Examination Memories

Multiple oral examinations were going on simultaneously in the Great Hall. One of my examiners pointed to another, rather elderly examiner on the other side of the hall. He had a pronounced kyphosis and I thought I would be asked what was the matter with him and I decided to say ankylosing spondylitis. However, my examiner then pointed to a portrait on the wall above and said: “That is of his grandfather named Gibson, who described a physical sign. What is it?” I had no idea and was not enlightened at the time. On return to my base in Dundee none of my contemporaries and few of my seniors knew the answer: the machinery murmur of patent ductus arteriosus ‘Gibson’s murmur’, which has naturally stuck in my memory ever since. How eclectic the exam was then compared with today.

About ten years after passing my MRCP exam, having attained the consultant grade, and not so very long after being elected to the FRCP Edinburgh and becoming the local Advisor for the College, I was very surprised but basically pleased to be asked to be an examiner in what was now a single part general medical MRCP(UK) examination. So I went and bought a new overcoat and booked into the Roxburghe Hotel in Charlotte Square at College expense.

On arriving in the snow the next morning at the Deaconess Hospital for the clinical cases I was greeted by a hall porter in full uniform, and asked politely to step inside his little box and wait a few minutes. After at least ten minutes I could stand it no longer and made my way upstairs where I found the assembled team of my prospective co-examiners involved in deep and serious discussion, while the porter and another person stood by bemusedly.

It transpired that the senior examiner had been warned that one of his team (myself) was rather young, and as he did not know me personally he had kindly asked the hall porter to look out for me and bring me up. The hapless porter had identified a suitably dressed young person arriving a little early and had conducted him up and presented him to the other examiners, who without any form of identity check welcomed him warmly and proceeded to show him round the assembled minor cases. It was some time before the penny dropped – the candidate thought this was uncommonly generous of the examiners, and they had only realised their error shortly before my appearance at the top of the stairs. As a new boy, I took no part in the subsequent damage limitation exercise, but did my bit in the regular conduct of the examination. It is just as important to identify the examiner as it is to identify the candidate!

I remember most vividly the long cases. The general medical examination was held in Glasgow. I received a half crown to pay for the train ticket. I cherished it and still have that half crown to this day.

The patient had multiple problems, including jaundice and a cardiac lesion, probably mitral stenosis. I was able to make the correct diagnoses, in spite of immense difficulties in coping with the Glasgow accent. In later years, talking about language, I lightheartedly said that I could not understand a word the patient spoke.

The long neurological case was held in Edinburgh. As my name was alphabetically at the end of the list of about six candidates to be examined I was the last candidate. Professor John Marshall, the famous Edinburgh neurologist, was my examiner. There were several factors in my favour. The examination was very tiring for both examiner and the candidate, and as the timetable was running late, I had more than an hour to think about my case, whereas the examiners were exhausted by the morning’s work. I had a very sympathetic supervisor, the person introducing the candidates and he asked me a question: “Is there any relation between the two lesions you had discovered?” I said no. He said, “That is right”. This gave me boundless confidence and I remember this colleague’s name with gratitude – of course I would not divulge it! The patient had motor neurone disease and a thyroid lesion and I managed to have a sensible approach to management.

The short cases and vivas went well, except when confronted by two neurosurgeons at the last hurdle, who quizzed me about cerebrospinal fluid dynamics, a question I apparently failed to answer correctly on the written paper and probably also on the oral.

I was sure I had failed. I was mortified and decided that it was the end of my academic career. I did not attend the publication of results, nor the farewell function and booked my ticket. I felt my path to specialisation in medicine was over and I was resigned and miserable. Then a telegram arrived from a friend in Edinburgh. “Passed.” I was so overjoyed I embraced and kissed passionately the elderly Nigerian lady who delivered the telegram!

In the good old days, before the rigour and objectivity of PACES, when examiners held a free reign over what questions they wished to ask candidates sitting the oral exam for Membership I recall an instance which still does not fail to amuse me. The candidate, of a Far Eastern appearance, had done rather well until it came to the contrived question of “the ethical dilemma” (more senior examiners from years past will recall this now defunct but once important component of the oral exam).

I presented the candidate with the oft-used scenario of a father who refuses to allow his child a blood transfusion, because of his beliefs as a Jehova’s witness. The candidate replied without a moment’s reflection that “Sir, in my country the father would immediately be thrown in prison”, thus bringing my moral dilemma to a surprisingly swift conclusion!

It was the one instance I recall where the examiner rather than the candidate was left at a loss for words.

Four decades ago, I visited the Royal College of Physicians. I did not meet the President. I met instead twelve ogres disguised as examiners, six in medicine and a like number in haematology. Ostensibly, they were there to assess my clinical competence. My own perception was that I had entered an obstacle race, and would win only if I jumped all twelve hurdles.

For the long case, the examiner led me to a patient lying comfortably in bed, and our discussion went something like this:

“This gentleman was anaemic when we admitted him to hospital. We prescribed some tablets and his anemia has improved considerably. What might we have given him?”

“An iron compound or folic acid.”

“Yes, true, true. Any other thoughts?”

“Well, he could have had a pyridoxine responsive anemia that did respond to tablets of the vitamin.” (This was, after all, a specialty postgraduate examination.)

“That, of course, is a possibility, although it is a rare condition. Would you please examine his abdomen?”

Under the examiner’s observant eye, I examined the patient’s abdomen. The striking finding was an easily palpable firm liver and spleen, with no signs of free fluid. I saw no spider angiomas suggestive of portal hypertension.

“Would you care to revise your therapeutic opinion?” the examiner asked.

I now had to come up with a diagnosis that would explain hepatosplenomegaly. Lymphomas are not treated with oral medications, and so this diagnosis was rapidly dispelled. There then remained a chronic leukaemia, myelogenous or lymphatic, but which one? Fortunately, my abdominal examination had included palpation of the groins, and detecting no inguinal lymph gland enlargement, I opted for chronic myelogenous leukaemia as the more likely diagnosis. “I believe the tablet was Busulfan,” I responded, indicating the treatment then used for this illness. With a grunt that I hoped indicated approval (one never knows), we moved on to the next patient.

“Did you visit the Castle?” someone asked me when I returned to London.

“Castle? What castle? Where?” I replied.

Edinburgh Castle, situated in the heart of the city is almost impossible to miss, but I succeeded in doing so. Two months later, the postman brought me a letter with the College shield embossed on the envelope. The missive did not say “Wow! You’ve passed!” but in a crisp and matter-of-fact manner indicated that I had satisfied the examiners and was now eligible for Membership of the Royal College of Physicians of Edinburgh.

A few months ago, I visited the College for the second time. On this occasion, I did meet the President. On my first visit, the concrete lions adorning the doorway had scowled at me. They appeared to have mellowed with age, for a benevolent smile greeted me as I entered the portals of the venerable institution. In the President’s chambers, that dignitary warmly greeted me. By previous appointment, I had arranged for the “Signing of the Roll”, a requirement expected of all Fellows. At this visit, I did see Edinburgh Castle.

Dick Turner had not failed to notice George’s reaction. The following morning we were paraded before the Chief. “Did I detect a note of rebellion recently, chaps? Don’t you know how lucky you are? My God, you might be bank clerks counting money all day. Life may be hard but it’s not dull. Face up to the next hurdle, the Membership. If you succeed you’re made. But should you fail, you’ll have to depend on the mercy of the Post-Graduate Board for an extension of your appointments. Don’t let me down! If you do, you might go hungry.”

The candidates rushed home as soon as possible for a last look at the textbooks. The underground in Medicine had it that only 20% of the candidates succeeded in the examination for Membership of the Royal College of Physicians and that it was really a competitive event. Their very survival depended on the result. On the clinical side George and David did well, but the written papers were tough going for both. Everything hinged on the ‘orals’. George was asked about his school, his father and his war record, before being nailed on an esoteric medical problem which made him quite speechless. I was led into one of the College cubicles and faced two expressionless men. The younger one, Dr Batty, began. “Tell me about the development of the lens of the eye.” The candidate was at least honest. “Sorry, sir, I don’t know.” “Tell me then, Illingworth, the percentage of people who are left-handed?” The other examiner stepped in as my stammer prevented articulation. I didn’t know anyway. A leaden silence ensued during which the candidate struggled for self-control and rational speech. But it was too late. I’d answered nothing! “Thank you, doctor, that’s all.”

I bowed and stumbled out to await the outcome of the examiners’ meeting the next morning. Things looked black! The examinees were huddled at one end of the large hall. At the other end stood the secretary who read out the names of the successful doctors in alphabetical order. “Illingworth”, located nearer the beginning of the alphabet, knew before George that he had failed. Thornton had to wait rather longer before joining the disconsolate majority who trooped away to their personal oblivion. Turner shuffled his feet. “Bad luck, chaps, but at least you’ve tried. Resit and I’ll try to get your appointments extended by the Post-Graduate Board.” “Might as well apply for a season ticket,” groaned George. “I think we should lay off for a bit.” I agreed that the dice had been loaded against us. The examination had devastated me. I had vomited each morning of its duration. On the third day, in an effort to occupy myself, I had bathed my baby son. So nervous was I that I dropped the child on its head. Lesley forgave me, understanding that her husband was playing for impossible stakes.

So we concentrated on medicine and forcibly forgot about our failures. We trundled from clinic to clinic, burning electricity far into the night as we devoured textbooks and articles and neglected our marriages. Happily there came easier times with the arrival of Drs Warnock and Robson to supplement Turner’s staff. Each newcomer had a sense of humour and a Membership of the College. Not only was the teaching load immediately reduced, but they began to help George and me in the examination gamble. It was the examination mixture as before. I vomited each morning; George had tremors. On this occasion it was the candidate in the next examination cubicle who was asked about the development of the lens of the eye. He promptly walked out and was replaced by a doctor, hooked on barbiturates, who had calmed his pre-examination nerves with sodium amytal. The first question answered, the candidate then dozed off and slipped from the chair. I looked across in time to see the servitor dragging out the examinee. “That’s two less to reckon with,” I thought and began to assert myself as Norrie Robson and Guy Warnock had taught me. The next morning our names were included in the 20% success list. George was speechless and quietly disappeared. As for me, stunned, I asked for confirmation and wandered blindly along Queen Street looking for a telephone kiosk. Each was occupied until I reached Castle Street. I dialled home and fell apart at the overstretched seams of my emotions. The instant security of success, although ephemeral like all else in medical life, was too much for me.

A key objective in my training was to pass the Royal College of Physicians membership examination. Founded in 1518, the several-century-old college had been conducting a standard membership examination for doctors like me since 1886. The recognition and prestige of the qualification had grown with time, and combined with the reach of the British Empire, the value of the qualification conferred by passing the examination extended out to all her colonies. I trained for the Royal College examination like my brother trained for the Olympics. Practice, practice and more practice. I had two coaches, both registrars in the department of medicine with whom I became friends. One of them called it hubris, but after the hours that I put in, I fully expected to pass the written part of the examination. It was the clinical exam that I and everyone else dreaded, and for good reason, because it was a serious challenge with a notoriously high failure rate.

As with postgraduate medical examining bodies elsewhere, the Royal College required the assurance of one’s supervisor that you were a “fit and proper candidate” to sit the examination. Professor Read and Dr Ken Heaton signed off on my application, and after passing the written part of the examination, I received a formal invitation to come to the Edinburgh Royal Infirmary to sit the clinical examination. I would be facing a panel comprised of a veritable who’s who of British medicine led by Professor John Macleod, whose textbook Clinical Examination is still a standard manual for medical students everywhere.

D-day began with a long case, where I was given an hour with a gentleman who had a mixture of problems stemming from chronic lung disease. The examiners gave no hint as to where I stood after that part of the exam, but my real anxiety lay beyond to the afternoon short cases. That was where most candidates failed.

When the time came to face my fears, eminent and unsmiling examiners holding clipboards ushered me into the cubical to see my first short case. The patient was a middle-aged man whose abdomen was grossly swollen. I was to examine him while they watched and then tell them what I thought. Within moments, I knew that the patient’s abdomen was filled with fluid; I found that he had signs that pointed to cirrhosis of the liver as the cause. My chief in Bristol was one of the United Kingdom’s foremost specialists in liver diseases, and because of this, over the preceding months, I had been seeking out and studying patients with every permutation of liver problems. On our team, we looked after patients like this one every day, so if this was the kind of thing the Royal College was going to throw at me, I thought to myself, they may as well start writing up my certificate right now.

After completing my examination of the patient, I thanked the gentleman and straightened up. Then I turned to my examiners, and I let fly.  The cases that followed, man with needle marks signifying heroin addiction who had heart disease and a lady with hands deformed by rheumatoid arthritis, also seemed fairly straightforward, but soon we reached the cubicle that rekindled my fears.

“Look at this lady,” began the lead examiner, “and describe what you see. Can you give an explanation?” Reclining on the bed was a plump woman who looked perfectly healthy. I stared at her, and she stared right back at me with a motherly smile. Could the examiners have wickedly planted a patient who had nothing wrong, or was I missing an obvious clue? My heart began to pound, and seconds ticked by when I suddenly noticed a slight indentation in the bridge of her nose. Then it occurred to me that perhaps the lady’s face was a little full, and that her cheeks might be a little rosier than one should expect. Could she be on steroids, or might this be the result of alcohol abuse? Why the nose?

Just to get my mouth and vocal cords working, I attempted to clear my throat, but instead, I blurted out that the patient might be alcoholic and that she could have fallen down and injured her nose. At that, the lady’s smile disappeared, and the examiner grunted, “Hmm, anything else?” Clearly, my theory did not go down well, but I suspected that I was on the right track, and that her face had indeed been changed under the influence of steroids. How, I wondered, could I connect steroids with the little indentation in her nose? I offered the diagnosis of relapsing polychondritis, a rare disorder that has a predilection to destroy the cartilage of the nasal septum, and that is treated with high doses of steroids. I had never seen such a case, but I knew that patients with rare diseases were often trotted out for exams.

Again, the examiner grunted, “Hmm, anything else?” I’m wondering now whether I am on target or whether the examiner is merely allowing me dig myself into a hole. Leprosy comes to mind since it too has a tendency to damage the cartilage of the nose, and a few sufferers develop a reaction, which is treated with steroid therapy. Doctors in the Far East saw this condition all the time. When I rolled out my far-fetched hypothesis, the head man simply snapped, “Well, we’re not in India, are we?” and he snatched the curtain open. In a daze, I was led to the next station and, eventually, out into the cool afternoon sun.

Milling next to the iron fence bordering the fragrant and colourful hospital gardens near to the clinic, a United Nations assemblage of candidates were dissecting the short cases. After listening for a while at the margin of the group, I asked, “What was that case with the lady in cubicle  4. Was something wrong with her nose?” Several of the doctors turned and looked at me; either it was my accent, or I had just asked the dumbest of questions. “Oh, she had Cushing’s disease,” one replied. “She had a pituitary tumor that was treated by transsphenoidal resection.” I had never before seen a patient who had a steroid-producing pituitary tumour that had been removed through the nose, but there was no doubt in my mind that the doctor was right. It was a depressing end to an afternoon that had begun so beautifully. Now I had to worry whether I would be in to receive the thick package in the mail that everyone who sat the exam feared.

We knew that it meant that you had failed the exam, and along with the bad news, the college was considerate enough to enclose a booklet of regulations and the application forms that one needed to resit the exam. After learning what I’d missed in cubicle 4, I feared that my fate was sealed.

It turned out not to be so. In November, a letter came in a plain flat brown envelope from Dr John Nimmo, registrar of the Royal College of Physicians of Edinburgh. It began, “Dear Dr Munnings, I have pleasure in informing you that you have satisfied the examiners in the Membership Examination,” and that was as far as I got before I did my imitation of the housewife being visited by the Publishers Clearinghouse Sweepstakes prize patrol. I ran down the hospital corridor looking for someone with whom I could share the news, and it was just my luck that the place was deserted; none of my coaches were around. I ended up in Professor Read’s suite at the other end of the building, and upon hearing the news, he opened a cabinet opposite his desk and poured a glass of sherry.

In my first short case I was horrified to see a patient whom I had seen in the ward of the Edinburgh Infirmary. (Throughout the year registrars and consultants are constrained upon ‘to dig up suitable patients’ which can be used as illustrative of this or that for examination purposes.) My heart sank as I had used this lady as a test long case in the ward not long earlier and at that stage they had no idea what was wrong with her.

“Excuse me, Sir, but I cannot in all honesty see this patient as I have used her as a long case in the ward.”

“Ah, thank ye kindly, laddie, I admire your honesty, maybe you should have a look at this laydee.”

The chances just had to be better – and they were. I guessed the blood slide correctly and was given no ECG to read. Someone must be looking after me, I thought.
Then there was ‘the-what-am-I-thinking’ game. It started with the usual polite introductions of “Now where would ye be from, laddie”.

“From Papua New Guinea, Sir.”

“So, what are you doing up from West Africa?” No response to that question.

“Well, actually I am from the Pacific Guinea.”

His colleague, wishing to recover ground asks, “And what is the most important medical discovery to come out of New Guinea?” Now what indeed!

“Perhaps the discovery of kuru, the neurological disease, caught by eating the brains of the dead?”

“Naw, laddie, it only occurs there.” I did not add, but could have “ but it will lead to two Nobel Prizes in Medicine or Physiology”. Try again.

Perhaps, “Pigbel – Enteritis necroticans – a kind of food poisoning which follows eating partly cooked pig meat several days old contaminated by soil.”

No? I was fast running out of potential candidates.

“Well, perhaps the use of injectable iodised oil in mothers to reduce the occurrence of endemic cretinism?”

No? I am getting to the bottom of my barrel and to the end of my tether.

“Eh, perhaps the immunisation of mothers with tetanus toxoid, and the subsequent transplacental passage of antibody to their babies, thus preventing neonatal tetanus.”

“Yeerse laddie, surely one of the greatest public health discoveries of the century.”

Pheew! I passed.