How to pass the MRCP by lhh12385


									                                                                                                                                      career focus
                                                                                                          be able to get through MRCP. Some do part
How to pass the MRCP                                                                                      1 after house jobs, but the fastest to the final
                                                                                                          clinical is two and a half years. We are looking
As part of our series to help you succeed in the current postgraduate royal                               at a doctor of that vintage.”
college exams, Sabina Dosani and Peter Cross give the lowdown on the
membership exam of the Royal College of Physicians and interview                                          Part 1
                                                                                                          “Part 1 has a pass rate of 35%. It’s tough.
examiners and candidates for their tips on passing                                                        Many doctors underestimate the scope of
                                                                                                          clinical knowledge expected. They are

       he MRCP part 1 examination consists          Part 2
       of two “best of five” (candidates choose     “I recommend Sanjay Sharma’s Rapid Review             unprepared. We may not want incredible
       the best answer from five answers)           of Clinical Medicine for Part 2. It got me            detail, but we do want breadth.”
papers, each lasting three hours. These ques-       through the written, but I messed up the
tions test a wide range of common or impor-         clinical. If a station goes badly it can mar the      Written exams
tant disorders. In part 2, two written papers       whole exam. The clinical component is                 “Best of five questions test basic science as
contain up to 100 best of five questions. All       unbelievably stressful and it is easy to muddle       well as statistics, clinical pharmacology, and
questions include a clinical scenario.              up clinical signs. If examiners are watching          other specialties. Areas that give specialist
   If you pass both written sections, you can sit   you and ticking boxes it is very easy to do           registrars the knowledge base and powers of
the practical assessment of clinical examina-       badly because it isn’t the same as real life. I       deduction to use basic information in clinical
tion skills (PACES). The PACES examination          don’t think any clinical exam is like real life.”     settings.
consists of five clinical stations, each assessed                                                            “Part 2 has a pass rate of 60-65%. Candi-
by two independent examiners. Candidates            Pass rates                                            dates tend to trip up on interpretation of
start at any station, before moving on to           “They only let a third of people pass at each         scientific information. ”
others, at 20 minute intervals. Part 2 must be      sitting. The vast majority of candidates are
completed within seven years of part 1.             doing busy district general hospital jobs and
                                                    cram their revision around that. Most people          “The college isn’t being obstructive by pro-
                                                    will pass, just not at their first sitting.”          ducing an exam that is too difficult or irrel-
How much will it cost?
+ Part 1 examination £275                           PACES                                                 evant. Any assessment will be flawed, but there
+ Part 2 written examination £275                   “Keep your head during PACES. As you do               has to be some sort of written assessment and
+ Part 2 clinical examination (PACES)               each station, forget the previous one. Even if        it has to be wide ranging.”
  £450                                              you have said something silly, like mention-
+ An additional £180 diploma fee before             ing a collapsing pulse on a patient with aortic       Revision courses
  you can put MRCP after your name                  stenosis, forget it. When I failed I was think-       “Preparation takes months. Crammer
                                                    ing about something I did wrong for the next          approaches are difficult to uphold educa-
Who writes the questions?                           half hour. Move on and do your best, over             tionally. There are always instances in PACES
The Royal College of Physicians’ specialty          and over. I did that the second time. It              where you see they’ve been taught this way or
question groups devise new questions.               worked.”                                              that way.

The candidate’s view                                Stress                                                Textbooks
Mark Westwood is a cardiology specialist            “Each time you sit the exam, it exposes you to        “We use the Oxford Textbook of Medicine as our
registrar at Barts and the London. He passed        extreme stress, which gets easier to deal with.       reference. If it isn’t in there then it won’t be in
part 1 first time, but passed part 2 at his         Courses recreate mock PACES, but because              the exam. We don’t look for obscurity.”
second attempt. He often helps senior house         you know it’s a mock, however mean and                   Professor Peter Kopelman is the incoming
officers preparing for the MRCP exam,               horrible your examiners act, it is nothing like       chairman of the MRCP clinical examining
sharing his successful formula.                     the big day.”                                         board. His area of expertise is PACES.
                                                    Final advice
Part 1                                              “This is going to be one of the most miser-
“The part 1 syllabus looks like the first year of   able periods of your life. You are working             Resources*
medical school, only twenty times harder.           very hard and being a student in your spare            + The Royal College of Physicians
Three months before part 1, I bought lots of        time. It feels like a treadmill, and that’s exactly      website exams page can be found at
MCQ books and ploughed through them. I              what it is. Remember you may not pass this     
went on the Pastest course four months              time but if you are determined, you will get             exam/index.htm (accessed 7 Feb
before the exam. I recommend going on a             MRCP in the end.”                                        2004).
revision course early as it showed me how              Claire Collett also took more than one              + Anchor statements, examiners’
much work there was. On the Pastest course I        attempt before passing MRCP at the end of                feedback and mark sheets are
was given a folder of questions that previous       last year. She recommends, “doing a bit each             available from
candidates have memorised, so when I sat            day and finding someone to revise with as              + Montgomery H, Goldsack H,
the exam I had seen some of the questions           you can motivate each other. I did thousands             Marshall R, Ashrafian H. My first
before.                                             of MCQs for part 1. For part 2 I did lots of             MRCP book. London, New York:
    Examiners may change the question               bookwork but with hindsight feel that                    Remedica, 2003.
slightly, but if someone has explained it to        Ryder’s An aid to the MRCP Short Case and              + Sharma S. Rapid Review of Clinical
you and you understand what you are being           Baglia’s 250 Cases in Clinical Medicine are the          Medicine. London: Manson, 2000.
asked, you are likely to score very well. Can-      only books worth getting. I revised for                + Ryder REJ, Mir MA, Freeman EA. An
didate’s mark distributions are so close that       PACES by using those two books and by                    aid to the MRCP short cases. Oxford:
probably all you need to pass is some past          seeing lots of patients. The first time round I          Blackwell Science, 1998.
questions. Read and learn Multiple Choice           got too nervous to think for the PACES                 + Baliga RR. 250 cases in clinical medicine.
Questions for MRCP by Hugh Beynon. He’s a           exam.”                                                   MRCP Study Guides. Saunders, 2002.
clever bloke. His questions are very difficult,                                                            + online MRCP course.
but the explanations are superb and you will        The examiner’s view                                    *The resources mentioned in this article are
learn a lot about weird and strange diseases        Dr Neil Dewhurst is an experienced                     not a complete list but those recommended by
that creep up because examiners like asking         examiner for MRCP:                                     the candidates and examiners the authors
about them. It gives you an insight into how           “Most UK candidates will be on an SHO               interviewed for this article
questions are written.”                             rotation and after eighteen months should

BMJ CAREERS   17 APRIL 2004                                                                                                                               155
                                                                                                                                           career focus
“Station 1 is on the respiratory system and                 THE WAY I SEE IT{
abdomen. There is an introductory spiel like,
‘This 44 year old man gives a three month
history of progressively worsening shortness                Why a middle aged
of breath.’ Just as in real life, there might be
patients without physical signs. At six min-                general practitioner sat
utes candidates are warned that there is one
minute left, then they are asked to present                 the MRCP
findings and discuss management and inves-
tigations. At the end of ten minutes, candi-

                                                                   hey say that there is no fool like an old
dates move to a patient with abdominal                             fool. So you might think that a 49 year
problems.                                                          old general practitioner (GP) taking
   “The candidate has five minutes outside                  the exam for membership of the Royal Col-
station 2, on history taking. They read a gen-              lege of Physicians (MRCP) either has delu-
eral practitioner’s letter, for example, ‘Dear              sions of grandeur or has something missing.        end was almost an anticlimax. For each part I
Dr X, I’m very concerned about this patient                 Having lived through the adventure and sur-        did a course and on each of those courses the
who has had an increase in bowel motion                     vived, I would disagree.                           audience listened diligently to the speaker
and is passing blood.’ They carry out a task in                As a rural GP with an interest in education     with little interruption. How different from
the letter, like ‘give your opinion.’ At 14 min-            and assessment, I found myself questioning         our Tuesday GP meetings, which are almost
utes the patient leaves, the candidate has a                the ways we teach clinical skills and decision     always interactive.
minute to reflect and examiners ask                         making. I was also becoming increasingly              I expected the clinical section to be a wel-
questions.                                                  disillusioned about the lack of communica-         come relief. Preparation included rustling up
   “Then the candidate goes to station 3 and                tion and understanding between primary             as many consultants as I could and trekking
faces a 10 minute examination of a patient                  and secondary care. Was I becoming pomp-           around the hospital with them, examining
with a cardiovascular problem and 10                        ous as well as old? To justify my scepticism, I    body systems. The bodies were not allowed to
minutes with a patient with a neurological                  decided that the first thing I had to do was to    speak and, as in the exam, would be
problem.                                                    make sure I was up to scratch myself.              described only as “breathless” or “losing
   “Station 4 is the communication station. It                 It seemed logical to use my prolonged
                                                                                                               weight.” From my standpoint, picking up the
may be breaking bad news, explaining a pro-                 study leave to spend a few months in second-
                                                                                                               patient’s hand in silence first (as one does)
cedure to a patient or relative, explaining                 ary care—so I did, in a busy “no stars” hospital
                                                                                                               seemed decidedly unnatural. Poking peo-
withdrawal of feeding or a decision not to                  with some excellent clinicians but little cohe-
                                                            sion. The senior and junior staff gave me free     ple’s offal for self interest seemed decidedly
resuscitate. My colleagues and I vet scenarios
                                                            rein and I gained enough from the experi-          rude. Still, rules are rules, and I gradually
before they are used. We rehearse scenarios
                                                            ence to produce 4000 words for the secretary       became skilled at lifting up every arm to
with simulated patients and agree what a
                                                            of state for health. Starting on the emergency     check for collapsing pulses and saying that I
doctor should do. We are trying to replicate
                                                            assessment unit, I was asked to demonstrate        would do a rectal examination while not
real life.
                                                            that GPs’ risk management skills could             actually doing one.
   “The last station includes other systems:
                                                            reduce the patient admission rate. A govern-          I passed, but not without a splutter.
eyes, skin, and locomotion. Candidates are
                                                            ment report backing up the idea followed           Although I had scored 100% half way
asked what they find, how they would inves-
                                                            shortly afterwards, and the same hospital          through the examination, I ran out of time in
tigate and manage, so it is more than just a
                                                            now has several GPs performing this role.          one of the clinical cases and didn’t fully
spot diagnosis.
                                                               The MRCP exam followed logically. I             examine a patient’s chest. At this point, I
   “Candidates fail because they have poor
                                                            befriended some senior house officers who          collapsed like an English test cricket side,
examination technique or poor history tak-
                                                            were taking the exam and jumped on the             crashing from 200 for no wicket to 210 all
ing skills. Others are unable to interpret find-
                                                            bandwagon. Part 1 was tough, with its              out. My confidence was in tatters. I had never
ings to put together a differential diagnosis.
                                                            emphasis on basic science. I realised how the      heard crackles above the clavicle before (or
Increasingly young doctors are aware that
                                                            world had come on over the past 30 years.          since) but interpreted them incorrectly
revision courses only tell you about exam
                                                            When I was at university there were no cyto-       because at that moment my brain had turned
method, and that application and interpret-
                                                            kines and no polymerase chain reactions. We        to porridge. The head porter would have
ation of physical signs comes from experi-
                                                            knew that genes made proteins but not              done better with the abdomen that followed.
                                                            exactly where the genes lived. The part 2             So why am I reliving all this? Firstly,
   “My advice to candidates is to be as experi-
                                                            written paper was different. The real chal-        because I would like to commend the Royal
enced as you can. Go back to day one of
                                                            lenge was concentrating for six hours while        College of Physicians for allowing me to
medical training and read a clinical methods
                                                            reading long, drawn out hospital type cases.       break the usual rules and take the exam at my
book. Appreciate the applied physiology.
                                                            To tick a box (one correct from five) at the       age. And, secondly, to share some of what I
Understand what physical signs mean. A lot of
                                                                                                               learnt. I am happy that the exam is valid and,
junior doctors are poor at analysing them. Be
                                                                                                               my own hiccups aside, reliable.
observed in your clinical method by a senior
                                                                                                                  I have learnt that I picked the right career
doctor prepared to compliment or criticise.
                                                                                                               as a GP, with or without a special interest. I
Courses can’t provide that but the consultant
                                                                                                               have learnt that my hospital colleagues want
on your post take ward round can.”
                                                                                                               good communications as much as I do. I have
                                                                                                               been reminded that candidates are in a state
Sabina Dosani specialist registrar in child and
adolescent psychiatry
                                                                                                               of fragility and when examining I will avoid
Maudsley Hospital, London                                                                                      untimely interruptions. Instead, I will try to                                                                                          bring out the best in them. Finally, I have
                                                                                                               learnt that no person can know everything
Peter Cross freelance journalist                                                                               and, in the words of Alfred Lord Tennyson,
London                                                                                                         “Knowledge comes, but wisdom lingers.”
                                                                                                               Michael Houghton general practitioner
          Go to web extra for a full list of acronyms and                                                      Brookside Surgery, Stretton on Dunsmore, Rugby
          their meanings, used throughout this series                                                

156                                                                                                                                   BMJ CAREERS    17 APRIL 2004

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