Our Stories

Clinicals - Our Stories

Sunday, 23 March 2008

Its yet again that time of the year when we have some of our colleagues running around to find that magic formula in their endeavour to achieve the ultimate nirvana of our academic/professional life – RANZCP Clinical Exams. For some these are the countdown days that are the only hope to get out of the everyday misery of basic training, and to live life in a more coherent manner.

Just writing this introduction is enough to reawaken all of those memories from 5 months ago when I was one among the “nirvana seeking” lot, picking up the scattered pieces of my ego after every trial OCI in the hope that the next one would be perfect. But that perfect day never came; not even the real exam day, yet somehow something worked for me that saw me through the whole process.

This is not just my story, it’s shared by my two (and many others whom I spoke to) other colleagues with whom I prepared for this exam. It was the first attempt for all of us and we all passed (hmm, still hard to believe, but its true).Now that we are somewhat recovered from the traumatic memories of those long months, we thought it might be useful for us to dot down our take on the process and share with you the “somehow something” (that I alluded to before) that worked for us.

We decided to share our personal stories in our own words to emphasize that there are different ways to go though this journey and yet pass the exam. We sincerely hope that this endeavour would give you hope, reassurance, and encouragement to keep going and may be you can find that “magic formula” in our stories.My preparation for Clinicals:

Raj Maheshwari

Time:

I gave myself 4mnths, including a month of procrastination and gradual warm-up. But I recommend taking 5-6mnths as a good preparation time, only if u can afford that.Where to start:

I started practice with a colleague on a very informal basis, which helped me control my anxiety and allowed me a easier way to check what was I getting into.

I contacted some of the colleagues who had passed the exams recently. They all had different success secrets that were modified to their very individual abilities, and most of it didn’t seem relevant to me at the time, but it was at the later stages of prep that I found them very handy in my darkest hours. -

ANZAPT website is an essential resource to start your preparation. It’s not only the study notes or the old exam questions, but also the “straight out of emotional pit” accounts of struggle and survival that gives you a glimpse into what lies ahead. -

“The Westmead Guide to the RANZCP Clinical Examination” is probably the best guide to give you a comprehensive overview of your coming 4-6mnths.What did I read?:

RANZCP information on the exams and its marking criteria (I read it almost like the God’s revelation to me...almost every few days….and surprisingly I could bring out new interpretations every time I read….College pays extra for the ambiguous language used in those explanatory notes )

RANZCP guidelines

For case formulations

Psychiatric Case Formulations –Sperry, Gudeman, Blackwell, Faulkner
An attachment theory approach to treatment of the difficult patient – Peter Fonagy (article from 1997) -

The Psychiatric Interview –Daniel J Carlat ( just the most simple yet comprehensive pocket book to prepare for the exams. It tells you interview techniques, questions to ask, framework for your interview, and the mnemonics –just the one stop shop) -

Beat The Boards (website) –12 mistakes that will sink your psychiatry oral boards (Dr Jack Krasuski may look bit dodgy in his photograph but he knows what gets you ticking in the exams; it’s a very valuable read to recognize your natural style and work on your weaknesses)

For Forensic stuff –Paul Mullen’s chapter in the New Oxford Textbook of Psychiatry (gives you a comprehensive picture of how the system works) -

OSCEs in Psychiatry – Albert Michael -

Learning Cognitive behaviour therapy - ??author?? -

Clinical neurology for psychiatrists – David Myland Kaufman

A gem that I came across accidentally was -Psychiatric Clinics of North America –Clinical Interviewing: Practical Tips from Master Clinicians June 2007; vol 30: Number 2 – do flick through it if you can get accessThe exposure opportunities:

I made some active efforts to lookout for all possible trial OSCEs in my ‘catchment area’ (I mean Sydney and surrounding suburbs). Luckily I was able to squeeze my way into the trials run by Janssen Cilag (exceptionally well organized trials), South Eastern Sydney Illawarra (yearly ritual by the hard work and commitment of Dr Kealy-Bateman), and my local area trials (Kindly organized by Dr Barrett who passed the exams in the previous go, a good tradition of successful peers helping the next lot).I am also aware of the yearly ones being run at the Cumberland hospital (I am sure there would be similar tradition in other states/town).

Some might think that it has the risk of over-exposing your anxiety receptor neurons, but I found the feedback very rewarding in finding out my areas of weakness....generally if more than two examiners point out the same mistake then its highly likely that someone in the real exam would pick it as well. -

Practice OCIs: you would soon gather that the validity studies on the adequate number of practice OCIs are quite shaky. I came across suggestions of one/week to “just do three”.I actually did 1-2/week for at-least 8weeks, taking some weeks off randomly whenever pressure was too much and self-confidence rock bottom.

I did practice with my “exam buddy”, with other registrars, my supervisor, consultants in my service, and only couple with consultants from other service. I think the choice of whom you should do the practice with is very much instinctual; I am not sure if it makes much of difference other than giving you a sense of achievement in exposing your foolishness in front of almost every clinician in the town.

Perhaps what I found most useful was to observe few selected consultants doing their assessments (now that’s what I call reverse psychology). It taught me how to think like a consultant, rather than always sticking to the ‘medical student history taking format’ (isn’t that what this exam is about - to be like one of them).The Day of Reckoning:

My OCI case was a developmental disorder + borderline IQ + dysarthria + childhood trauma – and my perception of my performance was disheartening, yet when I got the result it showed that my engagement with the patient and my formulation saved my day.Take home message is that be prepared for anything to happen in the exam, you may not do a sterling interview, but a good enough attempt will get you a fighting chance. -

OSCE is almost a blur for me, from one room to another, trying to forget the experience from the last station and focusing on the new task. It needs practice and some sort of mental formula (hopefully you would have prepared that during the practice OSCE) that you stick to.Chances are you would never be sure if you have ticked all the boxes in a station, but trust your instincts and take clues from the actor.

There is so much more that I can share with you, but I suppose there is only so much that can be told, rest can only be experienced (my psychotherapy spill).Good luck to you all on this journey, remember that it’s very rewarding the other end.My Exam Experience: Matthew Holton.

It can sometimes be difficult to know what you do well. The following was at least what I thought helped me pass the clinical exams. It was good to start preparation about six months out from the exams. This allows time for procrastination so that you can gently ease yourself into the anxiety-provoking and at times belittling experience of practising the OCI’s and OSCE’s.

Get involved with other candidates who you can share the ride with. I initially chose some consultants who I trusted and respected and who were relatively nice as my first examiners for the OCI’s. During this stage I found that the desensitisation to anxiety and just learning the technique was most important.

The next step was then to go home and reflect on what I did well and what I had done poorly. Think about what diagnoses and differentials you should have thought about earlier in the interview and what questions you should have asked. Think about why you may have missed an important mental state finding or why you didn’t do a full cognitive assessment in someone who was clearly dementing.

It was helpful to rewrite the seven-minute presentation and redo the formulation in a more succinct fashion.

How many practice OCI’s and OSCE’s you do is a matter of choice. I think it was important to try to vary the type of patients seen and try to vary the setting. Arrange practises at a hospital that you have never been to before.

Useful advice that I received was that if you are getting tired of the exams, take a break from them for a while. It is hard to keep up the momentum right to the real exams. Quantity is not necessarily important when practising as all registrars see a lot of patients and formulated a lot of management plans every week.You do have to do enough though to get good at knowing how the College wants you to present the case and how you have to ‘perform’.

With the OSCE’s try to practice in as close as possible to exam conditions. One of the drug companies in Sydney arranged a trial OSCE with real actors, examiners and the real timing schedule. This was invaluable to see how I was going. It especially helped me to work on time management.

There is a skill in the OSCE’s about how you pace yourself during the seventeen minutes so that all the important components are covered.

Another important component of exam preparation was trying to maintain a life. Although having kids limits the time available to practise, it also puts things into perspective. They don’t care if you do a good or bad case. Life goes on.

Maintaining confidence is also important. Be confident that you assess and manage patients everyday and that you do it well. Be confident that you have a lot more knowledge than is required to pass the exams. Believe and trust people who tell you that you are good at what you do.

During the exam week I didn’t find it useful to read through study notes. Very little of the knowledge I used during the exam came from notes; most of the knowledge I used just came from seeing real patients. The day before the exams it was useful to visit the exam sites and just familiarise yourself to the environment.

The final piece of advice that I was told was that you really don’t know how well you did. You always remember the things you did poorly and never the things you did well, especially when you are pondering your performance lying in bed at 3 o’clock in the morning.

I thought that my real OCI was one of the worst that I had done and was convinced that a mark near 50% would have been optimistic.

Sitting the OCSE’s seemed a waste of time but I gave them a shot. When I did get my results I found out that I had passed all components of the OCI. Despite seeming like just a cliché, you do never really know what the examiners are thinking. I hope this helps.Exam Preparation: Carolyn Jones

At about 5 months out, I formed a study partnership with a likeminded colleague. I found this to be extremely beneficial for morale, and bouncing ideas off each other, and for giving honest, brutal, constructive criticism. None of the practice examiners are as motivated or enthusiastic as this person in seeing you develop and improve as it helps you both. We met once a week initially and did one practice exam, (ie. one per fortnight each).

These first few exams all we did was try to cover all areas of the history and to stick to 50 mins. We didn’t present to each other until we had this down pat. Our initial formulations we did in our own time and then compared with one another to try and refine.

We began practicing presenting at about 3 months out, and our initial presentations were way over 7 mins. Rehashing and discussing cases was tedious but really helped in refining what to present. Spend proportionately less on the history (no more than 90 secs as the examiners have heard it all), and go to town on the mental state and formulation, and finish with a punchy diagnosis and differential, sticking to DSM criteria as best you can.

I didn’t become confident in presenting a management plan until the final weeks of the preparation. Many of the practice exams I did, the examiners didn’t even want to hear it. I believe what I was repeatedly told that if you get the history and formulation and diagnosis reasonably correct, the management does tend to flow, and I did manage to ‘lead’ the examiners in the real thing, in terms of management plan and the questions they asked.

In terms of preparing for the OSCE, this was what I found the most frustrating part of the exam. It does feel somewhat ridiculous pretending to be a dr with an obvious pretend patient/ scenario in which you know there is a very specific marking criteria, so it is very hard to just do what comes naturally as you don’t normally try and second guess how the station might be scored.

Having said all of that, the reassuring thing about the OSCE is that everyone has the same pretend stations, so I managed to convince myself that as long as I was average, I would be ok. My study partner and I did do 1-2 practice osce’s with one another per week, and in hindsight, I think it was too much. I think my performance actually deteriorated the more aware I became of the specifics of the criteria on the marking sheets.

I would therefore suggest trying to get use to the 17mins and know that on the day it is a whirlwind of doors opening and closing and it is all over sooner than you think it will be. Remaining calm between stations, and not ‘losing it’ if you think you’ve done one poorly is actually an important skill. I found by about the 4th station I had to read the instructions about 3-4 times to remember what my tasks were, and in one station I actually had to pause and re read the instructions as I forgot what they were assessing exactly. I didn’t do much extra book/ journal study. I did brush up on anxiety disorders as I thought I’d need to have a good handle on explaining CBT/IPT or relaxation etc.

I also revisited exactly how I would explain drugs and side effects and initial workups etc. Of course trying to anticipate stations is a waste of time, though tempting to do.

My last piece of advice is not investing your all in the exam. It is significant and important and of course you want to pass, but your significant others (for me my partner and son in particular) are also significant and spending time with them was both essential for reality testing and ‘keeping it real’. Knowing they would be there whether I passed or not and that our world would keep going, and that my every happiness was not contingent on passing, made it a bearable concept, and kept the anxiety in check.

Finally, THIS EXAM IS PASSABLE and when you do pass don’t forget to share your story with the rest.

Raj Maheshwari

Matthew Holton

Carolyn Jones out, and our initial presentations were way over 7 mins. Rehashing and discussing cases was tedious but really helped in refining what to present. Spend proportionately less on the history (no more than 90 secs as the examiners have heard it all), and go to town on the mental state and formulation, and finish with a punchy diagnosis and differential, sticking to DSM criteria as best you can.

I also revisited exactly how I would explain drugs and side effects and initial workups etc. Of course trying to anticipate stations is a waste of time, though tempting to do.

Finally, THIS EXAM IS PASSABLE and when you do pass don’t forget to share your story with the rest.

Raj Maheshwari

Matthew Holton

Carolyn Jones