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 12^th 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 1^st 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 4^th 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 15^th 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….

Haiku on Horror/ Bridge/ Feel/ Always

Horror

Go to the movies

Horror in every film

What's the point of that?

Watch the TV News

Horror in every story

What's the point of that?

Read the newspapers

Horror on every page

What's the point of that?

Bridge

One of life's helpers

Creating links for others

They called her Bridget

Bridge players don't die

Always making new contracts

With what they are dealt

Music Therapy

Reinvigorates old minds

A bridge to the past

Feel

I feel the feelings

Watching facial expression

Good for therapy

Reach across the bed

Refuge in the darkest night

Need to feel you breathe

Synaesthesia

Look at this brilliant painting

Feel what the artist felt

Always

Always thinking good

Positive connotation

Very hard some days

Had this brilliant thought

But then you announced lunchtime

Always important

In total silence

There is always some small sound

Listen to your heart

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!