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Friday, July 22, 2016

Making of a Child Psychiatrist: (43) Exams… (1)

The next few months are a blur. I really did want this. It appeared that on a good series of days, with the right questions to suit what I had been learning, and interesting clinical cases (that I may have seen before), and nice examiners, I could actually become a doctor; something I had been dreaming about since the age of 12, and had thought to be possible since about the age of 16.
The season was rolling towards winter, and Christmas. So we went out less and less, and avoided too much in the way of social contact. This suited Jan, who was often tired from working full time. I really did set about revision in a big way. I say that, but there were topics I avoided because I found them boring. For instance, I continued my difficulty with pharmacology.
At Med School there were ongoing clinical firms with increasingly high expectations. I spent less and less time in the Common Room (perhaps for reasons I have already described). I spent less and less time playing squash. I had been very keen at one time, Secretary for the club and involved in organising teams for tournaments. This just faded out. I withdrew a lot from my peer group and, if you are not living with a group, you hear less and less of what is going on. If you are married you get invited to fewer parties. From card-playing, squash-playing, party-going, thespian having fun, I became a bit boring. I had little interest in reading the News about the vagaries of the outside world. My world contracted to a tunnel. Possible daylight in about March seemed a long way away.
There were actually three different exam systems. One was the Licentiate in Medicine and Surgery of the Society of Apothecaries (LMSSA), which has not been offered since 1999, and was often seen as either a fallback for any medical student who thought they were unlikely to pass the University degree course. As an organisation, LMSSA had an illustrious history deriving from various trades going way back to about the 12th Century. Originating from the coming together of people who knew about substances that could be taken to remedy an increasing range of human ills, the Apothecaries gained a Royal Charter from James the 1st in 1617. Latterly, they were seen as the precursors of general practitioners, and the Society of Apothecaries were licensed to examine in medicine under an act of parliament from 1815.
There were some quaint rumours suggesting why it might be worth taking the examination. One was that it gave you the right to drive a flock of sheep over London Bridge; a second being the right to ask a policeman to hide you behind his cloak if you wanted to pass water. Given I could never see myself in either of those situations, I could not see the point. One contrary rumour was that you could be examined in Latin, and I deemed my 4th form Latin was now defunct. Two other reasons lurking in my mind were that I had been told there was a strong focus on medication and an understanding of pharmacology, the other that I doubted I would be ready for examination by the date required. I persuaded myself I would not need it; in other words I ‘piked’!
The Conjoint LRCP, MRCS examination was run jointly by the College of Physicians (which gained its Royal charter in 1518) and the College of Surgeons. It was scheduled to begin in early March. This was much more recognised, and would have allowed me to begin to practice medicine and complete further training anywhere. Again, it was thought of as insurance against failing the University degree; at that it was cheap at the price. My preclinical and clinical training fulfilled all the requirements for examination, so I put in my application to the Conjoint Examining Board with the appropriate fee.
As expected, the structure of exams included written papers, clinical examination and vivae voce. Perhaps it is not surprising to have forgotten the contents of papers and viva details given the passage of 50 years. Sadly, I did not save the printed papers. All I really remember is some weeks later attending an overwhelming edifice with marble flooring and imposing columns, where we milled about anxiously awaiting the sentence. One by one we were called to an imposing lectern; those who had passed were asked to enter the portals behind the lectern, and turn left. Those who had failed were left to wander back out onto the street.
Once inside we were given a short address of welcome and congratulation, and then asked to confirm our personal details and sign a register. We were told that we could now use the post-nominal letters LRCP, MRCS, and that our certificates would be posted out within the next few weeks. That was it; I was an honorary doctor. But not yet a ‘proper’ doctor with a University degree! Those exams were a couple of weeks away. So, despite some sense of relief, celebrations were muted.
These processes of examination are never to be taken as just a matter of course. You may have the basic ability, have attended all the teaching offered, have worked hard in small group training sessions, and studied assiduously. But there are always pitfalls - questions in exam papers that seem impossible to answer, or impossible to answer within the allotted time; tired out patients in the clinicals, who have answered the same questions twenty times and have had enough; examiners in the Orals who are getting more grumpy and caustic as the day wears on.
There are few things I remember about finals. From memory, the writtens took place morning and afternoon over several days at Queen’s Square in London. I remember struggling to manage some questions, but other than that all I remember are the toilets. They were the old penny in a slot type, for which you had to be prepared. They were clean, but absolutely covered in graffiti - some rather funny, others absolutely unrepeatable in good company. The one I remember was: “Here am I broken hearted, paid a penny and only farted”. Ah, so true. I believe subsequent clinical exams were at a number of hospitals around London, but I cannot recall where, nor the content of exams.
So a couple of weeks later it was all over. On the appointed day, results were posted behind glass in a freestanding noticeboard outside Senate House of the University of London in Malet Street. I did not want to go with others, so I turned up alone in the late afternoon. The square was empty apart from two students with University College Hospital scarves, sauntering back from the Board looking very pale but smiling. Rather gauche, I asked: “Did you pass?” to a conjoint “Yes, thank God” and they walked on. One turned and, as an afterthought, wished me luck. Heart pounding, and slightly blurry eyed, I had trouble finding my name, but there it was sandwiched between a Machin and another Martin with different initials. My visual blurring became worse as the tears ran free, and I crunched back over the gravel. I sat for a very long time on the Vespa, before feeling safe enough to drive back to Camberwell Grove to tell Jan. We breathed a collective sigh of relief, given it meant I would now be able to carry some of the financial burden of our lives. More than that, I realised how traumatised we had both been by the months of intensive study, and the repeated trauma of exams under pressure. Of course our marriage was only nearing its first anniversary, but if we could survive all we had been through in the lead up to the exam program, we could probably survive anything. I am not sure that I realised, nor fully acknowledged just how much I had been supported by my stoic little wife. We went down to a public phone box to let both sides of the family know about the results, and discuss plans for a weekend of celebration.
So, should I be concerned that I have so little memory of the examination process? I do not believe so. When the level of stress is so high, consistently every day, and when you are having to perform at the peak of your ability, think on your feet, and use every bit of your memory for the task in hand, the brain adopts a protective mechanism of shutting off anything that is not focused on the issues in hand; anything that is not germane. I have argued that I have brilliant recall of clinical casework, with images of people, the circumstances at the time, and the information provided. But the exams were different; sadly I have to say that the patients who offered their services to be examined repeatedly for the purposes of the exams were somehow ‘other’; they were not my patients to be cared about and cured. Like the environments, the papers, and the examiners who interviewed me, they were sadly just part of a process that I had to endure. As we shall see in a later narrative, I think if I had had a particularly bad experience that had led directly to failure, then my memory would have remembered the episode, and replayed it repeatedly – possibly to see how (or perhaps whether) the episode could have had a different outcome. Luckily that was not the case, and I can let it all rest.   
The next day, I found out in dribs and drabs that all of my peers at King’s had passed. Of course I had been keen to know about my old flatmates. Within days, the allocation of house jobs was posted on the Information board. The next year was now secure with my first job to be in Casualty for 6 months, followed by my treasured job in the Professorial Medical Unit. As a married couple, we had also scored one of the medical officer flats on Denmark Hill, just down the road from King’s. So there was a mad scramble to pack up our beloved flat, and get family support to move, as soon as the hospital flat was emptied and cleaned. We were able to walk to and from work each day, and the Vespa, parked in the car park in front of the flats, began to look forlorn.
On Monday 15th May 1967, at an annual salary of £800 per annum as a very junior house officer with newly minted qualifications, I began work in the Accident and Emergency Department at King’s. Yes, this is the place now made famous by the British television program ‘24 hours in Emergency’. In many ways, watching the TV series, it appears that not much has changed over the years in terms of the space available, and the sense of excitement or impending doom (however you like to construe it) is well transmitted. That probably sounds like a glib, superficial comment given advances in technology, and training. But accidents and acute medical problems are similar through time and space. How effectively we deal with them does in part depend on technology, but mostly depends on the skills and teamwork trained into the system.
Alongside about 50 nursing staff on rotation, there were 10 medical officers working shifts, and this included four registrars at differing levels of seniority. With a day off each week, my monthly roster was 96 hours a week, followed by a couple of weeks of 78 hours, followed by an easy week of 66 hours, so we were working very long hours each day. Each week included nights shared amongst us, when we were expected to sleep in a single room on the premises (wives not allowed). As you would know from watching the TV series, there is no real regularity about casualty work, so there are some quiet times, and some quiet days. While I was there, we saw and managed an average of 1400 people a day, but of course many cases were dealt with by nursing staff, although the rule was that all new cases had to have a medical oversight. The whole process, of course, was backed up by the rest of the hospital; so many cases coming through were very quickly sent to specialist units for urgent care.
What fascinates me looking back after all these years is that, contrary to the recently completed examination process (which is a blank), I can remember the atmosphere. I remember so many cases in some detail (even if I have forgotten the names), and I was to be forever grateful for the training I gained. After a brief induction, we were straight into it, with decisions made up the chain about what we may be competent to deal with. And you were aware that in the confined space, there was a tight monitoring process going on. Once again, I became aware of the high level of training of nurses, even at an early level of experience. And that sense of close hierarchical management was ever present.

More tomorrow….

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