In the exam, how do I decide what is most important to treat?

I will never be able to give a satisfactory answer to this question, so my apologies in advance.

If I was to try to give guiding principles however, I would probably fall back to 3 aspects of a patient’s situation.

• Addressing significant safety risks

• Their goals and what they want to achieve.

• Discharge considerations (especially if they are an inpatient)

In an exam situation, where the funding consequences of a long rehab stay are blissfully not as relevant, the above order is how I would most likely rank their importance.

But the question then could be, how much of a safety risk does it need to be for safety to be more important than a patient’s goals? Again, in real life that is a very delicate balance. In an exam, most times the clues will lie in the way the case has been portrayed to you.

To give an example:

• If in an exam a patient mentions that they trip sometimes that is important.

• If it is mentioned in the patient history and in what the patient tells you then it is something they WANT you to address.

• If the patient mentions tripping more than once….. take the hint

In the absence of stronger clues like mentioned above I would in most cases steer towards addressing the safety issue, BUT I would describe my concerns about safety and what I’d suggest we do about it to the patient and seek their permission to address the safety concern today, whilst stating that you would address their goal in the next session.

So keep the considerations described above in mind, but remember that it will always be a judgment call rather than something that can be determined by a rule. After all, the exam is set up to assess your judgment and very rarely will a predetermined plan or set of “rules” work in the exam