Tuesday, 15 January 2013

Good med students pass exams?

A few days back I was speaking with a relative of mine who I get on with very well. This relative is roughly the same age as me and is also an undergraduate student, though a non-medic. Whilst catching up and exchanging stories of the latest goings on at uni, they asked me how my latest set of exams (see previous entries) had gone and how I think I'd done. The conversation went like this:

Relative: So your exams are all done now eh?
Grumpy: Yep, thankfully, maybe I can start getting some sleep now.
Relative: When do you find out how you've done?
Grumpy: Should be within a few weeks or so I think.
Relative: How do you think you've done?
Grumpy: Erm, not sure really. I mean, I really hope I've passed, I spent a fair old while revising over Christmas so I feel like I put the work in, but you know, it's always difficult to tell...
Relative: Yes, I suppose so...I mean what happens if you don't pass?
Grumpy: Oh, nothing awful, these exams are formative, so you just have to have a meeting with some med school bigwigs who'll tell you to get your act together a bit more.
Relative: Oh, so you don't get kicked out or anything?
Grumpy: No. If you fail the summer exams and the resit, then you get told to leave.
Relative: Do you think that would ever happen to you?
Grumpy: I'm not sure really, I mean, I really, really hope it won't, but I haven't a clue what the summer exams will be like and they're supposed to be more difficult than the January ones...so I wouldn't like to say I'm going to pass with 100% certainty...
Relative: Oh I see. Well I suppose if you did fail it would be better if you get told to leave as you'd end up being a bad doctor...

Anyway, this conversation got me thinking about some things. Firstly, how exactly does one define a "bad doctor"? There's an old joke which goes: "what do you call a med student who graduates bottom of their year?" with the reply being "doctor" (ho ho ho). Is a doctor who scrapes a pass in finals automatically a "good doctor" whilst a med student who marginally failed finals did so deservedly because they would have become a "bad doctor"? I'm not sure it's that simple really. Looking at things from another angle, is a grumpy*, rude surgeon with top marks in med school and membership exams automatically "better" than a more academically average colleague who nevertheless genuinely makes their patients feel well looked after and cared for? Doc Martin is a great TV show, but would you really like Dr Ellingham to be your GP, despite his excellent academic credentials?

I sincerely hope there's more to being a "good" med student or doctor than doing well in exams, but unfortunately many members of the public don't see it that way. It's not that I have a massive thing with exams, but I don't like the assumption that "good" med students or doctors are those who pass exams and don't fuck up along the way. In a sense, the public can't be blamed for having these high expectations: in their minds a med student who fail an exam = more likely to be a rubbish doctor = more likely to make a mistake on the job. In most lines of work fucking up isn't really that much of a big deal (if you're a politican fuck ups are practically expected, nay encouraged, on a weekly basis), but in the collective mind of the public "medical mistakes" immediately evoke memories of news stories on botched operations and lethal prescribing errors. Medical mistakes can clearly be much more serious. However, it's also worth bearing in mind that many of the doctors involved in these incidents were actually perfectly competent students and junior doctors, which again makes me wonder just how much of one's performance ought to be judged by exam results.

Let me put it another way: this relative of mine knows that I failed two modules during my BSc. They know that I failed them, not because I was stupid or lazy, but because a few years ago I just didn't know how to revise and work efficiently. They also know that I later resat those exams and passed. And that ultimately that I did well in my degree. At no point was it suggested that I was a "bad BSc student" for failing those exams, because failing exams is a normal and common occurence for many BSc students, and everyone knows this. But there seems to be a whole other level of expectation for medical students: even if, like me, they're just as inexperienced as a first year BSc student is with their BSc. My relative didn't actually say I've been a bad med student (I haven't even done summer exams yet), but I'm just trying to examine a train of thought here. It was actually a very laid back conversation which we had if you want to know the truth, despite how seriously I'm taking it all here.

But at the same time, it seems that some non-medics think that if you're smart enough to get into medical school that therefore you're smart enough to be able to cope with anything which gets thrown at you and still pass with flying colours. Never mind if it's all totally new and unfamiliar to you, that there's a lot to learn and not that much time to learn it in. All of these grittier details aren't known by them; they assume that since their GP is confident and smart, that therefore they were like that right from their first day at med school and anyone who isn't like that clearly doesn't have a decent future ahead of them anyway. In actual fact however, for all they know, their GP (like lots of other medics) might have screwed up an exam here or there along the way. And in my opinion, it's still perfectly possible to mess up exams and go on to be a good or even great doctor.

In my opinion medical school (and the formative stages of a doctor's career) are all a massive learning experience, both from an academic and a personal perspective, and whilst exams are, to an extent, a useful method of assessing someone's understanding of a subject, they shouldn't be seen as some sort of yardstick against which medics are measured. Becoming confident in learning and applying medical knowledge and practical skills is something which takes time, and not everyone adapts to learning these new skills straightaway. I don't think that makes someone necessarily a "worse" medical student, I think it means that they need to reflect on what they're going to do to address the problem and then fix it, and there's nothing wrong with that in my opinion. But ultimately it's hard to try and explain this all to people who have never experienced medical school.

*Yes, I know I'm grumpy on here and often sometimes in my personal life too, but I won't be grumpy with patients. Mainly because I've had a few doctors who were irritable at me in the past, and I know just how "not cool" it is.

Thursday, 10 January 2013

Paper Two

Okay, so, this was in the same format as paper one - the final four questions which continued to test us on the different areas we'd covered in semester one. Five questions need to be passed overall from the eight we've done since Tuesday. On the whole, I felt this paper was much nicer than Tuesday's, but because I've never done medicine exams before, I'm not sure if I'd like to say with any degree of certainty if I think I've passed or not - these kind of exams are something totally new for me, so I'm not sure if I did amazingly, but I guess I'll find out over the next few weeks.

Question 5

A mixture of public health and anatomy. Generally alright, no massive problems but realised I may have screwed up a couple of the finer anatomical details. Don't ever expect to see me doing the MRCS is all I can say!

Question 6

A mixture of medical sociology and public health questions. No real problems here, but the thing with medical sociology is that on the surface it just appears to be a load of waffle - but in actual fact you need to mention some very specific phrases and concepts to get the marks. I hope I've managed to do this, but I guess we'll see.

Question 7

Best question in the entire exam, from both papers. Pure biochemistry. The good thing about biochemistry is that it's either right or wrong. You either know the pathways and reactions involved or you don't. This is pretty much the only question I can say I think I've passed with any degree of certainty and without feeling like I'm being a cocky bastard.

Question 8

A mixture of questions on physiology and medical sociology. Once again, with the physiology you either know if you've got it right or wrong, there aren't tonnes of isolated, random details to memorise like with anatomy. So I think I did alright on this question but again, we'll see. After exams I always get this feeling in the back of my mind that even though I think I gave the right answers, in reality I was barking up the wrong tree and wrote down totally irrelevant stuff. It's pretty crazy.

Final thoughts

Well that concludes my first experience of pre-clinical medicine exams. Luckily these exams are formative so it's supposed to be a good learning experience rather than something to worry about getting kicked out over. That said, I still hope I've passed. I'd really, really like that, it would show that the work I've been putting in over the past few months has been on the right lines and it would be a nice little confidence boost at the start of the new term, but if I haven't I guess the only thing I can do is try and figure out what went wrong so I don't repeat the same mistakes next time. It's weird to think that there are two more sets of pre-clinical exams this year, and that if I pass them, this time next year I'll be doing clinical medicine. It seems much closer now than it did in September. Anyway, now I get to relax for a few days before starting semester 2, something I fully intend to do!

Tuesday, 8 January 2013

Paper One

OSCEs done and dusted, it was on to the written exams today. Two papers, eight questions, all formative, so no big consequences for failing. Today's was the first paper which had four questions each with several parts to them (a, b, c, d, etc). Thing is, these kinda short answer questions are different to the questions I had before during undergrad. During undergrad, each module would have its own exam paper. Let's pretend it was a biochemistry paper. You'd cram everything you knew about biochemistry in the days running up to the exam. You'd do the exam, then promptly forget everything about biochemistry within hours of putting your pen down. Then you'd start cramming for genetics or whatever was your next exam.

No such thing here. The questions here are all drawn from the different modules studied during the course of this term, so it's all jumbled up. For example, part a could be about biochemistry, part b could be on anatomy, and so on. This is presumably to stop people selectively learning, which I suppose is necessary (you don't want a doctor who doesn't know any anatomy), but it does tend to put a bit of pressure on you. Each question is worth 20 marks and usually you need to get 10-12 marks to pass a question. Five out of eight questions need to be passed overall. So here's how I found the questions:

Question 1

Really liked this question, no problems really. Lots of medical sociology. No complaints here.

Question 2

Whoops! From the fluffiness of medical sociology to some serious anatomical theory and then some public health. I think I did alright here, but there was a particularly nasty anatomy question which threw me a bit.

Question 3

Totally FUBAR, to use military parlance. This question was split between anatomy of the nervous system (which we had a single introductory lecture on - and are due to have an entire module on next year), and questions on cancer. The questions on cancer were alright, but the ones on neuro anatomy were a total write off, and unfortunately these parts carried the most marks in this question. I didn't have a clue, and frankly you'd hope that instead of testing you on a single introductory lecture they'd test you on stuff you'd actually been taught in a comprehensive kinda way.  I think a lot of people came out of the exam feeling rather pissed off and genuinely disappointed at this question:

Question 4

Nice question here, lots of biochemistry, lots of public health. No complaints again. Certainly no need for an outraged gif at any rate.

Final thoughts

Well, Qs 1 and 4 went well enough, I think I've managed to pass them. Question 2 might have been a pass, I hope so anyway, but I won't hold my breath on Question 3. Whilst there's no guarantee that the same topics won't come up again in the next paper, the chances are that they won't. So I'll be putting slightly more effort into revising those things which didn't come up today. Really hope the second paper is nice, I don't think I can explain just how much I want to pass these exams, it'd definitely make me feel more confident in my abilities and learning techniques!

Thursday, 3 January 2013


Barely 48 hours after my New Year's Eve moan about how much I hate the run up to exams and all that it entails (insomnia, more insomnia and even more insomnia - and the occasional feeling of total stupidity and utter ignorance) I was launched into what will be the first of many examinations throughout my medical career. That is, assuming I still have a medical career to look forward to - lately I have to keep reassuring myself during moments of uncertainty that "people pass, so I will too if I work hard enough because I am a person too". That sometimes works, but occasionally I still have these blind moments of panic where it feels like it's all going to be a total write off.

So, OSCEs. For the non-medics these are exams which test your practical skills. The bread and butter of being a doctor, as it were. This ranges from relatively simple things like taking a blood pressure to more lengthy processes like examining a "patient's" abdomen or whatever else. The inverted commas are there because the people were examining were actors who were hired to pretend to be ill or to generally be poked and prodded by us. There were six stations to go through, and like the two written exams I will sit next week, it's all formative, but damn it all, I still want to do well. I hate feeling like an idiot, and I do (on the whole) try and work quite hard...so I'd like to see some pay off. But I've long since realised that it's not all about working hard, it's also about working smart - and that's something which comes with experience, and experience of medicine and med school is something I'm severely lacking at the moment, but unfortunately I don't have all that much time to gain experience either on an accelerated course. You need to be pretty good from the outset. Anyway, here are the stations I went through today:

Station 1: Medline

Medline is a database with medical journals and such. Searching this thing is a pain and I do wonder whether it's something which doctors and med students need to use everyday. I prefer Pubmed anyway. So I walk in and there's a computer terminal and an examiner and a task i.e. you wish to find out more about this particular subject, find the relevant article. Well...to cut a long story short, I just couldn't find the damn article. When my time was up I had managed to find some articles on the general subject we were looking for but not the specific one we needed. The examiner noted that I did manage to identify the key search terms and so on well, but I needed to refine my search technique. On the other hand, I did manage to answer her follow up questions well, so hopefully I may have scraped a pass in this. But obviously I didn't find the sodding article, which was the whole point of the exercise, so it's all a bit hit and miss really.

Station 2: Blood pressure and BMI

Right, so, not the best first station, but never mind, we persevere. Or not. I'm still feeling nervous and slightly disappointed after a rubbish first station. Anyway, I enter the room and there's a patient and an examiner. Smile, introduce self, ask patient to stand next to wall to be measured. Ask her to take a seat. Remember that I haven't taken her weight. That's kind of crucial to do a BMI. Apologise and ask her to step on the scales. Work out BMI. Fix bp cuff on too low. Realise this after a second and re-adjust it. Much better. Take blood pressure. Answer the examiner's questions. Get told that I didn't remember to wash my hands. Fuck! Definitely not feeling happy with myself after this.

Station 3: Taking a history

So, I move on to the next room feeling like a prize idiot. How the hell could I have forgotten to wash my hands? Really hope I won't be hung out to dry for that. So in this room there's a patient with chest pain. I take a history and keep things friendly, the patient's nice and so it all seems good. Go through the SOCRATES mnemonic, make sure to ask her for her own ideas, concerns and expectations. Finish up and thank the patient. Comments from the examiner: generally good but too many closed questions in some places. Also seemed to jump around a bit from topic to topic. Feel marginally less awful after this station but still wish I could simply get something right for once.

Station 4: CPR

Pretty simple really, the only station where you don't have to introduce yourself to the patient or bother with the social niceties. Mainly because the patient is a plastic dummy and supposed to be in cardiac arrest. They're probably not too fussed with giving consent at this point, they just want to be resuscitated. I'm able to do that, reasonably well I think, and I time my chest compressions to the tempo of Another One Bites the Dust. How appropriate. Answer the examiner's questions well for the most part. I didn't know what should be done with C-spine patients i.e. the "jaw thrust", but I did know about shockable rhythms, how deep you should compress, when you should stop CPR, etc. Hopefully passed this one.

Station 5: General examination

Feeling slightly better as this weird experience trundles on. Go in, introduce self, get patient to lie at 45 degrees on the examination table. Take her pulse. Realise that I've forgotten to rub hands with alcohol gel, so do that, and the examiner smirks - hopefully this will still count, but I'm not optimistic. Is it better to do it later than never? Get back into it and do the general exam. Examiner's feedback is that it was generally okay, but he gives a few points for improvement.

Station 6: Abdominal examination

Feeling slightly heartened by the not totally awful experience of the previous station, I go in for the last one. I remember to wash my hands with the alcohol gel (first thing I do, whilst I'm introducing myself to the patient) - congratulate self on finally beginning to remember to do this at the right time. Decide to go out drinking later to celebrate. Remember that I still have revision to do for the written exams. Crap. Carry on with the exam. Inspection, palpation, percussion, auscultation. All over within a few minutes. Examiner seems happy and remarks that I "percuss and palpate better than most, most students are very timid". Surely something to be happy about? Hey, I might have given you some awful germs when I was taking your blood pressure, but at least I can tap on your belly like a boss, that surely counts for something! He asks a few questions...they're alright but I flounder when he asks what else I would do after the abdominal examination. The answer is hernial, genital and rectal examinations. I actually DID know this and had revised this particular bit multiple times, but for some reason I drew a blank and started rambling about cardiovascular examinations instead. Slightly disappointed that it wasn't as amazing as it could have been, but otherwise this is the only station I'm genuinely reasonably happy with.

Final thoughts

I have no idea when we're getting the result from all of this, but I imagine it will be in a few weeks or so. We need to pass 4/6 to "pass" overall, but since it's a formative there are no penalties for failing. However, if I have failed, I think I'd be very disappointed with myself. I've wanted to be a doctor for so long and if I stumble at the first hurdle that's not exactly promising is it? I've looked over my notes and (Medline aside which was totally FUBAR) I've managed to remember to do most things the way they should be done, so I hope I've passed. Though even with Medline I still managed to get the follow up questions right, I think. That might count, mightn't it?

However, I'm rather worried that little (but important) things like forgetting to wash my hands with the gel at station 2 will see me being failed despite managing to get the blood pressure to what the examiner said he expected was the correct value. I feel this way because he stressed that handwashing is important and "could be the difference between a pass and a fail". I'm not feeling particularly encouraged by that, was that a subtle hint that I've screwed up and that's the reason why? Or simply good advice for the future? Never mind, it's all a learning experience I suppose. Anyway, now I need to revise for the two written exams which will be next week. Over and out.