Second Edition
This edition first published 2017
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The second edition is dedicated to Hector, Juno and Caleb.
‘I take the view, and always have, that if you cannot say what you want to say in twenty minutes you ought to go away and write a book about it’
(Lord Brabazon, 1884–1964)
After our group of registrars sat the RACP Written Exam in 2005 in Auckland, we thought back on how our lives had changed. Our houses were full of notes, textbooks and journal articles, and we were proud owners of impressive collections of highlighters. Our minds were full of little snippets of advice snatched in hospital corridors from our consultants and senior registrars: how to find old exam questions, how to sign up for courses and how to start a study group. After most of us passed the Written, we were compelled to write these snippets down so the collective wisdom could be passed on to the 2006 registrars. Then reality hit; there was another, harder exam to sit – the Clinical. Once again, we muddled through with an enormous debt to seniors who hauled us through short cases and long cases, gave us pep talks and lent us books. Many of us passed the Clinical Exam somehow. And what better way for us to continue the fine physicianly tradition of helping those who come after us than to write a book?
Ingrid and I, with the help of Pat Starkey, our editor with the patience of a saint, wrote How to Pass and published it through our local hospital. Our little book was well received and reprinted twice. Ingrid and I moved on to advanced training, fellowships, consultanthood and family life. Requests for copies of How to Pass kept popping up, and while there was content that remained relevant, it was time for an update. Ingrid passed the baton to me to update the book, which I have done with the help of Cheryl, some amazing guest star chapter authors (including paediatricians) and the current generation of exam‐sitting registrars.
The journey through the RACP exams is long, arduous and, at times, painful. You’ll laugh. You’ll cry. You’ll hurl. You’ll lose some friends but make others. You will also gain a lot of knowledge, become a better doctor and before you know it, advanced training will be upon you, and your life as a physician or paediatrician will begin.
Take heart that you are not the first person to study for this ‘quiz’ and you won’t be the last. With hundreds of hours of study, some personal sacrifice, advice that works and a spot of luck, we reckon you’ll figure out How to Pass too.
In 2005, Zoë was so convinced she’d failed her Written Exam that she jotted down some tips for the next attempt to help herself and anyone else the following year. She and her study group passed that year, they all passed the Clinical and have been friends ever since. She kept busy with advanced training in gastroenterology and general medicine, married Ben Hill and was involved in the RACP as chair of the College Trainees’ Committee and Director of the Board. Zoë dragged Ben to England, did a fellowship at the John Radcliffe Hospital in Oxford in 2009 for a couple of years and returned (with a mind full of ideas, a passport with lots of stamps and a lovely little boy) to New Zealand for a consultant post at Waitemata District Health Board in Auckland. Zoë became an RACP examiner in 2016. Such is her dedication to this book, she wrote this bio three days before the birth of Juno, Hector’s little sister.
Ingrid sat and passed both sets of RACP exams in 2005 in Auckland. She now lives on the Sunshine Coast, Australia, with her husband, two kids and their dog. Ingrid works as a private rheumatologist which involves a lot of polypharmacy, social isolation and ‘balancing the demands of competing medical conditions’ (that phrase still comes in handy for GP letters). She doesn’t miss doing weekend nights on call.
Cheryl passed the RACP Written and Clinical Exams in 2008. She spent the next five years in advanced training and became a geriatrician and general physician in 2013. Cheryl then overqualified herself as co‐author by accepting a Geriatrician and Medical Tutor Specialist position at Waitemata District Health Board in Auckland. She is the RACP Director of Physician Education and is on the working group for the redesign of the Basic Training Curriculum. Cheryl has been an RACP examiner (NZ) since 2014 and organised the 2013 and 2015 Clinical Examinations at North Shore Hospital. She is the current chair of the Auckland Medicine Vocational Training Committee, the mother of Caleb who is at start school, uses her considerable charm to convince consultants to come in on Saturday mornings to tutor the candidates and is the adoptive big sister to all the trainees she whips into shape for these exams every year.
Many people have walked us through exams, advanced training, fellowship, motherhood and consultancy. We’d like to thank our friends, families, study groupies and fellow candidates. We couldn’t have done it without you. We are eternally grateful to the patients and examiners who endured our practice cases – thanks for not laughing too openly at the time. We’d like to thank our colleagues, chapter authors and trainees who have been so generous with their input and contributions, be they emails, scribbles on napkins or chats in corridors. Your words of wisdom will smooth the path of those who follow. Thanks to our publisher for taking How to Pass to the next level and our wonderful families for teaching us about what matters in life every day.
While we can’t list you all, there are some notable people who gave substantial time and advice for this book. Thank you for your contributions.
Chapter 20 Suggested Approach to a Māori Patient in the Long Case – Dr Matthew Wheeler, Advanced Trainee, Dunedin
Chapter 30 How to Fail – The Outsider’s Guide to the FRACP Exam – Dr Roderick Ryan, Paediatrician, Box Hill Hospital and Maroondah Hospital, Victoria, Australia
Chapter 32 Studying for the FRACP with a Family on Board – Dr Robert Wakuluk, Advanced Trainee, Auckland
Chapter 35 Preparing for Your Medical Interview – Dr Nalin Wickramasuriya, Paediatrician, Queen Alexandra Hospital, Portsmouth, UK
Dr Genevieve Ostring, Paediatrician and Clinical Examiner, Waitemata District Health Board
Dr Colette Muir, Developmental Paediatrician, Starship Hospital
Dr Stephen McBride, Infectious Diseases Physician, Middlemore Hospital
Dr Chris Hood, Renal Physician, Middlemore Hospital
Dr Mark Simpson, Neurologist, Auckland City Hospital and Waitemata District Health Board
Dr Diana McNeill, Endocrinologist, Middlemore Hospital
Dr Sophie Leitch, Advanced Trainee, Auckland
Dr Chloe Khoo, Advanced Trainee, Auckland
Dr Amanda Chen, Advanced Trainee, Auckland
Dr Michael Lee, Advanced Trainee, Auckland
Ms Pat Starkey, Clinical Education and Training Unit, Auckland City Hospital
Ms Gill Naden, Clinical Education and Training Unit, Auckland City Hospital
Dr Melanie Ang, Paediatrician, Middlemore Hospital
Dr Anthony Concannon, Paediatrician, Middlemore Hospital
Diagrams, pictures and photographs by Zoë Raos
This book is littered with acronyms ranging from LFTs and ILD to RA and DLCO. We could have written the words all out in full but that would have taken us years and the book would have been enormous. We have worked hard to canvas as much advice from many registrars and consultants for both editions to reflect a range of successful approaches to the Written and Clinical Exams. There was not time to do a randomised double‐blind placebo‐controlled study on all the advice herein, so this book hovers above Z grade evidence with plenty of hearsay and rumour to further dilute the science. Please apply a large amount of common sense to your situation. If there is something earth‐shatteringly awesome that helped you pass that is missing, please email us for the third edition. Our use of pronouns may also cause confusion. Usually, ‘I’ means ‘Zoë’ and ‘we’ can mean anything from ‘Zoë and Cheryl’, ‘Ingrid and Zoë’ to ‘everyone we’ve talked to about this’.
Congratulations on embarking upon one of the most difficult but rewarding of career paths, that of internal medicine. Perhaps you see yourself as a budding neurologist or daydream about leading an adoring team on a fascinating general medical ward round. Maybe you will reach nirvana catheterising a left anterior descending artery. Maybe you enjoy working out a target weight for haemodialysis. Perhaps you’ve ruled out surgery (not crazy about detailing the boss’s Audi), anaesthetics (big syringe, small syringe), radiology (too dark) and general practice (too general) and it comes down to internal medicine for adults or children. Internal medicine is not the career choice for everyone. The job of a long‐suffering medical or paediatric registrar with the relentless on‐call roster, permanent eye bags and a cynical outlook becomes even less attractive with exam stress. Please remember that you will be a consultant a lot longer than you will be a registrar. Your training will not last forever, so think of the career you want to have at the end of your training as well as the thorny and intense journey travelled to get there.
Historically, it has been rather straightforward getting a basic training post in medicine and paediatrics (a desperate phone call from the head of department the night before the job started worked for me). Times are changing. Before being eligible to even think about sitting the Written Exam, the trainee will need to have completed the requisite number of mini‐CEXs and done some concerted navel gazing with the PREP programme. Paediatric trainees will have had a taste of exams with the Diploma. You may even have had (Shock! Horror!) an interview; if one is coming up then check out Chapter 35 for medical interview tips.
The FRACP Written Exam is infamous for an enormous syllabus and intense focus on the minutest of details. The thought of this exam sends many prospective physicians packing to alternative careers. Another off‐putting factor is that the examination, unlike many other specialties, is only held annually. High stakes. High stress. The preparation takes most candidates 8–12 months. Add study into the life of a busy medical or paediatric registrar and it is a miracle anyone sits at all.
While looking at old questions makes all newbie candidates clutch their heads in their hands, there is a method to the madness. The year of preparatory study lays the groundwork for advanced training, sharpens the mind, creates a robust knowledge base, increases confidence and improves performance at work.
The proportion of candidates passing the exam varies from year to year, and from region to region, but is generally above 50%. In the Auckland region, for example, the pass rate has risen from 50–70% a decade ago to over 80%. This means the majority of registrars, who commit to sacrificing almost a year of their life, put in the hard yards, work in a supportive hospital and revise properly, can hope to pass the Written Exam in their first attempt or, failing that, their second. Auckland paediatric trainees are even better off with a highly organised training programme, reflected in a 92% pass rate.
Tricky. There is no perfect time in anyone’s life. Candidates have sat (and passed) whilst heavily pregnant, newly postpartum, in the middle of house renovations, moving interstate and training for triathlons. Even so, it is crucial to weigh up the rest of your life goals before signing up.
A cautionary tale to those who have a burning desire to surge ahead and get that Written Exam over and done with as soon as possible. We have observed that candidates who allow for 1–2 years in addition to the minimum allowed by the College have an edge. These registrars handle work stress better, have more clinical experience to help with tricky and obscure Written Exam questions and perform to a higher standard for the Clinical Exam. Your registrar years will whizz by very quickly. Take another year now – no shame in it, might even do you some good. Also, once the exams are over, you want to be able to move straight into advanced training without having to spend another rotation doing more of the same work.
The exam is always in February for paeds and adult medicine. One year (i.e. starting in March the year before) is about enough time to get through the material. Some people start earlier, but find it difficult to keep up momentum. There are anecdotes of candidates who ‘did no work until the November Sydney course’ and passed, with tales of ‘studying smart, not hard’ – we don’t believe them! The Law of Mass Effect states the harsh truth – the more time you put in, the more you learn. In Chapter 3 we will give some pointers to efficient and effective revision. This is a high‐stakes, high‐calibre examination. Give yourself plenty of time to prepare.
If you’re not sure that you want to sit just yet, consider sitting in with an existing study group and see how you fit. Canvas opinion from local registrars who have passed (and failed) recently. Finally, if you’re still in a quandary, it can be useful to ask your ward consultant or educational supervisor if he or she thinks you’re ready. Once you have decided to sit then the best approach is to hurtle wholeheartedly into revision. The best strategy is to commit to sitting, work hard and pass the first time. Candidates with multiple half‐hearted unsuccessful attempts are even more distraught than those poor souls who slog their guts out, have a bad exam day and fail. If you haven’t made your mind up by July whether to sit the following year, leave it for another year as there may not be enough time. There is no shame in this decision and it will probably pay off, as that extra year will mean more experience (as long as the procrastination ends eventually!). Remember – better to sit once and sit well.
Congratulations! You are not put off! It is important to know what you’re up for. Before we embark on the intricacies of how to pass, may we introduce you to the exam itself.
Without giving away trade secrets, we will attempt to describe how the exam is set. Knowing how the exam is written helps you tackle it. There are four RACP exam committees.
The two Written Exam Committees do things slightly differently but the overall premise is the same. Both committees have representatives from every medical subspecialty known to the College/humanity. Each member of the committee formulates a number of questions that they think should be included in the exam. Other College fellows are able to submit questions also. The committees meet and all submitted questions are reviewed and agreed upon, revised or rejected. By September of the prior year, the exam is set in stone. So anything in a journal after the end of September is unlikely to be examined.
The brief of question writers is to come up with an MCQ that is set at the level of a trainee at the end of basic training. Not a subspecialist. Not even advanced trainee level. For example, you are not expected to know every single monoclonal antibody in existence, but it is fair game to be asked about the complications of TNF inhibitors.
For those who have sat the exam before, or who have already started studying, you may be quietly laughing (or perhaps crying) to yourselves at the thought of that last question you spent four hours trying to solve being allegedly set at basic trainee level.
Here is the format of the exam. It is the same for paediatrics. It is worth noting that, especially in Paper 1, questions can be very similar if not identical across the adult medicine and paediatrics papers.
Morning
Paper 1 – Medical Sciences: 70 questions; time allowed: 2 hours
Lunch break (where no‐one really eats that much)
Afternoon
Paper 2 – Clinical Applications: 100 questions; time allowed: 3 hours
Most questions are in A‐type multiple‐choice format, meaning the candidate chooses the single best answer of the five options given, and shades the appropriate box on a separate answer sheet.
Since 2013, extended matching questions (EMQs) have been included in the exam. Several questions (each worth one mark) based around a theme are bunched together and organised into three parts. The first part is an option list of eight possible answers. The second part is a lead‐in statement. The third part has the stems (the actual exam questions) as clinical vignettes. To answer each exam question, the candidate works backwards: reads the vignette, keeps the lead‐in statement in mind, then chooses the correct answer from the option list. Each correct answer scores one mark and an incorrect answer zero. Confused? Best to go through an example.
Your papers are handed in, the candidates collectively collapse in an exhausted heap, then the papers are marked electronically. It is not quite as simple as one correct answer = one mark chalked up. Some questions are flagged as ‘good discriminators’ by a complicated actuarial equation. If the vast majority of candidates get a question correct or incorrect, it is chucked out as being a poor discriminator. This usually applies to repeated questions from past exams. Questions that discriminate between the highest and the lowest candidate scores are given more weight. After more statistical jiggery‐pokery, the candidates are ranked in order, a percentage pass mark is decided upon and a line is drawn between successful and unsuccessful candidates. At least, that’s our understanding of the whole thing.
Finally, whether you pass or fail, the College sends you a postmortem of your exam with your marks for each paper and ranks you against all the other candidates. This information is for your eyes only – no one else receives it and you can choose to burn it once you have read it!
We have included a past candidate’s results statement as an example.
Results Statement
Before you open a book or look at an MCQ, we suggest getting some essential jobs done first. We have observed several pre‐studying strategies that successful candidates have in common.
Make sure you’ve ticked all the boxes for PREP with the RACP so that a year of hard work is not thwarted for the sake of a missing mini‐CEX.
Alternatively, make the decision not to sit, be glad you didn’t and enjoy your year of freedom. We labour this point for good reason: it is indecision that has killed the possibility of passing for many candidates, as they flounder about for six months, sometimes committed to studying, sometimes not. If you’ve not started studying by June, it is far too late. Make an active decision.
This seems obvious but some candidates have studied hard until November, then discovered too late that they are not eligible to sit. Don’t let this be you! Fill in the forms and check with your Director of Physician Education.
From our observation, this will increase your chance of passing so much that we have dedicated Chapter 5 to it.
These well‐run courses are hosted for adult medicine trainees in Dunedin, Sydney and Melbourne and for paediatric trainees in Auckland and Sydney roughly four months before the exam. They are an excellent way to consolidate knowledge, give a boost of momentum and get the candidate used to exam conditions two‐thirds of the way through your preparation. Exam courses are covered in detail in Chapter 8, including for paediatric trainees. Secure a spot.
Get these organised well in advance with your hospital, including the days leading up to the exam. You may need to do swaps with other registrars to get out of night duty on the night of the exam or to get to a study course. This is better done now, as the last three weeks before the exam is the worst time to ask for favours! For study leave, most candidates find 4–5 single weeks spaced over the year, plus two weeks off for a revision course, works well. You only have a finite amount of study leave so allow for some to cover the Clinical Exam. Make sure you plan for breaks and holidays too. Don’t take so much leave that your rotation can’t be accredited by the College. It’s a balancing act.
Some jobs are incredibly busy, with 0% chance of getting to teaching. Some are so cruisy your brain turns to mush. There is no perfect job for passing this exam, but ask around about jobs with high pass rates, forgiving rosters and the possibility of taking study leave. Consider a job share with a fellow sitter, if you can afford the drop in pay, but check it is allowed in your centre before setting your heart on it.
Almost more important than a relaxed timetable are two other things – first, proximity to peers in the same boat and second, the quality of FRACP teaching. Some hospitals are incredibly well organised with access to lectures, protected teaching time, extra tutorials and clinical teaching. This is not restricted to big academic centres; there are many smaller hospitals across Australia and New Zealand with an outstanding track record in supporting their trainees through their FRACP exams, and this is reflected in their pass rates.
Explain to your family and friends that you are becoming a self‐imposed slave to the Written Exam. This is a tough exam that will require a lot of your time and energy, and support (be it moral or practical) is crucial. Do not take the support of your loved ones for granted – put in some effort to maintain relationships. If you have children, this will be really hard on you, and them. Plan fun things to do, and include family time in your study timetable. Use this as a reward for study sessions. And remember, by passing this exam you are advancing your career, so you are better able to provide for your family. Please check out Chapter 32 for more tips on studying when there are ankle biters in the house.
Explain to your house officer and boss that you need to be freed from duties when at all possible for teaching sessions and lectures. Apologise in advance for the grumpiness that will come as the exam draws ever nearer. Regular bribes of coffee and cake can grease the wheels. Your boss will have endured exams, and will hopefully understand. Your juniors will be looking ahead to their own career paths, and will hopefully take this as an opportunity to step up. Remember that you are an employee and a colleague; there is a delicate balance between assertively getting to teaching while leaving your patients and juniors organised with clear plans, and aggressively skiving off to the library before the ward round with ill‐prepared patients and furious colleagues. Generally speaking, medical and paediatric registrars are a dedicated bunch who could take a lesson from their surgical colleagues in asserting their right to attend teaching, but there are a few who take the proverbial.
Find someone friendly from the previous year from whom to cadge lecture notes/old exams/material from course/tips. They will surely be delighted to offload five boxes of material to weigh down your bookshelves in lieu of theirs.
Set aside a pleasant place at home with a desk, decent chair, a good lamp and logical storage for the phenomenal amount of written material you will receive and generate, even in the electronic age. Many candidates need a change of scene and prefer the library, but you still need somewhere to keep all the guff.
This is the hardest task by far. Have your eye on the prize, and take time to plan the attack. A wall planner is useful, as is setting goals for the overall study plan. Decide on your approach (see Chapter 6 for wallpapering your mind) and accept that your goals will shift as the year progresses.