DCH Clinical examination candidate guide

The Diploma of Child Health (DCH) Clinical exam assesses whether candidates have reached the standard in clinical skills expected of a newly appointed General Practitioner (GP) who has completed a short period of training in paediatrics. It is one of two exams for the Diploma of Child Health, and is currently available in the UK, Hong Kong, India and Egypt.

This page gives guidance to candidates preparing for the exam.
Status
Last modified
8 May 2019

Aim

The aim of the examination is to assess whether candidates have reached the standard in clinical skills expected of a newly appointed General Practitioner who has completed a short period of training in paediatrics, and who displays a special interest in paediatrics.

Scenarios are generally written with reference to the candidate being a GP. 

Candidates are expected to demonstrate proficiency in:

  • communication
  • history-taking and management planning of chronic conditions
  • establishing rapport with both parents and children
  • physical examination
  • child development
  • clinical judgement
  • organisation of thoughts and actions
  • knowledge and understanding of common problems in child health
  • professional behaviour
  • ethical practice
  • interpretation of data
  • safe prescribing

Format

The DCH Clinical Examination includes:

  • 12 objective assessments of each candidate at 8 stations.
  • structured testing of communication skills
  • observed history taking and discussion of management
  • one clinical examination station
  • testing of skills in developmental assessment and neurodisability assessment
  • interpretation of data
  • safe prescribing
  • structured discussion of a child health topic

Examination circuit

DCH Clincal exam circuit diagarm
DCH Clinical Examination Circuit Diagram

Talking stations - six minutes each

The first rotation of the day begins at approximately 09:00 and is comprised of four stations. These stations include:

  • two communication (twice)
  • one data interpretation
  • one structured oral station.

Two sets of four stations run at the same time (double circuit). It is run this way for the first eight candidates and then repeated again for the second eight candidates.

Total time taken to complete the first rotation of eight candidates is 36 minutes. The second rotation of eight candidates will run immediately after and will also take 36 minutes to complete.

There is then a 40 minute break for the host team to reorganise rooms for clinical stations and for examiners to standard set the clinical station patients.

Clinical stations - nine minutes each

The clinical stations, like the talking stations, are run in a double circuit and run before and after lunch.

The first rotation of clinical stations will begin at approximately 10.57 and is comprised of four stations. These stations include:

  • one clinical assessment
  • one history taking
  • one child development
  • one safe prescribing station.

Total time taken to complete a rotation of 'clinical stations' is 48 minutes.

Finally there is then a 20 minute break for hosts to reorganise rooms for the final cycle of ‘Talking Stations’ and for examiners to standard set the talking station role-players.

General

  • Eight examiners for each rotation, one additional senior examiner for back up/quality assurance
  • Examiners will examine the same two stations (one six-minute station and one nine-minute station) throughout the day but will swap rooms with their standard setting examiner partner. This is to ensure that candidates are not assessed by the same examiner twice.
  • In total there are 12 objective assessments per candidate. The six-minute stations have one mark and the nine-minute stations each have two marks.
  • There are three-minute breaks between each station with an entire circuit for a candidate (two separate rotations – one talking/one clinical) taking about 84 minutes to complete.
  • The sequence in which a candidate takes the stations in their exam will vary depending on which station they start.

Timing

All candidates can expect to be examined for the full allotted time. Strict time keeping is essential. The host examiner will indicate the system of time signalling. Candidates are shown into stations at the correct time.

The DCH circuits consist of stations of six minutes and nine minutes in separate circuits, with intervals of three minutes between stations.

Talking stations

Six-minute stations: In this circuit, a warning knock will be given at five minutes and a bell will ring at six minutes to mark the end of a station. The bell will ring again three minutes later to mark the beginning of the next station.

Communication

  • Two minutes: Candidate reads instructions outside room (during interval)
  • Six minutes: Candidate in room with role player and examiner
  • At six minutes: Bell rings, end of station.

Data interpretation

  • Two minutes: Candidate reads instructions / interprets data outside room (during interval)
  • Six minutes: Discussion with examiner
  • At six minutes: Bell rings, end of station.

Structured oral

  • Two minutes: Candidate reads instructions outside room (during interval)
  • Six minutes: Discussion with examiner
  • At six minutes: Bell rings, end of station.

Clinical stations

Nine-minute stations: In this circuit, a warning knock will be given at appropriate times by helpers at each station. A bell will ring at nine minutes to mark the end of a station and then three minutes later to mark the beginning of the next station.

Clinical assessment

  • Candidate given task once in room with the examiner
  • Six minutes: A warning knock signals three minutes left (begin to report findings/summarise to examiner)
  • Eight minutes: One minute knock to notify station soon to end
  • At nine minutes: Bell rings, end of station.

History taking

  • Candidate reads instructions outside room (during interval/station break).
  • Six minutes: Candidate takes Hx from parent/role-player. There is a warning knock at 6 mins to signal end of history taking with parent. Parent/role-player remain in station
  • Discussion with examiner on management planning begins
  • Eight minutes: 1 minute knock to notify station soon to end
  • At nine minutes: Bell rings, end of station.

Child development

  • Candidate given task once in room with the examiner
  • Six mins: Candidate assesses patient. There is a warning knock at six mins to signal end of developmental assessment. Parent and child remain in station
  • Discussion with examiner on findings begins
  • Eight minutes: One minute knock to notify station soon to end
  • At nine minutes: Bell rings, end of station.  

Safe prescribing

  • Candidate reads instructions/scenario outside room (during interval/station break)
  • Six mins: Candidate has a maximum of six minutes to write prescription in station with examiner (examiner should try to time this in the station and if candidate completes prescription ahead of time discussion can begin)
  • Discussion with examiner begins
  • Eight mins: One minute knock to notify station soon to end
  • At nine minutes: Bell rings, end of station.

Marking scheme and the pass mark

At the end of each station the examiner will make an overall judgement as to whether or not the candidate’s performance was as below.

Category Mark Comment
Clear pass 12 Demonstrates the competencies being tested int he station; this includes candidates who have satisfied the requirements and those who excel
Pass 10 Elements of the performance that are not as good as expected but that are not sufficient to give a fail grade; where a candidates exhibits some minor failings
Bare fail 8 Has made an inappropriate number of minor errors or some more important errors
Clear fail 4 Poor performance in one or several areas
Unacceptable 0 For unprofessional or dangerous behaviour (rough handling of a child, rudeness, etc.) or for extremely poor performance

Anchor statements outlining the expected general standard for each station are provided to all examiners in order to aid them reach their overall judgements.

There will be a total of 12 judgements. Candidates will fail if they do not obtain a total of 120 marks.

The final pass/fail mark can be raised at the Clinical Exam Board Meeting held after each exam period.

If a candidate’s behaviour is unprofessional, under these exceptional circumstances, candidates may be stopped by the Senior Examiner from continuing with the examination.

Candidates will not fail on the basis of a single encounter (unless there is unprofessional behaviour of sufficient severity), but will be marked on an accumulation of marks.

Candidates known to examiners

We will endeavour to avoid placing candidates within Trusts where they have previously worked and where they may have prior knowledge of any of the patients selected. However they may be known to others than the host examiner.

If an examiner feels that this creates a significant difficulty with a particular candidate, please ask the host/senior examiner to be present for that candidate. 

Stations one and two: Communication skills stations

Time of station

Two stations of six minutes

Aim

To test the ability to communicate appropriate and factually correct information in an effective way within the emotional context of the clinical setting.

Communication is most frequently with a surrogate parent or health care professional or adolescent. A candidate may be asked to talk to a real parent and/or child, a health professional, or a member of the public.

The task

There are six main patterns of communication scenario:

  • information giving (eg please tell this parent about the diagnosis)
  • consent (eg please explain why you need to do a lumbar puncture with a view to obtaining consent)
  • critical incident (eg please talk to the parent of the child who has been given the wrong drug)
  • ethics (eg please discuss the problem as Anna has refused to have any blood tests)
  • education (eg please explain to the health care professional so that she can deal with the situation)
  • candidates may be asked to explain use of common medical devices; a manikin or model may be used in the station.

Candidate information

Written information will be provided about your role, clinical background and the task required. This is provided to read while sitting outside the station. If a candidate is sitting this station they first must make sure they are ready outside the station two minutes before the exam starts. 

You will not be required to examine any patient; information including growth charts and results of investigations may be provided if relevant.

Assessment

Candidates will be marked on their communication skills.

This means that a candidate needs to:

  • select the most appropriate information to communicate
  • provide information that is correct
  • explain issues in an appropriate way without jargon
  • respond and adapt to the emotional context of the station.

It is not a test on the amount of information conveyed in six minutes. In some scenarios, the task would normally take more than six minutes and may not be completed. Candidates should be penalised for asking irrelevant questions or providing superfluous information.

Candidate tips

  • Ensure you read the scenario carefully.
  • Establish what the 'parent'/health professional already knows in order to give you a baseline from where to start.
  • Establish what the parents concerns/anxieties/question are

You are not expected to examine in this station.

Sample communication skills scenario

Sample instructions to candidate

This station assesses your ability to give information to a parent/patient.

You are: A GP working in a small rural market town

You will be talking to: Jane Smith the teenage single mother of Jason, aged 18 months.

Task: To explore her concerns about febrile convulsions

Setting: GP Surgery

Other information: You are not expected to gather the rest of the medical history during the consultation.

The examiner will have both the candidate sheet and role player sheet.

Examiner marking criteria: Candidate should be able to:

  • clearly explain febrile convulsions
  • explain good long-term prognosis.
  • show empathy for parent concerns.

Station three: Data interpretation

Time of station

One station of six minutes

Aim

To assess ability to interpret data in a clinical context

Task

To interpret data provided and discuss with the examiner the implications of the data and an appropriate management plan

Examples of data include blood tests, urinalysis, audiograms, growth charts, diabetic diaries, peak flow charts and laboratory reports etc.

Candidate information

Written information will be provided about the task required. This is provided to read while sitting outside the station. If a candidate is doing this station first, make sure they are ready outside the station two minutes before the exam starts. 

Timing and marking of the station - this will be:

  • If you have completed answering the examiner’s questions in less than six minutes, the examiner will check that you have finished. 
  • If you have, you should remain in the examination room until the end of the allocated time.

Candidate tips

  • Ensure you read the instructions carefully as they will inform you of what is expected.
  • Do not spend too long reading the data – remember there are questions for which you need to write down the answer.

Sample data interpretation scenario

Sample instructions to candidate

Task: to interpret data in the clinical context provided.

Discuss with the examiner the relevance of the data in the diagnosis and management.

This is a six-minute station. You will have two-minutes beforehand to read this sheet and prepare yourself.

You may take the sheet with you into the station but you must return it at the end.

Role: You are a GP

Setting: GP Surgery

Task: Interpret data

Candidate information: A 14 year old girl has a five day history of fever accompanied by tiredness, anorexia, headache and a sore throat. On examination, she has pharyngitis, generalised lymphadenopathy and palpable spleen.

Investigation:

  • Hb 1.9 g/dl (11.0 -17.0 g/dl)
  • WBC 19.2  x109/L (4.5 - 13) 
  • neutrophils 2.6 x109/L (1.5 – 6)
  • lymphocyte 12.3 x109/L (1.5 – 4.5)
  • monocytes 2.0 x109/L (0.15 – 1.3)
  • eosinophils 2.2 x109/L (0.05 – 0.8)
  • basophils 0.1  x109/L (0.02 – 0.12)
  • atypical mononuclear cell 33%
  • Platelets 157 x109/L (150 -450)

Station four: Structured oral

Time of station

One station of six minutes

Aim

To test knowledge and understanding of common child health problems, and the principles which underpin them. 

Assessment

The examiner will discuss one scenario with you during your time in this station. The examiner will ask you a number of questions about the scenario which tests your knowledge, and the application of that knowledge to the scenario. The scenarios address clinical presentations, management of common conditions and processes relating to the care of children.

Candidate information

Written information will be provided about the task required. This is provided to read while sitting outside the station. If a candidate is doing this station, first make sure they are ready outside the station two minutes before the exam starts. 

Timing and marking

This will be six minutes duration.

  • If you have completed answering the question in less than six minutes, the examiner should check that you have finished.   
  • If the candidate has finished, he/she should remain in the examination room until the end of the allocated time.

Candidate tips

  • Read the scenario given to you.
  • Ensure you are answering the question that is asked. If you are unsure ask for clarification.
  • Be aware that there is a list of questions you have to answer so time management is key.

Sample structured oral scenario

Instructions for candidates

Role: You are a GP Registrar.

Task: A four-year old boy presents with 'ballooning' of his foreskin over the end of his penis. He has had this once before. He comes with his father who is sure he needs to have a circumcision.

Questions:

  1. What would you look for on examination?
  2. What investigations would you ask for and what advice would you give to these parents?

Answer guide:

  • Examination – careful assessment of the foreskin.
  • Gently retract but do not force it if it will not go. (Even if foreskin appears very narrow, symmetrical pouting of the mucosal/inner layer generally indicates a normal non-retractable foreskin).
  • Look for scarring or an irregular opening – more likely to represent pathological rather than normal physiological variant (and could indicate balanitis xerotica obliterans although less common at this age).
  • Look for inflammation or discharge (balanitis is inflammation of the glans, posthitis is inflammation of the foreskin).
  • (Draw the foreskin forwards by pulling upwards rather than retracting. This usually demonstrates the true calibre of the opening. Showing this to the parent/s is also very useful in reassuring them that the foreskin is not narrow).
  • (Palpate/percuss looking for bladder distension). 
  • (Take this opportunity to check the position of the testes).
  • No investigation usually required
  • Swab if any discharge, MSU if suspicion of UTI. 
  • Reassure that the normal foreskin is often not retractable in young boys and often does not retract completely until puberty.  Ballooning does not matter as long as the established stream is adequate.

Station five: Clinical assessment

Time of station

One station of nine minutes

Aim

To assess clinical examination skills and interpretation of clinical signs. There is only one patient/examiner in each station. 

Candidates will be tested in any of the following areas:

  • cardiovascular
  • abdomen
  • respiratory
  • surgical
  • neurology
  • other, eg endocrine, eyes, skin, etc.

Candidate information

Each candidate will be given the same brief introduction to each child and the task required. This will be provided verbally by the examiner. The examiner will introduce the child. The examiner may intervene at any time, and will ask you questions about the clinical findings and their interpretation or management implications at any stage during the nine-minute station. 

Details about what is expected of candidates when performing a clinical examination of a child (Clinical Assessment station) and a developmental assessment of a child (aged 0-5) can be found here. DCH Clinical candidates should pay particular attention to pages six onwards within the ‘MRCPCH Clinical Exam Technique’ guide. For guidance on developmental assessment please refer to page 29. Pages 1-5 of the document relate specifically to the MRCPCH Clinical exam only. DCH Clinical candidates should disregard these first five pages.

Example: “This is Meg who is six months old and her parents are worried about a swelling of her umbilicus. Please examine her abdomen."

Candidate tips

  • In the clinical assessment you could be presented with anything – CVS, RS, GI, thyroid, etc.
  • It is designed purely to test your clinical examination skills.
  • There is no need for you to take a history.
  • Introduce yourself and establish rapport.
  • Listen or read instructions carefully and do what is asked. Answer any questions posed by the examiner.

Station six: Focused history taking and management planning

Time of station

One station of nine minutes

Aim

To assess the candidate’s ability to take a focused history, summarise and formulate a management plan.

The task

To review chronic disease management. This may be with a parent and child or a role player. The candidate will be expected to take a focused history. Candidates will not be required to examine the patient; relevant information including growth charts and results of investigations may be provided. After taking the history, the candidate will discuss a management plan with the examiner.

In some ways it is easy to think of this station as being the 'long case' but this is old exam speak. The centre chooses the cases, the subject, and the summary. The only input of the College is to provide a proforma for the information sheets for the candidate and the sheets for the examiners.

Candidate instructions

The aim of the station is to take a history focussed on the child’s chronic condition. If the parent/role player ask questions during the consultation, it may be appropriate to answer these. However, the parent should be discouraged from asking any questions about management of their child’s condition.

Candidate information - written information will be provided about the task required. This is provided to read while sitting outside the station. If a candidate is doing this station first, make sure they are ready outside the station two minutes before the exam starts. 

Timing and marking

  • The total time taking a history from the patient will be a maximum of six minutes. The examiner should then award a mark for this section.
  • A warning knock will be issued after six minutes (usually a knock on the door).
  • The examiner will then discuss the case with the candidate for the remaining three minutes.  A mark should be awarded for this section.

If you have reached the end of the history-taking in less than six minutes, the examiner will check that you have finished. Should you finish early, the examiner will ideally wait until the six minutes have elapsed before continuing the examination. Candidates can be told to take the time to compose and reflect over their notes. The patient/parent will remain in the room during the entire nine minutes.

Candidate tip

  • It is advisable to use the break between stations to write down areas you wish to cover, in order to structure your history taking.
  • Ensure you ask about past medical history and drug history
  • Ensure you leave enough time to discuss management.

Sample focused history taking and management planning scenario

Sample instructions for the candidate

The task with the parent/role-player is to take a focused history.

The examiner will focus on your understanding of chronic disease management.

This is a nine-minute station. You will have up to two minutes before the start of this station to read this sheet and prepare yourself. You may make notes on the paper provided.

When the bell sounds, you will be invited into the examination room. You may take this instruction sheet with you.

You will have six minutes to take a history from the patient, with a warning knock after six minutes. The examiner will observe your history taking during this time.

You will then have three minutes with the examiner for discussion.

You are not required to examine the patient.

Role: You are a GP

Setting: GP surgery

You are talking to: Gregory a six-year-old boy and his mother.

Task: Take a focussed history for this case and discuss your management plan with the examiner.

Background information: George is attending your surgery for the first time with his mother. His family have recently moved to the area. George has diabetes.

Any other information: George has two older siblings

Station seven: Child development assessment

Time of station

One station of nine minutes.

Aim

To assess the candidate’s ability to perform developmental assessment by:

  • clinical developmental assessment of the child
  • brief assessment of neurodisability if present
  • supplementary history taking from the parent if appropriate
  • any other material provided at the station, e.g. the parent held record, growth chart.

Candidate information

The emphasis is on clinical developmental assessment. Candidates are expected to make an assessment of development and recognise neurodisability. Candidates should be able to discuss the implications of their findings and the child’s management. 

Suitable toys and other equipment will be provided. You will need to select the most appropriate tools for developmental assessment.

General points:

  • The child will have a developmental age of less than four years.
  • The examiners will decide which aspect of development they wish the candidate to assess.
  • Toys and tools will be provided at the station. You should not bring your own toys.
  • Candidates are not expected to perform psychometric testing. 
  • Within six minutes the candidate should be able to test the indicated area of development and determine the nature and severity of any problem, and the degree of confidence with which this assessment is made.
  • The candidate should be able to outline the main areas of management and demonstrate their knowledge of the roles of the members of the multidisciplinary team dealing with child developmental problems.
  • The candidate should understand the principles of vision and hearing assessment.

Timing and marking of the station

  • The total time for the examination of the patient will be a maximum of six minutes. The examiner will then award a mark for this section.
  • A time warning will be issued after six minutes during the clinical examination.
  • The examiner will discuss the findings and interpretation with the candidate for the remaining three minutes. A mark will then be awarded for this section.

Candidate tips

  • Listen/read instructions carefully
  • This is not a history station – purely examination
  • You are not allowed to ask the age of the child unless specifically stated in the information provided
  • It is important to be systematic
  • Focused usually on one area of developmental examination

Station eight: Safe prescribing

Time of station

One station of nine minutes.

Aim

To assess ability to write a prescription with correct dosage according to a child’s age and weight and appropriate to the described clinical scenario, and to understand the implications of this prescribing

Task

To write a prescription on an FP10 (British National Formulary for Children, BNFC, provided) and discuss with the examiner the implications of your decision with reference to indication, dose calculation contraindications, potential adverse reactions and specific issues related to taking the medication.

Please familiarise yourself with general guidance and prescription writing; these can usually be found in the first few pages of the BNFC and you should read them before attending the exam. It is important to remember to write your full name clearly next to your signature when writing your prescription.

Examples could include treatment of asthma, infections, epilepsy.

Candidate information

Written information will be provided about the task required. This is provided to read while sitting outside the station. If a candidate is doing this station first, make sure they are ready outside the station two minutes before the exam starts.

Timing and marking of the station

  • The total time for the candidate to complete the prescription will be a maximum of six minutes. The examiner will then award a mark for this section.
  • Once you have finished writing your prescription, the BNFc will be taken from you by the examiner.
  • A time warning will be issued after six minutes during the clinical examination indicating that the candidate must begin discussion with the examiner.
  • The examiner will discuss the implications of your decision with the candidate for the remaining three minutes. A mark will then be awarded for this section.

Candidate tips

  • Ensure your script is legible.
  • Check dosage – you are expected to refer to BNFC.
  • Ensure you prescribe the right drug as prescribing an inappropriate drug could lead to a fail. 
  • Look at Paediatric Prescribing Principles: an eLearning course for paediatricians and all health professionals with a role in prescribing drugs for children and young people. For registration please visit: http://rcpch.learningpool.com/ 

Sample safe prescribing scenario

Sample instructions for the candidate

  • To prescribe effectively and in context using the BNFc provided
  • To discuss with the examiner your knowledge and understanding of the medications prescribed

This is a nine minute station. You will have up to two minutes before the start of this station to read this sheet and prepare yourself.

When the bell sounds you will be invited into the examination room. You may take this instruction sheet with you.

You will have up to six minutes to write the prescription and three minutes for discussion.

Role: You are a GP.

Setting: GP surgery

You have seen: Laura Smith, a fourteen year-old girl and her mother. Laura has had three episodes of generalised fits. Her EEG has confirmed that she is suffering from epilepsy. Mum is keen to commence her on medication to prevent further fits. Please prescribe a suitable antiepileptic agent for Laura. Her weight is 50Kg and height 160cm.

Task: Write a prescription using the BNFc provided

With the examiner: Discuss issues of safe prescribing

Equipment needed: BNFC, Prescription pad/Hospital Drug chart     

General instructions for candidates

  • Please allow plenty of time to reach the clinical examination centre. Trains do not always run on time and cars can break down. We suggest you stay nearby if your examination begins the next morning. Once the circuit starts, it will be almost impossible to let you catch up if you are late – although we will always do our best to do so. We will not allow your late arrival to affect the performance of other candidates.
  • Please note exams can often run over time so please allow for this when booking return travel.
  • Please ensure that you switch off all electronic devices including mobile phone and beepers as soon as you arrive. Please remember to bring photo ID with you.
  • Candidates may bring refreshments/water to the exam. Host venues are not responsible for supplying refreshments to candidates.
  • Remember, we are not examining to in order to find outstanding candidates. We are looking for candidates who meet the standard required for success. The standard is clear. We require successful candidates to demonstrate that they can perform at the level expected of a new, competent GP.  We do not try to trick candidates but look to see how you are likely to perform when going about your usual work.
  • Please bring with you your own stethoscope, which must be wiped with alcohol between patients. Electronic stethoscopes should not be used in the exam unless a candidate has a hearing impairment. If so, candidates should declare this on their application forms in the section named ‘reasonable adjustments’.
  • Do not bring equipment or toys for developmental assessment as these will be supplied for you.
  • Candidates are expected to dress in a manner appropriate to a normal working day in clinical practice, and to familiarise themselves with the principles of infection control.
  • If candidates are unsure please contact the hospital/centre you are attending and ask about suitable dress for clinical practice.
  • You will be given a station at which to start and will be taken there.
  • Complete and sign all of your mark sheets and put them in the order in which you will hand them to your examiners – you will leave the relevant mark sheet at each station as you go around the circuit.
  • Please read any instructions given to you at the start of the station very carefully. There will be three minutes to read this and you must use the time profitably. Finish reading instructions even if the bell announcing the start of the station rings – you will be unlikely to be able to perform at the station without knowing the instructions.
  • Please clean your hands between each station. You can usually do this in the gaps between stations. Performing this function is part of being a successful candidate.
  • Examiners will meet before the start of the examination to determine the pass/fail criteria. Examiners are given guidance notes to mark.  Any examiner who departs from these guidelines will have their marking reviewed and unless there is good reason altered. In addition, an extra examiner may be present to monitor examiner performance to check that the exam is fair and consistent.
  • You may come across a station where videoing is in progress: this is for examiner training and for performance checking of examiners only. The video is not used for candidate marking.
  • You may also come across observers. These individuals may be examiners in training or may be others such as clinical tutors who need to better understand the examination in order to help their trainees.
  • You must not communicate with other candidates on the same or other examination cycles.
  • When you have finished, please remember to collect your belongings before you leave.
  • You must not provide details about the stations to commercial organisations or post them on the Internet without permission of the College.