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The last exam youll ever sit might just be the most terrifying! This month
we hear one trainees account of sitting the general surgical exit exam but
Im sure her experience echoes across other specialties. I passed the
orthopaedic FRCS at the start of this year and found it a thorough yet fair
test. My top tips are to answer the multiple choice questions (MCQs) as
rapidly as possible (because time is short) and in preparation for the vivas
have the first line of an answer prepared for every conceivable question.
Merely knowing about a subject is not enough: you must be able to talk
about it. Practice makes perfect!
Matt Freudmann, series editor
Ann R Coll Surg Engl (Suppl) 2008: 90:1819
DOI: 10.1308/147363508X265208
Surviving the exit exam
Kathryn McCarthy Year 5 SpR, General
Surgery, North East Thames
The exit exam (intercollegiate
specialty examination) is the final
rite of passage for surgical trainees.
Old-system SpRs like us have spent
many years as SHOs, several more
years in research and are then lucky
enough to become registrars. The
final years of training have been
spent developing specialist operative
skills and gaining as much practical
experience as possible before taking
on full responsibility as a consultant
surgeon. During these years learning
the craft of surgery is at its most
intensive. The prospect, therefore, of
a sudden return to a theory
examination is a daunting one.
By concentrating on the practical side of
surgical training, the ability to answer a
question succinctly on theory may suffer.
Multi-tasking is difficult at the best of times.
Surgical trainees may also have become
extremely competent in their technical
ability over the years and a lifetime of
praise may cloud their judgement on their
ability to perform in an exam situation.
Having spent many years tutoring junior
trainees through their exams, it is a
humbling process once again to be grilled
by colleagues and to take criticism on viva
technique and clinical examination.
The intercollegiate specialty exam has in
the last two years introduced a new
section to the traditional exam format. It
involves two 2-hour papers of extended
matching questions (EMQs) and single
best answers (SBAs). The intercollegiate
specialty board feels that this is an
excellent method of quality assurance.
For current trainees, EMQs and SBAs are
unfamiliar territory. They are an entirely
different concept to the old-fashioned,
negatively-marked MCQs we have toiled
over for years.
A whole new coping strategy is required
when approaching these questions and
unfortunately, as the exam is in its infancy,
there are no past papers to rely on. Its
usually all about technique. Sure enough,
on the day I found there was plenty of
scaremongering about the pass mark
being ridiculously high and there were
lots of tales of candidates who had
previously failed by 0.01%.
I took the exam in general surgery with
colorectal surgery as my specialty at the
end of my fourth year of training. With a
second baby on the way, I decided to take
it at the earliest opportunity as I saw my
limited free time for study disappearing
rapidly. In order to prepare for the
EMQ/SBA papers, I tried to get as much
practice as possible with similar questions
aimed at the MRCS exam, in which this
style of question is more familiar. Websites
such as Pastest (www.pastest.co.uk) and
onexamination (www.onexamination.com)
provide some questions that were of use
and gave me the opportunity to see some
of the tricks used to pass or fail.
Being a surgeon, I also felt it necessary to
re-read Lasts Anatomy surely there was
going to be some obligatory anatomy?
Alas, out of approximately 350 questions
there were only 2 on anatomy: the
parotid gland and the inguinal canal. The
rest of the questions were very clinically
oriented and a good, broad range of
knowledge was required in all specialties:
from calculating a Nottingham prognostic
index in breast surgery to interpreting
the Wexner incontinence score in
proctology. There was also a sprinkling of
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THE ROYAL COLLEGE OF SURGEONS OF ENGLAND BULLETI N
those rare topics we all know and love
from our MCQ days traumatic
amputation of the pancreas, etc.
Surprisingly, however, there was no basic
science. I for one was envisaging the pain
of immunology and a fair smattering of
questions on genetic mutations. There
wasnt even a great deal of pathology.
Statistics, however, featured heavily and a
good grasp of everything from definitions
to applications of tests to data was
required. I was recommended Statistics at
a Glance by Aviva Petrie and Caroline
Sabine; however, I found Medical Statistics
Made Easy by Fiona Broughton Pipkin
much more digestible.
I was fortunate enough to pass and sit
the next stage, a day of vivas followed by
a day of clinical examinations. I felt that I
had done a reasonable amount of revision
and at this stage of my training, felt
reasonably confident of my knowledge. I
was trying to convince myself to enjoy
the experience: an opportunity perhaps
to show what I did know and had learnt
over the years. As I stood in line, waiting
for the walk into the examination room,
all my confidence evaporated in an instant
with the familiar return of a dry mouth
and tachycardia. I suddenly remembered
how horrible it feels to be on the other
side of the viva table, how confrontational
the whole experience is and how,
suddenly, you might as well have done no
revision whatsoever. As with the MCQs,
its all about technique.
Terrorised is probably a good way to
describe how it feels when bell goes at
the end. Its difficult to imagine that you
have passed, let alone performed well.
It felt as though all my old tactics of
coming up with succinct definitions,
answering all questions broadly, refusing
to dig myself into holes and trying to
come across as safe as possible, were in
vain. Clearly they werent, but the ability
to pick yourself up after a possible bad
performance and maintain a fresh
approach for the next viva is a skill in
itself. The examiners are told to examine
on three topics and give each topic a
mark. It is therefore possible to perform
disastrously in one area and shine in
another and average out at the pass
mark. Apparently there is none of the if
you fail the anatomy we wont let you
pass the exam ethos that accompanied
the MRCS exam.
On the whole, I found the questions to
be relatively straightforward. I found the
Dukes Club website
(www.thedukesclub.org.uk) useful for
topics appearing on previous occasions. I
had done the rounds with the younger
consultant surgeons in my department for
viva practice and found that useful in
practising formulating my answers.
Though I didnt go on any courses myself,
some candidates at the exam had been
on the Manchester course and found the
viva practice useful. I was particularly
concerned about the critical care viva and
spent time being grilled by anaesthetists.
This I found demoralising as their trainees
have formal teaching from SHO level, so
as a surgeon, its hard to look as though
you know any basics at all! Fortunately in
the actual exam, the examiner was a
surgeon and therefore the questions
asked were a lot more relevant than I had
anticipated.
The only wild card is the academic viva. I
had heard it was a relaxed affair where
you critique two papers and eventually
everyone runs out of things to say. Some
candidates did not experience this at all.
Some felt it had gone extremely badly and
had differences in opinion with the
examiners, which is never a good position
to be in as a candidate. Having read the
papers, I was quietly confident that I had a
lot to say about both. What I didnt
bargain for was that I wasnt given an
opportunity to talk freely about the
papers. Instead, I faced a battery of
questions about specific aspects of each
paper (eg power calculations, the number
needed to treat) from professorial
surgeons. I got up at the end of that viva
not really convinced Id done myself
justice.
The clinical examinations on the following
day were something I hadnt really done
any specific revision for. Like the other
candidates, I felt my clinical experience to
date should equip me to tackle most
scenarios. It is fair to say that most cases
were straightforward. Some time does
need to be spent, however, perfecting that
Oscar-winning performance! I had
forgotten how nerve-wracking it feels
when youre waiting your turn to be led
round the patients. It is not really the
case that all your knowledge escapes you
it is after all what you do on a daily
basis. What is difficult, however, is judging
how best to answer the questions
without digging yourself into a hole.
I wasnt exactly expecting them to say
Arent you a good egg!, but I wasnt
expecting it to be quite as confrontational
as Just answer the question my dear! and
Do you honestly think that? Also, it can
be quite an unnatural environment. The
elusive Ask this patient some questions
is usually a very straightforward affair in
outpatients; however, in the exam setting
it can be quite ambiguous, with patients
leading you down the garden path. There
is also the obligatory group of
professional patients who have become
expert at withholding information from
trainee doctors over the years. It can be
very difficult to manage with two bow-
tied surgeons standing over you.
All in all, Im glad its over and relieved
that it wasnt stressful enough to bring on
labour. As with all exams, you just need to
do the work and practice. I borrowed all
Saunders Ltds Companion series from the
library and didnt go on any courses, so it
neednt cost the earth. Its also very
strange once youve passed. In spite of
how much training you may still have to
complete, in the eyes of everyone else
you may as well apply for your consultant
job there and then. Oh yes, and the
certificate is a bit disappointing
TERRORISED IS PROBABLY A GOOD
WAY TO DESCRIBE HOW IT FEELS
WHEN THE BELL GOES AT THE END OF
THE VIVA.
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