PACES 2014 June Diet, Singapore

Station 4
The task was to speak to a Mr P Loh who the son of my patient Mr J Loh. Mr J Loh had been admitted to hospital with severe pneumonia. He had been having symptoms about 1 week ago, consulted a GP and was given antibiotics. He completed about 2 days worth of antibiotics and stopped because it gave him diarrhoea. When his son visited him a week later, he was noted to be drowsy and had shortness of breath. On admission to the hospital he had a right upper lobe pneumonia with type 2 respiratory failure. He was already given a trial of NIV. The task required me to (1) update Mr P Loh (2) explore the patient's premorbid and (3) discuss resuscitation status.

Seemed like a fairly straightforward case. For some reason I miscalculated the time and ended up being truncated abruptly in the middle of my summary section. I found out that the patient was a previous chronic smoker, likely COPD, had good functional capacity being ADL independent and community ambulant, and this was his first admission. I proposed intubation should the patient deteriorate further. The surrogate seemed to have many questions, asking about the risks and benefits of intubation, and there did not seem to be a definite conclusion. During the questioning, the examiner seemed to ask questions that were directed at leading me away from planning to go ahead with intubation. So, what if the son decides that he does not want intubation? What if there are not enough ICU beds? I held my ground and explained the necessary medical decision making process under the principles of beneficience. The examiner also asked me if I knew of any legislative ruling which may apply should the patient's son insist on max ward management. I was stumped at that. Am not sure if she was refering to the mental capacity act.

Station 5A
25 year old female, on OCPs, came in with monocular blurring of vision which has since resolved after 30 minutes.

When I saw blurring of vision my heart sank. FUNDOSCOPY. This will certainly be the end of my PACES. Had a few differentials and went in. Met Prof Raja (!!!) and some other UK examiner. History sounded like amarousis faugax. Bravely offered to do a fundoscopy in light that there was one sitting on the table next to me but was saved when the examiner said IT IS NORMAL. Weird also because I was going to allocate a significant amount of time to it. No clinical findings on examination - screening cranial nerves, pronator drift, UL and LL power and auscultated the carotids. No swollen lower limbs either. The only thing I left out was auscultation of the precordium, which I should have done on hindsight. I had little time left so I explained the problem being that of a nerve problem (DDX being AF vs optic neuritis) which did not require admission (low ABCD2 score) and required further investigations. Last question she had for me was, should I stop taking the OCPs? I was not sure about the causality but I told her to stop anyway. Questioning was directed at differential and further evaluation - which I gave amaurosis fugax and optic neuritis as my top differentials. The question I had in my brain was BUT SHE IS SO YOUNG?? I said I would do cardiac evaluation. When asked what I was looking for, I blurted out patent foramen ovale, after which the bell rang.

Station 5B
57 year old female, in your hypertension clinic, comes in with numbness in her fingertips.

This case was weird. Patient had a 3-4 month history of numbness in her finger tips with wrist pain. Wrist pain did not sound inflammatory. On gross inspection there was no obvious arthritic deformities. Medication list revealed that she was on carbimazole and propranolol. According to her, the symptoms started after she was put on these medications. I decided to bite the bullet and examine the neurology of the upper limbs. I was throw off when the biceps jerk demonstrated finger flexion, however there was no brisk triceps. The sensory testing, which I did in a very haphazard way, was in ALL finger tips, and did not conform to median nerve pattern. I FORGOT TO DO THE TINELS TEST :( I also did not do the thyroid exam, although I looked for tremor and also checked the pulse. Questioning was done by the UK examiner this time, and he did not look pleased at all. My differentials were cervical radiculopathy, or peripheral neuropathy related to hypothyroidism. I did not state bilateral carpel tunnel syndrome (another candidate said Tinels test was positive).

Break
As I sat in the 5 minutes waiting for my next station, I could not help but ruminate over the previous cases. Oh whywhywhy did I not do this, why did I say this. Whywhywhy. That went on for about one minute before I snapped out of it to prepare for my next station. Abdominal and respiratory system.

Station 1: Respiratory
Young boy 17 years old with chronic cough.
In the anterior chest I was actually very scared because (1) he was so young OMG what does he have and (2) I did not find anything in the anterior chest wall. I finally found some dullness in the back and concluded it was a right pleural effusion. The diagnosis was clear when the examiners nodded happily once I said it, and the discussion went all the way past Light's criteria, definition of empyema, etiologies, treatment regimens for tuberculosis, when to do pleural biopsy and finally differentials for a transudative effusion.

Station 1: Abdominal examination
Middle aged man with abdominal distension.
Clinical examination revealed spider naevi and a ?duputryens contracture over the right palm (looked a little weird though, like a little bit too off centre). No evidence of decompensation. The liver edge was palpable below the costal margin but the liver span was measured about 9cm. Presented as above, said the liver was not enlarged because the span was 9cm, but the examiner asked me if I was able to feel the liver below the costal margin to which I replied yes. Discussion was on clinical features of decompensation, causes of ascites in the patient, as well as surveillance monitoring for HCC.

Station 2: History taking
Note: This was a total disaster.

The stem was a referral from a GP for a 35 year old female with a known diagnosis of Type 1 DM at age 19 years old, who defaulted treatment for several years, and now returns with poorly controlled DM HbA1c of 10%. The task was to review the poorly controlled DM.

Now in retrospect the case was not that tricky. Well, in the 5 minutes I had outside, I was planning on finding out reasons for non compliance, complications and the works. However, when asked during systems review, the surrogate would reveal that she has this intermittent nausea and vomitting for 8-9 months. I cannot remember what my frame of mind was at that time, but I know that I kept thinking that my focus was on the DM and not so much the nausea and vomitting. As such, I ended up barking up the wrong tree. The questioning was honestly quite painful. I could tell that the examiner was trying very hard to guide me, pushing me for differentials about nausea and vomitting, for which I had not thought much about. After much egging, I finally offered hypocortisolism secondary to autoimmune adrenalitis in association with type 1 DM, as well as autonomic neuropathy. I never got to say gastroparesis before the bell rang. :(

Station 3: Cardiology
This patient presents with chest pain, please evaluate.

This patient had a midline sternotomy so I thought HURRAY valve replacement! Then I saw the CABG scar and felt sad. That said, in the midst of doing the examination, I thought I heard an occasional click. And another click. I wasn't sure, since there was a CABG scar, so I listened very very...very hard. Gritted my teeth and said mitral valve replacement. I was inclined to say aortic valve replacement as well, but the sound in the aortic area was very soft so I let that go. My presentation was very shaky though, because clearly I was not like 100% sure and all my signs were all over the place. The examiners never pushed me for any aortic replacement though, so I guess maybe not. Discussion went on to evaluation for this patient with chest pain, and also advice for warfarin and bridging with LMWH and infective endocarditis prophylaxis prior to dental surgery. Seemed alright.

Station 3: Neurology
This patient presents with feet numbness. Please examine the lower limbs.

When I saw the patient a lightbulb lit up in my head. I remember Yanru telling me about a famous patient in a particular hospital with charcot marie tooth and he is famous for coming for exams. When I saw tall angmoh man and a request for lower limb examination, I was like THIS MUST BE HIM!!!

The patient was sitting on the edge of the bed when I entered. In retrospect, I should have examined his gait first. Instead, I told him to lie down. He had very deformed feet, and also deformed hands on inspection. Many calluses. Paradoxically, the lower limb tone was not flaccid at all. In fact it was more hypertonic than anything. There was however no ankle clonus and reflexes were absent. The was a clear sensory loss of a stocking distribution until the midshin as well as loss of priopioception. I ended off by examining his gait, which he required the aid of a walking stick. I presented a case of peripheral neuropathy of chronic etiology in view of the deformities and marked wasting, for which I offered some differentials. CMT of course was my top differentials (in retrospect the patient was hearing impaired!!! Which is also seen in patients with CMT). I then rattled off a few more, B12 deficiency, alcohol, drug induced...the examiner kept pushing me more and more, and said that I was missing out one common one. At that time I had a mind block. He then asked me how I would investigate, which I answered by saying I would evaluate his fasting glucose for...DIABETES. And then the examiner smiled. The last thing the examiner said was, there is one other thing in his left foot that you have not mentioned...As I looked at his feet for the last time, I said, he has a hallux valgus deformity. The examiner clearly looked unimpressed and said, you do note that he has a missing 2nd toe right...AND THE FINAL BELL RINGS.

The day I failed my PACES

I can envision it, and it feels so real.

I would have gone through the exam, station by station, a grand total of 120 minutes, 8 patients, 16 examiners. I would have done okay at some, badly at more, stumped at most. And then the result come out, confirming that I need more practice, more finesse, only to reinforce that knowledge cannot make up for lack of clinical experience and acumen. There is no other way. Another 6 months, another $5k.

People say that this exam is a poor sorting hat. Great clinicians have failed once, twice, seven times. A stroke of good luck determines your grade, a bad draw seals your fate. Bad patients, bad examiners, good patients, good examiners, but MBBS all over again. The only difference? In this exam, one has failed until proven otherwise.

I confess that this has taken its toll on me. My sleep has been poor, my attention at work is directed at finding pockets of time to study, I have been having diarrhoea on a daily basis. Weekends burnt at courses and the remainder spent rounding the wards. There is fear, a lot of fear.

"You will surely pass! You have NEVER failed!" A friend commented, in response when I told her that whether I could make it for church retreat would depend on whether I needed to do the retake.

Never failed? There have been so many more failures in my life than you could imagine. The day I missed 2 bars of notes during my grade 5 violin exam, the day our tower collapsed at the Oddessy of the Mind national competition, the day I went for the PreU Sem interview, Law interview. But perhaps the greatest failure of this time has been my abandonment of spiritual growth amidst stress. God has missing from this equation. Pride, security in knowledge, selfishness, hypocrisy. I've been just so consumed.

So if today is the day that I've failed my PACES, let me accept it, believe it and live past it. Only by doing so, can I then go on to pass.

Isaiah 43:1-3 NIV
But now, this is what the Lord says— he who created you, Jacob, he who formed you, Israel: “Do not fear, for I have redeemed you; I have summoned you by name; you are mine.   When you pass through the waters, I will be with you; and when you pass through the rivers, they will not sweep over you. When you walk through the fire, you will not be burned; the flames will not set you ablaze.   For I am the Lord your God, the Holy One of Israel, your Savior; I give Egypt for your ransom, Cush and Seba in your stead.

Life in brief

Completed three months in KTPH Geriatrics.

Will miss having slack calls and very awesome call rooms and barney scrubs.

Thoughts about dengue, hits and misses.

Epiphanies about infantilization of the elderly.

Exceeding expectations, but not outstanding.

Thankful for friends to rant to in the middle of the night and/or call for help.

Thoughts about career progression, life in general.

MRCP Part 1.

Moving on to new grounds, exciting and very intimidating.

New Orleans, maybe?

How to prepare for the MRCP Part 1

Disclaimer: The opinions expressed in this blog are my own and do not reflect the views of any institution of which I may be part of.  I disclaim all liability in respect to actions taken or not taken based on any contents of this site.

Know the enemy

The Part 1 comprises of two papers, each with 100 best-of-five multiple choice questions over 3 hours. This means a total of 6 hours with about 1 hour break in between. The syllabus of the Part 1 is well displayed on the Pastest website so please do go through it to look at how certain topics are given more weightage than others. Of note would be that pharmacology and clinical sciences take up a huge load of marks, so that's where more studying should go to. Remember that the passing mark is not 50%. It usually is about 60-65% so that is where you should be aiming.

Medicine is all about pattern recognition. Diabetes, panhypopituitarism, tanned = haematochromatosis. The MRCP is very much like this. When they describe something related to hypocortisolism and some neurological deficits, think of X linked adrenaleukodystrophy (whatever that is!). In this respect, the Part 1, I feel, really does not accurately reflect the mark of a good clinician. It does, however, pick up someone with very good exam technique. As you prepare for the exam, pick up these clues and use them as wildcards along the way.

$$

The exam costs about GBP500+ but this is completely claimable under the MOHH post graduate exam sponsorship. This can be found on the MOHH Physician website.

Ammunition

Most people will tell you that you need at least (1) a basic text and (2) a question bank account. The Part 1 bible would the be purple book by Kalra, which really is the most boring book on earth. In my own preparation, I read about 10 pages of Kalra and never made it past Cardiology (which is always the first chapter of any Internal Medicine text). Instead, I focused most of my time and energy going through the 5000 questions in the Pastest question bank. As for the question bank, the two most popular are Pastest and Onexamination. I've never seen or used Onexam but I've heard that it's comparable if not better. Pastest seems to be the more tried and tested though.

One other resource that is not so well known is the PassMedicine study notes. This stack of notes is actually an accompaniment to Passmedicine, which provides another question bank. It provides very quick points on each subtopic with fast facts and no lengthy prose. Very good for quick revision and palatable bits of information. This could be a good substitute if you're too lazy like me to go through Kalra.

The last thing you must remember is that Pastest also has online lectures that are veryvery useful. I only listened to them 1 week before the exam and it highlighted a lot of things that were very relevant for the examination itself. Go through ALL the lectures and revision questions that come along with them.

Starting off

For a comfortable start, sign up for the 6 month Pastest account and do questions slowly to get a hang of what the questions are like. You will have the option of paying less and signing up for the 3 month account, but I'd suggest investing more money to have a go at the questions early to try and cover as many as possible. (Some people even do all the questions twice over!) On the Pastest website, you will have the option of filtering questions according to topic and difficulty (easy, average or hard). Go through the questions sytematically, starting with the Easy questions in each topic, followed by Average and finally Hard. Take it easy and read your text (Kalra or other notes) as you go through the questions. Complete each chapter one by one in sequence to know what you have or have not covered.

If you find that you will not have time to complete all the questions, focus on the Average questions. Make sure you do all the Average questions. This is because if you go through past year papers, you will realize that most of the questions are Average questions anyway. The Easy ones you should be able to get correct, and the Hard ones no one will ever know. The Average questions are possibly the distinguishing factor.

I did not have a detailed timetable, but closer to the exam (about 1-2 month), try doing the questions in random order. This is because doing questions within the same topic makes it easier for you to guess the answer, and hence does not accurately reflect your exam psyche. Doing random questions makes the difficulty level higher and would be a better gauge of your ability.

Finding time

In medicine, we have too much, yet too little time. A significant amount of time in the day is "in-between" time, Time spent waiting for Reg to round, for Consultant to round, for the Porter to pick the patient, for the Radiologist to finish his procedure and talk to you. At the end of the day, we end late, are too tired and just want to go home and sleep. In preparing for this exam, make use of all this "wasted" time. Get familiar with using Pastest on your smart phone. Do a couple of questions in between patients, while waiting for your friend for lunch, on the bus home. There is great utility in that 5 minutes you spend stoning as you queue up for your cai fan on a dreary Tuesday afternoon.

Pastest has got podcasts which are readily downloadable onto your smart phone. You can play them on your driving/ride home back from work. They are in 10-15min recordings, so very manageable.

Finishing well

In the time leading up to the actual paper, get your body and mind into shape. The paper is usually in the early afternoon, so practice doing a good number of questions at that time, all at one go. Sit down over the weekend for a mock exam using past year papers. Get over that afternoon stupor, eat a light meal before to avoid that post prandial brain hypoxia.

Leave. Different people have differing opinions about this. Some people do not believe in taking leave to study and are working right up to the day before the exam. Well, I took about 4 days of training leave (plus 2 weekend days) inclusive of the exam day itself. Personally, I think this was crucial because a lot of the MRCP requires you to know random bits of information (often esoteric) that stay in your brain for very transient periods of time. Doing questions in the last 4-5 days increase chances of you remembering if for the actual exam.

Random stuff

I would advise that you come up with your own cheat sheet. On this piece of paper, write down tidbits of information that often come out or are so random that you just need to remember before the exam. Things that I'm referring to include:

1. "Collapsed nose bridge" = think of Wegener's granulomatosis
2. Amenorrhoea + tall and beautiful female = androgen insensitivty
3. Anti-Jo antibodies = dermatomyositis/polymyositis
4. DO NOT GIVE ciprofloxacin to a pregnant woman
5. etc.

There may be one million one things to write on this paper, but just collate these bits of information for your to nibble on just before the exam.

Also, statistics comprise about 4-5% of the total score, but can potentially be very very simple. I'd suggest getting all your formulas right to ace this part of the exam. 

At the end of the day

Even if you fail, it is okay. There is always the next sitting, and lots of PTF (personal training fund) money to claim from. All the best!

Fragile

Have lots of thoughts now, post first attempt MRCP Part 1. Wanted to write a long post about how to prepare for the Part 1 (as a reminder to myself for potential future attempts and maybe for juniors), but then I learnt of news of someone's loss. Felt stunned for a while and overboiled my eggs. Had some friends over and now it's time for bed.

Flying off tomorrow for a strange land. Half excited, half apprehensive.