Waikato Hospital as seen over lake Rotoroa

I spend a lot of my time thinking about the Primary FANZCA exam, and how best to prepare trainees to pass it. I have collected some of my thoughts together into short articles, which I published in the Latest News stream, but they have been gradually buried by new material on the top. I therefore thought I would collect them here, into a series of reflections on the exam; on exams in general; and on exam performance.

I am hopeful that these reflections will be useful to all candidates at any stage of exam preparation, and not just the ones coming to our course. Please feel free to open a dialogue with me about any of this at any time.

Aidan.

 

What are Exams actually for?

I came across this podcast from the BBC here. Presented by academic Professor Mary Beard, the 30-minute podcast addresses several aspects of examinations. Just be glad that you don’t live in 7th-century China, where state examinations were so gruelling that occasionally candidates died during them.

Beard tackles the question of what exams are actually for. Although she concentrates on school and university examinations, many of her points seem directly relevant to our exam. She talks about a theme which I have often reflected upon: why is the Part 1 FANZCA exam so difficult? Surely it tests knowledge which is rarely called-upon in clinical practice? She talks about examinations having some of the attributes of a game (another frequent theme of mine). She talks about candidates sometimes being more focussed on technique than content (something we talk about a lot), and sometimes being focussed so exclusively on passing the exam that they refuse to learn or consider adjacent material which is not going to be tested.

So if our exam isn’t just a test of knowledge, what else could it be testing? What else does success in the exam reveal about you? (Caroline Whymark discusses this in her book too; see further down this page).

I don’t have clear answers to these questions; feel free to add your own. However, I do think success reveals these things:

(1) Determination. The exam requires such enormous investments of time, effort, and in some cases, money, that it is an index of your ability to marshal all your personal resources to the pursuit of one single goal. Not only does this show that you have grit, but also that you have commitment to anaesthesia as a career, or indeed to any objective you set your mind to.

(2) The “right” way to think, especially under pressure. Successful anaesthetists have a particular pattern of thinking, of approaching a problem (any problem). Of course, this isn’t the only way to approach a problem. But anaesthetists seem to have a very structured way to think, and this almost becomes a language of its own. Being able to use that language (in spoken and in written form) tells the examiner that your thought patterns run parallel to those of other anaesthetists.

Here’s an example. You develop a flat tyre. It’s dark, it’s raining, and you are an hour’s drive from home. The kids and your partner are in the car. If you are an anaesthetist, you might find yourself approaching the scenario like this (I know I would!):

Call for help (summon the breakdown service)
Assess the priorities (ensure safety of the team, change the wheel, get home)
Communicate the problem with the team (“OK, guys, here’s what we need to do”).
Ensure safety (Get the kids out of the car onto the verge, far from stray drivers; deploy hazard lights and/or signs; wear bright clothing)
Work with partner to arrange equipment (spare wheel, jack, spanner, torch)
Apply jack to car body…

flat tyre2

Exams: make you feel like this

OK, you get the idea. But that approach (prioritise; break down a complex task into manageable chunks; address problems one at a time; communication; leadership; effective teamwork) is at the core of anaesthetic behaviour. Anaesthetists prosper who can work like that, think like that, and communicate like that. And this is tested in the exam, with very short time-periods in vivas and SAQs, where you must organise your whirlwind of thoughts, under considerable pressure, into sensible categories, and provide clear answers.

(3) A vast amount of knowledge. Nobody in their daily practice thinks about the pKa of fentanyl when they are giving it to the patient. But having those underpinnings, that vast body of detailed knowledge about physiology and pharmacology and anatomy, means that the information is in there. And who knows when it might become useful?

I often draw the parallel with racing drivers. Their job is to drive the car, as fast as possible. But that the best ones also understand the fuel composition, the engine compression ratios, the torque curve, the tyre compounds, the oil pressure, the aerodynamics, in considerable detail. Why? Because knowing these things helps them to get the very best performance out of the car, in all conditions, even (perhaps) ones which the engineers did not anticipate. Michael Schumacher came second in the 1994 Spanish Grand Prix, in a car which was stuck in 5th gear for most of the race, and I am sure that he already knew everything there was to know about that gearbox.

Spending some time thinking about what the exam is actually testing is helpful, because if you think that the exam is just about studying, you will founder.

 

Added Value

So here’s a question. How much value does our course add, to you, the candidate? It’s a question I dwell on quite a lot, because I want everyone to pass the exam.

It’s clear that, even without the course, some of you (x) would pass the exam. It’s clear that most of those who attend the course (y) do pass the exam. So what does this course add? What is the value of y-x?

I can find out one part of the answer, and I have been, for the last four years. That is, how many people who attended our course, actually passed the exam at the next attempt? (And I will ask you in turn to let us know your results). But I cannot say how many of them would have passed anyway. The answer is that, from our course, we scored 59 passes out of 78 attempts; a figure of 75.6%.

addition

Us plus you: more than 2?

A reasonable surrogate to the figure of x would be: considering that sitting of the Part 1 exam as a whole, how many people pass it overall? What I want to know is: how many candidates attempted the exam? How many passed the written (and how many failed)? And how many passed the vivas?

ANZCA started to publish these figures in 2016. This might be partly because I wrote and asked them to. The Royal College of Anaesthetists publishes a beautiful table of exactly these results, and states it is “committed to ensuring that the FRCA exam statistics in the form of exam pass and fail rates are placed in the public domain as soon after the ‘release of result date’ as possible.” I pointed this out to ANZCA in my letter.

Over the last four years, our course has had 78 candidates attempt the exam. Those who withdrew were not counted. We scored 59 passes overall, a creditable 75.6% pass rate.

For the last 4 sittings of the exam (the only ones I have figures for), 773 candidates attempted the exam, and 468 passed, for a pass rate of 60.5%,

The crude figures, y-x, would suggest that our course adds roughly 15% to your overall chance of passing. This is a significant number. I can’t give you the figures for any earlier years, since the College didn’t publish the figures before 2016.

These figures come from the Examiners’ Reports, which is available for free on the College website. I highly commend these reports to you. One of the interesting things is that, of people who attend the Vivas, the great majority pass the whole exam.

 

Marginal Gains

climbing a mountain

I came across this article on the OUP Blog, which I think is very pertinent. Entitled Exam preparation: More than just studying? the article discusses several aspects of exam preparation, and compares passing the exam to sporting success. The author, Caroline Whymark, points out that success requires “prioritisation, motivation, focus, support, time management, and importantly, life management”. And she is trying to sell you her book, Preparing to Pass the FRCA, which is very good. A lot of it is pertinent to this exam as well. The first part of the book concentrates on preparation for the exam, and it would be useful for just about any major postgraduate examination.

The second half of Whymark’s book describes in detail the techniques she recommends for approaching the FRCA exam. The FANZCA exams are similar enough that some of Whymark’s material is valuable. Unfortunately, the specific details of the two exams are different enough that her specific advice isn’t pertinent to us. Overall, though, it’s a good read, is reasonably short, and contains much which is wise, sensible and useful.

This touches on another of the themes I had been meaning to bring into these posts, which is the theme of marginal gains. I came across this theme when watching this video, with Tim Harford, one of my favourite writers and broadcasters. Harford discusses the success of the UK Olympic Cycling Team, and a man called Matt Parker, whose job it is to create tiny improvements in all aspects of a cycling team’s performance.

The lesson we can take from Parker and Harford (and also Whymark) is that every single little improvement in your performance helps, from the way you sleep, to the way you eat, to the way you write, to the way you speak, to the way you dress.

The video is fun and entertaining, but the bit I am recommending is only the first 4-5 minutes or so. Watch it, and take a good look at all those little marginal gains you can give yourself.

 

Code Breaking and Exam Preparation

In Bletchley Park during the Second World War, the codebreakers were able to crack the German Enigma cypher. The Enigma machine was a mechanical coding machine of enormous complexity, which required the application of considerable intellectual force to crack. The Bletchley codebreakers used cribs to help them crack the code. Cribs are the “rules of the game”– they were the physical and mechanical limitations of the machine, together with the habits of the German High Command in sending specific patterns of coded text. The Bletchley codebreakers were able to exploit those rules to their own ends, wedging open those tiny cracks in the Enigma edifice to get a foothold.

enigma machine

Harder than the FANZCA: Enigma machine

This exam has cribs too, though they might not appear obvious. Cribs are the rules and mechanisms of the exam. They apply equally to every candidate– therefore using cribs to your advantage is not cheating.

One obvious example is multiple-choice questions. The scoring system will award you one point for a correct answer, and zero for a wrong answer. So far, so good. However, it will also award you zero for missing a question completely. Therefore it is in your interests to answer every question, even if you don’t know the right answer. (Where negative marking is in use, different cribs apply!).

Another crib is that the College itself shows you what the exam will be like. It gives examiners’ reports going back over several years, which not only tell you the written questions which were asked, but then (in detail) how they should be answered.

This information is pure gold. You might think that this material (since it isn’t syllabus material as such) should just be skimmed through. Instead it should be read and re-read, very closely. You will, when you read it, get a flavour for the sorts of questions which may be asked. You will get a feel for the sorts of answers which will work (and more importantly, what sorts of stuff to leave out of your answer). It also tells you important things to not do (e.g. to not write your answer across a double page).

You should also browse the resources available to candidates, which are already available, for free, right under your nose at the ANZCA Networks website. There is a lot of material there to support you in your attempt on the exam: how to pace yourself, how to study effectively, how to manage stress. There are example viva videos, including a “perfect” viva, followed by some “disaster” vivas where common pitfalls are demonstrated. OK, so the dialogue is a bit wooden, but the scenarios strike me as being very real, and they have clearly been scripted by real examiners, and filmed in the actual examination room.

I cannot recommend this material to you highly enough. The College has put it there for your benefit. It’s free. Use it. It’s all linked to from the College webpage here.

 

Good Handwriting

This may seem like a very tangential topic, but I’ve been chewing it over and I thought I would write something here.

I listened to this episode from one of my favourite podcasts, Freakonomics Radio. Incidentally, I highly recommend subscribing to the podcast, as well as reading the books, but save this until after the exam!

In it, the presenters (correctly) mention that handwriting is a dying art. Large areas of the US are no longer teaching children cursive script, but only printing, since (basically) the keyboard is all they need these days.

Can this really be so? That handwriting has become obsolete? We don’t need to be able to write by hand any more?

script

I still have all my old notes from the Part 1. This is the alveolar gas equation.

As a writer myself, I abhor the idea that handwriting is dying. Of course, I use keyboards all the time, but I still write in pen and ink every single day. I think that the almost universal teaching of reading and writing to everyone (rather than just an educated elite) is one of the pinnacles of human achievement.

But over the last few years, the number of people taking notes on their laptop on our course is rising. (And when I visited my friend, a professor in Canada, more than half of his students were making notes on their laptop or tablet rather than on paper).

But why should you care? Right now, all you care about is passing the exam. So let me put it to you this way.

(1) The SAQ exam is still a written exam. That means you need to be able to express your thoughts by writing them down by hand (and drawing diagrams, which is a different skill, which we also attempt to address on our course). Whether you like it or not; whether it’s right or wrong, the exam will not change between now and the time you sit it. That means you need to be good at writing, and that SAQ is a marathon for even the best writers.

(2) There is some evidence that people who write neatly do better in exams than people who don’t. This was expressed in the Freakonomics podcast. Of course, it isn’t because those people are smarter, but because they write neatly, they are perceived as better than those who can’t. There may also be a component of their writing being easier to read, which makes it easier to mark their scripts. I can certainly attest to this from personal experience.

(3) There is some evidence that people who take notes by hand learn the material more effectively than those who type it in. Again the podcast mentions why this is (in some detail). In brief, because you can’t write so quickly, you process what you write rather than just transcribing what the speaker says. If you process it, it sticks more and is easier to learn.

(4) Handwriting is a learned motor skill. You might say: “But my writing has always been terrible”. And you might be right. Nonetheless, while it may not be possible to make it perfect, practising it will definitely make it better. Marginal gains matter.

(5) Being able to make legible clinical notes by hand is a core skill for medical practitioners. We don’t yet have paperless hospitals. They may yet come. But while we still have paper and pens, you will still need to write neatly in the notes. And if it comes to court, and the court (or worse, you) can’t read what you’ve written, the temperature of the water you are in will rise sharply. Trust me; I have been in court.

So, overall, I recommend to you in the strongest of terms that you become used to writing things down by hand. There is evidence that it helps you learn. There is evidence that neatness improves your chance of a good mark. And there is evidence that many doctors’ handwriting is basically dreadful.

After the exam you can burn your paper notes (though I advise that you don’t!) or scan them all into your laptop. You can cast away your pens and get back to your voice-recognition dictation software. But for the next few months, get those pens out, and get scribbling!