Examination Medicine: A Guide to Physician Training (5 page)

Although most candidates report that the time limit is sufficient for the completion of Paper 1, this is not the case for Paper 2, which is considerably more rushed. Some candidates have reported difficulty completing Paper 2 in the time allowed. The questions in Paper 2 are clinical scenarios and often contain long preambles, which may include a clinical history and the results of numerous investigations. They can be spread over several paragraphs. The clinical application questions are designed to include
tests that a practising clinician must be able to interpret. Various X-ray films (including chest radiographs, computed tomography (CT) and magnetic resonance imaging (MRI) scans), blood films (actual photographs or reports, or both), photographs of urinary sediments and histopathology slides (e.g. renal biopsies) may be included. Photographs (both black-and-white and colour) are usually of high quality. Interpretation of biochemistry results (e.g. liver function tests) is also examined. Normal values are always supplied. Recently the examination has had rather shorter preambles than in previous years, providing more time to complete the paper.

A pencil is provided at the test, as well as a well-used eraser. It is advisable, however, to bring a pencil sharpener, a spare soft B pencil and a good eraser, particularly if you are indecisive.

The marking system has changed. All questions are approved by a test committee. About one-third of the questions on each paper come from previous papers. These are questions that have been found to be particularly discriminating. In the past there was no predetermined pass mark and statistical methods were employed to separate candidates into high performing and less well performing groups. Now the pass mark is set using a criterion-based reference standard – see the College website for details. The pass mark is not set according to the number of places that are available in the clinicals. It is expected that about two-thirds of candidates will continue to pass the written examination each year.

The examination used to be held in winter, when experienced candidates could be spotted in the centre of Sydney equipped with coats, scarves and thick woollen socks (for some reason the examination room at the University of Sydney was not heated). This problem has been solved by changing the date of the examination to March.

Approaching multiple-choice questions

By the time most candidates sit this examination, they will have had considerable experience with multiple-choice questions. However, it is worth stating a few relevant points:

• 
Ensure that you estimate in advance the amount of time you have for each question.

• 
The questions are complicated and each one tests several items of knowledge. The correct answer may be a number of steps removed from the initial statement. This means that it is important to read each question with great care; noting or underlining the salient points that may be helpful, and looking out especially for negatives and double negatives.

• 
It is worth remembering that the words ‘always’ and ‘never’ do not often apply in medicine. The word ‘recognised’ means that an association has been described, whereas ‘characteristic’ implies that the given factor is important to the condition and essential to the diagnosis.

• 
It is always better to guess at an answer when the question is obscure rather than leaving it out entirely.

• 
To avoid coming to the end of the paper and finding an unexpected unfilled space on the answer sheet, keep a constant check that question and answer numbers match.

Preparation for the written examination

The College provides a curriculum relevant for the written examination. You should consider reading major textbooks and some journals. We recommend concentrating on the latest edition of a standard textbook (e.g. the most recent edition of
Harrison’s Principles of Internal Medicine
or the
Oxford Textbook of Medicine
); it is a most satisfactory method of preparation. The
Medical Knowledge Self-Assessment Program
(
MKSAP
) of the American College of Physicians is also very useful. It contains brief, up-to-date accounts of most areas of internal medicine. It clearly indicates the currently fashionable topics on which questions are likely to be set and has a comprehensive series of multiple-choice questions (and excellent critiques) based on the text. We particularly recommend you read the
Board Basics 3
book or app in the series – it is an excellent source of tricks and tips! However, only some of these questions are of a similar standard to the written examination questions. Another excellent learning tool is the
Internal Medicine Review Core Curriculum
(15th edition) from MedStudy.

In addition, the College regularly produces its own self-assessment questions – the Adult Medicine Self-Assessment Programme (AMSAP). None of these questions is ever likely to appear in the examination paper, because the AMSAP is primarily educational and therefore tends to have a bias towards positive responses, unlike the written examination.

There is great value in practising answering multiple-choice questions. Sample questions from past papers are available from the College. These are taken from papers that have been used in recent years. Currently, every second year on the College website the Committee for Examinations also releases complete copies of written examination papers that were set 2 years previously. The College has a large bank of questions that are adjusted annually. The Written Examination Committee adds new questions and updates and improves old questions.

Many hospitals conduct their own trial examinations, with questions written by staff. Also available on the market are books of multiple-choice questions based on other postgraduate examinations such as the MRCP, but these are of less value.

Many candidates find it helpful to practise multiple-choice questions in a study group of three or four to discuss the various options.

There are a number of general medicine journals that candidates should read regularly. These currently include (roughly in order of usefulness):

• 
New England Journal of Medicine

• 
Annals of Internal Medicine

• 
Lancet

• 
British Medical Journal

• 
Internal Medicine Journal

• 
American Journal of Medicine

We recommend concentrating on editorials and review articles. Study of specialist journals is not required.

Each year, postgraduate institutions hold courses on various topics, which some candidates find helpful. A course of lectures lasting 34 weeks (one night per week for 17 weeks per year over 2 years) is available for candidates in Sydney. Short but comprehensive courses are also available in Australia (e.g. at the Royal Prince Alfred Hospital, Sydney) and New Zealand (e.g. in Dunedin), and can be particularly useful for revision.

The thorough lecture series given by the Victorian State Committee of the RACP, running over 40 weeks of the year and held once a week in the evening for 3 hours, is now video-conferenced widely across Australia. The series covers the entirety of the syllabus in 1 year. This is particularly useful for trainees in regional centres. Details can be obtained from the RACP Department of Education.

A number of audio programs are available on medical topics. The Audio Digest Internal Medicine programs are available in many libraries and provide updates of topics, but are mostly from a North American perspective and of somewhat patchy quality. The
American College of Physicians sells recordings of Board Review Courses in Internal Medicine that contain excellent summaries of recent topics. The Mayo Clinic Board review video lecture series and multiple-choice questions is another excellent resource.

In summary, here are a number of conventional but important suggestions for the written examination:

• 
Be well rested and avoid travelling long distances on the eve of the examination. Make sure you know exactly where the examination centre is situated.

• 
Be familiar with the format of the paper and know how much time to allow for each question.

• 
Work through the paper at a leisurely, deliberate pace and return to troublesome questions at the end. Inspiration may well come from other questions.

• 
First, careful impressions are important, but change your answer if on review you see a flaw – the data suggest that well-prepared candidates are more likely to change a wrong answer to a right answer (50% increase their test score), rather than a right answer to a wrong one (25% decrease their test scores, although rather memorable).
¹

• 
Check every tenth question or so to be sure that answer numbers match the question numbers.

Have a short rest after the written examination before beginning work for the ‘viva’ examination, as time between the two parts of the examination is limited.

¹
L Di Milia. Benefiting from multiple-choice exams: the positive impact of answer switching.
Educational Psychology, 2007. 27(5):607–15.

CHAPTER 3

The clinical examination

This is a very testing part. It is more difficult than the written test.

Nick Talley and Simon O’Connor (1986)

The examination format

The clinical examination is divided into two sessions (morning and afternoon), each comprising two parts (one long case and two short cases), and now takes up a whole, rather exhausting, day. There is evidence to suggest that lengthening a clinical examination improves its reliability.

Candidates are notified of the starting time of the ordeal after their success in the written examination. Be on time for the clinical examination: it runs to a strict timetable and no allowances can be made for late arrivals.

On the exam day

For half of the candidates the first session begins with a long case. At the appropriate moment, each candidate is escorted to the patient by a proctor attendant or ‘bulldog’ (a term derived from the name of proctors attendants at the universities of Oxford and Cambridge).

The proctor attendant is usually a resident medical officer working at the examining hospital who has an interest in sitting the clinical examination. They introduce the candidate to the patient and then leave. If ever you have the opportunity to work as a proctor attendant, you should take it. There is no better way to come to understand what is expected of candidates in the exam.

There are never any examiners in the room during a long case. The time is limited to 60 minutes with the patient. A 5-minute warning is given after 55 minutes. At the end, the candidate is escorted by the proctor attendant from the patient’s room to a chair outside the examiners’ room. Ten minutes are allowed for candidates to pull themselves together and get to the examination room. A glass of water or weak orange juice is usually offered at this stage. If not, do ask for a drink if you need one.

A bell then rings and the candidate is taken in, seated and introduced to the examiners.
Try to appear self-assured (even if you are weak at the knees), but don’t give an air of nonchalance (e.g. by slouching in your chair). By the time the last long case candidate of the day has arrived, it may be the examiners who are slouching in their chairs.

As a rule there are two examiners in the room, but there may be three (one as an observer only) and there may be a proctor attendant sitting in as well. One examiner will be a member of the Committee for Examinations (CFE), National Examination Panel (NEP) or Senior Examination Panel (SEP), and the other will be an experienced examiner who is a local physician (a co-opted examiner), perhaps even the DPE. Local examiners and NEP and CFE members undergo ‘calibration’ exercises before they examine. Even experienced examiners are not allowed to examine unless they have been ‘calibrated’ that year. Immediately before the examination, the examiners interview the long-case patient. Usually one examiner does this ‘blind’; that is, without reference to the patient’s problem list. Patient notes are no longer provided to the examiners, who only have a summary of the patient’s problems to look at. This ensures that the history is up to date, helps gauge any difficulty in terms of the patient’s ability to give a history and enables the examiners to assess the physical signs. If the examiners cannot agree with each other, or don’t agree with the summary about signs, they do not expect a candidate to find those signs.

The examiners assess the candidate’s ability to take a detailed history and complete the examination. They also assess the candidate’s ability to identify the patient’s active problems and to recognise priorities for investigation and management. The examiners are interested in seeing whether the candidate recognises the effect of the patient’s disease on the patient and his or her family.

The examiners mark the candidate’s performance in each of these ‘domains’ according to set key criteria. It would be wise for candidates to examine these anchor statements carefully; they are available on the College website or from the DPE at each hospital.

Concise, standard questions will usually be asked. Only two examiners will ask questions; one ‘leads’ the discussion and the other follows near the end for 5–7 minutes. The lead examiner will usually introduce him or herself and the other examiner and then ask if there were any problems during your time with the patient. For reasons of fairness, it is unusual for specialists to ‘lead’ the examination of a candidate on a patient with problems in their own field. Examiners will not lead if they know the patient or the
candidate. Twenty-five minutes are spent with the examiners, presenting the case and discussing diagnosis and management. The discussion period is critical to passing (or failing).