Thursday, July 21, 2016
Making of a Child Psychiatrist: (43) Exams… (1)
We caught the ferry back to Dover on the Saturday morning, called in to the families to let them know we were safe if not sound, unfolded the highlights of our trip, and stayed overnight with Jan’s parents. We had proper baths, and slept in a proper bed. By Monday Jan was back at work, and I was back into study, and we were back in our cosy home.
There were four lots of exams to be survived. I had rather cheekily put myself in for the King’s student prize exams, more to give me experience of the standard I might have to achieve, than with any real chance of winning, whatever that meant. So late in 1966, a number of us sat down to do written exams. I have to say now that it is all a bit of a blur, and I can no longer remember where we sat; I suspect it may have been in the library. When I looked around, there were most of the people from my year, those that I reckoned to be brilliant and from medical families and therefore bound to succeed, the serious minded swots who spent almost all of their time working, the fun-loving set whom I had not seen for many months because they had been head down in their books, and even some of the sporty group. Exams existed for most of the topics we had studied over the years.
I guess I had learned something about exams over the years. I would read and re-read the question, and be clear what I thought the examiners were asking. Then I would do a brain dump of all that I knew about the topic or question, quickly shape an answer and then write until I knew I should move on. There were mini-essays, short answer questions and some multiple-choice questions. I was nervous, which could have been read as excitement (from a positive mind perspective). I was not overwhelmed, because in truth I had no expectations. This may all sound very glib and superficial. But with the passing of the years, I have truly forgotten al the detail. I do have an odd collection of old exam papers in a box in my study (yes, I am a hoarder), but they are somewhat random and incomplete. I had enjoyed the Clinical Medicine and Psychiatry exam papers, thought I had done passably in Obstetrics and Gynaecology, knew I had not done particularly well in Pathology, Surgery, or Ear, Nose or Throat.
A week or so after the writtens, we were filtered out and allocated times for vivas, followed by clinical exams where relevant. If you had not scored enough in the writtens, then you were out of the latter processes. Very efficient! I did not resent only getting vivas in two subjects; it made sense in terms of my experience of the writtens; I was actually excited given my prior lack of expectation. I was also quite surprised as I began to learn about my colleagues who did not get vivas in my subjects. It did not make sense in terms of who I thought they were, or how they had performed in ward rounds. I guess they had just had a bad day at the writtens.
I do remember bits of vivas; as you might expect they were subjects I had really enjoyed, or had really focussed on and therefore read something about. Given one of the vivas was in Medicine, I wondered about my clinical immersion down in Kent before our wedding, and how much that had filled out my knowledge and confidence. Or, coming back to an old theme, what may have helped is my apparently in-depth knowledge related to patients for whom I had a visual memory. That had made me curious to know more to flesh out the background, and clinical details; perhaps that knowledge had ‘stuck’.
I enjoyed the viva in Medicine where I was asked about renal physiology and pathology and clinical signs; the topic had fascinated me for a brief while, I actually had read some texts, and Jan and I had discussed laboratory tests. They moved on to questions about Neurology; again this had fascinated me since pre-clinical days and I had read several tomes. In particular there were questions about acromegaly, and I could recall at least two people I had seen over the years - which had led me to understand the pathology and treatment. Finally there were a few questions about Thyroid disorders. As I have mentioned before, my mother had suffered from a goitre, so I had spent a lot of time with my clinical patients with disorders of the same origin, and then read relevant texts afterwards.
When it came to the clinical exam, once again it seemed that luck was with me. I was introduced to a nice older man who had the classic symptoms of a recent coronary thrombosis. In the brief history time we got on well, and apparently I was able to represent his symptoms accurately and report on the minimal signs I had found on examination. I was then handed an ECG from the patient, and asked what I thought of it. I thanked the fates that I had completed my GrundyTutor course, given I found myself confidently noting the irregularities in rhythm, and changes in the waves – particularly the S-T segment. “Thankyou, Mr. Martin. Let us move on,” was the only response from the consultant (whom I did not know). For a short case, I was then shown a man who had loss of function in an erratic pattern that included symptoms in his hands and arms, right more than left. In particular, he had wasting of the small muscles of the right hand, and a loss of flexibility, power and sensation. Sir, I think this man has some spinal cord damage at the level of C5-6. “Would you care to hazard a guess as to what may have caused this, Mr. Martin?” I suspect this may be Syringomyelia, sir. May I have a look at any x-rays? These were duly produced, and showed what I suspected – literally some elongated holes in the spinal cord. “Does this fit your diagnosis, Mr. Martin?” Yes, sir, I believe it does, I said pointing out what I had seen. “Thank you. That is all.” That was it; 20 minutes, short and sharp on two clinical cases with some interpretation of technology. I counted myself very fortunate.
The only other topic for which I was called to be further examined, was Psychiatry. Psychiatry did not allow access to patients in medical student exams, so it was limited to the viva voce. There was a lengthy section of questioning on the possible causes of Anxiety, and I felt comfortable weighing the pros and cons of psychological versus organic. I was able to list a number of illnesses for which anxiety was a major feature, and that led us into a discussion of Thyrotoxicosis (would you believe), and how I would diagnose this clinically in patient presenting with anxiety. I rattled off the symptoms that may suggest a physical presentation rather than primary psychological reasons. We moved on to depression and its types, and the range of treatments available. It was comfortable for me and I felt on firm ground. Then: “Have you ever heard of Capgras Syndrome?” Yes, sir, from memory it's a belief that someone you know really well has been replaced by an identical stranger. “So if you came across someone with this strange belief, how would you investigate further?’ Well, sir, it is a delusion, but probably not psychotic. It usually has an organic cause. “So what do you think you might find?” On Xray, I think you may find something like a tumour in the brain, sir. “Do you have any idea where in the brain?” I think it might be the parietal lobe, sir. “Thankyou Mr. Martin, that is something like it”. You are excused. I was not sure what to make of that last quip. But, when I looked up Capgras again in my neurology book later that evening, I was sort of right, even if I had not been specific.
I did not find out about the results for some weeks, but I was not worrying about it. I had no expectations, and so had nothing to be anxious or troubled about. I knew for certain that there were many of my colleagues who had worked much harder, and on their own report seemed to have done well in the clinicals.
I was stunned when I found myself being congratulated by friends, and immediately had to hunt down the noticeboard with the results. To cut a long story short, I had won the White Prize for Psychiatry, and also the Robert Bentley Todd Prize and Medal for Clinical Medicine. I counted myself very lucky for the questions I had been asked, and was actually a little embarrassed round some of my friends. I had to go back a couple of times to check those same results, the second time just before leaving at the end of the day. I did not want to get Jan all excited about my success, unless it was certain. The prizes would be awarded at the end of the 1966-67 clinical year Graduation Ceremony in June. Right. I was excited, as was Jan. My parents and parents in law were over the moon. And I had some thoughts that actually I could become a doctor.
There was a not very hidden bonus to doing well in prize exams; it put you in the running for house jobs. So, in the New Year I found out that I would be offered the house physician post in the Professorial Medicine Unit. Ah, right, so all I had to do now was to pass my final examinations! I was also given the opportunity for informal discussions about the possibility of getting a job in psychiatry. I was told that I would have to complete at least a year of house jobs, and have gained my registration before I could take on a Senior House Officer post, the base grade for training in psychiatry. So, no, I could not make an application at this time. Wait and see!