

Candidates are expected to demonstrate good communication skills across a wide variety of socialsituations irrespective of the patients gender, race, religion or sexual orientation.

Professionalism (global)Professionalism is considered to be an essential part of doctor-patient interactions. Therefore,professional aspects of behaviour will be assessed and marked in all stations.

Professionalism can be defined as: honesty

integrity respect for patients good moral reasoning and ethical practice (including cultural competence, with respect to

gender and race boundaries and New Zealand biculturalism.

ManagementThis entails devising a management plan for a particular clinical circumstance. It should be basedon all available information. A management plan should be formulated in conjunction with, andrespecting patients rights and beliefs.

The standard expected of candidates in these areas is that of a recent graduate from a NewZealand medical school. Dangerous and highly inappropriate management will be marked down

heavily.

Clinical reasoningThis will require you to demonstrate a logical and reasonable approach to making a diagnosisand/or devising a management plan.

This will include prioritising clinical intervention in a timely manner according to severity andimmediacy of clinical need.


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HistoryStations focusing on history taking will assess your ability to seek relevant information from apatient that will allow the formation of a differential diagnosis or diagnosis. You are expected todisplay an ordered logical sequence of information gathering in these stations. A standardapproach to taking a history in a hospital setting would be set out in the form of: history of presenting complaint past history relevant family history current medications and allergies relevant social history.

In the early part of the interview, the use of open questions is appropriate as this tends to gathermore information. Closed questions are necessary at times to clarify particular points. At the end oftaking a history, the candidate should have gathered sufficient information to formulate adifferential diagnosis.

Investigating

Ordering:When ordering investigations you are expected to demonstrate an efficient and effectiveapproach to investigation of a particular clinical scenario. Good clinical reasoning shouldpredict choice and sequence of testing.

Interpretation:You are expected to interpret and act on appropriately, all basic investigations. This willinclude, but is not limited to: ECG standard x-rays haematological investigations pathology results.

For investigations such as MRI and ultrasound you would be expected to understand the result andbe able to interpret and explain to the patient the significance of the findings. You would not beexpected to interpret the films.

Clinical examinationYou will be assessed on your ability to conduct a physical examination on either a real or simulatedpatient.

The physical examination that you are expected to undertake may include, but is not limited to,cardiovascular, respiratory, neurological, musculoskeletal, abdominal, ears, eyes, and mentalstate.

The standard of physical examination expected is that of a recent New Zealand medical graduate.

You are expected to inform the examiner of the process you are going through during theexamination. Examiners will be looking for a structured, organised approach to physicalexamination.

Pass markThe standard of the NZREX Clinical examination is primarily determined to ensure the safety of thepublic of New Zealand.

The NZREX Clinical examination is a high stakes, high quality exam, which is reliable [fit forpurpose]. The results are determined by using a criterion referenced, contrasting groups system todetermine a cut score, the score above which the candidate is deemed to have passed. For somestations, a modified Angoff process will be used to inform the cut score.


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Theoretically, if all candidates are at a standard above the criterion, then all would pass.Historically the pass rate for NZREX has averaged around 55 - 60%. Candidates will be scored foreach of the 16 stations separately and the scores aggregated into a final mark. For moreinformation about the statistical methods by which the standard is set, please read the Frequentlyasked Questions section in this web site.

Unlike other examinations, all stations in NZREX Clinical are of equal importance. There are nostations which if failed will result in failure of the entire exam.

Examination resultThe examination result will reflect your overall clinical competence. You will be marked ascompetent or not yet competent. Domains of subject matter will not be marked separately,grades will not be given and there will be no partial passes.

ImpairmentA candidate may have been disadvantaged during the examination due to a temporary impairment,which occurred close to, or during the examination and which affected his or her performance.

This may include situations such as illness or pressing domestic circumstances. Submissionsclaiming impairment must be lodged in writing within 3 working days of the examination.

Appeal of examination processA candidate may consider that an incident, which occurred during the process of the examination,impacted on his or her performance in the examination. Appeal submissions must be lodged inwriting within 3 working days of the examination.

Review of resultA candidate may consider that his or her examination results do not accurately reflect his or herperformance in the examination and may request that the result be reviewed.

Applications for a review of result must: be lodged in writing, no more than 10 working days after receipt of written feedback from the

Council office include specific reasons for requesting the review, based on the feedback provided include payment of $127.78 for each review requested (this fee is for the entire exam to be

reviewed not individual stations).

Once the application has been received it is sent to the Examinations Director.

The Examinations Director or assistant Director will check each marking sheet to ascertain that allmarks for the station have been awarded and accounted for, check that the overall mark has been

correctly calculated, check that the mark has been correctly compared to the pass mark, and makea recommendation to Council on this basis alone.

Any decision made by Council will be binding by both parties.

Privacy issuesCouncils current policy is that candidates will only receive their overall result (competent or notyet competent). Feedback will be provided to candidates deemed not yet competent to enablethem to determine the areas in which improvements are required, prior to further attempts.


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Transferring between examinationsPlease carefully select the examination date you wish sit. Due to the NZREX Clinical examinationfilling quickly, once you are placed an examination you may not be able to transfer to an exam at alater date. You will not be able to transfer to a later examination date if your IELTS or prerequisiteexamination results exceed the relevant time frames.

Withdrawals

(i) Applicants whose written withdrawal is received prior to the closing date forapplications will be entitled to a full refund of their fee.

(ii) Applicants who have been accepted as candidates for the examination will be entitled to arefund of fee less 20% only if a written withdrawal is received by the Registrar of theCouncil up to 28 days (4 weeks)before the first day of the examination.

(iii) Applicants who have been accepted as candidates for the examination and who withdrawwithin 27 days (4 weeks less 1 day)of the first day of the examination will beconsidered for any fee refund only in exceptional circumstances (eg. severe illness orpressing domestic circumstances). Documented proof is required.

(iv) Applicants who travel from overseas to sit NZREX Clinical and withdraw due to beingdeclined New Zealand visa, will be subject to the Medical Councils usual withdrawalpolicy (refer points (i)-(iii) above).

False declarationsA person, who wilfully makes a false statement or provides false information in his/her applicationforms or in the documents attached, may have committed an offence. In addition, an applicantmay forfeit his or her eligibility to take NZREX Clinical or, if registration has already been obtained,may be subject to disciplinary action.

Late applicationsApplications received after the closing date will not be accepted and applicants will be notifiedaccordingly.

CommunicationCandidates must not approach actors regarding the examination cases before or after theexamination.

Candidates must not communicate directly with the examiners or the Examinations Director orassistant Director regarding their performance or results in NZREX Clinical. All communication isto be directed to the Council office. Failure to observe this rule may lead to the prohibition fromfurther admission to NZREX Clinical.

Candidates must not communicate with the actors, Council, or administration staff either during orafter the examination regarding the possible outcome of their grades.

After NZREXAn information pack on how to register as a doctor in New Zealand will be sent to all candidateswho are found competent.

To be eligible for registration in a general scope, candidates must successfully complete four 3month runs as follows: 1 category A medical run 1 category A surgical run

2 other runs which may be A, B or C runs. Category D runs are not acceptable.

It is advisable to work in a variety of scopes of medicine during this time.


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Work in primary careCandidates can apply for an exemption from working as a house officer in an accredited hospital inorder to work in a primary care setting if he or she has: completed a general intern year passed NZREX on his or her first attempt has 5 years or more experience in primary care has similar primary care experience a job offer where his or her nominated supervisor is not the employer.

If a candidate is approved to work in primary care, he or she must complete the following in orderto be eligible for registration within a general scope of practice: practise for a minimum of 12 months in a primary care setting approved by Council and under

the supervision of a doctor approved by Council receive satisfactory supervision reports for three runs completed (or 9 months worked)

immediately prior to applying for registration within a general scope been recommended for registration within a general scope by his or her employer.

Certificates of Good StandingBefore you can be registered and begin work, you will need to provide a certificate of goodstanding from the regulatory authority(ies) of each jurisdiction in which you have worked for 5 yearsprior to your application for registration. It can take some time to obtain certificates of goodstanding. If you want to start work in New Zealand immediately after passing NZREX, you maywant to request certificates of good standing from the applicable authority(ies) prior to passingNZREX. Be cautious about obtaining a certificate of good standing too soon they must be issuedwithin 3 months of the date you intend to start work.

Policies

Policy on approved English Tests

Policy on exemption from an approved English test

Policy on validity time for the USMLE Step 1 and Step 2

Policy on clinical observers

Policy on impairment, appeals, and review of NZREX Clinical

Policy on withdrawals

Policy on Critical Incidents

Documents

NZREX Clinical Handbook for Candidates 201 New Zealand