The monitoring system demonstrates a concerning trend in the prevalence of a specific autoimmune condition within a particular demographic group in the Pacific Rim region. This scenario is professionally challenging because it requires rheumatologists and autoimmune medicine practitioners to move beyond individual patient care and engage with broader public health principles, specifically addressing health equity. The challenge lies in identifying the root causes of disparities and implementing interventions that are both clinically effective and socially responsible, all while adhering to the ethical obligations of the profession and any relevant regional health guidelines. Careful judgment is required to distinguish between correlation and causation, and to ensure that proposed solutions do not inadvertently exacerbate existing inequities. The best approach involves a comprehensive, multi-faceted strategy that prioritizes understanding the underlying social determinants of health contributing to the observed disparity. This includes conducting further epidemiological research to confirm the trend and identify specific risk factors, engaging with community leaders and affected populations to gather qualitative data and co-design culturally appropriate interventions, and advocating for policy changes that address systemic barriers to healthcare access and quality. This approach is correct because it aligns with the ethical imperative to promote health equity, which requires actively identifying and mitigating disparities in health outcomes. It also reflects best practices in population health management by focusing on upstream factors and empowering communities. An incorrect approach would be to solely focus on increasing the availability of specialized rheumatology services in the affected area without investigating the reasons for the disparity. This fails to address the fundamental issues that may be preventing individuals from accessing care in the first place, such as transportation, financial constraints, or cultural mistrust of the healthcare system. Ethically, this approach is insufficient as it does not actively work towards equity but rather assumes that simply providing more resources will solve the problem, potentially overlooking the nuanced barriers faced by the population. Another incorrect approach would be to attribute the higher prevalence solely to genetic predispositions within the demographic group without robust scientific evidence. This can lead to stigmatization and a lack of targeted interventions for modifiable environmental or social factors. It is ethically problematic as it risks oversimplifying a complex issue and may divert resources from addressing preventable causes. A third incorrect approach would be to implement a one-size-fits-all public health campaign that does not consider the specific cultural context or literacy levels of the affected population. While well-intentioned, such a campaign may be ineffective and could even be perceived as insensitive, further alienating the community. This fails to uphold the principle of cultural humility and can hinder engagement and uptake of health promotion messages. Professionals should employ a decision-making framework that begins with data interpretation and problem identification, followed by a thorough investigation of contributing factors, including social determinants of health. This should involve interdisciplinary collaboration and community engagement to develop contextually relevant and equitable solutions. Continuous evaluation and adaptation of interventions are crucial to ensure they are achieving their intended impact and promoting health equity.

Scenario Analysis: This scenario is professionally challenging because it involves a patient with a complex autoimmune condition exhibiting new, potentially serious symptoms that could be related to their underlying disease, treatment side effects, or an unrelated concurrent illness. The physician must balance the need for prompt investigation and management with the patient’s comfort, existing treatment plan, and the potential for iatrogenic harm. Accurate and timely diagnosis is paramount to prevent disease progression or severe complications. Correct Approach Analysis: The best professional approach involves a comprehensive assessment that includes a detailed history of the new symptoms, a thorough physical examination, and targeted investigations. This approach is correct because it systematically gathers all necessary information to differentiate between potential causes of the patient’s new symptoms. It aligns with the ethical principles of beneficence (acting in the patient’s best interest) and non-maleficence (avoiding harm) by ensuring a well-informed diagnostic and treatment plan. Regulatory frameworks for medical practice emphasize evidence-based diagnosis and patient-centered care, which this approach embodies. It prioritizes understanding the patient’s current state before making significant changes to their established management. Incorrect Approaches Analysis: Initiating immediate escalation of immunosuppressive therapy without a clear diagnosis is professionally unacceptable. This approach risks exacerbating an infection or causing other adverse effects from unnecessary medication changes, violating the principle of non-maleficence. It bypasses the crucial diagnostic step of identifying the root cause of the new symptoms. Delaying further investigation and attributing the new symptoms solely to the known autoimmune condition without a thorough review is also professionally unacceptable. This can lead to missed diagnoses of other serious conditions, potentially resulting in delayed or inappropriate treatment, which is a failure of beneficence and could breach professional standards of care. Consulting a specialist without first performing a basic clinical assessment and gathering initial diagnostic data is inefficient and potentially delays care. While specialist consultation is important, it should be informed by the primary physician’s initial findings, ensuring the specialist receives relevant information and the patient benefits from timely preliminary assessment. Professional Reasoning: Professionals should employ a systematic diagnostic process. This involves: 1. Gathering comprehensive patient information (history, examination). 2. Formulating a differential diagnosis based on this information. 3. Ordering appropriate investigations to confirm or refute differential diagnoses. 4. Developing a management plan based on the confirmed diagnosis, considering patient preferences and potential risks and benefits. Regular reassessment is crucial.

Scenario Analysis: This scenario is professionally challenging because it requires a rheumatologist to navigate the complex interplay between their personal understanding of a patient’s condition and the formal requirements of the qualification’s blueprint, scoring, and retake policies. Misinterpreting or disregarding these policies can lead to significant professional consequences for both the physician and the patient, including potential delays in patient care or the physician’s professional advancement. Careful judgment is required to ensure adherence to established qualification standards while still advocating for the patient’s best interests within the defined framework. Correct Approach Analysis: The best professional practice involves meticulously reviewing the official qualification blueprint, paying close attention to the stated weighting of topics, the scoring methodology, and the explicit retake policies. This approach ensures that study efforts are strategically focused on areas with higher weighting and that the physician understands the criteria for passing and the consequences of failing. Adherence to these documented policies is paramount for maintaining the integrity of the qualification process and ensuring fair assessment. This aligns with the professional obligation to meet the standards set by the credentialing body, which are designed to ensure competence in the field. Incorrect Approaches Analysis: One incorrect approach involves relying solely on personal clinical experience and assuming that a strong track record in practice automatically translates to success on the qualification without understanding its specific structure. This fails to acknowledge that the qualification assesses knowledge and application against a defined blueprint, which may cover specific theoretical aspects or newer research not routinely encountered in daily practice. It also ignores the explicit retake policies, potentially leading to unexpected consequences if the qualification is not passed on the first attempt. Another incorrect approach is to prioritize studying only the topics the physician finds most interesting or personally relevant, disregarding the blueprint’s weighting. This can lead to an imbalanced preparation, where high-weightage areas are under-prepared, increasing the risk of failure. This approach neglects the professional responsibility to demonstrate competence across the entire scope of the qualification as defined by the examining body. A further incorrect approach is to assume that retake policies are flexible or can be negotiated based on individual circumstances or perceived effort. This disregards the formal, often strict, policies established by the qualification provider. Such an assumption can lead to disappointment and professional setbacks if the physician is unable to meet the stated requirements for retaking the examination. Professional Reasoning: Professionals should adopt a systematic approach to qualification preparation. This involves first obtaining and thoroughly understanding all official documentation related to the qualification, including the blueprint, scoring guides, and retake policies. Next, they should create a study plan that aligns with the blueprint’s weighting and their own identified knowledge gaps. Regular self-assessment against the qualification’s criteria is crucial. Finally, understanding and accepting the established retake policies is essential for managing expectations and planning accordingly.

Scenario Analysis: This scenario presents a common challenge in rheumatology practice: balancing the need for evidence-based management with the individual patient’s unique circumstances and preferences, particularly when dealing with chronic conditions and preventive care. The professional challenge lies in navigating potential conflicts between established guidelines, patient autonomy, and the practicalities of healthcare delivery within the specified regulatory framework. Careful judgment is required to ensure patient safety, efficacy of treatment, and adherence to professional standards. Correct Approach Analysis: The best professional practice involves a comprehensive assessment of the patient’s condition, a thorough discussion of evidence-based treatment options, and shared decision-making. This approach prioritizes understanding the patient’s values, lifestyle, and potential barriers to adherence, alongside their clinical presentation. It ensures that the management plan is not only clinically sound but also practical and acceptable to the patient, thereby maximizing the likelihood of long-term success and adherence to preventive strategies. This aligns with ethical principles of patient autonomy and beneficence, and regulatory expectations for informed consent and patient-centered care. Incorrect Approaches Analysis: One incorrect approach involves solely relying on the most recent clinical guidelines without adequately considering the patient’s individual circumstances or preferences. This can lead to a management plan that is difficult for the patient to follow, potentially resulting in non-adherence, suboptimal outcomes, and a breakdown in the therapeutic relationship. It fails to acknowledge the importance of patient engagement in their own care and may not be the most effective strategy for chronic disease management. Another incorrect approach is to defer entirely to the patient’s initial preferences without providing them with sufficient information about the evidence-based options and their potential benefits and risks. While patient preference is crucial, it must be informed. This approach risks overlooking established best practices that could significantly improve the patient’s prognosis or quality of life, and it may not fully meet the professional’s duty of care to provide optimal medical advice. A further incorrect approach is to implement a treatment plan based on anecdotal evidence or the practices of colleagues without reference to established, peer-reviewed evidence. This deviates from the core principle of evidence-based medicine, which is fundamental to professional practice. It exposes the patient to potentially ineffective or even harmful treatments and undermines the credibility of the healthcare professional and the profession itself. Professional Reasoning: Professionals should adopt a systematic approach that begins with a thorough clinical assessment. This should be followed by an open and honest discussion with the patient about their condition, the available evidence-based treatment options, and the rationale behind each. The patient’s values, goals, and concerns must be actively sought and integrated into the decision-making process. The resulting management plan should be clearly documented, and regular follow-up should be scheduled to monitor progress, address any emerging issues, and adjust the plan as needed, always in collaboration with the patient.

This scenario presents a professional challenge due to the inherent conflict between a physician’s duty to provide optimal care and the patient’s right to self-determination, particularly when the patient’s capacity to make informed decisions is in question. The physician must navigate complex ethical principles and regulatory requirements to ensure the patient’s well-being while respecting their autonomy. Health systems science principles are also relevant, as the decision impacts resource allocation and the broader healthcare team’s responsibilities. The best approach involves a systematic assessment of the patient’s capacity to consent. This includes clearly explaining the proposed treatment, its risks, benefits, and alternatives in a manner the patient can understand, and then verifying their comprehension and voluntary agreement. If capacity is deemed lacking, the physician must then engage with the legally authorized surrogate decision-maker, providing them with the same comprehensive information to facilitate a decision aligned with the patient’s known wishes or best interests. This aligns with fundamental ethical principles of autonomy and beneficence, and regulatory frameworks that mandate informed consent and the protection of vulnerable patients. Proceeding with treatment without a clear understanding of the patient’s capacity or without involving a surrogate decision-maker if capacity is absent is a significant ethical and regulatory failure. This bypasses the core requirement of informed consent, potentially leading to treatment that is not aligned with the patient’s values or best interests. It also undermines the physician’s duty of care and can lead to legal repercussions. Failing to involve the patient in the discussion about their treatment, even if capacity is questionable, is also problematic. While the ultimate decision may rest with a surrogate, the patient should still be treated with dignity and respect, and their perspective, as much as possible, should be considered. A professional decision-making process in such situations should begin with a thorough assessment of the patient’s capacity. This involves evaluating their ability to understand the information, appreciate the consequences of their decisions, and communicate their choice. If capacity is present, the process continues with obtaining informed consent. If capacity is impaired, the process shifts to identifying and engaging the appropriate surrogate decision-maker, ensuring they are fully informed and empowered to make decisions in accordance with the patient’s wishes or best interests. Throughout this process, clear documentation of assessments, discussions, and decisions is crucial.

Scenario Analysis: This scenario presents a professional challenge for a rheumatology practice preparing for a specialized qualification exam. The core difficulty lies in balancing the need for comprehensive preparation with the practical constraints of time and available resources, while ensuring adherence to the specific learning objectives and assessment standards of the Critical Pacific Rim Rheumatology and Autoimmune Medicine Practice Qualification. Misjudging the preparation timeline or relying on inadequate resources can lead to exam failure, impacting professional development and potentially patient care if the qualification is a prerequisite for advanced practice. Correct Approach Analysis: The best professional practice involves a structured, multi-faceted approach to candidate preparation. This includes a thorough review of the official qualification syllabus to identify all key topics and their weighting, followed by the strategic selection of a diverse range of preparation resources. These resources should encompass official study guides, peer-reviewed literature relevant to Pacific Rim rheumatology, case studies reflecting regional autoimmune disease prevalence, and potentially structured revision courses or study groups. A realistic timeline should be established, breaking down the syllabus into manageable study modules, allocating sufficient time for each, and incorporating regular self-assessment and practice examinations. This approach ensures comprehensive coverage, targeted learning, and adequate time for consolidation and revision, directly aligning with the qualification’s stated aims and the need for robust knowledge acquisition. Incorrect Approaches Analysis: One incorrect approach involves relying solely on general rheumatology textbooks and online forums without consulting the specific qualification syllabus. This fails to address the unique focus of the Critical Pacific Rim Rheumatology and Autoimmune Medicine Practice Qualification, potentially leading to an inefficient allocation of study time on topics not heavily weighted or even included in the exam. It also risks overlooking region-specific nuances in disease presentation, management, or epidemiology that are likely emphasized in a specialized qualification. Another incorrect approach is to adopt an ad-hoc study schedule, cramming information in the weeks immediately preceding the exam. This method is highly unlikely to facilitate deep understanding or long-term retention of complex medical knowledge. It neglects the importance of spaced repetition and gradual assimilation of information, which are crucial for mastering the intricacies of rheumatology and autoimmune medicine. Such an approach also increases the risk of burnout and anxiety, negatively impacting performance. A third incorrect approach is to prioritize preparation resources based on popularity or perceived ease of access, such as relying exclusively on condensed revision notes without engaging with primary literature or official guidance. While condensed notes can be useful for revision, they often lack the depth and detail required for a comprehensive understanding of the subject matter. This can lead to a superficial grasp of concepts, making it difficult to apply knowledge to complex clinical scenarios presented in the exam. Professional Reasoning: Professionals facing similar preparation challenges should first consult the official documentation for the qualification, including the syllabus, learning outcomes, and recommended reading lists. This provides the foundational understanding of what needs to be learned. Next, they should conduct a self-assessment of their current knowledge base to identify strengths and weaknesses relative to the syllabus. Based on this, a realistic study plan should be developed, incorporating a variety of learning methods and resources, and a timeline that allows for thorough coverage and revision. Regular self-testing and seeking feedback from peers or mentors can further refine the preparation strategy.

Scenario Analysis: This scenario presents a professional challenge due to the inherent uncertainty in diagnosing and managing complex autoimmune conditions, particularly when integrating foundational biomedical science with clinical presentation. The physician must balance the need for timely and accurate diagnosis with the ethical imperative to avoid unnecessary or potentially harmful interventions. The risk matrix highlights the potential for both under-diagnosis (leading to disease progression and patient harm) and over-diagnosis or misdiagnosis (leading to inappropriate treatment, patient anxiety, and resource waste). Careful judgment is required to navigate these competing risks. Correct Approach Analysis: The best professional practice involves a systematic, evidence-based approach that prioritizes a comprehensive clinical assessment, supported by targeted investigations guided by the initial findings. This approach involves carefully correlating the patient’s reported symptoms and physical examination findings with known pathophysiological mechanisms of autoimmune diseases. It then involves selecting diagnostic tests that are most likely to confirm or refute specific hypotheses, considering the sensitivity, specificity, and clinical utility of each test. This aligns with the ethical principles of beneficence (acting in the patient’s best interest) and non-maleficence (avoiding harm) by ensuring that interventions are justified by a strong clinical rationale and are tailored to the individual patient’s needs. It also reflects good medical practice by avoiding premature conclusions and ensuring that diagnostic pathways are efficient and cost-effective. Incorrect Approaches Analysis: One incorrect approach involves immediately ordering a broad panel of advanced immunological assays without a clear clinical hypothesis. This fails to adhere to the principle of judicious resource utilization and can lead to a cascade of further, potentially unnecessary, investigations based on incidental findings. Ethically, it risks causing patient anxiety and financial burden without a clear benefit. It also bypasses the crucial step of clinical correlation, potentially leading to misinterpretation of results. Another incorrect approach is to rely solely on a single, highly specific biomarker without considering the broader clinical picture. While biomarkers are valuable, they are rarely definitive in isolation for complex autoimmune conditions. This approach risks overlooking other contributing factors or alternative diagnoses, potentially leading to delayed or incorrect treatment. It fails to uphold the principle of holistic patient care. A further incorrect approach is to defer definitive diagnosis and management until the patient presents with severe, irreversible organ damage. This represents a failure to act proactively and ethically, as it prioritizes a “wait and see” strategy that can lead to significant morbidity and mortality. It violates the principle of beneficence by not intervening early to prevent or mitigate disease progression. Professional Reasoning: Professionals should employ a structured diagnostic framework that begins with a thorough history and physical examination. This should be followed by the formulation of differential diagnoses based on the integrated understanding of biomedical science and clinical presentation. Diagnostic investigations should then be selected strategically to systematically rule in or rule out these differentials, prioritizing tests with the highest clinical utility. Regular reassessment of the diagnostic pathway and treatment plan based on evolving clinical information and test results is crucial. Ethical considerations, including patient autonomy, beneficence, non-maleficence, and justice (fair allocation of resources), should guide every decision.

The risk matrix shows a moderate likelihood of a patient experiencing a severe adverse drug reaction to a newly prescribed biologic, with a high impact on their quality of life and potential for hospitalization. This scenario is professionally challenging because it requires balancing the potential benefits of a novel treatment for a chronic autoimmune condition against significant, albeit not certain, risks. Clinicians must navigate patient autonomy, their duty of care, and the evolving evidence base for new therapies. Careful judgment is required to ensure informed consent and appropriate risk mitigation strategies are in place. The best approach involves a comprehensive, shared decision-making process that prioritizes patient understanding and informed consent. This includes a thorough discussion of the specific risks and benefits of the biologic, alternative treatment options (including their own risk profiles), and the potential consequences of both treatment and non-treatment. The clinician should actively solicit the patient’s values, preferences, and concerns, ensuring they have the capacity to understand the information provided. This aligns with the ethical principles of beneficence, non-maleficence, and respect for autonomy, as well as professional guidelines emphasizing patient-centered care and informed consent. An approach that focuses solely on the physician’s clinical judgment without adequately involving the patient in the decision-making process fails to uphold the principle of patient autonomy. This could lead to a situation where the patient feels coerced or uninformed, potentially resulting in dissatisfaction and a breakdown of trust. It also risks overlooking the patient’s personal circumstances and values, which are crucial for effective treatment adherence and overall well-being. Another unacceptable approach would be to downplay the potential severity of the adverse reaction to encourage treatment initiation. This constitutes a failure in transparency and honesty, violating the ethical duty to provide accurate information. It also undermines the informed consent process, as the patient would not be making a decision based on a complete understanding of the risks involved. Finally, proceeding with treatment without a clear plan for monitoring and managing potential adverse events would be professionally negligent. This neglects the clinician’s duty of care to proactively identify and address complications, potentially leading to delayed or inadequate management of a severe reaction, thereby increasing patient harm. Professionals should employ a structured decision-making framework that begins with a thorough risk-benefit analysis, followed by open and honest communication with the patient. This framework should include assessing the patient’s understanding, exploring their values and preferences, collaboratively developing a treatment plan, and establishing clear protocols for monitoring and follow-up.

Scenario Analysis: This scenario is professionally challenging because it involves balancing the need for timely and accurate diagnosis with the potential for over-investigation, patient anxiety, and resource utilization. Rheumatological and autoimmune conditions often present with overlapping symptoms, making definitive diagnosis complex. The selection and interpretation of imaging require a nuanced understanding of the specific disease process, patient presentation, and the limitations of each modality. Misinterpreting imaging or choosing an inappropriate modality can lead to delayed diagnosis, incorrect treatment, and unnecessary patient harm. Correct Approach Analysis: The best professional practice involves a systematic diagnostic reasoning workflow that prioritizes clinical assessment and judicious imaging selection. This approach begins with a thorough history and physical examination to generate a differential diagnosis. Based on this clinical assessment, the clinician then selects the most appropriate imaging modality that will provide the highest diagnostic yield for the suspected condition, considering factors like sensitivity, specificity, cost, and patient safety. Interpretation of imaging is then performed in the context of the clinical findings, avoiding over-reliance on imaging in isolation. This aligns with ethical principles of beneficence (acting in the patient’s best interest) and non-maleficence (avoiding harm), as well as professional guidelines that emphasize evidence-based practice and efficient resource allocation. Incorrect Approaches Analysis: One incorrect approach involves ordering a broad range of imaging modalities without a clear clinical hypothesis. This can lead to the discovery of incidental findings that may cause patient anxiety and lead to further unnecessary investigations, increasing healthcare costs and potentially exposing the patient to risks associated with those investigations. This approach fails to demonstrate efficient and targeted diagnostic reasoning. Another incorrect approach is to rely solely on imaging findings without integrating them with the clinical presentation. Imaging is a tool to support clinical judgment, not replace it. Interpreting imaging in a vacuum can lead to misdiagnosis, especially if the radiologist is not fully aware of the patient’s specific symptoms and history, potentially resulting in inappropriate treatment or a missed diagnosis. This disregards the holistic approach to patient care. A further incorrect approach is to select imaging based on patient preference or availability rather than clinical necessity. While patient involvement is important, the ultimate decision regarding diagnostic investigations must be guided by medical expertise and the likelihood of achieving a definitive diagnosis. Prioritizing convenience over clinical appropriateness can compromise diagnostic accuracy and patient outcomes. Professional Reasoning: Professionals should employ a structured diagnostic reasoning process. This involves: 1) Gathering comprehensive clinical information (history, physical exam). 2) Developing a prioritized differential diagnosis. 3) Identifying the most appropriate diagnostic tests (including imaging) to confirm or refute specific diagnoses, considering their yield, risks, and benefits. 4) Critically interpreting test results in the context of the clinical picture. 5) Formulating a management plan based on the confirmed diagnosis. This iterative process ensures that investigations are purposeful and contribute effectively to patient care.

Scenario Analysis: This scenario presents a common challenge in rheumatology: differentiating between a patient’s subjective experience of fatigue and the objective signs of an underlying autoimmune condition. The professional challenge lies in efficiently and accurately gathering information to form a hypothesis without overwhelming the patient or missing critical diagnostic clues. The patient’s limited time and potential for symptom overlap necessitate a structured yet flexible approach to history taking and physical examination. Careful judgment is required to balance thoroughness with efficiency, ensuring that the most relevant information is obtained to guide further investigation and management. Correct Approach Analysis: The best professional practice involves a hypothesis-driven history taking and a targeted, high-yield physical examination. This approach begins by formulating initial differential diagnoses based on the presenting complaint of fatigue, considering common rheumatological and autoimmune causes. The history then systematically explores symptoms and risk factors relevant to these hypotheses, using open-ended questions initially, followed by more specific inquiries to confirm or refute suspected conditions. The physical examination is then tailored to assess for objective signs that support or contradict the leading hypotheses, focusing on joint examination, skin assessment, and examination of other systems commonly affected in autoimmune diseases. This method is ethically justified as it prioritizes patient well-being by aiming for an accurate and timely diagnosis, minimizing unnecessary investigations and delays in treatment. It aligns with principles of beneficence and non-maleficence by seeking to do good and avoid harm through efficient and effective clinical reasoning. Incorrect Approaches Analysis: One incorrect approach is to conduct a completely unfocused, exhaustive history and physical examination without any guiding hypotheses. This is professionally inefficient and ethically questionable as it wastes valuable patient and clinician time, potentially delaying diagnosis and treatment for more serious conditions. It can also lead to information overload for both parties, increasing the risk of missing crucial details. Another incorrect approach is to solely rely on a standard checklist of questions and examinations for fatigue, regardless of the patient’s specific presentation or potential underlying causes. This fails to acknowledge the diverse etiologies of fatigue and the specific diagnostic considerations in rheumatology, potentially leading to a missed diagnosis of a significant autoimmune condition. Finally, an approach that prematurely focuses on a single, unconfirmed diagnosis without considering alternatives is also professionally flawed. This can lead to confirmation bias, where the clinician seeks only evidence that supports their initial idea, ignoring contradictory information and potentially overlooking other serious conditions. This is ethically problematic as it compromises the clinician’s duty to provide comprehensive and objective care. Professional Reasoning: Professionals should adopt a systematic yet adaptable approach. Begin by actively listening to the patient’s chief complaint and exploring its nuances. Based on this initial information, formulate a broad differential diagnosis, prioritizing common and serious rheumatological and autoimmune conditions that can cause fatigue. Then, conduct a focused history, asking questions that help to differentiate between these possibilities, probing for specific symptoms, duration, exacerbating/alleviating factors, and relevant past medical history. Concurrently, plan a targeted physical examination that assesses for objective signs related to the leading hypotheses. This iterative process of hypothesis generation, information gathering, and refinement allows for efficient and accurate diagnosis. If initial hypotheses are not supported, be prepared to broaden the differential and adjust the examination accordingly.