Postgraduate Examinations

Dr Phillip Welsby shares some MRCP tales…

My guilty secret? It took me three attempts to pass MRCP.

I qualified from the Royal Free Hospital School of Medicine for Women (that’s another story that has nothing to do with my sexual orientation in case you were, as you were, wondering). In the olden days in London it was possible to take the Conjoint Board Finals before the “official MB BS” and this also allowed an attempt at part 1 MRCP only a year after Conjoint. So I turned up and used the technique that I subsequently recommended to students. Rapidly go through the questions only answering those you were sure of the answer. Then divide the time left by the number of unanswered questions minus those you were certain you did not know the answer and allocate each question this duration. Hopefully you would have time left to address the unknown answer questions. For these answer “Yes” if there is but one contradiction to “None of the above” or “No” if there is but one contradiction to “All of the above.” If there are marks deducted for incorrect answers then answer “Yes” and “No” alternately. If there is no negative marking answer “Yes” to all. I passed far too early in terms of lack of experience. I was however early leaving the exam about ten minutes before the end, so pass or fail I had gained ten minutes. I passed.

This disastrous passing meant that I attempted 2nd Part far too early and failed.

I was distracted from studying for my second attempt because I was constructing a virginal (that – in case you were wondering – is a box shaped harpsichord) and deservedly failed.

I then became sensible and passed at the third attempt. All my postgraduate posts had been in a peripheral “primary referral” hospital and when on-take we initially dealt with everything. When I returned to teaching hospitals I realised I had more clinical experience than my contemporaries, who had remained in the so-called centres of excellence.  Passing was a relief tinged with sadness. My time in the peripheries had been very happy but now I had to decide how to move on. I opted for the High Road to Aberdeen for a rotating registrar job where I discovered Infectious Diseases.

A Senior Registrar post back in London and then the High Road to Edinburgh for a Consultant post where my involvement with examinations including MRCP became a regular commitment. I was pleased to note that my recommendation to the Consultant interview Committee about how the MRCP should be improved “It needs to be standardised because candidates feel, especially about the long cases, that luck played a disproportionate role – if you had just finished a cardiac SHO post and you had a cardiac patient you were, and were perceived to be, distinctly advantaged.” No one on that Committee thought to ask me what my long case was!

Then, predictably but unexpectedly, I became a MRCP examiner. I was apparently rated halfway between a dove and a hawk. I like to think I would have passed all stations. Except one. A strikingly tall thin chap (spot diagnosis Marfan’s of course) and I was asked to examine his upper limb and whatever else I thought necessary. High ho!  Off I would have gone looking for signs of aortic valve pathology and trying to confirm a collapsing pulse with a wide pulse pressure. In my diagnostic overenthusiasm I would have failed to note the ptosis and his somewhat stiff arms and I certainly would not have tested his failure to relax muscles and their tendency to contract on gentle percussion. He had Dystrophia myotonica. Mind you, I occasionally used to bring up a lady with this when I hosted MRCP, and on the one occasion she turned up wearing Muscular Dystrophy t-shirt only half the candidates remarked on this.

Examiners are not supposed to ask questions of the candidates during a patient’s examination: sometimes a pity. We had a neurology patient with a hemiparesis and the candidate seemed particularly interested in the face and at the time we wondered why although we suspected the reason. It was confirmed when he replied to our initial request for his overall assessment and treatment. “Mr X has a left hemiparesis of long duration because of contractures and his carotid pulse is weak on the right side. The priority in his case is obviously to treat his facial basal cell carcinoma. I subsequently remarked to my fellow examiner “We should have passed him even if he had diagnosed in growing toenails!

The best reassurance I have ever witnessed was given by an Australian male candidate who had obviously developed “significant rapport” with a young lady who had developed post dysenteric arthropathy after a visit to India. She as instructed asked him how long it would be before she would return to normal. “Well, within the next three months you will be able to dance the night away every Thursday.” Neither the patients nor the examiners enquired about the specificity of the Thursday although I suspected it might have had something to do with his on-call rota…

The most theatrical exhibition by a candidate was at the examination of a degree in Tropical Medicine when I was a Senior Registrar at the Hospital for Tropical Diseases in London. The patient had recently returned from West Africa and had noted worms wriggling in her skin and across her eye (I have a picture of the Loa loa worm being pulled from her eye if anyone wants a copy let me know). The candidates had interviewed her and presented himself to the examiners. Unbeknown to the examiners the patient had noticed one under her skin and had nipped it out using her longish fingernails. He announced to the examiners “This patient has confirmed Loa loa.” The examiners asked how he could be so certain whereupon the candidate dropped the wriggled worm onto the examiners’ desk.

Some candidates achieve distinction by failing to note obvious abnormalities. We had a patient whose umbilicus had been rendered absent by surgical means after recurrent sepsis. Only half of candidates remarked on this.

Some candidates miss obvious clues like a splint beside the bed (foot drop) or on one occasion a patient was asked to get themselves out of bed and walk despite the presence of a wheelchair.

Some candidates thoughtlessly conduct a “technically perfect” examination including testing for coordination in a totally paralysed limb.

One serendipitous question occurred when a bowl of water was present in the corner of the ophthalmology section “What does this tell you about the patient?” That he is blind – in both eyes – as he needed a guide dog.

The ultimate failure was with a patient with Spina bifida who was sitting in a chair and the (male) candidate tested the knee jerks whilst crouching directly with his legs akimbo in front of the patient. This produced a dramatic confirmation of an increased knee jerk (in the circumstances only one was elicited).

My greatest worry as a host examiner is that patients would not turn up, because of adverse weather conditions, transport difficuties, or other unpredictable problems. I have to report that, thankfully, we were not hosting MRCP on the day Sean Connery was visiting the AIDS Hospice that lay within the grounds of the City Hospital. That one person could cause a focal benign hospital paralysis of psychoneurological origin verging on hysteria was an education.


Philip Welsby is a retired consultant in Infectious Diseases based in Edinburgh. He is an Assistant Editor of the Postgraduate Medical Journal.

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