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

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.

Journal Club - November

Hi all,

I was very impressed by the response to the first journal club paper. This month, I have chosen a paper that is very clinically relevant and addresses a common problem but management is often fraught with controversy. So this month's paper is:

J Bone Joint Surg Br. 2011 Oct;93(10):1362-6.

The non-operative functional management of patients with a rupture of the tendo Achillis leads to low rates of re-rupture.

Wallace RG, Heyes GJ, Michael AL.

I will pot my assessment in a few days time and would appreciate any input from you guys. Also if you would like to suggest any papers for next month, please go ahead! I would welcome input. FINALLY, I shall be putting up some posts on core training applications soon as well as more MRCS advice...

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

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

Journal Club

We are starting a monthly online journal club to try and stimulate discussion about the latest research in surgery. We will pick one article per month and post it a few days before we post our appraisal of the paper. Then we hope this will stimulate debate amongst our readers. If there are any particular papers you wish to submit then email us and better still if you would like to contribute to journal club then we would also love to hear from you. The reason we are doing this is it is difficult to keep up with what's happening in research on top of all the clinical and extra-curricular activities. We hope this will help in some small way.

The article I have chosen for this month is:

Eur Arch Otorhinolaryngol. 2011 Mar;268(3):405-14. Epub 2010 Sep 15.
Laryngeal transplantation in minipigs: vascular, myologic and functional outcomes.
Birchall MA, Kingham PJ, Murison PJ, Ayling SM, Burt R, Mitchard L, Jones A, Lear P, Stokes CR, Terenghi G, Bailey M, Macchiarini P.

You can find it on pubmed and sign in via athens/institutional login to get the full text.

Amel

Website Renovation Part deux...

Hi all

So sorry but moving the website along has proven much more time consuming than I initially anticipated. I can however give you a sneak peak on www.iwanttobeasurgeon.com. There is still so much content to move over including anatomy and videos of clinical skills. However it will all be so much easier to access once its all up there :) You will note that we have added a new research skills section which will contain articles on how to conduct research, how to write up papers and how to get published. We will also be introducing a monthly journal club onto this blog and I hope you will be able to partcipate by adding your comments :)

Anyway, good luck everyone sitting exams and especially those who have been emailing questions to us. Please write back and let everyone know how you get on.

Amel

Website and more

Thanks Amel for improving the website. More contents will be added in the next few weeks.

Good luck to those sitting the MRCS exams, it's a very passable exam.

Few tips to get through the exam:

1. If you don't know the answer to a question; ask the examiner to move on, and come back to that question depending on time. This is because, the marks are allocated per questions, and you do not need to get the questions correct in the order of being asked to progress through the station,

2. Some examiners take your first answer, where as others will permit a few attempts to allow you to get to the correct answer before moving on.

3. Basic finals standard examination, and history taking skills is enough to easily pass the exam.

4. Make sure you are familiar with dry skeletons, and all the points where any significant muscles or bone attaches.

5. Prepare from previous stations as they are likely to repeat stations. At least half of my stations were examined in the previous 2 years.

Good luck, hope you find this useful.

Keep tuned for more updates.

Romesh

Ps: click here for an interesting case report.

Website Renovation

As I have been promising, www.iwanttobeasurgeon.com is getting a makeover. I've reformatted it and there is a lot new content now including a research skills section. The old website will be down for the next few days and the new site will be relaunched on FRIDAY! So watch this space and let us know what you think of the new look...

Amel

PS
Good luck to everyone sitting Part B this February and I hope you found some of the blog posts relevant.

Application form

In general, most application form for all the specialties are similar. ACF application form consisted of
1. Listing academic achievements
2. Courses
3. A brief paragraph on audits.
4. Brief paragraph on teaching experience.
5. Brief description about my research projects, and then the next question asked to write in detail about one of the mentioned research projects.
6. Brief description about why I wanted an academic job.
7. Brief paragraph on my commitment to the specialty I am applying for.
8. Extracurricular activities


However, in my interview, I was asked to talk I'm detail about my academic achievements, research projects, and my interest in academia. There is not much emphasis on audits, however it is advisable to have one completed cycle as it is essential to be shortlisted for an interview.

I was lucky enough to have worked in a reputable hospital during my F1 year and with my interest in surgery and research, I was able to undertake a few research projects. Although it was very hard work, during my F1 year I was able to successfully pass MRCS part A exam, nationally present my research project as first author, as well as publish 3 papers (2as first author, and the second as 2nd author). Furthermore, I am in the process of writing 2 further papers for publication.

My advice for aspiring surgeons and academics would be to start early. It requires a lot of hard work, but show your enthusiasm to the consultants in your hospitals, and you will have opportunities to undertake useful projects which will help boost your CV to be successful in your choice of job.

Next post will be about setting up portfolios in preparation for interviews.

Contact me by email iwanttobeasurgeon@gmail.com for further information, or via this blog, and I will aim to answer any queries as soon as I can.

Romesh

Core surgery recruitment and Academic Clinical Fellowship

With the interviews for core surgical training underway, there's a lot of tension at work place.

Having secured an academic clinical fellowship, I have the luxury of sitting back and enjoying the rest of my foundation year 2 training. Sadly I'm not particularly enjoying the care of elderly attachmet as most involves countless paperwork and a lot of babysitting patients while they wait for nursing/residential home placement.

So what is academic clinical fellowship? Many have asked me this and it's surprising how little people know of such oppurtunity.

It is essentially a specialty training programme with protected time for research. Most candidates will spend the first 3 years doing a pre-pilot research with the aim of applying for an externally funded pHd or an MD. On completion of the pHd/MD the candidates will slot back into higher specialty training. It is essentially a run through training in which all candidates entering ST1 training is almost guaranteed a CCT (Certificate of Completion of Training).

Now you may think, then why don't many people apply for it?
The same reason I mentioned above; not many are aware of such opportunities, and it is also only suitable for those who are interested in research and academia. Competition is fierce with less than 10 ACF in surgery available in the whole of UK at ST1 or ST2 level.

My next blog will be about how to prepare your portfolio for ACF/ core surgery, how to fill out applications, and how to utilise the time to get the most out of foundation training.

Stay tuned.
Romesh

MRCS stations October 2010

MRCS Station October 2010

I will be briefly talking about the stations I had in my MRCS part B OSCEs. I will Mention them in the order I faced each station.

My first station was scrubbing. There were two examiners inside the station, and one was acting as the nurse. The description stated that you can ask the "nurse" for anything you want him/her to do. The examiners check the hands under the UV light at the end to see if you had covered all the areas during scrubbing. During the scrubbing, I was quizzed on the advantage and disadvantages of chlorhexidine and iodine, and when I would use one over the other in surgery.

Critical care: essentially the same station described by Amel. I was quizzed on TURP syndrome. As I managed to get through all the questions, the anaesetists quizzed me further on pharmacology of furosemide, and Mannitol, the mechanism of action. They also asked about the indication for intubation in a patient (all covered in Kanani's critical care vivas).

Communication skills. 10 minutes to read some notes about a patient who fell down some stairs after a drunken night out. He sustained a splenic haematoma, and the plan mentions that he needs to stay in the hospital for few days. The task is to convince the patient not to self discharge. The patient is very adamant that he wants to leave. Just had to make sure that he was not under the influence of alcohol, and has capacity to make decision. No one in my circuit managed to convince him to stay.

Pathology: scenario of a patient who presents with fever, new onset cardiac murmur, and has a previous history of rheumatic fever. The discussion was around major and minor criteria of endocarditis, most common organism, and treatment. The discussion then went onto cardiac transplants, and side effects of immunosuppression. Very straight forward station.

Critical care: scenario of a patient who was trapped under collapsed building. Discussion was around ATLS management of trauma, rhabdomyolysis, hyperkalaemia(potassium from muscle getting into the circulation).

Anatomy (specialty). Trunk and thorax. Dissection specimen of abdomen. Asked to point out stomach, duodenum, and pancreas. The different parts of stomach, blood supply. The arteries that bleed in duodenal ulcer. Parts of pancreas, blood supply, function of pancreas (exocrine and endocrine). Blood supply to the colon.

Anatomy 2. Live model present. Asked to point out tibialis anterior tendon on person. Point out Achilles tendon, Extensor Hallucis Longus, and digitorum. Dorsalis pedis and posterior tibial pulse. Show what happens when tibialis andterior and posterior contract together (inversion of the ankle). Point out where peroneus longus attaches. Nerve supply of tibialis anterior, and peroneous longus. Show me where you would test sensation of superficial and deep peroneal, and sural nerve. Demonstrate ankle and knee jerk, and the nerve roots.

Anatomy 3. Dry skeleton. Asked to point out the different parts of the humerus, and sites where nerves can be damaged. Asked what lies around the radial nerve in the radial groove (lateral and medial head of triceps). Origin and insertion of rotator cuff muscle. The examiner pointed to the ASIS and asked me what that point is called, and asked what attaches there (sartorius). Asked which nerve gets compressed around there and what is the pathology called (meralgia paraesthetica). Asked about origin and insertion of quadratus femoris.

Clinical skills: catheterisation on a plastic model (with a live patient sitting on the other side). Quizzed on what I would do if I can't get the catheter in (try bigger size, in experienced hands introducer, or SPC if still can't catheterise. Then quizzed on management of a patient who presents with abdo pain, and tachycardia.they were describing a ruptured AAA case, and how you would manage the patient.



Round 2.

Cardiovascular examination. Patient had a pacemaker. Asked about what precautions I should take; ppm check, careful use of diathermy.

Comm skills2. 10 minutes to read notes about a RTA victim with pulseless leg. Task was to call the trauma consultant to come to hospital. Quizzed about ATLS, management of open fractures, compartment syndrome.

Comm skills 3. Assess cognition of a patient awaiting elective hip replacement. Patient has AMTS of 2/10. Asked what I would do; collateral history from family, GP etc. If new, then investigate cause for confusion. Postpone surgery for now as needs investigation of confusion.

Examination 1. Knee exam of a patient with relatively new arthroscopic ports. Tender medial and lateral compartments, and patient had crutches hidden behind bed. Differential diagnosis: OA, and rheumatoid, tests I would do (weight bearing x-rays, bloods). Finally management of knee pain.

Hernia and scrotal examination: patient with bilateral inguinal hernia, and a hydrocoele. Simple question on differential diagnoses of lump in groin/scrotum, and management of hernias.

Head and neck examination. Examine a patient who has pain in submandibular region pain on eating. I performed normal neck exam, and then bimanual examination of submandibular glands, I wasn't able to feel any abnormalities, and was a but worried that i may be missing something. The examiner then said to me "I appreciate this is a normal patient...but what would you find in a patient with similar symptoms" I breathed a sigh of relief and talked about submandibular calculi. Asked about what nerves can be damaged in submandibular gland surgery, and quizzed about anatomy of parotid gland.

History. Take a history of a patient with increased urinary frequency, hesitancy, and dribbling. Basic questions on management of BPH.

Critical care 3. Scenario of a patient who had a reversal of ileostomy 3 days ago, now has abdo distension, spiking temperatures. Asked about bowel obstruction, and anastomotic leak. Differentiating true obstruction from pseudo obstruction (no bowel sounds in pseudo, and tinkling In true obstruction).

History. Patient with back pain, and numb great toe. Probable disc protrusion and compression of nerve roots. Quizzed about cauda equina, and how I would manage this patient.

Overall, very fair and straightforward exam. The examiners are generally very nice and will help you work out the answer. There are lots of staff that take you from one floor to the other, so no chance of being lost. The exam however is very long and tiring.There is a break between each 9 station where you get coffee and biscuits.