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!!

www.mrcpchrevision.co.uk 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:

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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:

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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…

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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!

Giving feedback

I found this article in the BMJ, which I thought was vaguely useful. http://www.bmj.com/highwire/section-pdf/9102/10/1

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…)

Give…

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