It’s the end of the road…

So, I haven’t blogged here for a very, very long time..

And that’s because we’ve launched a new website!! is trainee developed and led; it’s got podcasts, and video, and flashcards, and of course lots of blogs.

All the existing content has been transferred over to the new site, and we’re working on developing lots more content!

Hopefully, I’ll see you all on the new site!

Cardiovascular Exam prompt

The thing I said earlier about “using OSCEs”?  This is what I mean.

My cardiovascular exam prompt looks like this:


Overview of the CVS examination summary

Now, it doesn’t take a genius to work out that this is not going to get you through a post-graduate clinical exam.  I’m not even sure that would have got me through finals.  But it’s a scaffold that I could build information on.

Because for each of those points, I could generate a mind map or another list.

For each of those points, I need to know how to demonstrate that sign; what it signifies; and what clinical conditions it’s associated with.

It’s another example of learning to think backwards.  The MRCPCH starts with the clinical examination.  In order to make sense of the jigsaw, you have to be able to find the pieces (perform the examination), and put the picture together.

For example, one key finding is cyanosis:



And there’s another list somewhere that links cyanosis with other features (e.g. cyanosis + heart murmur = cyanotic heart disease)

This is why I have so many notebooks.  Because notebooks are how I work.

BTW, my handwriting does not normally look like that.  That’s the neat version because this was at the beginning of the book.  By the end, things looked a little different…


Slightly psychedelic CVS notebook…

Using OSCEs

For those that aren’t familiar with them, OSCEs are Objective Structured Clinical Examinations.  I did these at medical school, especially in the first few years.  They were the standard way of checking that you could do basic things like taking blood pressure, or resuscitation.  As an assessment, they’re quite formulaic: the mark-scheme tends to be quite prescriptive ((i.e. one mark for washing your hands, one mark for introducing yourself, one mark for palpating the apex beat…).  It’s a structured (hence the title!) assessment, and I never thought they were particularly useful in “real life”.  (Seriously, you simply cannot follow a structured examination sequence if your patient is running around a playroom, or trying to feed you soggy crisps…And if that’s what you’re trying to do, then you need to start being a paediatrician)

Now, initially, I thought that OSCEs had no place in the MRCPCH clinical.  I mean, these are clinical examinations to be a registrar!  It’s not supposed to be a tick-box exercise: it’s a serious, grown-up exam for “real” doctors who makes decisions and things.  Just going through the motions isn’t good enough.

But then I thought about the time restrictions, and the amount of things that you’re expected to get done, and how much I panic when I’m nervous… And I realised that the OSCE approach could actually be quite useful.  So if you’re like me, and you becoming a quivering tomato in the face of exams (my consultant’s description – thanks Jo!), then this might be useful.

When I revised for my medical school OSCEs, I made myself a tick-list of everything I had to include in my CVS exam.  Then I repeated this for every other system I could think of.  Then I practiced with my friends to make sure I could get all of this done in the time for the station, plus still leave 2 minutes for examiner questions and to go back and check things.  When it came to the clinicals, I did the same thing.  (I also did it for the “other” station – but that’s a whole other topic!).

Now, I am not for one minute suggesting that you treat the clinical stations like an OSCE.  Please, don’t go in there and just go through the motions so that you can get things ticked off a mark sheet (although, please introduce yourself & wash your hands!!)

But sometimes, it’s useful to have a structure, because:

  1. When your mind goes blank, and you have no idea what to do next, then having a routine is a useful thing to fall back on.
  2. It makes sure that you cover the simple, and basic things (like feeling the liver in the CVS exam, or checking for central cyanosis)
  3. The structure is also quite useful to organise your feedback to the examiner (again, if you have a total mind freeze)
  4. It helps with timing: if you know that you can do a structured, and (fairly) complete system examination in 5 minutes, then you know that in the exam you’ll have enough time to do the fancy extras, or to go back and confirm your findings, or spend a bit more time playing with the child and building their confidence, or have a chat about the weather… And you will still have time to answer any questions that the examiner has

Treat the OSCE structure as a template you can build your examination around; make it personal; practice doing it this way at work (on real children): it should become second nature, and then the exam will just feel like everyday… Hopefully. Unless you actually are a quivering wreck, in which case chocolate is useful…


Learning to think backwards

As you may have gathered by now, I like lists.

Lists of symptoms,

Lists of clinical features

Lists of investigations.

 I like lists.

Even more than that, I like lists that someone else has written.  So I went out, and I bought a lot of revision books (or got them from the library, if I could fight off the medical students…) that contained lists.  I copied them out, I re-wrote them with my own comments, I amalgamated different  lists, I split them into different components…

(It was just an excuse to buy more notebooks, honestly.  I have a notebook thing, not a list thing.  Not the lists, just beautiful stationary.)

My lists looked something like this:

Clinical features of Trisomy 21:

  • Brushfield spots
  • Sandal toe
  • Hypotonia… etc, etc, etc

If I was being really organised, then I had them arranged by system.

Or head to toe.

Or with a diagram (not reproducing those – drawing is really not my strong point).

Or chronologically if the features changed with time…

And then I realised how pointless this all was.

We don’t walk into clinic or clerk a patient with a diagnosis, and then try and find all the features that go alongside it.  Patients don’t come with nice labels attached to them, neither in real life nor in the exam. (And yes, someone is going to point out that some patients have diagnoses, like Trisomy 21.  They do – but that’s not why they’ve come to hospital at 3am on a Friday morning.)

What I had to do was learn to think backwards.

I’d been starting with the diagnosis, and learning lists of features.  What I needed to do was look at a presentation, or a feature, and work backwards from there.

Rather than thinking that Trisomy 21 is associated with hypotonia in neonates, I needed to think about hypotonia in neonates and what caused it.

Maybe this seems obvious to you (in all honesty, it now seems completely obvious to me!) but it changed how I approached the exam.

I didn’t walk in thinking it was a disaster if I couldn’t remember all the features of Trisomy 21.  I did think I needed to understand how to check for tone in a 3 month old, and what the possible causes of low tone in that infant would be.

This is how we work in real life.  It’s how the exam works. (It also meant that I had to write new lists… which meant more notebooks… Ah well)

I’ll post some examples this week, once I get my notes back!

But I did that!

I came out of one station in my disaster exam feeling incredibly annoyed with the world because I’d done a good examination, and nobody paid any attention to my findings.

What I’d actually done was found clinical signs, but I hadn’t demonstrated any of them.  I knew they were there, but the examiner had no way of knowing that I’d seen them.  I came out feeling very aggrieved: I’d found the signs, identified the diagnosis… what more did they want??

And then, I remembered my experiences of examining the medical students a few years ago.  It was a summer afternoon; it was hot; I was tired and I’d left my registrar on my ward.  By the time the 3rd candidate came through, it was really hard to focus on exactly what they were doing.  Added to which it was a tiny room, and I couldn’t see half the examination.  I was completely dependent on the candidate’s approach to telling me what they were doing, and the reaction of parent and child to decide if I felt they were competent.

The clinicals were the same.  I hadn’t been clear in what I was doing, and as a result, the examiner had no way of knowing what I’d actually done.  Finding the answer/diagnosis at the end isn’t what the exam is really measuring: it’s about how you get the answer.  And you have to show your working; demonstrate your findings (not just identify them).

It’s like a driving test…

I failed my driving test first time around too, btw.  Just saying.  And I can’t drive: I have a licence, but please don’t get me behind the wheel of a car.  It’s so long since I drove that my photocard has expired, and I can no longer use it for ID. Not that I get asked anymore…

Digression aside, just like in the driving test, you have to demonstrate that you’re doing all the right things.  Especially if the examiner is crammed into a tiny corner, or isn’t feeling too good (or just really, really needs a coffee).

Everyone has their own way of doing this.  But if your practice group don’t think that you’ve demonstrated the clinical signs, then the chances are, the examiner won’t think that you have either.

Giving feedback

I found this article in the BMJ, which I thought was vaguely useful.

It’s also made me think a bit more about the practice sessions that I had in the run up to the disaster exam, and the the lovely exam.  Basically, the point of doing clinical practice sessions is to get feedback from other people! Otherwise, you might as well just be at work*.

So, here are my tips on giving/receiving feedback, preferably without turning into a speechless, gibbering wreck (ok, that might just be me…)


1. Do it.

This is practice for the exam.  It’s not an exercise in sycophancy.  It’s not much good if you’ve spent 7 minutes examining someone’s nervous system, only to be told that “that was fine”.

2. Constructive criticism

It’s supposed to be constructive: so instead of just saying how not to do something, suggest an alternative.

3. Be specific

(See the “that was fine” comment above: what was fine???)

Instead of saying that someone has a good rapport with their patient, think about how they’ve achieved that.  This is for two reasons: 1. it’s more useful for the person who’s just put themselves through the trauma of being watched by 6 of their colleagues, 2. it’s more useful for you to think about what you can learn from each other.  Which leads me onto my next point…

4. Use the group!

I (very personal view here) don’t think this should be an individual vs. the group scenario.  I think it’s really useful if an individual’s examination is used as a starting point by the group for further discussion and suggestions.  Time is limited: think about your own CVS examination; what do you do differently and why; discuss it.  Use the expertise that you have = each other.  Much more useful than a textbook; usually easier to understand; and definitely easier to find the right information quickly

…and receive

1. Listen to the feedback

It’s not personal.  It’s not about what someone thinks of you as a doctor (I have to keep telling myself this).  It’s not about your ability to lead a crash call, or make a diagnosis, or talk to your patient.  It’s about demonstrating that in the exam.

2. Decide what’s important

Listen to the feedback, but you don’t have to let it change your practice.  Everyone has a different style and way of doing things.  (One of the criticisms I had in the “good” exam was my technique for examining ankle reflexes: it was how I’d been shown on a clinical course by a neurologist.  You can’t please everyone all of the time 🙂 )

3. Don’t dismiss it: take some time

I find the whole thing of having someone else watch me really, really upsetting.  I hate it.  Generally, I am in no fit state to listen to anyone else once I’ve finished.  Go away.  Have a coffee/glass of wine/gin/box of chocolates.  Watch a silly film/Scrubs/Cardiac Arrest (if you’re feeling really grim).  Then think about what the feedback was again.  You might still think it was completely wrong.  Repeat the Scrubs/gin/chocolate again, and think about it again after a week.  It might make more sense.

Basically, the feedback is more important than the practice.  You work a 48 hour week; you practice all the time.  Thinking and reflecting about your practice (see, the management speak is taking over my blog!) is what makes the difference.

At some point, I will share my personal disasters from the exam/practice sessions.

The disaster exam was almost two years ago… I still can’t quite face thinking about it!

*you can revise/practice at work as well.  It’s just not as predictable – might write about that later on

How not to prepare for the clinicals…

This is something I know a lot about (Did I mention just how badly I failed my clinicals the first time around??).  I was a lot more prepared the first time too – I was just badly prepared.  If you want to rival my disastrous score, and get asked not to come back at the next sitting… here’s how!

1. Buy into the mystique that this is somehow a “special” exam.

At this point, this feels like the most important exam you will ever sit.  Everyone will tell you that it’s the most important exam of your life. Nonsense (does that sound harsh??). Every exam that you have done up until this point is just as important, because it has got you to this point.  It’s just another exam.  If it’s just another exam, then you can revise and prepare for it in the same way as you have all the other exams that got you to this point.  (It’s not even the final exam of your professional career anymore.  It’s the exam that lets you practice as a registrar. So it’s the same as doing the APLS.  Think about it like that, it doesn’t seem quite as bad.  And which is more useful to you when the crash bleep goes off?? Exactly)

2. Use Nelson’s to revise (or other enormously large text book)

I love my copy of Nelson’s.  It’s the first major thing I bought with my first proper pay-check as an FY1 (there were shoes, obviously, but this was different).  So, when it came to preparing for the exam (see point 1), this was where I turned.  Here’s the thing: Nelson’s (or alternative massive reference work of your choice) is just that.  It’s a reference work.  It’s for looking up weird and wonderful diagnoses that geneticists write in the notes; it’s for diseases that your consultant mentions casually on ward round.  It will not help you pass the exam.  You know why? Because the exam is not about seeing if you have memorised a reference work. This is not what you need to know. If you could memorise Nelson’s, then you wouldn’t need to own Nelson’s.  So, don’t waste time.  (It makes a really good support for building flat-pack furniture when you live alone; not so good for revision. Just saying)

3. Forget what the exam is about

It’s a test to see if you can work as a registrar.  That’s all.  It’s not about memorising Nelson. It’s about being the doctor that a parent will trust at 3am or in a Friday afternoon clinic.  This is what you already do everyday at work: just make sure that you can demonstrate that in the exam.

4. Fail to practice

This is my main problem.  On our first practice run with a consultant, I got so nervous that she thought I was going to faint.  It didn’t get any better, mainly because my approach to every other practice session was a) hide at the back of the group, or b) start the session and turn into a gibbering wreck half-way through.  Everyone has points at which they panic.  You need to work out what yours are, and how to manage them. Repeating the “gibbering wreck who’s about to pass out” in the exam was a little embarrassing and didn’t help me pass.

5. Don’t plan your revision

There’s a curriculum – use it. But see point 6 below.  More importantly, remember that the exam is trying to see if you can work as a registrar/middle-grade/whatever we’re called at the current moment in time.  (Yes, I know I keep repeating this, but it took me failing and another 6 months to actually realise it).  You need to know the stuff that you’re going to see: diabetes, wheeze, constipation.  You don’t need to be able to replicate the Kreb’s cycle. (Not for the clinical anyway)

6. Spend more time planning than preparing

See the page on notebooks.  I love designing a revision plan, working out exactly how much time I have for each topic, drawing up a timetable… The problem is that real life and an on-call rota gets in the way of the world’s best revision timetable.  So, it’s one thing to have a revision plan; it’s another to plan more than work.

Having said that, there are some things that helped me.  Hopefully, if I get time in the next few weeks, I’ll put them up.

Any other brilliant ideas on how not to pass clinicals? Feel free to share 🙂