Interesting Observations on a mock OSCE Teaching Day

Hi all – so a few days back I had the unique opportunity to organize (OK who am I kidding? I helped to organise) a 1-day course for the FRCA OSCE exam in our deanery. We as the juniors of the department of anaesthetics/ITU/Theaters were called upon to help with various tasks: timekeeper for the different stations, be a patient for history taking, or be one of the relatives for counselling, be a mannequin for examinations, etc. I had a multitude of nominal tasks on the day, but what I found to be invaluable to me that day were a few observations that I made observing the various candidates as they filed through the different stations, and I list those observations here in no particular order to be taken as advice for all my colleagues who have OSCEs to take, bear these in mind:

– Be cognisant of time. As you walk up to the OSCE station, whether it gives you 30 seconds to read through an initial scenario or there is a piece of paper with questions written on it that you are expect to answer, get into the mental zone where you can mould yourself to give what is required of that particular station in the time provided. If there is one question that needs to be answered, you can be a bit relaxed, if there are 3 questions on the paper, make sure you are aware of the time you have to divide amongst them all to do justice to all. If the station requires an interaction with someone like a viva or a direct encounter, make sure you have a framework in mind, a mental checklist to check things off during the actual station so that you are not rambling on about your second point when there are 7 other things you need to be talking about.

–  When asked a question, don’t feel pressured to answer as soon as you sit down – take a breath, pause, ponder over the question for a few seconds, frame your answer for the next few, and then open your mouth to speak. Do not repeat the question back to the examiner in wonderment, as if puzzling it over, you may think you are buying time while you collect your thoughts, but it looks unprofessional. If you need time to answer, take it, but do not insult the examiners’ intelligence by repeating the question back word for word. It is a waste of time.

– When asked a question, avoid using pronouns like ‘you’ as a general term. “If you are on the floor for a long time, your creatinine kinase levels may rise.” While correct, it looks like you are addressing the examiner, whereas a more professional way to answer would be “Patients lying on the floor for extended periods of time may have elevated levels of creatinine kinase.”

– Following on from the previous point – when describing the anatomical location of anything, or a function, it is OK to use your hands to express yourself, but do not gesture towards your own body as a descriptor for your answer. In answer to the question Where can an IO needle be inserted? you may think it is the right answer to point to your sternum, your humerus or your tibial tuberosity, but it won’t score you any points. Also please practise certain expressions or gestures, gesturing towards your crotch for instance when talking about urinary catheterisation is inappropriate. And for goodness sake, it is even worse to point these things out on the examiners body.

– Use proper terminology, use buzzwords if you know them (we all know them) and specific things carry specific marks so make sure you attend some sort of course at least once in your life for OSCE practise so that you know what the examiner is looking for in a particular station when they ask you a particular question. Also, examiners know when you are beating about the bush and not getting to the point – so don’t waste their time (and yours), admit you do not know, and move on.

– Having done poorly in a previous station has no bearing on how you can or should perform in the next one – so do not let anything bother you. Yes, you may well have failed the previous station, but if you continue to mull over it or let it get to you, you may ruin your chances of passing the next one as well. Once you step out of one station, close that chapter, and open the next one with a clean slate.

–  Do not try to impress with big words and fancy terms – be simple, logical and just answer to the best of your knowledge. They are there to test your knowledge and see how good you are with using that knowledge. They are not there to ask for your hand in marriage.

–  If there is a written station, please write clearly. In our current professional examination climate, where usually there is a tick box or a fill-in-the-correct-circle type answer sheets, we forget how to answer the short answer type questions. Make sure it is legible. Your right answer is useless if no one can decipher it.

–  Read up on the simple things (in case of our anaesthetics colleagues, anatomy and physiology, undoubtedly – aside from the usual physics etc) – understand the concept behind why something is done or not done, and it will make it easier for you in these exams.

–  Study. I don’t know why it is so under-rated, that OSCE exams are interaction based and so I just don’t need to read up on how to take a history or do a pre-op assessment or perform a physical examination or test the cranial nerves – we do it everyday, and we get into a comfortable zone – but the exam might need for us to brush up on those skills and make sure we are not missing out on anything. MOST candidates missed an important part of the history taking station, as well as the counselling station – points were docked, valuable points, and for some that can mean the difference between passing and failing.

The Intestinal Obstruction That Wasn’t

84 year old male – known to have chronic constipation, and on warfarin for atrial fibrillation – referred in by his GP for ‘inability to open bowels for 2 weeks’ – yes you read that right folks, T-W-O W-E-E-K-S! – ‘increasing abdominal distension and abdominal pain, along with decreased appetite and a possible mass in the pelvis/abdomen going above the umbilical area’.
The nurse triaging him came to me, asking for some pain relief for the patient ‘and an enema because that’s what he usually has for his constipation’ – I decided to go see the patient myself. I stepped into the cubicle and the gentleman seemed to be in some discomfort, but he kept saying that he was in an uncomfortable position/posture rather than anything else causing him discomfort. I introduced myself and asked him what had brought him to ED – he replied by telling me he had not opened his bowels for 2 weeks now, and though was still passing wind and had passed some today, he was drinking very little and felt nauseous and omitted a few times in the past 3 days. I asked him if he had been passing urine normally, and he reported that yes he was peeing fine, but that he was drinking so less due to the nausea that only small amounts were trickling when he needed to go. I took that statement at face value and moved on. He was lying in a trolley, awake but lethargic and completely oriented. His observations were all within normal limits except for a systolic BP of 89, and his GP notes reported a background of chronically low blood pressure. I examine him, of particular note is his visibly very distended tummy – which assort but distended, feels like gaseous distention from the percussion notes, and with tinkling infrequent bowel sounds – and is quite sore particularly in the lower half of the abdomen, and I can also palpate a mass in the lower part of the abdomen – the patient reports that’s been going on for atleast 3-5 days, possibly when the vomitting began as well. This seemed very much to me to be a classic case of intestinal obstruction – and the management plan is – do baseline bloods (already very kindly done by the triage nurse), get venous access (also done), start some fluids, abdominal X-rays, nasogastric tube and surgical referral, and also catheterise patient, to monitor intake and output.
I speak to my registrar who agrees with said plan of action and while I request the X-rays and take the patient down for it, the lab apparently calls back and my registrar takes the call – the patient’s urea is 44, and the creatinine is 469, last creatinine 3 weeks ago was 141 – so he is going into renal failure, if not there already. While I seemingly faff around with the surgical consult, my registrar gets an ultrasound machine, and I assume it is to rule out a AAA, so I walk into the cubicle with him. And he explains to me a great pearl of wisdom that clearly comes with experience but is such a simple thing that I am left berating myself for not thinking about it earlier. He told me that if someone comes in with such significant renal function decline so acutely, always think of and rule out an obstructive cause for this presentation before moving on to other more sinister things. He was doing an ultrasound to look for hydronephrosis or hydroureter, which is basically the dilated urine collection channels in the kidney downwards and the reason they are dilated is due to an obstruction further down the channel. And that is exactly what he found. The left kidney was moderately enlarged but the right kidney was massive and its ureter was like a fire hydrant pipe rather than the small thin tube – and the mass in the lower part of the abdomen, going from pelvis and extending up from the umbilical area? His urinary bladder!!! I was in shock – as my registrar then gave me the second pearl of wisdom: never believe anything you are told, do not take it for granted until you have objective evidence. The patient felt he was peeing less and less because he wasn’t drinking enough. Yet he was peeing less because the channels beyond his bladder were so narrowed and obstructed that they did not allow emptying of the bladder and it just kept filling up till it was a massive huge thing floating in his belly. I at once made arrangement to catheterise the patient, whereby 2000 ml (that’s 2 litres!!!) of dark brownish urine poured forth out of him.

He had been in urinary retention for the better part of 3-4 days, possibly due to an enlarged prostate that had just gotten worse, and his constipation (though being chronic) was either a factor of his massive bladder pressing on his rectum/colon and not allowing the contents to move ahead; or (a bit like the chicken and egg thing, of which came first?) he was constipated, which gave him some abdominal pain (expected) and that pain had the added effect of causing urinary retention – anyways, after passing the catheter and draining all that urine the patient felt quite comfortable, and the surgeons took him away to do their wonderful things.

Sometimes it is the smallest things that make you the saddest

Ever notice how you can go on being an automaton, robotically engaging in work stuff, moving from one patient to the other, each one a statistic on your ever growing list of patients to see or having had seen – no interaction long enough to actually create a connection other than that of patient/doctor and you professionally enter and exit the cubicle and move on to the next job, next patient, or indeed next shift. And yet sometimes it does happen that something hits the mark, and there is a chink in the armour, the professionalism slips (not outwardly, but it surprises you that you feel something other than empathy towards the patient in front of you – you really look at the patient, not as just a patient but an actual human being with feelings, and thoughts start milling around your head – or your heart? – and you think of the patient’s feelings, their desires and weaknesses, the consequences of their actions – and you realise with a jolt that you are not an automaton, that you are, indeed, human.

I am usually a happy presence at work (if I may say so myself) but I was having a particularly ‘smiling-from-ear-to-ear’ day a few days back. A recent couple of professional achievements, along with being well rested from a full night’s sleep meant I was walking around with a bit more bounce in my step. I was working a late shift, but from the broad smile on my face you would have thought I was about to go home on a 2 week holiday! (I was not, but yes, I am a bit weird – I actually have fun at work!) – I was assigned to see paeds patients in ED, all the minors, majors, ENP ones etc – and I was going about my day when the consultant asked me to come out of Paeds for a bit and see the next adult patient, who was already at 3 hours (that much time had elapsed since she had come in to the hospital) – the brief note from triage nurse said that this was a young female between 25-35 years of age, who had come in with a self harm injury or injuries – she was categorised as a ‘yellow’ which meant there was no imminent threat to her life but she did warrant a thorough assessment.

Treatment/management of such cases is usually 2-pronged: one, manage the obvious injury or insult and treat the current presentation, and two (and more importantly) try to deal with and manage the longterm/shortterm psychological aspects of the presentation (not an ED thing but there are certainly specialist who are better equipped to deal with this and who very kindly assess and evaluate patients from that perspective after they have been treated from a physical ailment point of view. So anyway – I went in to see the patient – it had been mentioned in the notes that she was accompanied by her support worker – but the woman who stood up when I announced the name in the waiting area was alone. And she stood up at once and followed me into the cubicle to be assessed, along the way I introduced myself, and thanked her for her patience in waiting. She was extremely polite, and even offered me a smile, but she kept looking anywhere but at me directly. I asked her what had brought her to the ED that evening and she matter of factly stated that she was here because she had self-harmed. Again. She did not seem to be in any sort of pain, so I assumed (wrongly) that she had a superficial sort of wound that wouldn’t really require too much medical attention. I smiled at her and said something along the lines of ‘well, let’s see what we are dealing with here, and I will try to help you any way I can.” She exposed her left arm unto her shoulder, and I took off her temporary dressings from her upper arm (above her elbow) – while I was doing so, I kept making small talk, and registered the many, many scars from previous self harm attempts there before me were 4 very large, very long, and VERY gaping full thickness lacerations to her upper arm. In places where normally the skin/muscle sags a bit, it was really using the lacerated margins to gape quite widely. The patient had something like an hour left before they breached? NO WAY was I going to be able to administer local anaesthetic AND suture all 4 of these wounds in under an hour. Alone.

This patient completely threw me off my game. I have closed wounds in numerous ways, and in all sorts of weird and wonderful places – I have once years ago even raced my mentor consultant orthopaedic surgeon in bilateral knee replacements to see who closed up their respective knee first! – But this time was different. This patient was different. And the reason will become apparent up ahead.

I called my consultant because he may have been under the impression this was a quick ‘tape-wound-shut-refer-to-psych-move-on’ kind of situation – he stepped into the cubicle and hemmed and hawwed. I was silent throughout. This felt like an operating table scenario with a patient’s body cavity open up in front of me – The smell was exactly the same. Flesh. Blood. Sadness.

Right then, the consultant asked me to stitch the wounds up – I gave the wounds a good thorough clean with some saline and the patient did not flinch. She did however, apologise quite sincerely for wasting my time. I will not go into the details of why she thought she needed to do this today – absolutely no judgements to be passed here on that account. But I did assure her she was well within her rights to be there. I said I would go calculate the amount of local anaesthetic require and get it and get it all ready – and her polite demeanor stiffened up. She absolutely refused any local anesthetic. She said, and I quote: ‘ I am not here to waste any of your valuable resources. Please use them for someone who really deserves it – and anyway, I am not in pain and the stitching can’t hurt me more than I have done myself – also (and I was surprised that she knew this) the amount of local anaesthetic required would be a bit too much and wouldn’t be safe for me – and it would wear off by the time it was done being administered!” She was right on all counts – but I requested my consultant to give me an opinion, since she had me absolutely flummoxed. He agreed, no need for the anaesthesia – and that I would achieve better results with a skin stapler rather than suturing the wounds. I had never used skin staplers outside of an OR before, and never on a patient who was conscious and sitting up and talking to me and FEELING THE STAPLES GOING IN! I took a few deep breaths. Got the stuff ready. Took a few more deep breaths. And a few more. And dove in. I put in upwards of 45 or so staples (yes metallic pins sharp enough to stab through the superficial tissues of skin etc and pull them close to optimise wound healing) – did I mention the wounds were exceptionally gaping? Each staple gun comes with 30 or so staples – and I had to use a second one about halfway as well. Wow. My mind was already blown after the first 2-3 staples. But I went on putting more in. I did my best – and to her credit she did not flinch. There was silence. And that smell. And sometimes she would talk to me.

She kept thanking me, and apologising to me, and kept pushing her other hand through her hair as if berating herself mentally. She told me she had a masters degree in something (I forget what – my ears still start ringing everytime I think back to that cubicle) and we chatted about how I wanted to pursue another degree, maybe a masters of some sort and hadn’t quite decided what. She guided me about which staple to remove because it had been bent at an awkward angle due to how gaping the wound was initially, and so when I had ‘scaffolded’ it with staples next to it either side, I removed the offending staple and put another one in. Like I said, she didn’t flinch. At all. She kept that small polite smile in place, was very respectful and I learnt something new about myself that day. That this had gotten to me beyond what I can express here or anywhere. I had seen dead and dying people almost on a daily basis. People in pain, people vomiting with pain, people trying to process bad news or loss or a shock. I have been the villain in so many stories in peoples lives – the bringer or the news that someone they loved had passed away, or what the reports had shown or why we feel that further aggressive measures would be futile – But I had not been affected by those things as much as this calm young woman had affected me. What about her affected me? Nothing about her situation. It was sad, no doubt. But what really affected me was what I realised about myself: I judge people, I am cynical about them, about their diagnoses, about their mental health problems – I never fully appreciated that when someone comes in to hospital following an overdose or some deliberate attempt at self harm, I focus solely on the physical aspect of the case, and let someone else deal with the mental/psychological/psychiatric aspect of it. But this time, I was metaphorically chained to the situation I usually avoid and judge as a spectator – and I could not escape how normal this young woman appeared. She was well read, had a grace and calm in her manner that belied a good upbringing – yet she was obviously in this mental pain and it got so severe sometimes that like this day, the thought of cutting herself and so brutally was her only way to cope with it, and possibly caused her less pain that she was already in. And to be able to get sutures or staples without any anaesthesia on board – how remarkably strong a pain threshold would you have to bear that? Or that you were so used to it that this was all just commonplace occurrence to her. And this wasn’t even the worst part. The worst part was that this was neither the first time, nor (we both knew) the last time that she went down this route. I could help her physically, suture/staple everything – but did I actually do anything at all to really, truly help her?

So like I said – we are usually automatons, going about our daily drudgery – and then one day a patient really opens our eyes and makes us sit back – and question …absolutely everything we know and believe in and understand. Or don’t understand.

(Edit: The rest of the shift went by in a blur or a haze, I don’t know if it was all too fast or all too slow for me. I am I think back to my usual self now – albeit with one difference. I am maybe not so quick to judge – and maybe not so quick to dismiss mental anguish based upon my perception of the physical consequences of that mental anguish. I admit to not knowing enough – and hope I can change my practise in a way makes all of this worthwhile.)

Rat-Bite Fever

You really do learn something new everyday!

So today I had a patient – 4 year old male with a 24 hour history of abdominal pain which woke him up in the middle of the previous night (he kept crying and pointing to his tummy, saying ‘ouch’ over and over again), associated with 1 episode of vomiting, and this morning when he woke up he had a fever (40 degrees) and was off his food and drink – Mum took him to the doctors, who diagnosed him (provisionally, I guess) with tonsillitis and sent him home with oral antibiotics (phenoxymethylpenicillin) the child had as yet only had 1 dose od this antibiotic but Mum felt he was being very difficult to feed/keep fluids down so was concerned, child still had an ongoing fever of 39.4. There was no history of any rashes, no cough but had a sniffly nose the last couple of days. Wetting nappies as per usual (a sure sign he was taking in enough fluids) but no dirty nappies today (not unusual for this patient to go x2 days without pooing) Upon my review he was a bit upset, and seemed to be in discomfort, despite having had some sickly sweet paracetamol a while ago to counter the fever.

He had a background of some degree of developmental delay due to a disorder that I do not want to disclose here, for patient confidentiality so this story is untraceable back to them. There were no other comorbidities.

On examination, the child was sitting in Mum’s lap, crying but was settling down when soothed. ENT exam revealed a slightly hyperaemic throat with enlarged tonsils, no exudate or discharge. He kept sticking his tongue out and wincing when he swallowed – pointing towards the possibility of odynophagia or painful swallowing. May explain the ‘off food and drink’ as may be too painful for him to swallow. The mother was giving him regular round the clock calpol though, so difficult to say. Ears were wax-laden and I could not visualise a tympanic membrane in either. Chest was clear to auscultation, no heart murmurs or other weird sounds on listening to the chest. Tummy was nice and soft with no palpable masses and child did not appear to be in discomfort when tummy was examined. He was moving all four limbs, neck seemed soft and his observations (vitals – heart rate, capillary refill/BP, respiratory rate, oxygen saturation on room air – were all within normal limits; all except the temperature, which was still high despite the calpol. I prescribed some ibuprofen. There were no rashes (did I already say that? Yes, that was history, this is examination) – Moving on…

I asked mum if he had been unwell prior to the waking up with the ‘ouches’ in the abdomen? She reported he had spent the weekend with Dad, where he had been bitten by a rat (!!!) on the right index finger – sure enough, on examining, his right index finger had a blackened almost shiny minuscule raised bit – an unmistakeable bite mark, on the distal end of the finger. Surrounding area was a bit reddened and slightly inflamed looking. On movement of the finger, hand, wrist etc, he did not seem to be in a lot of discomfort, though he wasn’t exactly happy I was poking and prodding him so much. There were no palpable axillary etc lymph nodes either – but he was a bit warm to the touch still, and when the temperature was rechecked it was 40 again! We quickly started some antipyretic measures while I quickly listed the differentials in my mind. A) It seemed very likely that the tonsillitis was not bacterial (probably) as a sniffly nose and the acuity and high grade of the fever pointed towards a viral upper respiratory tract infection. It could still be a bacterial infection, though, so I wasn’t going to stop the antibiotics. B) I could potentially/probably send the patient home, as even though they did not seem to be drinking too much, they seemed to be weeing as per usual, according to their wet nappies frequency, with advice to sort of force fluids, along with some adequate antipyretic advice and analgesia advice, with followup in the GP surgery, and that if situation worsens or any of the red flag signs appears, to come to A&E instead. C) could it be an infection spread by the bite of the rat? This last bit I honestly did not know – I had heard and studied about (and mcqsed!) about cat scratch disease and dog bites and human bites and tick bites, but I had never in the course of my 5 year study or almost 10 years as a doctor come across a rat bite – my curiosity piqued. I did what everyone does when they are confused about something – I want to say something impressive like ‘I discussed it with my seniors etc etc’ but in reality I … googled it! (I discussed it with my seniors after that, though, who very kindly reviewed the patient, and discussed it with the paeds registrar and admitted this patient to the hospital – the rationale being they still had a fever despite significant attempts by Mum and A&E staff.) But my google search was very fruitful, and I present to you a few bits and pieces about RAT-BITE FEVER (yes, sounds very impressive and a little icky, and it is!): (this information is courtesy of the CDC website, which is probably the most reliable and authentic information out there as it is so aptly named the Centres for Disease Control and Prevention!)

It is a bacterial infection, has two types of bacteria implicated in it: the spirilary (spirillum minus bacteria) type and the streptobacillary (caused by streptobacillus moniliformis) type. It is transmitted by either being bitten or scratched by infected rodents, or with regular handling of infected rodents even without being bitten, or due to ingestion of the pathogens in food/water that is laced with rat urine/feces. It is not contagious. Symptoms include invariably a combination of any or all of the following: fever, vomiting, headache, joint pains, muscle aches, headache, rash, ulcer at bite wound, swelling around the wound and swollen lymph nodes. Can we agree we are ticking off a lot of the boxes for rat-bite fever? Symptoms may begin within a few days of being bitten by a rodent, or may present a few weeks after the bite. Rash is usually maculopapular. There are certain people at risk – like if you have a rat fetish or handle them or keep them as pets or if your local rat population lives alongside your local human population. Penicillin is the treatment of choice – don’t ask me what it is when you are allergic to penicillin! Complications include meningitis, myocarditis, pneumonia and rarely death. *cue ominous music* Prevention is a) avoid rats! duh b)practise good hygiene c) do not put infected fingers into the mouth.

AND THIS IS WHERE IT ALL CLICKED FOR ME WITH REGARD TO THIS PATIENT – HE PROBABLY PUT HIS INFECTED RAT-BITTEN FINGER INTO HIS MOUTH – AND INGESTED SOME OF THE PATHOGENS – AND HE WAS CURRENTLY AN IDEAL CANDIDATE FOR TREATMENT FOR RAT BITE FEVER! Fortunately he was already on the treatment for it – the Paeds registrar concurred with our assessment and the patient was moved to the pads unit.

I reiterate: Learn something new everyday!

FRCEM (Primary) – Done and dusted!

So I am happy to report that the results of the recent FRCEM (primary) exam were announced this evening – and I am proud (read ecstatic!) to share that I passed it! *takes a bow* (if you are interested in questions from the exam, read about that in a separate post here)

This is why I have been slightly out of the blogging scene for the past few weeks – prepping for the exam, juggling the ARCP for my first year of training and what has been very likely the hardest and longest and hottest summer stretch I have ever endured (and I am from Pakistan!) But I am back with the proverbial bang!

And I bring with it the novelty of experience.

It’s not a difficult exam per se – but it is an exam that requires commitment, and time and energy. Be ready to make that commitment. It’s a new exam, only started in Autumn 2016 I believe.

Back in the good old days when I was a (very) junior doctor back home in Pakistan, I had the luxury of having ‘many’ weeks off in lieu of exam prep – the job itself was intense but i had no other commitments; i.e training, portfolio, assessments, ARCP, etc. For this exam, I was working in your regular, run-of-the-mill A&E department in the UK, as a 1st year trainee. I decided to take the exam, decision was taken in January, I booked an online question database then, and I booked the exam in mid February, but I didn’t really get a good momentum going initially, and was still in 2 minds. Why? Because of the ARCP which is an assessment of all your competencies for a required year of training that you have managed to accumulate over the period of the past year, and a panel of judges basically sits and decides whether your performance (based on these signed competencies) is good enough to warrant your progression to the next stage/year of training. So this year was to be my first ever ARCP and coincidentally the exam fell on the exact same date as the ARCP, so in addition to the preparation of the exam, I had to focus on my assessments/requirements for ARCP – all to be juggled along side a full time job in the A&E as one of the juniors. It is doable folks.

So in bits and bobs I started my prep. I had that textbook of emergency medicine, but I must admit I never got beyond the first 5-7 pages of it! Doing the questions from the question bank is what helped me pass along with (as I said) youtube videos. I took a 4 month subscription for the FRCEM exam prep website – previously known as MCEM exam prep website. (‘tom-aye-to, tom-aah-to’). They have a good database of questions fortunately of the SBAQ type as well as the older true/false format. I have ready in many places that you could use any of the other websites/question banks as well.

On my days off, I aimed to do 50-100 question (see, I made you laugh there!) Who am I kidding, I barely got 30 done on a good day – these questions came with explanations, why this option is right, and why the others are wrong, along with a short description of the topic that the question deals with. I inevitably began making a habit of taking pictures of the explanations in my cellphone, and I went back to them again and again, for example before going to bed, or while waiting for my wife/son to wake up in the morning on my rare days off. I found this habit helpful, as you may not retain some of the information that you read, but if you go back and go through it again, or atleast if not all of it, then maybe just the major salient points, it is bound to stick to you.

On my days where I was working, I tried doing a few questions while at work, on my phone, between patient. That was a bad idea. Not only did I not have enough time to do even a single question justice – I also did not retain too much due to the lack of concentration in a busy A&E department. Ditched that idea fast. I did however vow not to waste any of the days I was working though, so after a busy shift, I used to come back, rest, recuperate or sleep (mostly slept) thanks to my wife who really upped her support game and banished me to a separate room in the house at all hours of day or night, waking or asleep – no diaper duty, no bath time no sleep time with the baby – just the books, fooding and my laptop. Where was I? Yes – days I was working, depending on what shift I had done, I still tried to get a good solid 3 plus hours of ‘mcqsing’ as I called it. On days that I was on morning shifts, I came home by 5 pm, straight to bed, slept for an hour and a half or 2 – woke up – tea/food/family time for an hour or 2 and then hitting the books (or laptop in this case) from 10 pm onwards up until 2-3 am – then 5+ hours of sleep and a repeat of this. Or on the afternoon shifts (2pm/4pm to 10 pm or midnight) similarly I used to come back home, freshen up, spend a minuscule amount of time with the family before they dropped off to sleep and then ‘mcqsed’ till the wee hours of morning, going to bed at 5 am or thereabouts, to wake up just in time for lunch and off to work. Night shifts were a bit more difficult, and I sort of gave up on trying to cram anything in my head during the 4-5 night stretch we have – the hangover like state I was in during the night shift stint was not really amenable for any further insult to the brain by forcing it to swallow any other bits of information/mcqs.

I also youtubed a lot of videos – specially anatomy ones, and one or two for physiology and microbiology. There are a lot of good ones out there. I focussed on upper and lower limb anatomy the most, along with the plexuses. You can just search for them under ‘anatomy, mcem or mrcem’.

My strategy towards the middle/end of my prep was to focus mostly on the maximum yield subjects – broadly anatomy and physiology which carried the most weightage in the actual exam, with 60 questions from each subject (out of a total of 180 questions!) Followed by significant input from microbiology/pharmacology/pathology. I used to do 3 sets of 20 questions in a row – the first set being anatomy, second physiology and the 3rd annoys the others, but I kept the first two sets the same, due to its weightage. Anatomy threw me, as it was basically learning a new something I had learnt almost 13-14 years back in the early medical school years! I think it was safe to say I had forgotten most of it, despite having a refresher course during my stint at the USMLE exams. But I digress. I found the following topics high yield, and got an inkling from my various forays into the question banks that these were important enough to be tested and warranted more attention (or repetitive attention) from my end.

ANATOMY

– Upper limb (muscles -attachments and function, nerves, bones, blood vessels) -Lower limb (Same as above) – brachial plexus – abdominal wall layers – blood supply of the heart – borders of the heart – contents of spermatic cord/inguinal canal – Sacral plexus – Optic nerve lesions – cranial nerve basics – triangles of the neck – foramina of the skull and their contents – diaphragmatic openings – Facial nerve – spinal cord lesions based on presentation – stuff going on at T4 level – brain blood supply

PHYSIOLOGY

Lung volumes – cardiac cycle – hormones (renin, angiotensin, mineralocorticoid, cortisol, adrenal medulla, pancreas, PTH, calcitonin, Vit D and its metabolytes) – renal physiology – 

MISCELANEOUS 

Vaccination program – Drugs that induce/inhibit cytochrome p450 – broad microbiology – allergic/hypersensitivity reaction types – types/examples of vaccines – immunoglobulin types – 

I also attended a course arranged very kindly by our deanery for candidates interested in the FRCEM primary. It was purported to be a tough exam, as the previous attempt had had a passing percentage of 43 percent. Yes, only 43 % of the candidates who appeared for the previous attempt passed. We gulped down our fears, and while the course gave us a broad idea of what wee needed to be doing (which was a lot!) it served no greater purpose than to tell us that we were not alone in being scared and that everyone seemed to be equally stumped by their performance in the questions – slightly reassured by the fact that during practise mcq sessions, when the consultants tried to solve the questions they were mostly unable to. Slightly reassuring, and mostly horrifying, as how were we supposed to pass the exam?! Yikes. What threw most people was that the exam format had been changed – from the previous true or false format, to the  Single Best Answer Question or SBAQ format. All options in a given question may be correct in different ways, but select the answer which is most appropriate according to the stem. Which basically translates to “guess what the examiner was thinking when he/she made this question” – so no pressure!

By the last few weeks, I was about to pull my hair out – the amount of mcps I was doing wasn’t too much, and I didn’t seem to be ding all that well if you calculated the number of questions I was getting right – overall a 52-55 percent of correct answers. Abysmal. I did not let that disappoint me, however, knowing full well that practicing questions was the way to go in such an exam format.

I used up all of my 2 weeks of annual leave and 3 out of 5 days of study leave for this exam, which brought me to just about 20 days of uninterrupted preparation (coupled with MANY visits to the department for ARCP related issues). That I feel was the single best thing in way of preparation – the time off was focussed, and I wasn’t tired from running around – preparation is mentally exhausting as it is, coupled with the physical exhaustion of day-to-day ED life – it takes a toll. All I did was sleep, eat and study. Lather, rinse, repeat.

But I will reiterate here what I have said before as well – you can never do enough questions as practise – just keep doing as much as you can, every waking minute make sure you are doing questions. Whether its 5 or 50 questions, make sure you stay consistent and do not get laid-back and forget to do questions – keep doing them, whether right or wrong, as long as you are also focusing on the explanations of those questions, its a learning experience.

Advice about the exam itself: Time management – 180 questions, 3 hours. The way I did it was divided it into 3 parts, so I needed to have completed 60 questions in 1 hour, and preferably even faster than that, since I needed to allow some time at the end to go back and tackle the more difficult or confusing questions. Keep track of time as well – if you seem to initially be on track, keep checking the clock every 10-15 minutes and make sure you are on track. If you feel you need to think more than 20 seconds for an answer and are still unable to do so, then mark the question and move on, return to it later. Do not waste minutes on a single question, causing a delay and jeapardising multiple other questions. Read the stem carefully – often we do not read the ‘except’ ‘all’ which’ ‘most appropriate’ next step’ gold standard’ ‘not included’ bits of the stem and inadvertently end up selecting the wrong option. In case of long stems, read the last bit/question and the skim over the rest of the stem, to gauge what they are looking for. If you don’t know the answer, go through the options by the process of elimination. Eliminate the blatantly wrong options. Think about the rest, if possible eliminate another 1 or 2 till you are left with one. If you read the stem and know the answer, look for that in the options, if you see it, select that. Always attempt all questions, no use leaving a question blank and lose an opportunity of a lucky guess. Feel free to draw, make flowcharts, write things down in the margins of the question paper if it helps you remember, calculate, reach a conclusion (I remember I drew the whole optic nerve/tract/radiation diagram to help me diagnose where a lesion was based on the hemianopia referred to in the question paper!) The questions may be easier than your practise question bank – don’t worry!

And I had the support of good friends. I don’t know, there is something about prepping for an exam (or anything in life for that matter!) and knowing that there is someone else going through the exact same thing as I am – it creates an interestingly unique bond. I had 2 such colleagues and friends, and I am pleased (and incredibly proud) that they have passed as well. We used to work together in the same ED department back home in Pakistan, and are now in different parts of the UK pursuing careers in emergency medicine. Onwards and upwards!