From: Harold Alexander Munnings Jr’s  autobiography Westward

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.