Hand Surgery and so much more!

For anyone interested in hand surgery and/or working in developing countries and/or anatomy and/or art:

www.donaldsammut.com

I went to a talk he gave at the RSM on tuesday and it left me very impressed and inspired. In fact the whole evening was a great start to the Plastics section.

MRCS Part B - Stations from yester year

Now please note, these stations are just to help give you an idea of what kind of topics could come up in the exam. There is no guarantee that they will come up again or even if they do the format maybe different as the exam structure has recently changed. MRCS OSCEs are designed to test your core surgical knowledge and ability. If you revise the theoretical stuff and ensure that you get experience in going to a variety of outpatient clinics as well as scrubbing in regularly in the OR then you should not have any problems.

Hope these are useful and good luck!

Clinical Skills and History Taking 

1. Examine this ladies neck I started peripherally with a thyroid status exam, but the examiner prompted me to go directly to the neck. She was an afrocarribean lady with what I thought was bilateral parotid enlargement:

Q's
• Causes of symmetrical bilateral parotid enlargement
• What is most likely cause in her (sarcoidosis)
• He asked me about other manifestations outside the neck

2. Examine this lump on a man's back: 

Large lipoma- I examined including assessing for fixity to muscle, transillumenence, draining lymph nodes etc

Q's
• What muscle was it overlying
 • What is blood supply and lymph drainage of that muscle (was Lat Dorsi)
• To describe how you would excise this lipoma
• Consent patient for procedure

 3. HISTORY: 

Very simple history for likely colorectal Ca,

Q's
• RF for colorectal ca
• Difference in presentation for IBD and colorectal ca --> why is this change in bowel habit Crohns or UC
• How you would investigate him
• Why CT pneumocolon is inferior to colonoscopy (you can biopsy with latter)

 4. CVS Exam:

Patient had AS

Q's
• Other causes of ESM --Hypertrophic cardiomyopathy
• How to investigate to see if fit for surgery- ECHO to look at EF and gradient across valve
• Any important considerations for anaesthesia? No epidural, cause hypotension which can be compensated in AS due to fixed output state

5. Hx and brief resp exam 

Completely normal exam, history of long-standing panic disorders

Q's
• Would you pass this lady in pre-assessment for an elective cholecystectomy
• What are the ASA gradings? - what would she be?
• Can you think of ways to optomise her- SSRI trial

Anatomy (3):

1. Upper limb, prosection, live patient and skeleton all in one: Rapid fire 20 questions e.g- where is the insertion of supraspinator, (demonstrate on skeleton), demonstrate pronation and supination (live pt) point out long head of biceps (pro-section)

 2. Unmanned prosection of mediastinum and thorax in saggital section. Lots of flags- just had to identify the structures - was v hard !

3. Manned station- very easy, lower GI/ Hepatobillary -prosection of bowels- asked blood supply, significance of water shed area and marginal artery of drummond. Also was given a colonoscopy picture of bowel ca and asked to identify it. Then asked dukes classification. Then hepatobillary anatomy on another prosection Skills

(2): Taking blood cultures Important points: patient was there- there were marks for interacting.

If you spoke to her, she told you she was IVDU and Hep +ve, so u had to take appropriate cautions-eye protection, and noting it on the form for the lab. Change needles before you fill bottles, and fill aerobic first. Offer to label them.
Also they had an obs chart and it said she was Pen allergic.
They said she had a new murmur, and was spiking on obs chart and asked for a differential. I said that I wld query infective endocarditis, they asked organism, I said staph, and they asked me if I want to write up Abx- I did, VANC--> she was penn allergic which was the trick of the station.

Scrubbing Self explanatory

Other stations: 

Critical Care: Definitions of sepsis, septicaemia, septic shock etc. Asked for intepretation of a HDU chart, and generally where and how to ressucitate a patient in shock, ABCDE...

Comm skills- Calming an eratic mother whose son had been in accident in playground and was on the table for an emergency splenectomy. Had to tell her risk and complications, long term e.g immunizations. and she was questioning why he was taken to surgery without consent, so u had to to know the legislation that the doc act in interest of child if no consenting adult is available in an emergency Comm skills- Discharge summary.

Information Giving- Polytrauma patient, needed to read notes in prep station and call trauma surgeon at home who is on call. He just asked questions to see if you knew the ATLS guidelines, and about management of open fractures.

Information Receiving (written stations)
ECG: AF with fast ventricular response- asked to inteprate rate/ rhythm, about reversible causes, and treatment
CT- Bilateral pleural effusions in a pancreatitic- asked about ARDS, and glasgow scoring
Erect Chest X-Ray- Perforated viscus

MRCS Courses

Enjoying watching the soccer this weekend but thought I'd give you the low down on the course I went on.

I found it super difficult to pck a course as very little info is available and because they are so expensive I felt more apprehensive about making a bad choice. AFter much debate and searching, I wittled it down to 3 course:
1) The St Thomas' 7 day course costing £1200. So ths course was highly recommended by my Reg because he said they got you to practise stations on real patients. However, as it is very popular, I couldn't get a place on he course.

2) The PASTEST MRCS revision course. Costs £799 and you also get the online revision course for free. This course is run over a weekend so its only 2 days. I didn't go as I wanted something longer. A riend went and said it was excellent. Apparently you get grilled all day as the course is mostly in OSCE format and you go around in circuits. He felt it was very useful.

3) The Royal College of Surgeons' Applied sciences for the MRCS course. This is a 5 day course at the Royal College in London and costs £1000. I went on this course and thought it was fantastic. They explained what the format of the exam would be like, taught anatomy on cadavers in small groups and gave lectures on pathology and critical care. There were also lectures and an opportunity to practise comm skills stations. I think the highlights of the course were the lectures on critical care (very comprehensive) and the anatomy demonstrations. You also get critical care viva and a physiology viva books for free. The two problems with the course is that it didn't cover clinical examination or neuroanatomy.

I don't think you need a course to pass the exam but the royal college course really helped me prepare as I was most concerned with anatomy and critical care. Much of the stuff covered on the course came up in one way or another on the course. Hope you found this useful and if you have any experiences of the other courses please share with us.

Amel

Post MRCS Part B

So I finally sat the OSCE on thursday and it was a very passable exam although I think I screwed up 2-3 of the stations and thus may lead to my failing the exam. However, results aren't till the end of June so I can still try and be mindlessly optimistic.

Anyway, for all those considering sitting the exam this winter (which will very likely include my self), I shall endeavour to give you as many tips and advise as necessary using my experiences. Over the next few weeks, I shall blog about the format of the exam, the level of detail questioning required as well as books, courses and other revision aids.

Firstly, the exam involves 18 stations in addition to two 10 minute rest stations whereby you sit by yourself in a cubicle and one twenty minute rest station separating the exam in two and during which everyone who has sat the same stations gathers and has tea. Of the 18 stations these are divided as follows:

1) Anatomy and pathology:
1x speciality anatomy station
2x generic anatomy stations
1x generic pathology station

2) Communication skills:
2x history on speciality topics
1x generic history
1x explain something to patient/relative (also has a 9 minute prep station whereby you read the notes)
1x communicate with a colleague over the phone (also has a prep station whereby you have 9 minutes to read notes and prepare)

3)Clinical skills and patient safety:
3x speciality topics- physical exam
1x generic system- physical exam
2x procedure e.g gloving/cannulation/blood cultures/excision of lesion

4)Critical care and physiology
1x manned station with imaging/results for interpretation
1x 2 manned station with a scenario and viva on critical care
1x manned station and viva on physiology and critical care

Ok so that's me done for now but watch this space for further info in the coming days and weeks.

Amel

MRCS Part B

So the next Part B exam is coming up in May. As the exam is relatively new, it can be a bit of a cahllenge preparing as there isn't the wealth of information out there for other exams. The format for the exam is OSCEs with 18 stations (4 of them rest stations). On application (DEADLINE is 19th March!!) you are asked to decide he following:

1. Choose a region in which you will be assessed on Anatomy, History taking and physical exam.
2. Choose a region in which you will be examined on History taking and physical exam.
3. Choose a region on which you will be assessed on physical exam alone.
4. The rest of the exam will be basic surgical skills, communication etc...
5. The regions available are Thorax and Trunk, Head and neck, Limbs and Spine as well as Neuro. You can only pick one region per assessment and can't pick the same region more than once.

Advise from other people who have sat the exam and passed has been:

1. Revise your anatomy very well as there are anatomy stations. However, on applying you get to pick which region you would like to be examined on.
2. Read up on physiology and pathology.
3. There is no substitute for clinical experience so increase your exposure by going to clinic, theatre etc...remember people are supposed to sit the exam in their surgical training years although more and more junior people are sitting it early.
4. Get a good clinical tutor who can take you through examining patients correctly and test your knowledge as preparation for the exam.
5. If you work in groups and know people who are sitting the exam; revise together as you can get constructive feedback.
6. The area of going to revision courses is still contentious but most people go to courses in order to get a structure for their revision and polish their performance. I will try and research some of the courses and give feedback on this blog.

So here you are. A little breakdown of the exam. I must admit I'm finding it difficult to get meaningful advise about how to prepare for the exam but like any exam, I guess knowing your stuff well and seeing as many patients as possible is key to being successful.  Things that do not help in focusing on revision is knowing that you can only take this exam 4 times and the cost of the exam as well as revision courses/books. Its important to remember though that even failure in the exam itself should not be seen as a collossal negative as it can just act as a mock for the next time you sit it. Good luck and watch this space for more info on revision tools for Part A and B.

Amel

MRCS approaches

The spectre of MRCS looms ever closer and we will be blogging regular posts to help with preparation. Ideally, you should have started thinking about revisng for Part A by now as the exam's in April. Revision tips and advice will be published by Mr T very soon. From experience, I found that there are a few things that were vital in my passing the exam:

1) Anatomy revision: REVISE REVISE REVISE anatomy as the first paper has anatomy & Physiology only. I really liked "Instant Anatomy" (little orange book) as it was concise, split into logical chapters and had diagrams that were easy to memorise.

2) "Basic Sciences for the MRCS" by Rafftery is invaluable for learning physiology and if you want to brush on some pathology. The anatomy section is a little weak (as I unwittingly told the author whilst I was awaiting to sit the second paper and really didn't stop to think why someone who looked quite senior would ask what I thought of the book!!!) but you can't have everything. If you're good at learning anatomy from text rather than need viusal aids (as I do) then the anatomy sections will do very nicely for you. One thing to make note of is that although dry, make note of the little details like paths of major nerves and embryonic development as they do come up in the exam.

3) PASTEST question bank all the way! Honestly, I'm not being paid/sponsored by them before the accusations start flying but those questions were life savers. I did not revise any pathology as that was my strong point and I wanted to focus on anatomy and physiology which I was dire in. I did every single question on the database and the pathology was spot on! Its the exact same level and many of the exam questions were very similar.  Also make sure you dont just do EMQ/SBAs as although the exam is in that format, T/F questions will test your knowledge to a higher detail and all practise is useful to building knowledge. The anatomy and physiology questons were also very useful but you definitely need to revise these to a bit more detail for the exam.

4) Try to get a few days off as zeros/annual leave around the exam if at all possible so that you can touch up on areas of weakness.

Anyway, that's it for now. Watch this space for more MRCS Part A and B information from all of us.

Amel