The "Killer" Introduction: Perfecting Your Opening

In the Fellowship Clinical Exam (Short Case), the examiners often make up their mind about you within the first 60 seconds. This is the phenomenon of "thin slicing"—where observers make accurate judgments about personality and competence based on very brief exposures.

A weak, meandering introduction puts you on the back foot. You spend the rest of the case digging yourself out of a hole. A strong, structured introduction controls the room, relaxes the examiners, and sets the trajectory for a "Pass" or "Gold Medal" performance.

Visual Element: A "Pyramid of Presentation" graphic. Base: "Raw Signs". Middle: "Synthesis". Top: "Diagnosis". Arrow pointing up indicating the flow of a good presentation.

The Psychology of the Examiner

Examiners are tired. They have seen 20 candidates today. They are bored of hearing "I would like to complete my examination by..." They want:

1. Safety: Did you spot the big sick thing?
2. Competence: Can you synthesize signs into a diagnosis?
3. Efficiency: Can you get to the point?

The Formula: Headline - Evidence - Synthesis

Stop listing signs like a shopping list. Tell a story.

1. The Headline (The "Hook")

Start with the most obvious, high-yield finding. Do not start with "inspection revealed normal skin." Start with the pathology.

• Weak: "I examined Mr. Smith. On inspection..."
• Strong: "I examined Mr. Smith, who presents with a gross varus deformity of the left knee."

2. The Evidence (The "Why")

Support your headline with the cluster of positive signs. Group them logically (Look, Feel, Move).

• Strong: "This is associated with an antalgic gait, medial joint line tenderness, and a fixed flexion deformity of 10 degrees."

3. The Synthesis (The Diagnosis)

Commit. Don't say "it could be." Say "this is consistent with."

• Strong: "These findings are consistent with end-stage medial compartment osteoarthritis."

Templates by Subspecialty

Memorize these structures. Adapt the content to the patient.

The Hip (Osteoarthritis)

"I examined this gentleman who demonstrates a Trendelenburg gait on the right side. On inspection, there is a fixed flexion deformity of 15 degrees and apparent leg length discrepancy. Movements are restricted in a capsular pattern, with internal rotation blocked at neutral. This clinical picture is consistent with severe right hip osteoarthritis."

The Knee (ACL Deficiency)

"I examined this young athlete. On inspection, there is mild quadriceps wasting but no effusion. Crucially, the Lachman test is positive with a soft end-point, and there is a Grade 2 Pivot Shift. There is no joint line tenderness to suggest meniscal pathology. This is consistent with a chronic Anterior Cruciate Ligament rupture."

The Spine (Lumbar Stenosis)

"I examined this lady who stands with a stooped 'Simian' posture. Gait assessment reveals a wide-based gait, but no ataxia. Neurological examination of the lower limbs demonstrates weakness of Extensor Hallucis Longus (L5) bilaterally, but preserved reflexes. Given the postural compensation, this is suggestive of Lumbar Canal Stenosis."

The Hand (Dupuytren's)

"I examined this gentleman's hands. There is a flexion contracture of the ring and little fingers of the right hand. On palpation, there are thickened pretendinous bands and skin pitting, but Hueston's table top test is positive. Sensation is preserved. This is characteristic of Dupuytren's Disease, likely Tubiana Stage 2."

The Shoulder (Rotator Cuff Tear)

"I examined this lady who has supraspinatus and infraspinatus wasting on the right. Active abduction is limited to 40 degrees with a significant shrug sign. Passive range of motion is full, ruling out adhesive capsulitis. Lag signs are positive for External Rotation. This is consistent with a massive, potentially irreparable, rotator cuff tear."

Practice Drills

You cannot learn this by reading. You must speak it.

Drill 1: The 20-Second Challenge

Pick a pathology. Record yourself giving the intro. If it takes longer than 20 seconds, cut words.

• Tip: Cut "I would like to say that...", "It appears that...", "On my examination..."

Drill 2: The Randomizer

Have a study partner give you 3 signs (e.g., "Wasting, Sensory loss little finger, Positive Froment's"). You must instantly construct the intro: "This patient has an Ulnar Nerve Palsy..."

Drill 3: The Mirror

Watch your face. Do you look terrified? Or do you look like a consultant? Fake the confidence until you feel it.

Summary

The "Killer" Introduction is your shield. It protects you from the examiner's doubt. It frames the rest of the discussion on your terms. Master the formula: Headline -> Evidence -> Diagnosis.

Clinical Case Library

Watch videos of candidate performances for common short cases to hear these intros in action.