Stage 2 – The GuideSTAGE 2 – THE GUIDE

Hi everyone – this comes in response to a couple of people asking me how I approached the mountain that is Stage 2. It isn’t a definitive how-2 instruction manual, more of a collection of suggestions and approaches that I took over the course of the year (with reasonably good results).

Obviously what I’ve written here is only a guide, based on my experiences at the time. The course (and its teachers and examiners) will obviously change over time – but this may be good place to start! There is probably plenty more that I could tell you, if you want me to – please email me if you need anything. For those of you that don’t appreciate my sense of humour, ‘…’ normally means that I’m being sarcastic…

Feel free to amend and pass on to whoever (especially the year below), as I know how stranded you can feel at the start of stage 2 with so much to cover.

Good luck,

BenAugust 2009

This version:The 2009 edition is now quite out of date so I have tried to update the things that have changed and add a couple of extra tips.AKG (2012)

Contents NRO – or, how much material can we fit into 6 weeks? MAD – never was an acronym more accurate Paediatrics – cute kiddies and starting medicine from scratch O&G – everyone’s favourite… Psychiatry – totally mental Pathology – the beast

There are four GP blocks, each two weeks (excluding Fridays). As ever, GP is very hit and miss – some people get fantastic clinical experiences and teaching in a practice 30s walk from their front door while others fester in a corner as bad GPs churn slowly through mounds of nothing-wrong patients in a town that has yet to build a railway station. The good news is, the clinical school is pretty good at giving the GPs a push if you let them know you aren’t getting what you need and they should now (from 2012) reimburse some of the transport costs.

In the olden days (2009), they had ‘case based learning’ weeks every placement. We no longer have them but they still have CBL stations in both the paeds and the O&G exams. They mostly involve just applying some common sense and basic knowledge of what services are available to a case incorporating every possible social problem that a paeds/O&G patient can have. You get time to read the case then sit with the examiner, blethering out anything you can think of, hoping it will get you points. The examiner has the marksheet in front of them so ticks when you say something you get a point for – this effectively turns the station into a ‘hotter/colder’ game – if you mention something and a tick occurs, keep on that topic until the ticking has stopped!

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Stage 2 – The GuideNEUROLOGY, RHEUMATOLOGY, ORTHOPAEDICS

NRO, in my opinion, was actually quite a good rotation, with some great teaching that is normally quite uniform between all students as the entire thing is based at Addenbrookes. The biggest problem is organising the multiple timetables and coping with the shift in gears from the N to the R to the O numerous times in a single day! Teaching is divided up into:

Bedside teaching, hopefully at least 4 hour-long sessions with 4 registrars/consultants during the rotation, one each in neurology, neurosurgery, rheumatology and orthopaedics. Get onto your assigned doctor as early as possible as each session may take weeks to arrange.

Lectures, sprinkled through the timetable Medportal cases in neuro and rheum, which aren’t particularly taxing but cover some of what the

course organisers think you should know. Outpatient clinics and operating theatres – you have a signup sheet to make sure that you attend the

absolute minimum, but there are plenty of extras The odd extra seminar-thing here and there

Neurology

Potentially a massive subject, I found that most of the bedside teaching in neurology and neurosurgery was pretty good (dependent on your consultant/registrar). The lectures tended to be slightly non-comprehensive, taking the form of case discussions rather than actual memorable teaching. Outpatient clinics are good, especially the general ones, though there are also a lot of specialist ones (Huntington’s, MND, epilepsy, etc) that are not placed on the timetable and are well worth chasing. And ANYTHING involving Dr Roger Barker is worth its weight in gold. There are also neurosurgery theatres located above A5 – they aren’t on the sign-off sheet but are worth doing once as the equipment is incredible; the anatomy different to any other surgery and, come on, it’s brain surgery! Plus, this was the only rotation where I received comprehensive radiology teaching, courtesy of Dr Antoun – slightly slow, but also slightly brilliant.

I’ve heard many people say that neurology (with nephrology) is the big discriminator in finals and MRCP exams, so it may be worth taking a little time to get properly to grips with it, especially the examinations.

Textbook – Essential Neurology, written by Cambridge professors including Dr Lennox, is a very digestible guide with nice diagrams and covers a lot of neuro that you may never be taught. (That said, if you’re really interested in neuro this may be a little basic).

Rheumatology

Again, the bedside teaching is generally good. The lectures are more didactic than in neuro. Outpatient clinics are fought over viciously, as there is a deficit of clinics in relation to the number of students. Many of the rheumatologists do general clinics at other hospitals if you’re keen, but the specialist clinics (such as Dr Hall’s CTD clinic, the metabolic bone disease clinic, etc) may be difficult to get into. If you’re finding it difficult to get into one, considering splitting them (90 minutes of osteoarthritis is often enough), or even going during a holiday week if you want to. If you are interested in rheumatology, it’s worth joining a ward round.

Textbook – personally, I think that a rheumatology chapter of a standard textbook is as good as anything, e.g. Kumar and Clark.

Orthopaedics

Some people love it, some people hate it. The teaching is very ‘surgical’ – ordered, nuts ‘n’ bolts and a little inconsistent. Most of the lectures were quite good, but you may well find that there are holes in your knowledge at the end. Some of the theatres and clinics are welcoming, some aren’t, but I would try and see

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Stage 2 – The Guideat least one of each of the major operations and clinics (hip replacements, arthoplasty, etc). If you’re keen, then there is plenty to see and many of the orthopods are keen to get you involved. There is also ‘trauma week’ when you go into the ortho office every day to get grilled looking at radiographs of broken bones – try and get involved, appreciate the ridicule as their way of being friendly and hone your skills of avoiding consultant flak as it flies towards you.

Textbook – actually, the orthopaedics section of Surgical Talk is a really, really good base (and I would definitely recommend reading it before trauma week). For more info/pictures, there is a book called Essential Orthopaedics and Trauma that I found which was quite good – but because of the expectation of orthopods that you know a little bit of everything I would definitely start with Surgical Talk and then fill in your gaps afterwards…

NRO before path (AKG) - I had my NRO attachment just before path so was less thorough than it looks like Ben was. There is very little orthopaedics in path and you can get through the NRO OSCE and MCQs with a very very basic knowledge of orthopaedics plus being able to do the examinations smoothly (Surgical Talk is way beyond what I knew and I passed). While some orthopods need vast knowledge to be impressed, many others think you a genius if you can just name all the bones in the hand and the Garden classification of hip fractures.

Examination

NRO OSCE at the end of the rotation. To be honest, there shouldn’t be any massive surprises in this exam, especially after the stage 1 OSCE.

In 2011/12 we had the OSCE on the R&I Monday and the MCQs on the Thursday. The OSCE includes: CCS – explanation and planning. You are given it in advance Examinations – neuro, orthopaedics and rheumatology Skills – lumbar puncture; ophthalmoscopy (you’ve had all the teaching you’ll get on this - a random

afternoon in stage 1 most of us still can’t remember) – you use the ping pong eyes with writing at the end of the vessels; knee aspiration

MAJOR ADULT DISEASES

This is, essentially, 4 consecutive fortnights each covering massive topics that between them constitute over half of the pathology syllabus (something that I would bear in mind when doing the rotation). This makes it quite difficult to swallow, but is always interesting.

Papworth – Cardiothoracic Medicine and Surgery

Papworth is like the Marmite of rotations – you either love it or hate it. Accommodation is generally poor (unless, like me, you get put up in a brand new gorgeous house in the village!), but the enthusiasm of the place is great. You spend two weeks on the ‘heart-side’ of the hospital and two weeks on the ‘lung-side’; you are attached to a home firm for each of those two week stints, who you spend some ward-time with, etc, but are free to attend other firms’ clinics, theatres and so on. While I was there, I was also attached to a supervisor, who you will meet with you on a regular basis, follow your progress and guide you through the coursework that they may or may not encourage you to complete…

Card and resp form a fair whack of the path syllabus (though to be honest cardiology appears under-represented in the actual exam), but more importantly they constitute much of the work of a junior doctor. Getting to grips with them is therefore essential, but it can be a challenge to do in only two weeks each! I

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Stage 2 – The Guidethink that, if the exams aren’t looming, the best experience you can get is to do a combination of heart and lung pathology but also to brush up on some clinical cards and resp, e.g. interpreting ECGs, the principles of angiography, treatment of ACS, asthma, etc.

Teaching is divided into: Lectures, many of which will be cancelled or re-arranged at the last minute and which are highly

variable, but do cover a lot of very important general medical topics. Student-led presentations. Every student does one, they are usually good fun and a good opportunity

to indulge your powerpoint fetish discussing one of the weirder pieces of medicine/surgery that you find interesting

Outpatient clinics, operating theatres, other procedures – mostly very interesting, mostly welcoming. The heart surgeons in particular I found to be very keen to teach, if you are keen to learn, and their theatres were easily the best surgical experience of my first two years. In addition to the elective surgery, there is also an active heart/lung transplant unit at Papworth, and I have known students go on retrievals, etc, if you are interested. I would try and get to at least one outpatient clinic for each of the specialities at Papworth if possible – most of the medical doctors are great. There is also a number of other procedures that occur in Papworth, particularly angiography, that is great to see.

Home firms – you are attached to a consultant and attend their ward rounds, etc. Because they are mostly welcoming, in retrospect this was a good experience, because of the lack of ward time generally during stage 2

Ward time – clerk patients and listen to as many hearts as possible. Because this is a tertiary hospital, there are loads of really interesting cases and not one of these people will have a normal CV/resp exam. An excellent opportunity to tune those ears, and brush up on history taking.

Plus various seminars and teaching sessions with consultants on wards, in ICU, etc. Opportunistically, the pathologists at Papworth have a reputation for giving excellent teaching and

are normally very happy to see students. If you are interested in a case that you have seen or just fancy an hour’s session discussing some aspect of the path syllabus in the past they have been happy to oblige. Well worth going to a post mortem.

Textbooks – whatever path textbook you are using (see below) for the theory of cards and resp path. Plus a good medical textbook such as Davison, Kumar & Clark. OHCM is good on the wards and in outpatient clinics to go over the basics. Otherwise, there is a great if tiny library in Papworth with more specialist books.

Examination – an hour-long formative MCQ paper at the beginning and the end of the attachment, that is more for the hospital’s benefit than yours, and which currently contributes nothing to your permanent record and which the clinical school will never see.

Oncology

Luke Hughes-Davies runs this rotation practically single-handed. I thought that it was brilliant, if demanding, and most people agree with me, though LHD does have his dissenters. The ins and outs of oncology are very difficult, but I think that he gets the clinical principles across rather well. He won’t teach you everything that you need to know about breast cancer, say, or prostate or thyroid or one of the dozens of cancers that litter the path syllabus (and WILL come up in the exams), but rather the things that they don’t cover in the textbooks – how to assess an oncology research study, the principles of chemotherapy, etc.

Because time is short, it is very difficult to cover all of the details of every cancer in this fortnight alone. I would advise keeping up with the work that he sets you and try and read up on a few cancers if you have the time, perhaps the ones that you see in clinic.

Teaching is divided up into:

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Stage 2 – The Guide LHD seminars – one hour a day, every day, for two weeks. An unparalleled experience that I think is

brilliant, where he covers the kind of things that you won’t find easily elsewhere. Outpatient clinics – the bulk of the rest of the placement, which is available on your personalised

timetable. Most of the oncologists are good, but rushed off their feet which makes teaching difficult but not impossible. If you get the opportunity, this may be the only chance that you get to experience the joys of an adult haem malignancy clinic, which is surprisingly prolific and important in doctoring practice generally but is poorly reflected in our student exposure.

Various mornings and afternoons in places – the ward, radiotherapy, etc. LHD homework – a case a day (similar-ish to the Medportal cases from last year), that he doesn’t

mark but does provide the reading for. These are the cases that he bases the end of rotation assessment on.

A few tips for surviving the LHD experience: Don’t be late – he locks the door when his teaching begins Don’t yawn Be engaged and try and keep up with the work that he sets Learn the hallmarks of cancer and an example gene for each Appreciate the beauty and wonder of the New England Journal of Medicine *Memorise a list of the Nobel prize winners *Memorise the details of the first X-ray

(* is optional, but he would be so unbelievably impressed if you knew!)

Textbooks – whatever path textbook you have on the go for the basics, plus a good medical textbook and the OHCM for (generally) good summaries of the clinical aspects of most of the cancers that you will see in clinic.

Examination – end of the fortnight assessment on the final Friday, normally 3 cases based on the homework that he has set you in the last two weeks (but bear in mind that LHD is a clever guy – knowing that some of his students hadn’t attended his NEJM club that week he changed the assessment to reflect the contents of the journal that week!). Most groups in 2011/12 didn’t have it (although the cancellation came as late as 9am on the day of the test) but some did. And don’t forget – cancers ALWAYS come up OVER AND OVER again in the pathology/finals exams.

Infectious Diseases and GUM

ID is a much more ambiguous rotation. Dr Carmichael is (loosely) in charge of the ID side, Chris Carne the GUM. You get a personalised timetable from Medportal, which has massive holes in it for personalised study, that I would take advantage of because the teaching will not cover a fraction of what you could (and maybe should) know.

Teaching is divided up into: Clinics – GUM and HIV. There isn’t that much to GUM, and you are likely to see the main things.

The clinics are very variable depending on who you are with. A major issue is whether the patient or even doctor is keen to have students with them or not – students of the opposite sex of the patient often have trouble here. There is a lab in the clinic, with slides etc that you can use if you have the time, plus lots of books kicking around, but I would be prepared to be kicked out of consultations…

Ward time – rounds, clerkings, etc. The exposure is wholly dependent on whatever happens to come into Addenbrookes while you are there. It will be far from comprehensive, especially when there are so many students on the rotation for so few patients. I think it is difficult to get a lot out of this, as so many students pass through the rotation with so little knowledge and doctors with far too much to do, but the usual approach of being keen and enthusiastic does help.

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Stage 2 – The Guide Organised teaching sessions with Dr Carmichael et al, possibly with a hint of bedside teaching.

Again, very far from comprehensive. They try and cover important topics, but there are far too many to be comprehensive, and because of the ad hoc nature of the sessions dependent on patients that are around, they tend to be inconsistent.

A few homework sessions from Dr Carmichael, i.e. how to use Google for really obscure diseases A few online cases and reading from Dr Carne, which are actually quite useful There are hundreds of R&I week lectures on micro, which I think is probably the best lecture series

overall and a much better source of info than the attachment itself. See below in the path section…

Textbooks – There is no definitive ID textbook, and you don’t need one for the attachment. The OHCM is a start in clinics when you get bored, and I used Lecture Notes on Medical Microbiology and Infection much later in the course when I was revising path. I couldn’t honestly recommend a good GUM textbook, but then I’m not sure you actually need one…

Examinations – End of the fortnight formative ‘quiz’ from Dr Carmichael, and a more formal R&I week assessment (which contributes to passing the attachment, but not necessarily anything else) from Drs Carmichael and Carne – the latter involves a picture quiz, so make sure that you take mental pictures during those GUM clinics!

PAEDIATRICS

The paeds experience varies depending on where you do it, but it seems to be a speciality that everyone at least considers a career in at some point. Some people describe paeds as being an experience ‘like learning medicine all over again’ – not wrong, as it is so broad.

Teaching comes in the form of: An introductory two days of lectures – lots of odds and ends and important lectures introducing

important topics. An online ‘syllabus’ like thing – basically a massive long list of stuff that you should be learning,

which is probably a good place to start. I did paeds shortly before the panto and was therefore very busy at the time, but even if I didn’t sleep for 6 weeks I don’t think I would have touched the contents of that list! BUT it does give some structure to reading and the way that you should be approaching paeds.

Other teaching depends on where you are placed. I was in Luton and received daily bedside teaching with the consultants, and had the run of the outpatient clinics and wards. But not all of the hospitals are like that – Huntingdon, for example, has fewer patients and your experience will depend on who comes in the door. I would suggest getting as broad an experience as possible, for example going to an outpatient clinic in each broad speciality (cards, resp, gastro, neuro, haem, etc), but without getting bogged down in specialist clinics (a potential problem in Addies, where I attended a paeds haem onc clinic and saw multiple patients with Diamond Blackfan syndrome).

The inevitable question is, then, how to approach it. I got one of the paeds textbooks and just worked through it, based loosely on the Medportal list for guidance. I stayed on the wards during the day (don’t be afraid to get involved – make sure that you are completely comfortable examining children before the end of the attachment, otherwise the exam will be that much more difficult) and read up on things in the evening (in between hunting down sound effects for the panto). It is difficult, however, and if anyone has a better plan I would be glad to hear it!

In retrospect, having done the exam, it would have been much much easier for me if I had sorted my examination skills out at the start of the attachment, allowing me to practice on all of the children properly.

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Stage 2 – The GuideThere is also a bit of coursework to get done, in the form of a critically-appraised topic and ethical case. If you can, try and get these done before the end of the rotation so that you can discuss them with a consultant in your hospital. While it is tempting to wait until the end of your attachment to find an inspiring case, it is worth making sure you have access to NHS evidence (need an Athens password) earlier in the placement as that can take a while to come and makes life soooooooooo much easier. The trick is finding a topic where you can reasonably narrow down your pool of papers to about four. I did this by choosing a really obscure disease (malignant infantile osteopetrosis) but others have chosen common, heavily-researched areas and demanded vast sample sizes of them.

Textbooks – I used Rudolf and Levene (2nd Ed), which is very comparable in content to Lissauer and the other recommended textbooks, which are easy to read and laden with summary pages and diagrams to help digest the info. I’ve heard that the Crash Course and At a Glance aren’t really sufficient for what you need to know, and because the other textbooks are so manageable, I would suggest avoiding them.

Examination

One OSCE at the end of the year worth the same as the whole of path so well worth getting any easy marks you can! Don’t wait to get details about what is in the OSCE before preparing for it because they never came. We got a lecture on it a week before during which we were just told where to go and that we shouldn’t cheat. If you are in a regional, make friends with people in Addies as they probably have notes and/or handouts from teaching sessions from the people who set the exams. I was in Whipps Cross and we were taught to do examinations in a completely different way to the Addies way.

Things to make sure you can do: be comfortable around children; know the developmental milestones and have a clear pathway and patter for how you will go about assessing a child (pillows make excellent models, as do housemates), be aware of what you can ask the mother if you find the child to be uncooperative; make sure you know the easy mark points for doing a growth chart and clinical skill stuff like when to wash a spacer. Most of the rest of it is just dealing with what is put in front of you, I spent most of the exam thinking, “what on earth are they wanting me to say/do?!” It is not an exam you can feel in control of!

OSCE 2013 (AWM)1. History. From a parent whose child has started limping. Cough and fever present. ?transient

synovitis. Asked for summary of Hx, differential, any investigations to be performed.2. Skill + CCS – explaining inhaler to father as per 2012.3. Data station. Plotting birth and 6W weight on a chart (crossing two centiles), then shown a video of a

childin respiratory distress, then told to listen to a murmur via some headphones (PSM), then shown a radiograph showing cardiomegaly... Asked at each stage about what we were thinking. These are all meant to be the same case (i.e. same child) which not everyone realised. Had congenital VSD so some questions on that, ended being asked about pulm HTN etc.

4. GI examination. Child was healthy, but at the end asked what thoughts would be had we found a L iliac fossa mass (constipation) and what we would do.

5. Developmental assessment.6. Data station. Picture of meningococcal rash, X-ray with consolidation (What organis? What Rx?),

UTI results (Ix? ABx? Complications?).7. E&P. Congenital hypothyroidism case. Mother was quite nervous and didn’t seem that concerned

about the ins and outs of CHT to be honest.,,8. CBL. Pregnant 17 y/o, basically every line in the case Hx has a potential issue, just use

biopsychosocial.9. Skills – baby check. Measuring occiptofrontal circumference, hip exam, shown picture of eyes

(congenital cataracts). Asked about neonatal screening (Guthrie + hearing stuff +

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Stage 2 – The Guidecataracts/hips/testicles/CHD all have specific pathways after they’re checked at birth). Rx for congenital dysplasia of hip? Immunisations before 1Y?

OSCE 2012 (Anna and Ben P)1. Baby check. There were models of hips and pictures of eyes and a growth chart. The examiner

guided you on what to do next but didn’t give an idea of how much there was to do overall which made pacing it hard. They gave the scenario that there was retinoblastoma in family so the neonate was being checked for it. The baby didn’t have it so they asked “what would you do next?” All I could think of was doing nothing other than checking them again at their 6 week test but that got no ticks. When I said I’d document that their eyes were normal, the ticking started up. Paeds seems to have a lot of marks for that kind of stuff – stuff you’d do but don’t think to mention – so just say everything you can think of.

2. Developmental milestones – I had a 6 months old. Really enjoyable station3. E+P – given in advance. Single mother worried about child with diarrhoea. Social issues to discuss

with her. Follow how they teach you to do it and the actress will give you the information4. CBL – very similar to the O&G one. Young mother, difficult social situations, child protection issues5. Skill and CCS – a father at the GP surgery coming to ask questions about his daughter’s new steroid

inhaler (had read on google about the side effects of steroid use) and for you to teach him how to use the spacer.

6. CCS – straight forward history. Diabetic symptoms. Governess kept being mentioned but don’t assume that means the mother works – possibly a trap for the mother to get angry/upset as she massively overdid being upset when I asked if she worked. Questions about what to do next.

7. Video of CP child then questions about their condition and the support available8. CV examination – really good fun. My child was completely normal. Worth listening in to anything

the mother(/father/guardian) is saying to the examiner during your reading time – I palpated the jam sandwich she’d mentioned while feeling for my boy’s liver. It may not have got me points but the look of awe he gave me made me smug for hours.

OSCE 2011 (unknown source) History (post-streptococcal glomerulonephritis)

o 7yr old with oedema up to and including the scrotum, bubbly urine, previous history of throat infection

o Questions on differentials and management E&P

o Newborn with raised TSH. Explain differential diagnosis and management to mum. Mum worried about long-term effects of hypothyroidism and how to administer the thyroxine.

CBLo Young child with Down’s Syndrome, parents are arguing, father can be aggressive and short-

tempered with child. o Questions start broad: “what issues are apparent in this scenario” use bio-psycho-social model,

ethical and legal, and public health on a national level. Questions focus on this framework. Cardiovascular examination – 10yr old with VSD Development examination

o 2yr old with normal development Data Interpretation Station

o Photo of florid meningococcal rash, discuss differentials and managemento X-ray of pneumonia and pleural effusion, discuss likely organisms and treatment

Practical Stationo Explain to a parent how to teach their child to take a peak flow reading and how to use an inhaler

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Stage 2 – The Guide DVD Station

o 1min video of a child having a febrile seizureo Questions relate to features of the seizure (i.e limb involvement etc), differential diagnosis, how you

as a junior doctor would manage this scenario (Hx, examination, treatment). Would you follow up the pt?

OSCE 2010 (by Nathan)

1. CBL- can’t remember what the case was but it fine (do you still have this)? For Paeds, just remember CHILD PROTECTION is the buzzword they want to hear.

2. Rash DVD: 5 pictures of rashes asking a). What is the most suitable treatment (i.e. steroids, emollient, antibiotics, nothing)? And b). What referral would be appropriate (i.e. emergency, outpatients, none, child protection)? Quite hard.

3. Growth Chart station: just plotting the data they give you. Only trap was that they were premature so you had to adjust accordingly.

4. Developmental assessment. Child and mother there + a box of toys etc. Think ours was 7 months.5. Abdo exam. 9 year old, perfectly normal (other people had kids with hepatosplenomegaly or a load

of PEG tubes). Genuinely fun station6. Neuro DVD. Much like the one the year before.7. E&P. Hard- you’ll get the scenario in advance but ours was an angry Mum who’d been kept waiting

and wanted to know what was wrong with her kid (asthma) and then you had to make a plan to deal with it. I ran out of time.

8. History taking. This was something Musculoskeletal. No idea what because I actually knew very little paediatrics but just talked through what I hope was a reasonably sensible differential with the examiner afterwards.

OSCE 2009 – 12-ish minute stations, steeplechase style (the kids get a balloon, a certificate and a few quid for coming)

1. Neuro DVD stationa. Watch a DVD showing a child (with cerebral palsy) and then answer 5 set questions from the

examiner (who will not discuss or deviate from these questions) based on the DVD, e.g. what signs you noticed, likely diagnosis, suggested treatment

2. CV exama. Examine the child and then answer a few simple questions based on the examinationb. A significant proportion of the children will be totally normal, and the rest will have stable

conditions, most likely a murmur (VSD, aortic stenosis)c. They use a range of ages, from babies right up to 16 year olds, and you will need to adapt the

examination appropriately.3. Respiratory exam

a. Again, most are totally normal (most, in fact, are either children of the consultants, or chronic asthmatics), of a variety of ages. If they have anything, they will not be unwell with it.

4. History taking stationa. Nocturia – the majority of the time is devoted to taking the history, and the rest to answering

a few questions from the examiner about a differential diagnosis, and its management5. Explanation and planning

a. The examiners will send out a sheet telling you exactly what to do a week or so before. Ours was about a child with simple viral gastroenteritis, and we had to explain it to the mother, suggest she went home and what to look out for in case the child got worse. We were also asked for a differential diagnosis after the explanation had finished

6. CBL station

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Stage 2 – The Guidea. We were given a quite reasonable case about someone with cerebral palsy, asked to read it

for a few minutes and then and asked a series of set questions about it, e.g. identify the issues within this case, what sort of support is available for this family, and so on. All stuff that will be explained to you in a lecture before the exam, and ad infinitum during the CBL course (but make sure that you know the aims and objectives for the paeds component before the exam – this is what the case is based on)

7. Growth stationa. This had multiple small components – we were asked to measure the head circumference of a

doll, talk through weighing a child, etc, and then interpret and plot growth charts. This is a really common station because it is very reproducible and demonstrates people who have been on the wards/in clinics, so it would be good to get very familiar with growth charts (though not in the biblical sense)

8. Radiology stationa. Wasn’t expecting this one! 8 chest x-rays and 5 abdominal x-rays on a powerpoint

presentation, with an MCQ answer sheet (no examiner). The conditions on the answer sheet were common enough, but the radiographs (especially the AXRs) were tough to interpret.

9. Developmental assessment stationa. Another tick box exercise with no examiner – we were shown a short video (twice) with a list

of developmental characteristics (lifting head independently, pincer grasp, walking independently, etc etc) and were asked whether the child could do each of these things or not (either true or false). Right at the end we were asked to work out the child’s likely age (in this case 6 months)

OSCE 2008 (I think from Ara)1. Respiratory OSCE2. Developmental Assessment OSCE3. Urinary Tract Infection Clinical Investigation (we were told that unless you get taught this, it won’t

come up)4. Growth5. Acute Paediatrics Emergency DVD station6. Neurology DVD station7. Paediatric (Neonatal) SCEE8. Cardiology (Heart Murmur) SCEE9. CBL GP station

OSCE 2007 (don’t know where this comes from)1. History-taking station

a. Elicit from mother a history of neonatal jaundice. Be prepared to discuss a differential diagnosis and your reasoning. Discuss management; i.e. investigations and treatment options.

2. GP station – Nb the format of this exam changed for our yeara. Examiner asks ten questions about the case scenario published before the exam. Our scenario

centred on childhood obesity and how you would engage with the child and family to tackle the weight problem.

3. Explanation and planninga. You are asked to explain to a mother that her child has had an infantile convulsion. You need

to explain what an infantile convulsion is, natural history of the condition, risk of further fits, risk of developing epilepsy, and advice about what to do should he have a further fit etc. Basically apply the same communication skills that you learn in the E&P module during NRO.

4. Clinical skilla. Explain and demonstrate to a mother how to use a peak flow meter and a metered-dose

inhaler with spacer device.5. MCQ Picture quiz

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Stage 2 – The Guidea. Identify a series of rashes/skin conditions and choose appropriate management plan e.g. treat

in the community, refer to routine paediatrics OPC, urgent referral etc. Chickenpox, HSP, NAI.

6. Developmental assessmenta. Engage the child in some play activities e.g. drawing shapes, stacking blocks and make an

assessment of their developmental age. Mention that you would also like to measure height, weight and plot on a growth curve and look at their “Red book”.

7. Neurological examinationa. Normal child. Mention that you would like to measure and record height and weight, head

circumference and plot on an appropriate growth chart. Ask to see the red book.8. Cardiovascular examination

a. Normal child. Again, mention about measuring height and weight and plotting on a growth chart and ask to see red book.

OBSTETRICS AND GYNAECOLOGY

Everybody’s favourite… 4 weeks at Addenbrookes rotating around the 4 sub-specialities there, plus 2 weeks at a regional hospital. O&G is promoted as being ‘the place where medicine meets surgery’, which is true, but it’s also the place where lack of teaching meets stubborn midwives. Personally, this was my least favourite rotation of the year – not because I inherently dislike the subject (I mean, I even teach it!), but because there is little teaching of poor quality from a very mixed bunch of consultants and registrars. Unlike, say, Papworth or NRO there is no continuity of consultants – every week you will start a new firm, which for me gave the rotation a very disjointed feel.

As with all of the rotations, it’s important to be confident examining patients early on.

At the end of the day, the teaching that you will get will almost certainly be full of holes and necessitate some support from your own reading. Having said that, the subject is much more manageable than some of the other rotations; it’s just the inconsistent teaching and seemingly endless waiting around that makes it difficult. For many years, apparently, people have complained about the course, or suggested improvements which have been largely ignored.

The rotation works as follows: 1 week of reproductive medicine – Mr Prentice and co, infertility, menorrhagia and the like. 1 week of foetal and maternal medicine, including one day on the delivery suite, which is just not

enough to learn the whole of obstetrics 1 week of gynae oncology (surgery) – stick to Baldwin and Latimer would be my advice (the legends

of Mr Latimer playing panto soundtracks in theatre are totally true), because year after year they are the consultants that are kind, interested, engaged and will acknowledge your presence in the operating theatre. DO NOT GO TO THE MDT – trust us…..it is not worth it……or if you do take entertainment OR play the drinking game designed by DB – drink every time Latimer mentions panto or fat people!

1 week of urogynaecology – Mr Slack et al, a very slow week that may afford some reading time 2 weeks of regional placement – this is where I would recommend you try and learn O&G properly,

because you get 2 weeks of consistency with a consultant that may learn your name. Also a very good time to get your pvs signed off. Don’t rely on it for seeing births as most DGHs have student midwives timetabled around the clock who will always be given priority over you.

Teaching It is based on Mr Prentice’s premise of doing rather than reading, which is great if you are a doer

rather than a thinker. For those of you who prefer to learn about gynaecology before inserting the speculum into the wrong orifice, this can prove challenging.

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Stage 2 – The Guide The timetable (again personalised) in Addenbrookes largely consists of outpatient clinics and theatre

lists. I would try and get to one each of the major clinics (as per the timetable) and one each of the major operations – if you’re interested continue, if not then I would shift focus elsewhere. It contains some teaching sessions and meetings but we found (2011/12) that most of these did not happen, at least not at the times on the timetable. There is one session called ‘ward round’ and put at ‘lunchtime’ without any location which turns out to be teaching by a really good consultant – you just have to do a bit of research in advance to find out where and when to find her. After three 7:30 non-starts in a row during panto week, we (MD and director) gave up on going to anything we hadn’t got strong, consistent confirmation of in advance.

You have to get 5 vaginal examinations signed off, which I think is more to do with the communication skills of getting consent rather than the actual practice. I found that this is incredibly difficult, but comes as a softer question after you have got to know the patient a little better and obtained a history. I also found that it was a lot easier to plan and achieve this in the regionals than in Addenbrookes, but that hasn’t been everyone’s experience. Some people report that a termination clinic is the best place to get the majority signed off, because of the large number of short operations: in my opinion this is somewhat challenging given the fragile state of some of the women going for a termination (and in many cases is actually very inappropriate), but is a practice that continues. Your PV sign off sheet will quickly become the most valuable thing you own – do not lose it!

Seminars and group teaching – inconsistent, far from comprehensive, regularly cancelled, but may occasionally be useful.

Regional placement – highly contingent on where you go. I was by myself in Bedford and received an hour of quality teaching every day from Mr Datta. I also used the regional attachment to try and fill in the blanks from what I hadn’t seen in Addenbrookes.

You are also expected to write some (very specific) reflective cases that admittedly no-one actually reads! See Medportal for further time-wasting details.

TextbooksI used Impey, written by someone in Oxford, but beautifully laid out in bite-size chunks with really nice summaries (especially at the end of the book).

ExaminationVery similar to the paeds OSCE – 8 x12-ish minute stations in steeplechase format. Details will be on Medportal, with a lecture (supposedly) in one of the final two R&I weeks explaining it all. Many people in my year found it tough, in part because all of the examiners are explicitly told at the start that they are not allowed to give you a hint of feedback as to your progress – hence they are all stony faced and impassive. Also bear in mind that you are likely to be examined on each component of the rotation, e.g. at least one station from urogynae, one from gynae onc, etc

Here’s what happened during the last 5 years:

OSCE 2013 (AWM)1. Contraceptive history – lady looking for a reliable contraceptive although she may want children

again at some point in the next year or so. Previous focal migraine and sister had a bad coil experience. Fairly straightforward if you know your contraceptives and the contra-indications. Viva was on summarising her history in 2-3 sentences, what her options were and what you would recommend.

2. Fertility history - given a referral letter showing normal tests for ovulation and partner’s sperm count. On history 2 years of trying and some recent deep dyspareunia. Viva questions on likely causes for her subfertility (tubal) and what investigations this would require.

3. Post-op history – vague pelvic pain two days after a (traumatic) birth with some systemic symptoms. Questions on what you would be looking for on examination (BP, HR, RR, T etc.), what tests you would do and your management (including ABx). Thought it was probably endometritis.

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Stage 2 – The Guide4. E&P – lady with 8cm fibroid, wanting to preserve fertility. Telling her what a fibroid is was not

necessarily part of the history. Mainly involved talking through UAE vs myomectomy and checking she understood.

5. Pregnant abdo – as standard, used both Pinards and sonicaids. Questions on investigations and management of pre-eclampsia.

6. Urogyynae history – post-menopausal lady who’s been told she might have a prolapsed by a nurse, ask her about it. She also had urge incontinence. Questions on management of prolapse investigation and management in primary and secondary care.

7. CBL – older woman with multiple kids, domestic abuse, DM, HTN, basically every problem in the world. Just say everything you see using biopsychosocial model. Knowledge of how to deal with domestic violence and public health – screening for it in pregnancy.

8. Cervical smear – standard stuff – remember to do the bimanual after! It probably won’t say to do one in the instructions, but it’s definitely a mark. Questions on post-menopausal bleeding investigations and management.

OSCE 2012 (Anna) 1. Urogynae history – lady with urge incontinence who was worried she may have MS as a friend of

hers did. Nice station – she had stuff to say for each history section and was very forthcoming – quite like stage 1. Questions about investigations and management in primary care and in the hospital.

2. Antenatal history – bleed at 30w. She seemed to have a learning disability; either that or the actress was having an odd day. She had had a miscarriage previously and was emotional about it. Low lying placenta. Summarise the history – she said in 2-3 sentences but I don’t really speak in sentences, particularly in OSCEs, so I waffled on for ages and every time I paused she looked like she expected more. Questions about likely diagnosis, other possible diagnoses and why you thought it was the one you said.

3. PCOS – not sure what they were looking for. You get a letter from the hospital to read first showing they have ruled out hypothyroidism and hyperprolactinaemia then you speak to her. She seemed to have very little to say – a very classic history of PCOS with no sexual history or obstetric history to spend time on. I finished very early (despite hundreds of “anything else you’d like to tell me”s), it was pretty awkward – I eventually told her her diagnosis just to break the awkwardness. Not sure what else should have been brought out – most people seemed to finish very early. Questions about causes of amenorrhoea.

4. E+P – the standard fibroids and wanting to stay fertile one with some cultural diversity thrown in. You get it in advance

5. Pregnant abdomen – standard examination then we were given sonicaids – we’d been expecting Pinards. They are easier to actually hear the fetal heart beat with than Pinards but harder to fake hearing it. Got some questions about investigating pre-eclampsia (or, rather, the question “what other investigations would you do?” many many times over.

6. Post-op – I didn’t get how this worked til a bit too late. We were expected to take a full history from the patient before speaking to any staff or reading her notes after being called to the ward to see her. Once you start asking to see the obs, etc, you can no longer speak to the patient. We were asked what we’d want to do then given the results of investigations and asked to interpret them. Spent the last 5 minutes discussing plans for elective. // Post-Op complication (kidney infection) – and management viva

7. Smear. Grumpy examiner who asked me to talk to her as the patient but then needed prompting to answer the questions – two unresponsive patients! She didn’t watch what I did and wouldn’t tell me

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Stage 2 – The Guidewhether or not she wanted me to do a bimanual and swabs too – I didn’t (there were no swabs), perhaps I should have done the pv. Questions about what to do if she had moderate dyskaryosis. // Cervical smear and explanation of screening program and followup

8. CBL – read case about girl who had had underage sex and abortion then given inappropriate contraceptive and now at risk of domestic violence. Lots of ticks for listing different support agencies. // CBL – 17 yr old female with previous TOP and social issues

9. Rest station

OSCE 2010 (Nathan)- I thought this was quite different from Stage 1: all the Hx stations had 3 minutes at the end to question you around your diagnosis- much more knowledge required than Stage 1 (or indeed Paeds for that matter).

1. Examine pregnant abdomen. Felt so long trying to palpate the ruddy thing I didn’t have time to use the Pinard. Present findings, discussion with the examiner about what I’d think about if urine dipstick found protein and her blood pressure was 160/95.

2. Amenorrhoea. Take history: she had PCOS and gave a pretty classic picture of it. Examiner then gave me some blood results, had to talk about how they’d influence my differential, then asked causes of amenorrhoea (and I forgot the pill).

3. Urogynae. Take History: she had urge incontinence, and was worried about MS which her friend had had. Examiner asked about treatment and hospital/GP investigation.

4. Gynae Onc. Take History: had felt a mass in her abdomen. Examiner asked about investigation of ovarian cancer and gave blood results, US report to comment on.

5. Ante-natal bleeding. Take History and reassure mother. She was 32 weeks I think and had placenta praevia. Examiner asked about possible causes of bleeding and how you’d manage it.

6. Smear. Easy, just practice it a lot. Also wanted us to do bimanual even though in reality it would be inappropriate and that wasn’t obvious from the instructions: for this one ask if they want you to do a bimanual (or vice-versa). Examiner asked about what the next steps would be if the smear came back moderately abnormal (i.e. she needs colposcopy etc.).

7. CBL. Again, just picking buzzwords. The case was somewhat forgettable.8. E&P. You’ll have scenario beforehand- ours was fibroids, lovely lady, good station.

OSCE 20091. Post-menopausal bleeding –

a. Take a history from a patient for 8-ish minutes and then answer some questions from the examiner about likely causes and further investigation

2. Post-operative complicationsa. Questions related to general surgical complications, and surgical complications specific to

O&G, are common in OSCEs, I think because it encourages you to think out of the box slightly and cast your mind back to last year’s surgical rotations.

b. We had to take a history from a woman who was some time post-CS delivery, who was now experiencing lower abdominal pain and fevers

c. After the history, we had to answer questions about a differential (remember to be logical about it – likely causes, what makes you think of them, and other things that you would be keen to rule out), and further management

3. Clinical skills – inserting a speculum and taking vaginal swabsa. Role-play with the examiner playing the part of the patient (I had a 40-something male

examiner pretending to be a twenty year old woman, complete with falsetto voice and lots of ‘oh thank you doctors’)

b. Just remember to keep calm and communicate!4. CBL

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Stage 2 – The Guidea. As with paeds, you have some reading time and are then asked a series of broad questions

(about 5 I think), e.g. identify the issues in this case, what agencies exist to support this person, etc

b. Our case was absolutely ridiculously complicated – everything on the O&G CBL aims and objectives was involved. I talked incessantly for the entire time but still missed things out

5. Urogynaea. Take a history from a woman with urinary incontinence for 8-ish minutes and then answer a

series of questions on how you would further investigate this patient, management options and likely diagnosis.

6. Examination of the pregnant abdomena. Examine a genuinely bloated pregnant abdomen and use a pinnard stethoscope (which you

will probably have never seen before in your life! – don’t panic, it is very easy) and answer a couple of questions on the examiner, including a presentation of your findings

7. Explanation and planninga. It will vary every year, but in O&G Mr Prentice is keen to highlight cultural issues which will

form a component. We took the role of a GP who had to explain fibroids and management options for a woman who wanted to retain her fertility

8. Subfertilitya. Another history taking session from a young woman (around 30, I think) who had been trying

for some years to get pregnant with her partner, before a couple of questions from the examiner on the likely diagnosis

OSCE 2008 (possibly from Ara)

1. APH2. Menorrhagia3. Case-Based Learning4. Partogram5. Post-operative Complications6. Cervical Smear7. Contraception8. Obstetric Examination

OSCE 2007 – Unknown source

1. History takinga. 8 minutes to take a history from a 35 year old woman presenting in 31st week of pregnancy

with an isolated bleed 3 hours ago accompanied by a poorly localised lower abdominal pain. No mucus PV. She has had a previous bleed at 9 weeks. Worried about miscarriage - sister had prem labour at 32 weeks (I think). Also, had a previous miscarriage at ~11 weeks 3 years ago. That is her only previous pregnancy. A previous USS revealed a low-lying placenta.

b. The consultant then interrupts you and asks for a 3 sentence summary of your history and asks a series of questions: What is your main diagnosis? What is your rational? What else in on your differential diagnosis? What further investigations would you like to perform and what is your management?

2. Viva on recurrent miscarriagea. What is the difference between sporadic and recurrent miscarriage?b. Why is the definition of recurrent 3+ consecutive miscarriages? Why is this a trigger for

further investigations?c. How would you investigate recurrent miscarriage? Mention:

i. Autoimmune causes - lupus anticoag, anticardiolipin, antiphospholpid antibodiesii. Karyotype of parents

iii. PCOS etc - measure androgens, ovary u/s, hairy

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Stage 2 – The Guideiv. Anatomical causes- pelvic u/sv. Infection - swabs

vi. obesity, age, smokingd. The consultant shows you a picture of a balanced Robertsonian translocation from the father

and asks you what it is.e. Why would you be interested in the father’s parents’ karyotype?f. What is the chance of the fetus being phenotypically normal? Explain how you came to your

answer.3. Clinical skill 

a. Perform a speculum examination and bimanual pelvic examination on the manikin, Communicate with the patient (the examiner!!) and talk through each step as you go. Fortunately my examiner was female!!

4. Management of ectopic pregnancya. The examiner asks you a series of questions about how you would manage an ectopic

pregnancy. b. You are a junior doctor

i. What aspects of the history do you specifically want to know about? E.g. Past history of STIs, IVF, past episodes of PID, IUD, surgery

ii. What is your management over the next 30 minutes? E.g. summon senior help, Bloods – FBC, U&Es, crossmatch, fluid resuscitation, analgesia, consent for surgery.

c. She has a salpingectomyi. What is the rate of recurrence- 10% chance of recurrence, 30% never conceive again.

d. Further management? - counsel the couple about getting pregnant again etc.5. Explaining and planning

a. 35 y o woman bridgette jonesb. presents in 11th week of pregnancyc. She’s just had an u/s scan which was normal - viable fetus etcd. She is concerned about Down’s Syndromee. Basically you have to elicit her concerns about Down's and explain the principal and process

of screening and diagnostic tests for Down’s syndrome.6. Interpretation of a Partogram

a. What is a partogram?b. When would you use it?c. The examiner points to the Alert and Action lines and asks you to explain what they are.d. An intervention is given at 1400 hours. What is the intervention and what is it used for? I

think the patient was given oxytocin.e. Ranitidine was given at one point? What is ranitidine and why was it given?f. Why is the fetal heart rate accelerating  (?from drug or something)g. What other method for measuring fetal heart rate is thereh. What intervention would be given at 23 hours- I think it was prolongation of first stage of

labour and so the answer was CS.

PSYCHIATRY

A very variable experience, depending on your interest in mental health and where your rotation occurs. There is a day of lectures once a week that will cover the majority of topics that you need to know about, but may not be comprehensive in covering all of the information that you need to know. Each regional hospital will manage their students very differently (and the same hospital may change their approach with each subsequent rotation), so it may not be worth my while telling you everything about my experience in Fulbourn.

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Stage 2 – The GuideGenerally, though, I think it’s important to be comfortable taking a decent psychiatric history and mental state assessment and being familiar with all of the major psychiatric conditions. Most people get the opportunity to see most things at some point, but some are luckier than others. You have to write up 6 cases and present them to a consultant – as they recommend, try and do one a week or you get VERY behind…

For those of you preparing for exams (as I was) the pace of psychiatry can be frustratingly slow at times, but also refreshingly holistic at others. It is certainly a very different experience from the other stage 2 rotations.

Teaching Lectures – every Friday of the rotation, of very variable quality and content. Most become available

electronically at some point (and they seem to be more receptive to giving their powerpoint slides away on USB sticks, etc, than other specialities, especially if you ask them nicely). They are mostly interesting, but I have to say that I didn’t get a lot of useful, clinically applicable information out of some of them.

Medportal materials – lots of old lectures (some of them on the same topics, so you can pick and choose the most useful) and a couple of great handouts (especially neuropharmacology).

Regionals – dependent entirely on where you are. Fulbourn was good, from what I can gather. I was attached (on my own) to two consultants (one based on the wards, another based in outpatients) who were both very keen to teach and involve me in everything, as were the reg and junior staff. We each had a personalised timetable of child psych clinics, and others were available if we were keen and asked the right people. For example, I was able to phone up various people and observe ECT, the eating disorders unit in Addenbrookes, home visits with the CPNs, on-call in Addenbrookes, etc. – loads of stuff. We also had a weekly teaching session in Fulbourn, and lots of ad hoc teaching from various people – one of the virtues of the slower pace is that people seem to have more time to discuss and teach! I would (as ever) recommend getting as involved with the ward and consultants as much as possible, to get a full view of what goes on in this rather unusual speciality.

TextbooksI was given the advice at the start of the attachment to learn Psychiatry at a Glance (4th ed – earlier ones are noticeably much poorer) cover to cover, plus the neuropharmacology handout on Medportal. This is excellent advice, especially if you don’t like psych. But even if you do, that is the vast majority of what you really need to know.

ExaminationAn exam on the Thursday of the R&I week after the attachment, the format of which changes every time. Some have MCQs, some short answer questions, some essays. Mine was 10 mini-essays in 90 minutes on subjects including:

1. Schizophrenia (diagnosis, features) 2. Depression (classification, diagnostic criteria) 3. Neuroleptic side effects 4. Rapid tranquilisation regimes 5. Personality disorders (features and methods of presentation) 6. Autism (features, epidemiology, prognosis) 7. Alcohol (intoxication, withdrawal, foetal alcohol syndrome, Wernicke's, Korsakoff's) 8. Easting disorders (differential diagnosis, investigations) 9. Conduct disorder (features, related disorders in later life) 10. Phobias (features and treatments)

There is, allegedly, a prize for the highest mark in each rotation.

Psychiatry is, as with everything else, tested in finals, including OSCE-style stations.

PATHOLOGY

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Stage 2 – The Guide

Lots of people will probably give you lots of advice about pathology, much of which is totally contradictory. Here’s my contribution to an ever-growing mess of suggestions…

SyllabusAlthough the exams ultimately don’t really reflect it, I would suggest downloading it and at least printing it out to give you some direction navigating this huge mountain of info. Printing it out and reading it takes at least a week… The tables give a rough indication of what you need to focus on, but they aren’t 100% complete (for example, influenza wasn’t in the tables, but we got an essay on it – that said, flu should obviously have been in the tables anyway). Be aware that the prose descriptions of what you should know often contain diseases not mentioned on the tables.

Materials Textbooks – see individual sections.

o People will inevitably ask when to start ‘revising’. For most people, it isn’t revision, rather ‘learning for the first time’…

o My advice is to start working on path at the start of stage 2, by doing the part of the path syllabus associated with your current rotation. E.g. doing all of the gynae-related path during O&G, all of the neuro related path during NRO, etc. It helps to understand these topics and it helps revise later on down the line if you’ve already started.

o As for starting revising properly, including all of the other things that you’re never taught about, many people say that after Christmas is the time. Personally, I think that it’s up to you, and how you like to work – but you must be well on the way by the time of your last rotation!

Lectures – see individual sections Medportal

o Contains a number of good powerpoint presentations from lectures (including previous years) if you can find them, which isn’t easy.

o The path section itself contains some good cases which serve as revision for the practical paper (some of the exact same pictures came up in the exam), though these cases are generally harder than the exam itself.

o There are also a set of good web links to a sample of MCQs, and some revision sites from other universities and elsewhere

o There are now podcasts. Our year (2011/12) was the first with them and so they were far from comprehensive, many only appearing near the end of the year. Personally, I find them completely unusable but many people seem to like them.

Supervisionso Are not forbidden! Officially, colleges are told they shouldn’t be necessary but they aren’t

banned. Some colleges get loads of teaching from the examiners themselves provided without the students needing to ask; other colleges refuse endless requests for teaching; and most fall between the extremes.

Previous exam questionso There are documents of essay questions (which should be somewhere in the clinical school

library) and practical questions. If you didn’t receive them with this document, ask around and someone else will probably have them. If not, my e-mail address is akg39@cam.ac.uk

Each other…o Realising that pathology was a mountain and that we were all slowly climbing up it together,

we at Clare decided to hold revision sessions between the 7 of us. Each week for 6-ish weeks, we wrote plans for 7 essays (each of us doing two different essays, so that there were two essay plans for each essay – get it?), covering 7 different topics each time. One of us chose the essays, looking back over previous essay plans and working out common/likely essays and emailed them out. We then wrote brief notes/diagrams/mnemonics/tables/whatever on a single sheet of paper to try and answer the question. Then, once a week, we would meet to discuss what we had written. Beautiful socialism in action.

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Stage 2 – The Guideo It worked amazingly well – of the 7 essays in our exam, we had already written plans for 5 of

them! We managed to cover the majority of the major topics, enabling to revise a vast chunk of the syllabus together. It really, really helped.

And now each of the components in turn…

Histopathology Something of a misnomer, as there is actually very little histology in the exam, but this forms the

biggest chunk of the path syllabus (if not medicine in general) Lectures – VERY mixed, but some good handouts did creep in. Textbooks – debatable.

o I used ‘baby Robbins’, i.e. Basic Pathology, rather than ‘big Robbins’ – big Robbins is huge and unwieldy. Basic Pathology is still big, with plenty of great information and diagrams and stuff, but has less detail that you simply do not need to know, and also less obscure diseases that you don’t need to have heard of.

o Pathology, by Stevens and Lowe, has some great diagrams for the practical exam, but the text I found to be inconsistent and not brilliant

o Crash Course Pathology – don’t knock it! Unlike the other books, it presents pathology in a memorable form, clearly organised. The chapters are variable, however, and do lack detail – for each topic I would start with Crash Course for the basics and a decent structure, and then go to Robbins to fill in the gaps

Biochemistry In my humble opinion, this was taught rather poorly in parts (especially those tutorials – ‘let’s quiz

the students on things that they haven’t been lectured on!’), but I understand that this section of the course is getting a revamp. (2011/12 update – not sure it’s really taught at all now…, although there are some excellent ‘revision’ lectures in the week before the exam)

Lectures – some are good, thorough and clear; others simply a mess Textbook – something thin and digestible. I used Lecture Notes on Clinical Biochemistry (or

something similarly titled), which I thought was fine, but there are a few comparable books (like Clinical Biochemistry: An Illustrated Colour Text) out there that are very similar content-wise – some are just more colourful than others! See what you fancy.

Haematology I never understood any of this until just before the exam. Our lectures were instantly forgettable and

confusing, and inconsistent. Lectures – apart from a few really good revision sessions right at the end (if you want to leave it that

late), not particularly helpful. Textbook – I used Essential Haematology – it’s quite long, but it also has lots of pretty pictures and

summaries, and I found it very readable.

Micro This is vast and complicated. I spent ages creating the ultimate reference table to micro during my

revision, but ultimately had the easiest possible questions in the exam. Can’t win, can you? There are two major approaches – infections by system (meningitis, pneumonia, etc) or infections by

organism (viruses, gram positive cocci, helminths, etc). I did it by organism, though I think that system is probably more sensible, and reflects the way that it was lectured

Lectures – probably the best in the pathology course – the lectures handouts (though they contain a few large holes) are generally very good.

Textbooks – difficult, because there is no comprehensive one that covers the course in the appropriate level of detail. To supplement the handouts, I would suggest Lecture Notes on Medical Microbiology (or similar title), which divides the illness by both system and organism. Very handy! But there are others that may be just as useful

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Stage 2 – The Guide

Immunology The dribs and drabs end of the course – I just used my lecture notes for this, because you cover the

majority of it elsewhere in histopath, etc.

ExaminationThe whole thing is split into the 3 familiar examination formats:

1. MCQsa. A mixture of true-false, best of 5s and extended matching, over 2 hoursb. Every year in March during the R&I week there is a prize (of book vouchers) exam with

questions that are very representative of the MCQ exam. Because there are no official past questions available (the one paper in the library marked ‘Pathology’, in my year at least, was a mislabelled finals paper), this is a good time to get a) practised, and b) petrified.

2. Practical papera. 3 hours, 10 stations, 18 minutes each.b. We had a steeplechase of folders that we passed along a bench to each other. Each folder

contains a clinical story, with blood results and macroscopic pictures (very few microscopic, if any) and 4-5 questions that you are asked to give brief answers to. The story is usually along the lines of: Mrs X is a 60 year old woman who presents to you with Y symptoms. Her blood results come back like this… What do you notice? What is the differential diagnosis? Two weeks later she dies. At autopsy this was revealed… This picture was taken. Described this picture. What is going on?’ etc etc

c. For example, we had cases of emphysema, thalassaemia, multiple sclerosis, cervical cancer, phaeochromocytoma, etc

3. Essaysa. 7 essays in 2 hrs 20 minutes (i.e. 20 mins each). b. The same essays come up time and again, and it would be foolish not to look at the previous

questions that I will amass and send to you. For example, you will notice that there hasn’t been a heart-related question for 10 years, and that cancer comes up at least twice a year… I can’t promise that you won’t get an essay on heart failure, but playing the percentages you would be crazy not to revise bowel and lung cancer.

c. I noticed that there is a trend for the same questions to come up every 2-3 years, so make sure that you consider answers to these questions.

VivaIf you are really talented (or just get really lucky, as in my case), the top 20-ish % of the year get viva’d for a distinction, which is CV-worthy material. In my year, around the top15-20 people got a distinction, following a viva which is on the Friday on the week after the exams. Those who have a viva are announced on the Thursday evening before the viva (!). We had two vivas, each lasting 20 minutes. In each viva is a panel of 3 people (most of whom will have lectured you and are responsible for the course, and normally ask you questions within their area of expertise), normally from different components of the course (i.e. histopath, chem, haem, micro or immunology). One person will ask a series of questions on one topic, then a second person will ask you a set of questions on a second topic.

There are no set questions, which vary from year to year and viva to viva, but tend to be on the nittier-grittier side of the path syllabus and yet still (mostly) things that you will have been lectured on. Examples of topics of questions that I, and other people that I have spoken to about it include: HbA1c; hereditary bowel cancers; LFTs; the relationship between CRP and heart disease; classification of ovarian cancers; the nature of prostate cancer screening programmes; glomerular disorders.

My advice – just go for it. Do a token amount of revision the night before to put you in the mood, but don’t worry about it, revel in the fact that you won’t need to repeat the exam in October, and try and give clear, structured answers. If you don’t know, try and work it out but don’t lie and acknowledge your boundaries.

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Stage 2 – The GuideThere is no way to predict the questions, and there is no way of revising all of the material in such a short space of time.

As an aside – don’t assume that you definitely will or won’t get a viva. Some people in my year revised all week for an exam that they didn’t get; others booked flights for their elective that clashed with their viva and returned from the airport to take their exam.

A few general points of advice: Never give up! A consistent amount of reasonable work over a period of months (rather than hours!) will almost

certainly produce both better results in exams AND a better appreciation of these topics when it comes to actually applying the stuff as doctors.

If you can, during every rotation try and cover the pathology related to that rotation as you go along (e.g. gynae malignancies, etc, during O&G; rheum stuff in NRO) – this will make the burden a lot lighter when you get closer to the exams.

Revision sessions with other students – essay plans and spider diagrams are the key to pathological success!

Don’t let pathology ruin your other exam results – people seem to get swept up in a big path competition during the exam season, and although it requires by far the most revision, it is actually worth less to the year’s results overall than O&G and paeds.

Never give up!

And the final word from Kenrick (sound advice): Don't panic. Save fancy/rare stuff for later (if time!) The Curriculum is confusing and difficult to understand. When covering a topic, look at both the

tabular section and the bulleted section (usually after the table). Tick off sub-topics as you cover them.

There's cross-over between histopath, chempath and micro e.g. infectious endocarditis comes up in both histopath and micro. In these cases, let your revision be guided by which subject (histo/chem/micro) the essay questions approach it from.

There's a huge amount to learn, but it _isn't_ conceptually difficult for the most part (renal histopath for me was an exception). It's a slog, but there's nothing intellectually difficult about it. A day or two spent organising lecture notes, finding (on Medportal or from friends) and printing missing notes, and getting books etc is time well spent.

One can't afford to have favourite/pet topics, you (probably) won't have time. Allocate time to topics objectively.

Lecture notes on their own (probably) aren't sufficient. I missed a fair few lectures and the handouts for a fair proportion were useless. Before covering a topic, decide what you're going to use as your reference material: lecture notes or textbooks (or a combination).

Books are only any good if you actually read them. Don't buy a big thick text if there's no chance you'll get through it - 'tis better to have a small/concise text and read it.

Essay plans are a Very Good Thing but remember you've only got 20mins, so keep it concise. The same topics come up again and again (e.g. micro/macro/normocytic anaemia for haem), so knock up some general essay plans that can be tailored to a specific question.

Remember there are 3 papers, equally weighted, so don't focus all revision on just essays or MCQs etc.

For endocrine path, it's a good idea to know the various tests and the order that they are used in diagnosis (i.e. cheap screening tests followed by specific expensive tests), and what is a positive and negative result.

The MCQ question bank is finite. The same question bank is used in the Henry Roy Dean exam, which counts for nothing (I bombed in it), but offers a 'free' look at a proportion of the questions.

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Stage 2 – The Guide Ignore what other people are doing. In my experience, everyone revised in a different way and to a

different depth in different areas We all still made it through.

Extra advice from Anna: There are many many diseases you will have to learn about that you won’t yet have seen patients

with. These diseases can all merge into one big mess of aetiologies/investigations/pathology/etc if you have nothing but black and white print to link them to in your head. I found I could make them realer/more memorable by

o Looking them up on Wikipedia and reading any ‘notable cases’ or ‘popular culture’ section. Not present for all diseases but very good for some – particularly porphyrias!

o Googling ‘[disease] forum’ – most diseases have specific charity websites and forums; I found reading patient stories and everyday concerns made the disease more interesting and memorable

There are some really useful apps. I found flashcardmachine particularly helpful – you can make flashcards online or on your phone (no limit on size) then use them when you have a moment. Particularly useful for memorising the rote-learny information like bugs

Don’t underestimate the oxford handbook! It’s certainly not a path textbook but it often has useful summaries of details that are widely dispersed through more pathy textbooks – e.g. antibiotics (p378-381) and autoantibodies (p555)

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