Deetas Tips

How to pass the Clinicals when you're fat, female, fertile and fourty...

Tuesday, 25 September 2007

Ingredients:

Method:

Well, I work in the country doing CAMHS so I had to get my head back into General Psychiatry. I fronted up to the task following a successful 8 week preparation for the Writtens 18 months earlier, but then fell over resubmitting Cases a total of 7 times. I was traumatized by this, angry, and my confidence fairly well trampled.

Nevertheless the instinct to escape Basic Training propelled me forward.Economy of approach is the key concept but this involves having as clear an idea as possible of what is needed -and delivering exactly that. This is doubly important with the RANZCP Clinicals because despite all the "standardized" rhetoric and "just do what you normally do" from the lovely Dennis the Clinicals felt highly contrived with a specific and refined approach required. I don't think the scatter gun "learn everything for 18 months solid" is worth it. If you've got through the Writtens -then you've done enough of that. Specific, specific, specific.

So I started by attending the weekly MSE tutorials for the second year trainees in Bendigo...about 4 weeks did the trick. I got used to the standard lingo again. In the meantime I fronted up to weekly practice OSCE'S arranged at one of the city hosiptals. It was a bit of a schlep in the car but well worth it.

The format was such that one week we were the patient, one week the candidate and the other week the examiner. Sitting in all of these roles was crucial to getting the gist of what was asked for. more important still was the fact that we had to design and write the stations too.

I think the OSCE's are the easier of the two components because they are highly formulaic, you have 6 shots at getting marks ie. on each station, so if you bomb on one you can recover or regain some ground on another. You may be relying on these to pull you over the line.

The OCI's are another matter, high risk, unpredictable, incredibly high stress and the most ridiculous obstacle course I have ever traversed. Everything seems to depend on the expansion, compression and re-expansion of knowledge under highly constrained conditions with virtually zero margin for error. Timing is EVERYTHING. I'm sure 5 minutes more thinking time would make a difference between a pass rate of 50 and 65 percent.

I started by trawling the adult psych wards with my mate Li. Because my preparation was highly compressed I realistically saw 5 patients under semi-exam conditions. That meant keeping to time on one or 2 components of the exam and blowing the rest.

I did 3 real practice OCI's under exam conditions and reckon if I'd done only 2 would have failed. In the practices I failed 2 and passed one, with a patient who was highly cooperative and a pretty good historian.

Some of my cohort were sitting for the 2nd or 3rd time and were very anxious and convinced this exam was not passable. We were all desperate to get through and would spend the weeks leading up to the big week trying to prop up each-other's confidence.

In the week before the exams we all tarted ourselves up in our exam gear and sat in a chair giving a 5 minute dissertation on our least confident topic. The plan was to see what gestures and body language we adopted when we felt we were bullshitting. The interesting thing that came out of that was the less we knew the more we talked, chewing up valuable minutes to score marks on another topic. So we resolved to give a brief answer attempt and move on to the next question for another mark scoring opportunity.

There are a few areas that need special mention and I'll list these randomly:

The week of the exam itself was scheduled like a military operation. I was sitting interstate. My OCI was on Wednesday AM and the OSCE was Saturday AM. My children are aged 8,6 and 3 and 1/2 and really miss me when I'm away for more than one night, so I elected to come home in between the 2 exams. The cost of the extra flights was about the same as the cost of staying in a hotel for the same time. This also worked out really well because I become a bit unhinged when away from home and my family. All my useful stuff was in my office or on my computer. Being able to kiss my kids good night and whinge to my husband was really important and kept the guilt and anger at having to subject my family to this stress and ridiculousness at bay.

The night before the exam I was lonely and freaked out and just studying over and over and becoming increasingly panicky. I slept poorly and had some Gulf soccer team sleeping in the room next to me. Their excited ,loud talking and carrying on kept me awake as well. In the morning I still felt pretty shabby and fragmented and Oh so tired. I pulled out the trusty ipPd and listened to Gillian Ross's meditation which goes for about 30 minutes. It did the trick and stuck me back together again -kind of felt calm enough and like I could think.

I arrived at the hospital early of course, and plugged myself back into the iPod. I'm to embarrassed to 'fess up to what I was listening to but had it going until the bulldog took me to the exam room...then GAME ON.

My patient was nice, she was recovering from a manic episode and a straw poll of all my mates revealed lots of patients with bipolar illnesses with lots of psychosocial and medication issues. Luckily there was a bit of lovely manic energy still driving her and she complied quite happily with a rather pressured interview.

When the interview was finished all I wanted to do was put my feet up, exhausted after completing a ridiculous amount of tasks simultaneously, but that is the exact time when you have to change gear and go for it all over again.

I always started with the Action Plan and worked my way back from there...but I didn't complete my Formulation or Mental State Examination properly because I went a bit baroque on the aforementioned Action Plan.

Winging it in the presentation was vile. All my video recorder rehearsed composure went out the window and all the characteristic panic and horror gestures returned, as I laboured my way through what I'd cobbled together.

Question time for the first sections was highly lumpy, and absent for the second section, because I'd gone overtime on the blessed Action Plan.

I exited smiling and shaking the examiners hand with a "positive" smile, nodded and smiled to my bulldog and thanked him, for he'd been very kind, and walked to the outside of the hospital where I found a bush, hid behind it and burst into tears.

I rang my husband and told him it was pretty ugly but I thought I might scrape through. But with every subsequent 5 minutes I had revelations of serious ommisions and further clumsiness or incompentencies, and returned home glum to submerge myself in my delicious family chaos as a welcome distraction.

The OSCE's was much more fun. You see we're all in it together. Many of my exam cohort that I had befriended at OSCE practice met in my hotel room the night before. We revised somewhat, and bitched and complained and catastrophized about all that had gone wrong in our OCI's.

The exam itself had a carnival atmosphere with actors, examiners, bulldogs and the like. The gist was guessing the overt and covert agenda and making sure all bases were covered. It, too, is a grueling exam but the worst bit is the 40 minutes or so after the exam where we're quarantined en mass while the next group are preparing to start...without grog!

By this time I was convinced of having to front again for this horrendous exam and resolved to bring a hip flask for this bit of it...I don't know if this is legal or not because I never got to find out.

I passed.

I bloody well passed.

I was shocked, really shocked but also elated and alternatively numb. My plan, if I failed, was that at least this time I'd have a clearer idea of what I was up for and target things just a little better...but most of my re-sitter mates did not seem to be reassured by this as their second or third passes at the exam approached. I think the stakes get so high that a "chocking" factor starts to operate that counteracts any experience advantage.

Anyway like many of my successful colleagues the crash was around the corner. You see, after smilingly informing all at work that you passed, you're suddenly up for Advanced Training, more work, a slab of learning goals, CME activities, leadership modules and so forth. Oh yes and risk assessments, difficult clinical work and all the other stuff we have to endure.

Three months down the track we're all dragging our heels and are "over it". It's Burn Out City.

So that's where I'm at...still just surviving training. I'm so grateful for all the great teachers and registrars, and of course patients who helped on this journey and gave their time and care so generously and unfalteringly. I simply couldn't have done it without them. It's not that I'm unappreciative, believe me I am. I'm just buggered, in a way that doesn't seem to get better over the weekend.

I'm retreating to research to heal and process much of what I've been through in the last few years. I just wish the College would collect some data on the impact this has...the cost to us and the profession and the subsequent fall out. Maybe then they will not stand there full of rhetoric about how good and fair and infallible this process is?

In the meantime take care...

And a very special thanks to Prem Chopra and Di Kirby and of course my very patient husband, beautiful kids and family.

Deeta Kimber