Abstract
A viva examination is like playing a game. The candidate should know the subject well, have a game plan and more importantly should know the opponent. A candidate who manages to answer the higher-order thinking/judgement questions at the end of the viva will make it a rewarding 5 minutes (for both the examiner and candidate) and more importantly will score a 7/8. An examiner relishes a candidate who takes control and makes their life easy.
Again, we must stress the importance of time management in the viva, as you have got only 5 minutes to score either eight or four and time is money! It is important to understand the scenario quickly and progress in the correct direction rather than using guess work. Avoid talking generally about the shoulder conditions to fill the time if your aim is to score well. Wherever possible support your answer by evidence (quoting literature) as this will get you past a basic pass and on to a higher score.
Introduction
A viva examination is like playing a game. The candidate should know the subject well, have a game plan and more importantly should know the opponent. A candidate who manages to answer the higher-order thinking/judgement questions at the end of the viva will make it a rewarding 5 minutes (for both the examiner and candidate) and more importantly will score a 7/8. An examiner relishes a candidate who takes control and makes their life easy.
Again, we must stress the importance of time management in the viva, as you have got only 5 minutes to score either eight or four and time is money! It is important to understand the scenario quickly and progress in the correct direction rather than using guess work. Avoid talking generally about the shoulder conditions to fill the time if your aim is to score well. Wherever possible support your answer by evidence (quoting literature) as this will get you past a basic pass and on to a higher score. Be careful, however, not to quote unnecessary or irrelevant evidence which will not only irritate the examiners and not score you any extra marks but is rather crass and bovine.
The main aim of this chapter is to express the importance of viva techniques and therefore it is not written as a textbook. Analyse the good as well as the poor techniques illustrated in the scenarios and follow the ones you find most useful.
Shoulder
In a shoulder structured oral question try and analyze the question according to its presentation. Broadly, shoulder pathology can be classified as painful, weak, stiff or unstable conditions. Shoulder pathology varies with different age groups and therefore you should have a list of age-related diagnoses clear in your mind, which will be helpful in the viva. There can be overlaps of these conditions, for example a painful stiff shoulder may represent frozen shoulder or acute calcific tendonitis or arthritis. Therefore, candidates should have a list of conditions and one or two classical questions to differentiate one from the other, to lead into the scenario comfortably right from the start.
Some scenarios to remember:
Young patient (less than 30 years of age): instability, SLAP lesions.
Middle-aged patient (30–50): impingment, calcific tendonitis, frozen shoulder, cuff tears.
Elderly patient (> 50): cuff tear, OA, cuff tear arthropathy.
Structured oral examination question 1
Tuberculosis shoulder
EXAMINER: This is a radiograph of the left shoulder of an 84-year-old lady. Describe the radiograph please (Figure 7.1).
CANDIDATE: Well … Good morning.
This is the plain radiograph of an 84-year-old lady’s left shoulder. Anteroposterior (AP) view. There is evidence of joint destruction with loss of articular anatomy …
EXAMINER: What do you think is wrong with this shoulder?
CANDIDATE: Well, to be certain, I need to ask a few questions and examine the patient …
EXAMINER: Go on then and ask some questions.
CANDIDATE: Is she right-handed or left-handed?
EXAMINER: Right-handed.
CANDIDATE: How long has she had a problem with this shoulder?
EXAMINER: 70 years.
CANDIDATE: How did the problem start?
EXAMINER: It started as a painless lump when she was 14 and a few months later she began to have a discharging sinus that required several joint washouts and medication.
CANDIDATE: Does she have an active sinus now?
EXAMINER: No, the sinus healed after she underwent shoulder washouts and started her medication and has never recurred.
CANDIDATE: That is good. What are her current problems?
EXAMINER: Well she has some restriction of movements and therefore visited her GP, who had performed this X-ray and sent her to you for your opinion.
CANDIDATE: Then I would examine the patient.
EXAMINER: She has 60° of abduction and forward elevation and has very restricted rotations.
CANDIDATE: I would like to know the power of her cuff muscles.
EXAMINER: It is not possible to assess the power as she has very restricted range of movements.
CANDIDATE: Now …
[Bell]
EXAMINER: Thank you.
Figure 7.1 Anteroposterior (AP) radiograph of left shoulder.
Did this candidate do well? Was there a diagnosis? Was there a discussion about the management? Only a 4 or 5 score would be given as the candidate did not even arrive at a diagnosis and missed all the clues/prompts.
A different candidate with the same scenario:
EXAMINER: This is a radiograph of the left shoulder of an 84-year-old lady. Please describe the X-ray.
CANDIDATE: This is an anteroposterior (AP) radiographic view of the shoulder that shows evidence of joint destruction and loss of articular cartilage.
EXAMINER: What do you think is wrong with this shoulder?
CANDIDATE: This appearance suggests several possible causes such as previous joint infection, trauma or a neurogenic cause. May I know how and when the problem started?
EXAMINER: Her shoulder difficulties began as a painless lump when she was 14 years old and after a few months she went on to develop a discharging sinus that required several shoulder joint washouts and medication.
CANDIDATE: The presentation sounds like she had a low-grade joint infection. Was there any microbiological investigation performed at the time of the joint washouts?
EXAMINER: Yes, it was diagnosed as acid-fast bacillus and now what will be your management?
CANDIDATE: Well, I would like to know if she had any reactivation of infection in the last 70 years?
EXAMINER: No.
CANDIDATE: In that case what is the expectation of the patient?
EXAMINER: The patient does not want any surgical treatment. She wants to know if she can have an injection into her shoulder which can prevent the pain at the extremes of movements.
CANDIDATE: I will be cautious about the intra-articular steroid injections as it can trigger the dormant bacillus and rekindle the infection.
EXAMINER: OK, the patient comes back to you after 6 months and wants a shoulder joint replacement as her neighbour had one performed for arthritis a few weeks ago and is now pain-free and doing great with her shoulder. The patient wants the same operation. Will you offer her joint arthroplasty?
CANDIDATE: Again, I would be cautious to do so. I will certainly investigate her in terms of infective and inflammatory markers. I understand the principles of management of this case with the potential risk of recurrence of deep infection. This case will potentially require a biopsy, discussion with a microbiologist as part of an MDT meeting and a staged procedure. If active infection was present a two-stage procedure should be performed. The first stage would involve humeral head resection and insertion of an antibiotic-impregnated cement spacer. Multiple tuberculosis drug therapy for several months. I would biopsy the shoulder again and if it was negative for infection I would proceed with the second stage. I would prefer to use a reverse shoulder replacement in this patient as there is likely to be extensive destruction of the rotator cuff. I would counsel the patient that the surgery was likely to be protracted and drawn out as active TB of the shoulder needs to be eradicated before undertaking the second stage. I would warn her of the risk of further reactivation and reoccurrence of infection in the future.
EXAMINER: Would you offer her a one-stage procedure if active TB infection was present?
CANDIDATE: I am aware of a few case reports in which a primary single-stage cementless hemiarthroplasty has been performed for active TB with satisfactory results reported at 5 years, but I would prefer a more cautious approach and opt for a two-stage procedure [1].
EXAMINER: The patient does not want to take this risk and wants to be left alone. Thank you.
Although the viva questions started in the same manner, this candidate with his/her knowledge took the viva to a good level of demonstration of his/her clinical judgement by asking specific questions and had control over the situation. Certainly, this candidate deserves a good score.
Reference
Structured oral examination question 2
Rotator cuff tear
EXAMINER: Good afternoon. Can you tell me what is going on in this radiograph of the right shoulder (Figure 7.2)? This patient had anterior dislocation 2 years ago and has ongoing problems.
CANDIDATE: Well, this shoulder is reduced congruently. I cannot see any interposition of bony fragments. And I would like to investigate this shoulder with an MR arthrogram.
EXAMINER: What do you want to rule out?
CANDIDATE: Well, the risk of re-dislocation of the shoulder is much higher with anterior dislocation due to labral detachment in younger patients and it could be treated successfully if identified with MR arthrogram.
EXAMINER: This gentleman is claustrophobic!
CANDIDATE: I would talk to the radiologist and anaesthetist to find out if it could be done under sedation.
EXAMINER: The anaesthetist is not happy! And your radiologist suggests an ultrasound examination of the shoulder.
EXAMINER: Well, the patient only had an ultrasound examination and it shows subscapularis tear!
CANDIDATE: There is then a high risk of having damaged the anterior labrum also … I think I have to speak to the anaesthetist again …
