Pressure of a Surgery Exam? Next to none.

Pressure? What pressure? I'ts what makes the kettle whistle.

I was talking to a friend recently, who is currently taking what is probably one of the most challenging, exhaustive, demanding and the most nerve wrecking set of exams on the face of this earth. That's right! Im talking about The Final Professional Examination in MBBS. Where all five years come together to bite you in the ass one last time. Months of endless studying, practicing and perfecting your clinical methods, and it all boils down to individual days of judgement. Let me walk you through what is an average exam for a medical student at Allama Iqbal Medical College's affiliate Jinnah Hospital when they walk in one fine morning ready (or not) to give their surgery practical/viva examination. This one day exam may run anywhere from 5 to 7 hours, depending on what the situation is. My Medicine exam started at 9AM and ended at 4:30PM. But I'm not going to talk about that today. Instead, I'm going to talk about my experience from the day of my surgery exam.

Wake up early morning, after a night of terrorising nightmares and waking up to the feeling of your heart beating faster than you can count. Taking a cold shower is important - followed by a clean shave, not taking any chances with a goatee on this blessed day. Pick out your favourite shirt and a neat tie will always land extra points (read on). Eat a light breakfast, count and check all the utensil and things you need on this glorious day to perform basic surgical methods. Also make sure your coat is as flawless white as it can be. The drive from where I lived in Cantt to Jinnah Hospital is painstakingly long and with the early morning traffic it is also very frustrating. I generally avoid calling any of my friends to talk about how they're feeling. That, I came to realise is a recipe for giving yourself unneeded stress at a time you need to stay calm. If it's a last minute freak out; call them up and ask for what you need.

8:45AM you walk into Surgery Unit I and find yourself among a hundred of your classmates ready for battle. You will find here a wide variety of the type of students that exist in medical school. The standard nerd who studied all year (no wait, all five years) and he has at least five guys huddled around him asking him questions to which he is parroting answers like no tomorrow. You have the type who know they're about to get royally f%$#ed - their facial expressions, the quiet demeanour, the oblivious look on their face when they hear something from the parrot that everyone else knows except them - it really is a sorry sight (and I have been in those shoes once). Also, you will find the super-freak, he will be freaking out so bad you'll wonder if he has taken PCP before arriving. He will be holding Bailey & Love (the heaviest text book in the world!) and flipping through pages like a mad man. He will rush from one group of students to another, asking the most irrelevant questions, but if someone else happens to know the answer, he will believe he's left behind in the race of life. Eventually, he will walk into a corner alone with his head buried in the book. He will do this until its 9AM - nothing unusual, we're all used to it after all these years. People like R naturally find it difficult to control their nerves in tense situations. Then there are the average people, who I get along with so well - we embrace each other in hugs as we meet, and have a few laughs. Deep down, we're content with our preparation for the day and now its time to let destiny take over. The tension between us is obvious despite our frail attempts at laughing it off . My restless leg syndrome is a fair testament to that. This is a tense experience for all of us. Margin of error is little, say one word the professor didn't want to hear from you and you're in a hole; say more than you were asked and land yourself in more trouble; one ill timed action while performing physical examination and you're toast; perform one task less, i.e forget to greet the patient when meeting him/her, forget asking for consent (cardinal sin), forget to re-drape the patient after examination and so on. An endless list of important routines that must be followed. And if you don't, it can cost you big time here. Controlling your nerves is the most important part, or so I've concluded in my mind. If we fail even one part of this exam by one mark, we will have to give the entire Surgery exam once again (including the two part written exams we gave earlier); nobody...nobody wants to go through that experience. Studying surgery all over again is not a cake walk.

8:55AM Everyone is busy making their last prayers, 100 students will be divided into four groups and sent to each of the four Surgery wards in our hospital. Each ward will be carrying out examinations. All the students are praying they don't get sent to Surgery Unit 3, anywhere but there! because Professor A.F is well known for failing majority of the students that appear. As students are divided into four batches, it turns out I'm going to Surgery Unit 3. Im smiling on the outside, but inside my head I'm screaming "F&^%!!" at the top of my lungs. The only positive in all this is that during my final year session, I had rotations in this unit and though the professor is quite demanding, he usually knows students with good work ethics who attended his ward. I busted my ass off all year, and especially in his ward. So I'm hoping that somehow I left a good impression on him (that is, if he remembers).

9:00AM: First part of the exam is about to start (OSCE). There are 15 stations inside a conference room, each having a piece of paper with questions on it, some stations will have radiographs, some will have surgical instrument, IVP, a CT scans etc along with two interactive stations with two Professors of Surgery, an internal examiner who is the notorious professor of Surgical Unit 3 (Dr AF), and one from Services Hospital Lahore. Both of them will be spending 5 minutes each with every student and ask their questions. The exam begins, I am able to diagnose cases at most of the stations. As I get closer to the professors though, I can hear them diagnosing which books my fellows read for surgery, AF has this sixth sense of knowing exactly which book you studied from after hearing your answers. The famous book, Shamim's Surgery, is quite a hot favourite among final year medical students, but if anyone mentions that they studied it to the professor - they are destined for failure. Luckily, I stayed away from that book. Im starting to freak out as I can hear Prof AF grilling students. Im first seated with the external professor, the one from Services Hospital, he has a radiograph showing air fluid levels in the intestines. Ah si! intestinal obstruction! a lightbulb turns on in my head as I answer his initial questions before I confuse myself and him with my lack of knowledge on the electrolyte imbalance following intestinal obstruction. He is not happy and instead of moving onto the next question, he is insistent on hearing my answer. He is waiting for me to say something really stupid, but Im not going to show him my cards in that manner. I will fold and stay quiet and let time run. I start to feel as if he's going to fail me so I try an answer, only to hear "vhat!?" from him. Oops! should've stayed quiet. Back to silence. Times running out, he changes his question and I answer the next one in galloping rhythms. Bell rings and now its time for the real deal, Prof. AF awaits. I sit infront of him and I see a T-tube between us on the table and his only question is to identify what it is and give 5 uses. I take less than 30 seconds in answering. He is impressed. Before anything else he says "that's a very nice tie you're wearing". And life is good!

Then he asks me about what book I read, and the default answer is "Baily & Love, sir", he asks how I read and retained such a big book. I told him I made notes of important topics, while I used other books for less important topics. In reality, I studied from this amazing Indian book called Manipal Manual of Surgery, but telling Prof AF that you studied any book other than Bailey & Love is like shooting yourself in the foot. First part of the exam is over and I am off to a good start. Onto the next part; short cases.

10AM: We are taken to Surgery Unit 2, where 25 of us are packed into one small room where there are a total of 5 seats. Comfort is a luxury nobody cares for. Next part of the exam, we'll each have to appear infront of two different professors one by one and we'll be given a case for which we have to perform the corresponding physical examination and present our findings to the professor - all within 5 minutes time limit. While everyone is crammed in this tiny room, there's hardly enough room to breathe, the level of stress is also rising, the students are busy discussing last minute methods, some of them have only done these methods a few weeks ago. Others, have been practising all year. There's a vast difference in performance, the confidence, the control, the intricacy and calmness of the two groups. An examiner can easily tell which student has been practising for a while, as opposed to someone who only recently began practising methods. I walk into the examination room and am assigned a patient, the external examiner here is from Punjab Medical College in Faisalabad, and I have a hernia patient. I remember examining atleast a fifty patients with hernia during my surgery rotations in S3, piece of cake!? not this case, he has a direct hernia which is not very common in elderly males, or does he? A direct hernia is what I believe he has after performing my examination, but maybe I'm wrong? could I be wrong? because I havent seen a patient like that before! Usually elderly males have indirect hernia's, I can't recall seeing a direct hernia in an older male before! ahhh the confusion! I tell the professor my findings and he is not very happy! but he can tell I am not sure of what type of hernia it is. He asks me to explain my reasoning, and I do so extensively. My clinical methods were all right, but correlating my finding with theory is where hernia can cause problems for medical students. I get out of it without making a meal of the situation - Im treading on the borderline in terms of if I'll pass or fail that case. Onto the next case, I have to quickly put the past behind me and concentrate on what's here and lo behold, it's diabetic foot, that's gonna stink! but Ive grown accustomed to the stink in surgery. I had a similar case for my ward test earlier in the year, and I nailed it. Should be easy again - I go through the check list in my head for examination of the ulcer, I do an arterial exam and local nodes for good measure, and present my findings to the professor. I go in such detail that time runs out, but who cares - he is happy. If he gives me good marks, I'll probably compensate for messing up on the hernia. Hope for the best and off we go onto the next part of the exam.

12 noon: We rush back to Surgery Unit 3 for the last part of the exam, the dreadful long-case. This is the part where everyone draws a number, and are allotted a bed with a patient on it. You take a full history of the patient, do a full physical examination, and then the specific examination. Last, you draw your diagnosis. But the main part is yet to come, knowing the diagnosis will get you 1/5 marks, if you're completing medschool - you are expected to know how to manage the patient, so you're supposed to know the complete treatment and related information to whatever the patients diagnosis is. If my luck couldn't get any worse, I draw a bed number on which there's a patient with a caste wrapped all around his leg. An orthopaedics case!!?!?! This is quite possibly the worst case anyone could have! "Why the f%@* do they have a orthopaedics case here!?" is all I'm repeating in my head.

I had only studied orthopaedics before my written exam, and as if the rest of surgery isn't enough, ortho is a whole different field on its own! Its very unusual to find this case here. I am now sweating a little, legs starting to tremble, ears must be red - ahh am I crumbling under pressure?! I tell myself to stay calm and get on with what I can do in my capacity with this patient - I can take a good history! I can do a mean general physical examination! Looking around at my colleagues, I can see one guy adjacent to my patients bed sweating like a pig. He has a patient with a case of undescended testis - but by the looks of it, my friends' testis have ascended so far up his spermatic cord that he is not sure where he is anymore. I tell him to calm his ass down, I studied Urogenital System last night so I knew quite a bit about his case. I share whatever I could about its management and tell him to wipe the sweat off his face. Geez! the thing I hate about people in medical school is unneeded tension they build up for everyone around them! It becomes contagious, now Im worried too! The House Officer on duty conducts a round to see if everyone's completed the necessary work before the oral exam starts. He tells me I need not to do a complete examination as the patient is immobilized. That's a relief, now I can concentrate my energies on trying to figure out what type of fracture this person has and how it is managed. But before I get time, the first examiner walks in. I begin with my history, and that I do impressively, I would always volunteer to present history in wards and the practise has made me confident. The professor is more than satisfied. He asks me my diagnosis before asking me the classification of fractures. I can hardly remember but I gave him a half-ass answer, and that seemed to have confused him, as he tries unsuccessfully to remember the classification himself. Obviously, he's not an orthopeadic surgeon. Followed by an entourage of house officers and attendings, he doesn't dwell in any further and says "ok good" and walks away. That wasn't too bad. If he had asked me any more questions than the two that he asked, I would've not known the answers. Now I'm really starting to worry, Prof. A.F is here and he starts taking vivas. Im going to be the last person left in the room, which means I have to stand and watch him tear other students up. Waiting bedside with my patient and watching as he rips new ones into students before me, I am officially starting to feel the butterflies in my stomach and my mind relapsing to glorious moments of medical school rapings that I have had to bear on my journey to getting here. Finally, my turn arrives, he is also with his entourage of house officers and attendings, they really know how to put you on the spot! Dr AF begins by checking my clerkship record, I attended surgery wards since third year of medschool so I know Im good on that. He asks me to present my history - once again, I give him a long well thought out history using words even I don't remember the meaning of (I am hoping he still likes my tie), he asks me why I think it's a road traffic accident. "Because the patient told me so". Just to make sure, he cross-checks with the patient. Fair enough. He moves onto the management of this patient, I give him my sloppy version. He is somewhat dissatisfied, but I think he still likes my tie. He asks me about the types of immobilization in fracture management, and about what type of fracture I think this patient has and why. I give him sharp answers, honest but not confident. He nods before asking me about possible complications that this patient may eventually have. I do not have them memorized as a list in my head, but thinking logically, I muster up a few. He isnt very happy but its better than nothing. He smiles and walks away. I am adamant in my head that I must've failed! And that's the end of my oral surgery exam at nearly 2PM. He walks away and one of the house officer stays behind and tells me that I did well, much better than others who had the same patient on previous days of examination. I am so relieved. All I'm looking forward to now is going home and sleeping for a day!

In the end, you can prepare all year and study as much as you want, but if you don't stay calm and collected you are going to risk losing it all. Also if you do not practise your methods all year, you can't expect yourself to do well in the practical examinations in final year of MBBS, which are probably a lot more important than written. You have to work all your life dealing with patients not with books, so it's important to lay strong foundations starting in medical school. Its also to be noted that there is a lot of luck involved, but my definition of luck is when opportunity meets preparation. If you are not prepared - you are not going to be lucky.