Training for Exams

Ask any cyclist what their ‘routine’ is in the run up to a race and you’ll likely be there a while as they carefully recount the day-by-day, minute-to-minute strategy to ensure they’re set up for the best possible performance on the day. Nothing gets forgotten, be it training, food, sleep, clothing – you name it, a cyclist has tweaked it to beyond-neurotic perfection. While they don’t usually require figure-hugging lycra and obnoxiously fluoro sock choices, I strongly believe that a lot of the same principles seen in bike racing can be applied to examinations, as they are essentially the equivalent of a bike race for your brain. So here is my 6 part breakdown on how to prepare for that all important event, and get the most out of that spongy brain-muscle between your studious ears…

Train how you race

There’s no point doing lots of long, gentle mountain riding if the race involves a short, high intensity blast around a velodrome; you have to ensure you’re training your body for the physical requirements on the day. Likewise, if your examination is going to be a series of multiple choice questions, you should practice doing questions rather than  just reading through blocks of material in prose format. Of course you’ll need to read and learn the relevant information, but if you use MCQs as a reference, you’ll see the sort of patterns that pop up, and learn to process the information in a way that anticipates the questions that might be asked of you on the day. If your exam is an essay paper, practice writing essays under timed conditions, in the same format, with the same pen, long in advance of the exam. You’ll be surprised how tired your hands get if you’ve not written a complete essay all year and suddenly you try and do three in an hour on the day.

Don’t overdo it

My guess would be that almost every cyclist at some point has fallen into the trap of overtraining. The sport is enjoyable, addictive and it’s very easy to assume that more training means more improvement. However the gains in your performance happen when you’re resting, allowing your muscles to rebuild and strengthen. Ideally you’d be sleeping all the time you’re not riding or eating…

The same principles apply to revision. Your brain uses its down time, particularly when asleep, to subconsciously sift through the material covered during the day and consolidate the useful information into its long term memory. To make your revision worthwhile, you’ll need to ensure you’re getting enough sleep to reap what you sow, so it may be a good idea to put the pen down a little earlier and get some well earned kip. This is doubly important if you’re doing exercise as well, which you should be!

Get your food right

If you put sludge in your car, it’s not going to run very well. If you try and win a bike race on KFC and doughnuts you’ll be sorely disappointed, and probably rather ill at the end of it. Equally, if you try and work your brain overtime in the weeks before the big day, and don’t give it good fuel to use, it will burn out very quickly. Having a tub of chocolate mini-bites next to you while you work may give you a little ‘lift’ every time you have one, but it is doing your concentration, memory and general health no favours in the long run. Fill up on good quality veg, oily fats and really complex carbohydrates and your concentration, endurance and performance will all speak for themselves. You may feel that you don’t have time to cook a ‘proper’ meal, but I promise you – you do. Not only will the break from revising give you a motivation boost, but concentrating on your food will make you feel fuller and stop you snacking between meals.

Coffee – this was almost worth a post in its own right. Caffeine has proven to be a powerful performance enhancer both physically and mentally, and is thought to have numerous health benefits that I won’t delve into here. Essentially, the best thing to do is work out just how much is right for you; be it none, a little or a lot, and keep it there. Don’t go overboard in exam term. If you think you’re over-tired and the coffee is no longer enough, it means you need more sleep, not more caffeine. On the day, have the same amount as normal – it’s what your brain is used to, and the smell of the coffee will trigger memories on a subconscious level too (Google ‘state dependent learning’ for more info).

Tapering

In the weeks running up to a big event, different cyclists will do their own things, but in general the weeks immediately prior involve a lower volume of training to allow the body to be as fresh as possible on the day when it matters. That definitely doesn’t mean doing nothing at all in the week before, rather just doing enough to tick things over and stop them going stale. The same goes for revision – you don’t want to be cramming until five in the morning and then turning up to sit the paper exhausted and demoralised. I usually work fairly solidly up until two days to go, then on the day before I take it easy. I’ll do some solid exercise, and a bit of light reading, but generally let my brain rest before the event. I’m always tempted to sit and cram, especially when I see other students working, but when I’m sat in the exam room, I’m always more grateful for the rest than the extra information on the day before.

Motivation

It’s hard to stay motivated when revising, especially for medical exams with their seemingly endless quantities of information and undefined syllabus. But keeping up your motivation is key to productive work – you will process the information more effectively and it’ll stick in your memory for longer. When I feel my own motivation slipping, I like to write down as many reasons why I’m sitting that exam as I can think of. Usually it’s enough to get me back on track and keen to work, but if it doesn’t, there are always fantastic motivational videos on YouTube to get you in a productive mood!

On the day

It’s show time. Exam day routine is a personal affair that everyone does differently. Some rise at the crack of dawn to cram last minute information that may be of use into their short term memory, while others saunter into the exam room at the last minute having just woken up. Find what works for you, and commit to it. Personally I don’t like to do any extra work on exam day, to leave my brain as fresh as possible for the task ahead. I have a big breakfast, a couple of coffees and then try to relax as much as possible before the inevitable onslaught begins. After the exam, forget about it, if you can. It’s easier said than done, but it doesn’t help anyone to sit there dissecting what happens; partly because it serves only to stress people out, but also because you’re likely to misremember questions or answers that you gave, even if only slightly, that can lead you to thinking you got things wrong when you didn’t. So chill out, and enjoy a well-deserved rest!

 

Abdominal Examination

Being able to perform a competent examination of the abdomen is one of the most important skills to accomplish at medical school. There are a lot of things that can go wrong within the abdomen, and equally there are many ways of determining what exactly is happening. Be systematic, thorough and don’t jump to any conclusions!

As with all examinations the best way to become proficient is to practice until you find a routine that works for you. I’m strongly of the opinion that there is no one way to do an exam, rather it is a personal process that you develop over time with experience. Once you have found a way you like to do it, do it the same way every time to reinforce it effectively. This is my way of doing it, so feel free to chop and change as you wish!

Introduction

  • Wash your hands and show your name badge to the examiner
  • Introduce yourself, with name and role
  • Confirm that you have the right patient in front of you, with name and age
  • Explain why you’ve come to see them.
  • Gain consent to do the examination, and you may offer a chaperone if you feel this would make the patient more comfortable
  • Ask if they are in any pain at present, and to tell you if it becomes too uncomfortable to continue
  • Ensure your patient is sat at 45 degrees, and exposed adequately.
    • Some say ‘nipple to knee’ but in reality as long as you can see the whole abdomen down to the pubic symphysis, patient dignity should be maintained.

General Inspection

Arguably the most important part. After a while you will be able to diagnose many conditions on inspection alone.

  • Looking around the bed for things the patient has brought with them will give you a clue as to their current function, and what pathology might underly their presenting complaint
    • Medications
    • Inhalers
    • Pumps
    • Walking stick
    • Prostheses
    • Stoma bags
    • Drains
    • NG tubes
  • The patient
    • Are they comfortable at rest?
    • Are they obese/malnourished?
    • Are they short of breath?
    • What colour are they?
      • Blue – cyanotic
      • Yellow – jaundiced – liver disease
      • Grey – iron infusion, haemochromatosis
      • Pale – anaemia – liver disease, GI bleed, Malabsorption
    • Can you hear anything?
      • metallic valves
      • stridor
      • wheeze
    • Are there any obvious scars or wounds?
    • Any visible abdominal masses?
      • Transplanted organs
      • Organomegaly
      • Cysts
      • Pulsating abdominal aorta
        • normal in thin people

 

Hands

The hands will give you an idea of the chronicity of a disease as clubbing and nail changes do not occur acutely.

  • Clubbing
    • Cirrhosis
    • Inflammatory Bowel Disease
    • Malabsorption
    • Hepatopulmonary syndrome
  • Nail changes
    • Leukonychia
      • lack of protein
      • ulcerative colitis
      • trauma
      • ?zinc deficiency
    • Koilonychia
      • iron-deficiency anaemia
      • Plummer-Vinson syndrome
  • Palm colour
    • Palmar erythema
      • Portal hypertension
      • Liver disease
      • Hyperthyroidism
      • Rheumatoid arthritis
      • Pregnancy
      • Polycythaemia
  • Dupuytren’s contracture
    • Associated with:
      • manual labour
      • alcohol excess
      • familial
  • Liver flap
    • Postural failure due to encephalopathy
      • Uraemia
      • Hepatic encephalopathy

 

Arms

  • Bruising
    • suggests poor clotting
      • liver disease
  • Needle marks
    • risk of IVDU/HIV/Hepatitis
  • Excoriations
    • scratching due to pruritus
      • liver disease
  • Hair loss from axillae
    • caused by
      • malnourishment
      • iron deficiency anaemia
    • acanthosis nigricans
      • GI adenocarcinoma
      • Obesity

Eyes

  • Corneal arcus
    • normal with increasing age
      • hypercholesterolaemia
  • Xanthelasma
    • elevated lipids
      • Hypercholesterolaemia
  • Jaundice
    • yellow sclerae
      • haemolysis
      • liver disease
      • biliary obstruction
  • Kayser-fleischer rings
    • rare
      • Wilson’s disease

Mouth

  • Anaemia
    • pallor of the underside of the tongue
  • Angular Stomatitis
    • inflammation of mouth corners
      • iron/B12 deficiency
  • Glossitis
    • beefy tongue
      • iron deficiency anaemia
  • Ulcers
    • ask about these
      • Crohn’s disease
  • Parotid hypertrophy – alcohol

Neck

  • Virchow’s node
    • left supraclavicular lymph node
      • GI malignancy
  • Lymphadenopathy
    • may suggest
      • infection
      • malignancy
  • JVP
    • may be raised in 
      • liver disease

Chest

  • Gynaecomastia
    • breast tissue develops in
      • liver disease
      • salbutamol
      • digoxin
  • Hair loss
    • seen in
      • liver disease
      • malnourishment
  • Spider Naevi
    • cherry red with wispy ‘legs’ – need more than 5 to be pathological
      • liver disease

 

Abdomen

  • Scars
  • Bruising
  • Swelling and distension
  • Prominent abdominal wall veins
    • Occlude the veins and ‘milk’ them to empty them, and see how they refill. 
      • Caput medusae refill towards the legs
      • Inferior vena cava obstruction – refill towards the head

 

NOW REPOSITION THE PATIENT SO THEY ARE LYING FLAT

People do the next bit differently depending on personal preference. I like to go organ-by-organ, palpating and percussing the liver, then the spleen etc – others like to do all of palpation, then all of percussion. Either is fine, just remember to do it all! I’ve written it here as palpation then percussion.

Palpation

  • Palpate the 9 regions of the abdomen, beginning away from painful areas
    • superficial palpation while watching patient’s face
      • guarding
      • rigidity
      • rebound tenderness
        • all signs of peritonitis
    • deep palpation for abdominal masses
      • Describe any mass by:
        • Size
        • Shape
        • Location
        • Outline
        • Consistency
        • Mobility
        • Pulsatility
        • Overlying skin (rashes/reaction)
        • Temperature
        • Auscultation – bruit?
  • Liver
    • use radial border of index finger, starting at the right iliac fossa
      • press in, and tell patient to inhale, feeling for liver edge against your hand
      • repeat, moving hand towards right costal margin each time until the costal margin is reached
  • Spleen
    • use same technique for splenic palpation, beginning in the right iliac fossa but moving towards the left costal margin
      • Features of spleen on palpation:
        • can’t get ‘above’ it (under ribs)
        • smooth edge with notch
        • moves down on inspiration
        • dull to percussion
        • if palpable, spleen is 50-100% enlarged
  • Kidneys
    • Using one hand to press into the abdomen, use the other to gently flip (ballotting) the kidney against the superior hand, and feel for an impulse. Normal kidneys aren’t ballottable except for particularly thin patients.
  • Aorta
    • gently press two thumbs above the umbilicus and feel for a pulsation
      • pulsation (moves thumbs up and down) is normal
      • expansion (moves thumbs apart) is pathological

Percussion

  • Percuss for the liver and the spleen
    • Liver
      • lower four ribs should be dull depending on level of inspiration
    • Spleen
  • Percuss for the bladder
    • ask patient if they need to urinate first!
    • begin at the umbilicus and percuss towards pubis. Dullness suggests a full or distended bladder

Test for ascites

Ascites is fluid in the peritoneal cavity that may cause distension. Remember the differential for a distended abdomen:

  • Fluid
  • Fat
  • Faeces
  • Foetus
  • Flatus
  • Fire (inflammatory mass)
  • F*** (malignancy)

 

  • Percussion
    • percuss over the umbilical region, which will be resonant in ascites as the air bubble sits at the highest point
    • percuss round towards the flank, and note the point at which the tone becomes dull – this is the fluid level
  • Shifting dullness
    • ask patient to roll onto their side (I get them to roll towards me and put their hand on my shoulder for stability)
    • The air bubble should now have moved round to the new highest point at the flank. Percussion of the flank should now be resonant and the new fluid level discovered towards the umbilicus
  • Fluid thrill
    • tapping on one side of the abdomen sends a shock wave through the abdominal fluid that is palpable on the other side. Usually only possible in massive ascites.

 

Auscultation

  • Auscultate for
    • bowel sounds
    • renal bruits
    • aortic bruits
    • venous hum (portal hypertension)

Finishing up

  • Check for leg swelling
    • pitting oedema in liver failure
  • Thank the patient
  • Sit them back up and help them get dressed
  • Wash your hands

 

Practise, Practise, Practise!

Preparation 

Fail to prepare, prepare to fail. Preparation is key in a lot of situations, and Medicine as a whole is one of those situations. Having a solid plan, thinking it through and making sure you have everything ready beforehand will save you a lot of trouble. A good way to do this is through visualisation of the procedure. When I get kit ready for cannulating, I picture myself applying the tourniquet, finding the vein, cleaning with the swab, putting some gauze just distal to where I’m going, inserting the cannula (with or without taking bloods from it), removing the tourniquet, applying the flush and then sticking it down with a dressing. While doing this, grab the equipment for each bit as you think of it, and always take a spare cannula!

You only ever forget a flush once…

 

Instructions

Like it or not, as a medical practitioner people are going to take what you say seriously. They will look to you for advice and reassurance during their most vulnerable moments, and will often follow exactly what you say to the letter. This means you have to be careful about what you say, and how.

Advice must be grounded in evidence, explained in understandable terms, with an idea of where to find further information should they forget what you’ve said later on. At home the patient is their own medical practitioner, so just as you’d hand over to a fellow clinician, they must be absolutely clear on the management plan. Your tone should be kind, non-judgemental and should demonstrate that you genuinely care about the person’s question. Instructions should be clear and complete – assume the person receiving the information knows absolutely nothing – and include a safety net for ‘if it gets worse’

(if it doesn’t go away in 3-5 days, see your GP is a fairly good one…)

Reassurance should be given where appropriate. There is always the desire to provide relief for parents and relatives from the anxiety of not knowing what is wrong, especially when a simple ‘It will all be fine‘ would instantly make everyone in the room feel better, however raising expectations in the face of a poor prognosis is going to hurt everyone a lot more down the line, so don’t jump straight in with grand reassurances unless you know they’re warranted.

Having said that, patients and relatives will often worry about things that you wouldn’t think of, so asking them if there is anything that needs explaining is always a good idea. I recently saw a paediatric patient being intubated for refractory seizures. She was completely stable on the ventilator, comfortably asleep, with reassuring vital signs and a promisingly normal CT scan. However her parents, who were NEWSing higher than their baby daughter, understandably interpreted ‘medically induced coma with a machine to help her breathe‘ as a bad sign.

As soon as the anaesthetist asked their concerns, and explained that they could wake her up at any time – this was just to keep her comfortable and free from seizures while they figured out what was going on – they immediately relaxed,

“Oh, well that’s not so bad…”

There was no false reassurance, no optimistic guesses at what the diagnosis might be; just a simple explanation of what was going on, that she wasn’t in pain, that the beeping alarms were just a reminder the infusion was nearly done, made a huge difference to that family’s experience.

Gunners

 

Urban Dictionary – A person who is competitive,overly-ambitious and substantially exceeds minimum requirements. A gunner will compromise his/her peer relationships and/or reputation among peers in order to obtain recognition and praise from his/her superiors.

It’s good to be good…

It’s always good to want to improve your own ability, build upon your existing knowledge and broaden your knowledge base. Medicine is a continuously evolving subject that requires by law that you do the same. I’d be worried if I knew my doctor wasn’t at least trying a little bit to learn more about the subject they’d chosen for their career…

However, comparing yourself to others can be dangerous. When we go out in the world we put on our public face, our public clothes, and our public attitudes. We don’t reveal our inner fears, our problems, our weaknesses. And since everyone else is doing the exact same thing we don’t ever see theirs. This combination of caging away our own issues and not witnessing those of others gives us the false impression that they’re finding everything so much easier, or that they’re so much better off than we are. This is further perpetuated online, as Facebook and Instagram give the opportunity to sell yourself to the world as that perfectly happy, exciting and fulfilled individual that couldn’t possibly exist in real life. It’s not exactly a recipe for sound psychological well-being.

But there is a limit…

Medical schools rank their students. Presumably it’s intended as an incentive to work harder, as a higher rank apparently brings the tantalising promise of a better job, more research opportunities and greater respect. Maybe it produces better doctors, maybe it doesn’t. What it definitely does do is discourage students from helping each other out. The stakes are raised, forcing us to show that we’re not struggling, that we know the required information, that we can hack it in this apparently brutal world of medicine. People become so preoccupied with that centile rating that they will give up relationships with their peers in an attempt to make excruciatingly small gains over them, be that by hiding information or learning opportunities, or even misleading them deliberately in the hope of sabotaging this ‘competitor’ and boosting their own ranking.

WTF?

I once asked someone what topics were covered in a teaching session that I had missed through illness, and they said to me, “It’s your fault you weren’t there”Turns out it was the Krebs’ cycle…

I’ve also heard rumours of students sabotaging the computers/iPad available during OSCEs to disadvantage those yet to complete that station.

It’s crazy!

The qualities we want in our doctors are compassion, teamwork, communication and integrity. Healthcare is never done on an individual basis, it’s always a team of teams of teams, each with their own area of expertise and interest, cooperating and communicating to ensure the best outcome for the person that really matters most – the patient. You can only gain by communicating well with others. Either you find out something you didn’t know before, you deepen your own understanding of a subject, or you have that satisfying feeling of helping someone else understand something just a little bit better, and knowing that you’re helping their patients as a result.

So I ignore the rankings. Always have, always will. I don’t care if the person I’m talking to is going to score higher than me. In fact, I’m happy if they do. Why? Because I’m determined to be a good doctor – it’s what I’ve always wanted to be – so anyone scoring higher than me in the rankings has to be pretty good as well, and they might be looking after my Mum one day.

 

Don’t be that guy – help each other!

How I work

Deciding how to work

After more than fourteen years of school and six years of Medicine at University, you’d think I’d have figured out how I work best when it came to studying for exams. Surely after that many years of studying, cramming seemingly endless reams of information into my head for retrieval on the big day, I would know whether I was benefiting most from writing out notes, listening to lectures and podcasts, making flashcards, or reading the textbooks…

 

I didn’t.

 

This was a constant source of stress for me as each year I would begin the process of walking out into the lapping waters of bottomless information, and not have a clue as to how best to study. Should I try and write everything down? Type it out? Make flashcards? Just listen? Whichever tactic I tried soon became either unmanageable, tedious, or I simply didn’t think I was learning anything from the process. So what did I do?

I thought about what I do when I come to retrieving the information. That is, in exams, whenever I’m trying to remember answers from my brain and wondering why I couldn’t remember medical facts like I could with cat videos or insulting jokes, how was the information presented in my head. Was it remembering the page of notes? Remembering the lecturer’s voice? The diagram on the flashcard?

It turns out that there were three main ways that I was retrieving these facts:

  • Remembering answers to previous questions that were similar to the one in front of me
  • Recalling specific experiences I’d had on the wards
  • Diagrams that I’d drawn and re-drawn until I could do it by heart
  • Flashcards that I’d done so many times that I didn’t even have to try and remember them.

It was a very rare occasion that I would remember a piece of information from notes I’d written or textbooks I’d read. So I figured I’d stick to these four categories, and hope that my analysis wasn’t way off..

How I work now

  1. I spend as much time on the wards as possible. This is largely because final year is meant to be as much of an apprenticeship as possible; you’re learning how to do the job of those a year ahead of you, so you’ll benefit most from observing, trying (and failing) to do the same things. Your brain is very good at remembering experiences that it has because it has so many ways of programming the information; sights, sounds, smells, temperatures, emotions – think of a time you screwed something important up – bet you never had to revise that again!
  2. I make flashcards. This is largely a convenience thing as you can make one or two in a spare moment, and review them during quiet parts of the day. I use Anki, purely because it’s free on android and you have your cards with you wherever you go.
  3. Nearer the time, when exams are looming, I talk myself through a topic, while drawing out diagrams. I then use the books to check what I’ve missed, and add the information to the diagram. Then I store the diagram away until next time, and attempt to copy it perfectly. Repeat until smart.
  4. teach! You never know information properly until you can teach it to someone who knows nothing about it. If you can explain something simply to a friend or patient, then you truly understand a topic.

Find your own groove

Learning is incredibly personal, and everyone does it differently. Try different methods, see which you like, and more importantly, which ones seem to work, and focus on those, rather than spending time doing ineffective studying that bores you and doesn’t help your exam performance.

 

Good Luck!