Core Surgery Applications - Part I (the form)

So, most people will be finishing off their forms by now and I thought I'd thrown in a few last minute tips on completing your applications.

1) Firstly, brevity is essential! Most of the questions are limited to 65 words!! Ensure every word counts but write in clear and concise sentences. Bullet points look scruffy and unprofessional. You do not have space to list every achievement so highlight the most impressive and quickly mention the others.

2) Be honest. Whilst its important to "big up" your achievements, lying will only hurt your chances at interview as they can be very thorough with questioning. Also this is a probity issue and can lead to referral to the GMC.

3) Teaching is a very important part of being a surgeon. Don't just list your teaching experiences. If you have organised teaching then explain this, mention any feedback you have received and any plans you have to build on your experiences. Also, if you have had any training or attended a course to help with teaching then also state this.

4) Audits. Be honest and explain how you contributed to each audit. Also, whether outcomes were implemented and if re-audit has been done (state this as that's key to finishing the audit loop). If the audit has been presented or published then state this too. If you have done tons of audits then state how many and highlight a few examples rather than listing everything.

5) Commitment to speciality. This is very personal and I think you need to show how long you have been interested in the speciality and how you have explored it further. Mention electives, courses, placements, research, if you have sat any exams etc...

Anyway, I know this is brief but just wanted to give a few ideas out there. Please note, I am only posting my opinion but I do not know what the Deaneries are looking for and how they mark these questions. This is just advise based on experience of having applied last year and as such should not be taken as anything more than this. I do not accept any liability for any unsuccessful applications (sorry).

Good luck!!!

Amel

There and back again (almost)

Ok so massive hiatus from the blog and website, I know and I apologise profusely. Its not that IWTBAS is not a huge priority for me, but I have had a lot of work to clear. So now that I managed to get into Core Surgery in London, passed USMLE Step 1 (and revising for 2CK), finished a Plastic Surgery Observership in the USA, completed 3 audits, implemented a DVT pathway at West Middlesex University hospital, written two case reports and finished off a meta-analysis, I am READY to get back to what's important! I will be regularly updating this blog and finishing www.iwanttobeasurgeon.com. So as a treat, the next post will contain some old stations from friends who sat the exam a couple of years ago and I will also scribble a few words on Core Surgery applications. Again, let me know what you would like to see more of in this blog and also on the site. Amel

Physiology of The Respiratory System I: Mechanics of Ventilation

Although I generally find physiology a tad on the dry side, a good foundation in this is vital for success in Surgical exams and patient care. I thought we could start with the respiratory system as I'm currently doing a Resp job.

Components of the Respiratory system

1. Nasal passages
2. Olfactory system
3. Conducting airways
• Nasopharynx
• larynx
• trachea
• bronchi
• bronchioles
• Alveoli

Functions of the respiratory system

1. Cleaning, humidification and warming/cooling of air: this is achieved by the nose hairs, mucociliary escalator and air flow through the conchae.
2. Respiratory gas exchange: flow of gases depends on pressure gradient between atmosphere and alveoli which can be represented as V (rate of air flow)  = Palveoli - Patmosphere/R (resistance). Thus bronchoonstriction leads to reduced air flow due to increased resistance.
3. Facilitation  of olfaction and sound production

Mechanics of Ventilation

Inspiration is an active process. At the start of inspiration the intrapleural pressure is about -4cmH2O. This decreases to around -9cmH2O when respiratory muscles contract to increase increase chest volume. This change in intrapleural pressure causes lung expansion and generation of of a negative intralaveolar pressure. The result of this is that atmospheric pressure is higher leading to air inhalation.  (NB at rest around 500mL of air is inhaled, during excercise pressure can decrease down to -30cmH2O and thus 2-3L of air can be inhaled).

Expiration is passive due to elastic recoil of the lung. However, during excercise, contraction of the accessory muscles of respiration (internal intercostals and abdominal muscles) can generate intrapleural pressures of up to +20cmH2O to expel air more quickly.


Pressures and forces acting on the Lung
Three forces act on the lung:

1. Elasticicity of the lungs: under normal conditions this keeps the lungs stretched whic results in a force that pulls inwards on the visceral pleura.
2. Surfactant: lines alveolar surfaces and produces surface tension thus producing an inward pressure which accounts for 2/3 of elastic recoil. Surfactant also increases lung compliance thus reducing work of breathing, prevents fluid accumulation in alveoli and reduces alveolar instability [ΔP (alveolar distending pressure) T (tension)/r (radius)] by stopping them from collapsing.
3. Negative intrapleural pressure: opposes the above two forces and is created by the chest wall and diaphragm pulling the parietal pleaura outwards. This results in the two layers of the pleura being pulled in opposite directions leading to a negative pressure.

 The pressure in the alveoli is equal to atmospheric pressure which is 0cmH2O. As intrapleural pressure is between -4 and -9cmH2O this results in a transmural pressure which keeps the lungs distended.

Compliance
This is the ease with which lungs can be inflated and can be expressed as:

Compliance = ΔV (change in volume)/ΔP(change in pressure)

It is governed by elsticity of the lung parenchyma and surface tension. Thus compliance is reduced in scarring or fibrosis of parenchyma, pulmonary oedema, deficiency of surfactant, reduced lung expansion (e.g. motor neurone disease/muscular paralysis), supine position, mechanical ventilation (due to reduced pulmonary blood flow), age and breathing 100% O2. Conversely, emphysema increases lung compliance to destruction of elastic fibres in the lung parenchyma. 

Regional differences in Ventilation

In the upright position the apices are less ventilated than the bases. This is due to gravity and the fact that the pressure-volume curve is sigmoid shaped and thus the two parts lie on diferent areas of the curve. This is because the bases lie on the diaphragm and are compressed whereas the apices re already stretched by their own weight this inflation begins further along the pressure-volume curve.

Well that's it for now, I shall be writing another two posts on Respiratory phyiology. The next shall be on Lung Function tests and the final on Blood flow, Gas exchange and the regulation of Ventilation. For more info, I found the following webites useful: www.acbrown.com/lung/www.acbrown.com/lung/Lectures/RsVntl and www.medicine.mcgill.ca/physio/resp-web. Hope this has been useful.

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

Hello and welcome

We are two junior doctors who want to pursue a career in surgery. We've all sat sat MRCS Part A and studying for part B. One of the things we have found going through medical school and our first year as doctors is that whilst there are many resources for revising surgery, few are free and even fewer offer a complete resource in terms of training, education and application for jobs. So, we decided to set up a website to help with these things and a blog to act as an up to date tool on current changes and developments in the world of surgery. We hope you enjoy the blog and website, please let us know if you think there is any way to make them better.

Amel and Romesh