DO-HNS (RCSI) common mistakes
DO-HNS (RCSI) · Understand the traps and how to avoid them.
When asked to interpret a pure-tone audiogram, the candidate reads the air and bone symbols as absolute hearing levels and reports the severity from the air line alone, without first computing the air-bone gap and classifying the loss as conductive, sensorineural or mixed.
Candidates memorise the symbol key but practise by reading the threshold numbers off the graph rather than systematically comparing air and bone at each frequency; under time pressure the comparison step is skipped.
What to do instead
Adopt a fixed reading sequence for every audiogram: state each frequency's air and bone thresholds, compute the gap, classify the type, then describe the configuration and severity; rehearse this aloud on ten varied tracings until it is automatic.
On a caloric or head-impulse question, the candidate names the affected ear by the direction of the nystagmus or the direction of the corrective saccade, rather than by applying the underlying vestibulo-ocular physiology to decide which labyrinth is hypoactive.
The quick-phase rule for caloric testing and the saccade rule for head impulse are easily confused because both are taught as 'opposite' or 'same' heuristics without the physiology behind them, so candidates recall a slogan rather than derive the answer.
What to do instead
For each question, first state which labyrinth is being stimulated or tested and the expected normal eye movement, then compare with the described finding; write out the derivation for warm, cold, right and left conditions once so the logic, not the slogan, is recalled.
In a paediatric case, the candidate applies adult dosing, adult anatomical assumptions, or adult investigation pathways (for example adult-sized equipment, adult antibiotic doses, or adult thresholds for abnormal hearing) without adjusting for the child's age.
Most revision material is written around adult practice, and paediatric variants are studied last and least; candidates default to the adult template when the stem does not explicitly flag the age difference.
What to do instead
Before answering any paediatric stem, consciously list the age-specific differences that could change the answer (weight-based dosing, airway dimensions, developmental milestones, age-appropriate hearing tests) and check the answer against each.
When a neck lump or head and neck mass is described, the candidate jumps to the diagnosis or the definitive treatment and omits the structured first step of assessment (history features, examination findings, and the appropriate first-line investigation such as fine-needle aspiration).
Candidates over-learn the management algorithms for named cancers and under-learn the generic assessment pathway, so an open question about 'next step' is answered with treatment rather than workup.
What to do instead
For every head and neck mass question, answer in the sequence: characterise the lump, identify red flags, state the first-line investigation, then interpret; only offer treatment once a tissue diagnosis pathway has been stated.
The candidate answers a basic-science question (embryology, anatomy, physiology, pharmacology) by pattern-matching a remembered fact to the key word in the stem, without checking that the fact actually answers the question asked.
Basic science is revised as isolated facts rather than as applied mechanisms, so a familiar term in the stem triggers an associated fact even when the stem asks for a consequence, an origin, or a mechanism.
What to do instead
Read the final clause of the stem first to identify what is being asked (origin, consequence, mechanism, next step), then select the fact that answers that specific clause; discard any option that is true but does not answer the question.
In rhinology or facial plastics questions, the candidate recommends a surgical or cosmetic intervention without first establishing the functional diagnosis (for example, addressing a nasal deformity without assessing the airway, or planning rhinoplasty before confirming the cause of obstruction).
Aesthetic and reconstructive topics are studied around procedures, so the candidate's mental model starts at the operation; functional assessment and conservative management are under-weighted.
What to do instead
For every rhinology or facial plastics stem, state the functional problem and its cause first, confirm that conservative or diagnostic steps have been considered, and only then select the procedure; treat 'assess function before form' as a standing rule.
The candidate commits to a single diagnosis early in the stem and then interprets subsequent findings as confirmatory, ignoring or explaining away features that point to an alternative diagnosis.
Exam stems are read linearly under time pressure, and the first salient symptom anchors the candidate; later discriminating features are then read through the anchor rather than weighed against it.
What to do instead
Read the whole stem before forming a diagnosis, list the two or three most likely diagnoses, and explicitly test each against the discriminating features; if a finding does not fit the leading diagnosis, change the diagnosis rather than the finding.
When asked for the next step in management, the candidate selects the definitive treatment or the most sophisticated investigation rather than the immediately appropriate next step in the sequence of care.
Candidates equate a good answer with a comprehensive or definitive one, and high-technology investigations feel more 'correct' than simple first-line steps such as examination, basic bloods, or a plain audiogram.
What to do instead
For 'next step' questions, ask what a clinician would do at this exact point in the pathway, favouring the least invasive step that changes management; reserve definitive treatment and advanced imaging for stems that have already completed the basic workup.
The candidate describes a clinical sign, test or lesion using imprecise or incorrect terminology (for example, mislabelling a type of nystagmus, a type of hearing loss, or a facial nerve segment), which changes the clinical meaning of the answer.
Terminology is learned by recognition rather than by production, so candidates can pick the right term from a list but cannot generate it accurately when writing or explaining an answer.
What to do instead
Build a personal glossary of core terms per domain and practise defining each in one sentence and giving one clinical example; test yourself by producing the term from the definition, not by recognising it.
The candidate manages time and structure poorly: spending disproportionate time on early questions, leaving later questions rushed, and giving unstructured answers that omit the requested components (for example, giving a diagnosis but not the reasoning or the management).
Candidates rehearse content but not exam conditions, so they have no practised pace and no template for structuring an answer, and anxiety drives over-investment in difficult early items.
What to do instead
Rehearse under timed conditions with a fixed per-question budget, a rule for flagging and moving on, and a standard answer structure (findings, diagnosis, reasoning, management) applied to every question so no component is omitted.