Guide to prepare for Postgraduate Examinations
This article is intended to assist medical trainees (and their trainers - educational supervisors and college tutors) in the preparation for their Membership & Fellowship diploma examinations. These postgraduate examinations are necessarily set at a high standard and the preparation required in order to pass any part of the examinations must not be underestimated.
As a qualified doctor, you undoubtedly have already engaged in numerous assessments and examinations and developed strategies to maximise your chances of passing them. This guide is written to help you fine-tune the techniques that already work for you and introduce new ones that may be useful for you in the future.
There are two fundamental differences in undertaking a postgraduate examination rather than one at undergraduate level. Firstly, you will be studying in addition to working. Secondly, at postgraduate level, the standard rises substantially. Therefore it is essential that you address your studies with a seriousness that matches the nature of the undertaking. This article does not attempt to replace any of your effective strategies but aims to supplement them with some helpful hints and advice. The areas to be addressed are covered under the following headings.
This refers not only to the commitment to your profession and specialty but to time management. You should be able to dedicate a minimum of 4 months, preferably 6 months of intensive studying. You need to ‘pace’ yourself so your peak and optimal performance culminates around the examination period.
Short Term Goal
Contrary to common beliefs, the majority of us can only focus on one main task at a time (cf aviation industry - a minimum of 2 commercial pilots in any flight). Ideally, the examination you intend to take should be your only goal in the short term. Your medium and long term goals may include running a personal best marathon, moving house and getting married but your 4 - 6 month goal should be the examination only. Failing that, you will need a very robust social infrastructure to support you.
Self Directed Learning (SDL)
It is expected that you will primarily prepare for a postgraduate examination by SDL with some taught elements. You should attend the teaching delivered locally and regionally. Apart from the content of the lectures and tutorials, this provides a perfect forum to meet up with your peers who are preparing for the same examination. Discussion of a difficult concept is much easier and rewarding with colleagues who are in the same boat! It also provides direction for your SDL in areas that you may wish to consolidate in your private study. Examination orientated courses may be important to gauge the general level of knowledge required. These courses, departmental teaching and tutorials should only be considered supplements to private study and are certainly not sufficient on their own, nor are they substitutes for periods of sustained hard work that must be examination curriculum orientated. You may wish to use the study skills questionnaire (with or without your educational supervisor) to gain additional insight into your learning style (Appendix 1).
Many specialty Colleges have e-learning modules (based on their curriculum). This is an excellent starting point to familiarise yourself with current topics and concepts. Whilst these are excellent tools to use, you will also need to use other educational resources, textbooks and journals. Although textbooks can be expensive, you will need to possess some ‘core’ texts, unless your local library is well stocked with current copies of textbooks. A common mistake is to underestimate the depth and breadth of knowledge required for each stage of the examination. You can get some idea from past papers and the published syllabus and, if in doubt veer towards being over-prepared. You should aim to be familiar with current editorials and reviews featured in specialty journals. This way you will be aware of major up to date developments which you might reasonably be expected to know about.
European Working Time Regulation
Potential examination candidates should use EWTR to their advantage. Be disciplined in allocating time for study on your time off after nights and weekends worked. It is a substantial chunk of time to tap into for short periods of studies (see below-memory skills). This also applies to time that may be unexpectedly available during your normal working day.
The key is to develop a routine. A routine which suits you and your family but to which you must ruthlessly adhere, in order to achieve this short term goal. This could be an hour after your session in theatre/clinic/ward round/surgery is over, alone or with your peers. Frequent and short periods of time are the name of the game.
A useful approach to learning includes peer group learning and support (and a healthy dose of competition!). This comradeship is reassuring to have whilst going through a tough period of time prior to your examination. Consider getting together with 2 or 3 peers to support and cajole one another as you work towards the examination. It is also very important to allow yourself time for private consolidation and reflection of some topics as we all learn at a different style and pace. We all have different degrees of ability and a harsh reality is that some of the very brightest amongst you appear to sail effortlessly through their training and examinations with little visible effort whilst others struggle with the same challenges. This is inevitable but bear in mind that some of us need to work much harder to attain a particular standard than do others. Be realistic about your own abilities and then be prepared to “go the extra mile” yourself. Mimicking the minimalist learning style of someone much brighter than you may turn out to be a mistake! In addition, you MUST practise for any OSCE and viva parts of the examinations. The stress and anxiety generated when observed by your colleagues during a group mock viva/OSCE sessions is invaluable as it simulates the ‘hostile’ condition when you are faced with the real examiners.
It is imperative to learn how you can best optimise your memory for learning. There are 7 important parts (Appendix 2):
- Maintaining attention and concentration is difficult beyond 20 minutes so design your routines round little blocks of time.
- Limit the amount of information you acquire in each session to a maximum of 7 chunks.
- Organise your knowledge so you work within a pattern - a clinical condition would for example include demographics, causes, presentation, history, signs from examination, investigation and management plan; whereas a basic science question would include pharmacodynamics and pharmacokinetic stems.
- Understanding of the knowledge – this can be greatly enhanced by group learning i.e. explaining to your peers a certain pathological condition such as the aetiology & mechanism of myocardial infarction.
- Make connections and links to what you already know. For example, you may have learnt about fibrosing alveolitis but cross referencing it with other causes of alveolitis would strengthen your understanding of the conditions.
- Set ‘SMART’ objectives on what else you need to know having fully appreciated what you already learnt.
- Essential active recall. It is known that if you revise a piece of information several times in a short period, the retention of the knowledge is less than if you space the revisions in a longer interval – ‘spacing effect’ – hence 4-6 months of preparation time.
Self Care Practice
This is as the title suggests. During this period of intense demand on your discipline and stamina, you must have a strategy to regularly relieve the tension. This could be exercise or any pleasurable activities which you enjoy – the important message is to make it part of your routine. This ‘downtime’ is enormously important to recharge your battery.
It is very important to understand the ‘red flag’ symptoms of stress and depression (Iversen et al 09). The idea is not to manage this yourself but to recognise them in yourself and the peers working with you should you come across them. Some of these symptoms are: lack of interest, trouble sleeping, and problems concentrating on things e.g. reading paper or watching TV.
‘Empty the Bucket’
This is the only piece of examination technique advice I wish to proffer. Some candidates having completed a single question, a viva or one station of the OSCE examination are convinced that they have failed. This is often a subjective perception of the situation. In fact it is possible that you are cruising and the examiner is pressing hard for a medal! Even if it was truly an underperformance on your part, it is probable that you may pull through if you perform well in the rest of the examination.
In aviation crew resource management, professional pilots often have a set routine before climbing into the cockpit. ‘Emptying the bucket’ prior to flying means locking yourself in a state of mind where no other thoughts should affect the safe operation of that flight until they get out of the cockpit. There is good evidence that some air accidents are subsequent to pilots bringing their personal ‘baggage’ with them on board – so to speak.
The message therefore is: start again after each interface with the examiner/question and never assume you have failed until it’s all over. Treat each OSCE station/viva/written question as the only one that matters.
However if all is not well and you have failed (hopefully this is less likely as you have read and acted on this guide!), do make use of the FAQs to investigate if your technique of approaching the examination questions needs refining (Appendix 3). Also, you could use the attached remediation framework as a guide to work through potential problems (Appendix 4).
Finally, don’t be daunted! Most trainees pass their exams through hard work, good mental preparation, peer support and with some assistance from their consultant colleagues. Good luck.
Dr WH Lam
Associate Postgraduate Dean (Performance & Support)
Health Education South West (Peninsula)
Iversen A, Rushforth B, Forrest K
The complete novice: How to handle stress and look after your mental health
BMJ 9 May 2009 volume 338
|Area||Screening Questions||What we recommend|
|2||Time spent on Self-Directed Learning (SDL)||
|3||Quality of Time||
|4||Planning Study Time||
|6||Question Answering Strategy||
|(Modified with permission from student support materials prepared by the Peninsula College of Medicine & Dentistry)|
Please use this blank form to review the questions with your College Tutor.
Much of the learning throughout the career of a doctor comprises of self-directed independent learning which underpins the foundation of Continuing Professional Development. The adoption of effective strategies to assist in this is of paramount importance to our busy clinical working life.
Independent learning can be defined as “that learning in which the learner, in conjunction with relevant others, can make the decisions necessary to meet the learners own learning needs”. (Kesten, 1987 p 3). You may find this contrasts with the way you worked at school or previously, where you are likely to have been given hand-outs or notes which if you learnt completely would give you good marks. Here you will be expected to think about what you need to know and then research this for yourself. This is much closer to the way in which qualified doctors learn and keep up to date.
It is worth learning how you can best learn for yourself. There are several key points to think about:
- Memory skills ,
- Time management skills,
- Reading skills
- Note-taking skills,
- Study habits,
- Revision skills
- Specific exam preparation
Or to put it another way
Areas for study
You will need to build in time for preparation and follow up for all the areas of the curriculum. As you progress through your specialty training, you will need to schedule time to revisit “old” learning which you may have covered already previously.
Many of the ideas of how to learn effectively are based on our current understanding of how memory works.
Memory is probably divided into three main parts. Research suggests that these are located in different parts of the brain.
Current theories suggest that working memory is located in the pre-frontal cortex, whereas the medial temporal cortex binds experiences together helping make connections and thus helping to form new memories. How long term memories are stored in the brain is less clear – this is likely to be widespread through the cerebral cortex.
Seven things are important:
- You must maintain attention and concentration. You cannot realistically do this for more than 20 minutes at a time;
- Organising what you learn into meaningful patterns will help. So for example if you are trying to learn the following series of words: dog, boat, spoon, hat, car, cat, cow, knife, coat – you are more likely to remember the list if you organise the words, for example some are animals, some utensils etc.. You will be encouraged to think of concepts as a way of organising your knowledge;
- understanding what you are reading or learning – this is often helped by working with others, and problem based learning, PBL helps as it encourages you to explain to others what you have learnt;
- Making connections with what you already know helps you form links which aid recall of your learning – in PBL you will often be asked what you already know about a subject. This also encourages you to focus on new learning rather than going over what you already know;
- Having thought about what you know, think then about what new things you need to know. Frame these as questions – SMART questions are the best:
Realistic and Relevant
- Limit the amount of information you cover in each session. Working memory is limited in the amount of information it can handle – the maximum is about seven chunks;
- Active recall is essential; we quickly forget what we have studied (see Ebbinghaus curve). Active recall means putting your books and notes away and writing down what you know from memory, then going back and checking if some of what you learnt needs reinforcing.
What has been found is that if you revise a piece of information a number of times in a short period of time, your retention of that material is less than if you space out the revisions of that material with an ever increasing interval. This is known as the 'Spacing Effect'.
One strategy for active recall is to do this after 30 minutes, at the end of each study period, at the end of a block of learning, at the end of the day, and at the end of a specialty module.
Understanding how to make the most of your memory suggests some ways of effectively managing your time:
- Study at the same time every day. As much as possible, you should schedule certain hours which are used for studying almost every day in a habitual, systematic way. Having regular hours at least five days a week will make it easier to habitually follow the schedule and to maintain an active approach to study.
- Make use of the free time (10-20 min blocks) during the “normal theatre day”. The hours between scheduled activities are perhaps your most valuable study time yet, ironically, the most frequently misused.
- Plan study periods to follow scheduled activities. This should be done whenever possible. The next best procedure is to schedule the period for study immediately before a theatre list in the morning (you’d have to be an early riser).
- Space study periods. Sixty to ninety minutes of study at a time works best. Relaxation periods of five minutes should be scheduled every 20 minutes. It is more efficient to study hard for a definite period of time, and then stop for a few minutes, than attempt to study on indefinitely.
- Plan for weekly reviews of new learning. At least one hour each week (distinct from study time) should be scheduled. The weekend is a good time for review.
- Leave some unscheduled time for flexibility. This is important! Lack of flexibility is the major reason why schedules fail. We tend to over-schedule themselves. A diary helps a lot.
- Allot time for planned recreation. When you plan your schedule, you should begin by listing the activities that come at fixed hours and cannot be changed. Next, schedule your flexible time commitments – these hours can be interchanged with other hours if you find your schedule must be changed during the week. Plan recreational activities last.
In practice this means,
1. When studying:
- Start with a five minute think about how you want to be, get motivated, find reasons why you want to do the work, think of how you will reward yourself as you go along. Plan how long you are going to work. Prepare your work space, and gather texts around you.
- Then spend five minutes thinking about what you already know about the subject, a mind-map can help. If you want to know more about mind maps buy one of Tony Buzan’s books, or see and hear him on YouTube here
- Having thought about what you know, map out what you need to know on top of that, you could add it to the mind map. Good questions are the key to good learning, and, a reminder, these questions should be SMART.
- Now read to answer the questions you have created. Avoid getting sucked into reading the text, use SQ3R (see later) as a way of helping you read more effectively. Do this for 20 minutes.
- Now have a five minute break, exercise a bit, stretch, and have a glass of water.
- Start studying again by actively recalling what you have learnt. Again a mind map is an ideal way of doing this – or make linear notes if you prefer. Remember this is active, it is not about reading notes you took. Check to see if you are right, if not do a spot of revision
- Repeat the cycle
- You can do this cycle three or four times. Shorter periods are better than longer ones. By dividing your work time into thirty minute blocks, you can make more effective use of short periods of time that you have previously thought were too short for learning,
- Reward yourself.
2. When taking part in a learning activity
- Make time before the session to think about what you already know about the topic and what you want to find out. This will help you engage with the session and retain information. Make sure you also do any preparation work you have been asked to do.
- Take an active role as possible within the session e.g. asking questions, jotting down key points.
- Build in time after each session to actively recall what you have learnt, perhaps using a mind map or notes. Then check back on your notes from the session if needed. Remember to revisit this learning (e.g. at the end of the day and end of the week)
- Build in time to do follow up work from the activity, including adding detail or following up anything you didn’t fully understand
- Reward yourself
Reading skills (SQ3R)
Skim the material paying attention to:
Maps, charts, graphs
Words you do not understand
Make your own questions about the reading based on the information you have surveyed. Include your own questions you generated in stage one of your learning plan above.
Read the material to answer your survey questions. Avoid getting sucked into the text itself. Much of what you read is padding. Always keep in mind finding answers to your survey questions.
Answer your questions without looking back on the reading. Use the method of recitation which best suits your particular learning style but remember, the more senses you use the more likely you are to remember what you read - i.e. TRIPLE STRENGTH LEARNING: Seeing, saying, hearing- and QUADRUPLE STRENGTH LEARNING: Seeing , saying , hearing, writing.
Look away from the reading material and focus on the major ideas and concepts. Review the reading material frequently i.e. every 30 minutes, at the end of the block of learning, at the end of the day and at the end of a week or fortnight. Periodically review the sheet, some students make flash cards which can be very effective
Note taking skills
The best way for you to take notes is to use the method that works best for you. If you are visual, mind maps work well, and there is some evidence that this works well for everyone. What does matter is that you make time to think about and make sense of what you have read and then make notes that summarise what you have learnt rather than it being an almost complete transcript of the chapter. Jot down key ideas or concepts as you go along, though avoid writing everything down.
You work more effectively if you are consistent in the way you work. Being consistent means the brain does not have to work out what you are up to. Consistency applies to how you work as well as when you work. Make a space in your room for work – that should not be the bed, as your brain will be confused whether you should be sleeping or working. Many students find the library is an ideal place to work, and find it anchors them into work mode. Remember that success is achieved through a few simple behaviours that are repeated daily.
Revision skills and specific exam preparation
You will find that if you continually revisit your work, you will need to revise much less. Ideally you will only need to look at the mind maps or conceptual summaries you have written, possibly fleshing out some of the detail.
You cannot specifically revise for the whole syllabus in details, though there are things you can do before the exam that are helpful. You may find it useful to refresh your memory by looking at the summaries you have made as you have been studying. You can also practice the technique of answering the style of question that comes up in the examination by looking at the past papers.
There are various ways of looking at how you learn. Honey and Mumford described learning styles – Activist, Reflector, Theorist and Pragmatist – and the learning cycle.
Other experts suggest we have different sensory preferences when we learn; we may be visual or auditory for example. Find out what you are.
Memletics have a comprehensive on-line questionnaire which you may find helpful and for a small fee you can obtain a detailed breakdown of your preferred styles.
View the index of learning styles questionnaire, which also looks at whether you are a global or sequential learner.
Completing the cycle
Remember, learning is about more than just remembering information. It is also about making sense of what you have learnt and planning how you will use this in the future. Linking what you learn to the real world will also help you retain it – and recall it when you need it. This means you will need to work in all parts of the learning cycle, even though you may have preferences for one particular style. Also, learning styles indicate your preferred way of learning but do not mean you cannot learn in other ways.
Keston, C (1997) Independent Learning: A Common Essential Learning: A Study Completed for the Saskatchewan Department of Education Core Curriculum Investigation Project - accessed 27 June 2007
(Modified with permission from student support materials prepared by the Peninsula College of Medicine & Dentistry)
Q Should I work late the night before?
A Working late the night before the exam only results in an overloaded and tired brain that cannot cope with a demanding exam. Sleep really is more productive than last minute cramming.
Q Should I read the answers and question at the same time?
A No. Sometimes seeing a particular answer convinces your brain to read the question in a way that fits this answer. Always read the question first and think what the answer might be before looking at the answers. Remember some answers may be there to trick you.
Q I tend to read the question in a hurry, is that okay?
A All parts of the question are relevant. Read it carefully. You might find it helpful to underline words or jot down key points.
Q I am nervous about doing that first skim through and prefer to go through slowly one question at a time. Is that OK?
A There is a risk if you go through the paper slowly one question at a time of running out of time so a whole section of the paper (usually the last part) is not answered. Remember, this section may include 2 or 3 questions you could easily answer and missing these could significantly affect your score. If you are someone who tends to be short of time, it is particularly important to do a first trawl through the paper.
Q I sometimes feel that if I wrestle long enough with the hard questions I am bound to find the right answer.
A It is not a good idea to spend valuable time and brain energy on questions you know nothing about and are very unlikely to be able to answer. Follow the advice above, identify these questions and move quickly on, saving your time for questions you have more chance of getting right.
Q I tend to be a perfectionist and feel very uncomfortable guessing.
A Only answering questions where you are absolutely sure of the answer will almost certainly lower your score. You need to be prepared to go with your hunches and make educated guesses. Being a good doctor includes feeling comfortable with a degree of uncertainty. And in the real world you can always put systems in place to make sure the patient is followed up so you’ll know if they aren’t getting better!
What is Remediation?
The dictionary definition is “The act or process of correcting a fault or deficiency”. However, correcting learning or performance deficiencies is not like fixing a faulty car. It is not something which can be done to you or for you. Remediation is something you have to do for yourself to improve your performance.
Identifying any weaknesses will occur as a result of reflection on your examination scores and feedback (formative and summative) that you should be doing regularly with your Educational Supervisor or College Tutor. Many Royal Colleges offer remedial meetings with candidates who had repeatedly underperform in the examinations. These are usually chaired by senior College Examiners.
These Meetings are only part of the remediation process and do not represent the progressive course of action or journey that is essential for successful remediation (except perhaps in the case of Professionalism – which is discussed further below). These meetings are intended to help you identify why you have not been performing as well as you had hoped, consider and select strategies you could put in place to improve your position and check progress with your revised personal development plan to ensure you are progressing to target. The meetings simply help diagnose, sign-post, reality check and monitor progress. The hard work of remediation is done out with these meetings by you.
Remediation for Poor Performance
This section provides advice on how to remediate based on the individual’s personal circumstances – you will need to decide, possibly following discussions with your Educational Supervisor & College Tutor, which of these would be most beneficial for you.
- What is your approach to adult learning?
- Do you have all the necessary study skills?
- Are you managing your time sensibly? How much time are you spending on personal study outside the scheduled training – is it sufficient and effective? Do you plan your study time realistically particularly just before the examination?
- Are there personal and social issues which are affecting your ability to learn?
There is no way in which you can ‘cram’ for any part of the Medical Postgraduate examination. It is a test of sustained learning. Remediation for poor performance should include:
- Revisiting the curriculum and syllabus published by the Colleges and making sure that the breadth and depth are equally tackled
- Checking that you have fully explored all the self study material and learning resources from courses, tutorials & e-learning available to you
- Revisiting basic and clinical science materials to ensure a thorough understanding of core scientific principles and concepts underlying medical practice even (especially) in the preparation of the Exit examinations.
- Reflect on the feedback from your peers and senior colleagues over the preparation period and identifying areas of weakness for further study. This includes refinement of examination technique.
- Reviewing your logbook and identifying areas which you have not covered sufficiently and address this with the help of your college tutor.
- Practicing communication skills – video yourself with a colleague in a practice session with clear objective and debriefing procedure
- Here the meeting with the educational supervisor/college tutor is an integral part of the remediation process as it is here you are asked to reflect on your behaviours, your Portfolio Analysis and multisource feedbacks from colleagues in order to identify how you can improve matters in the future.
- Where an unsatisfactory Professionalism judgement is involved, a discussion with the person who gave the judgement may be appropriate
Sometimes your performance will have been affected due to personal circumstances which are largely out of your control - such as illness, finance or family issues. These circumstances may well affect your performance in the examination.
However, sometimes the personal circumstances will also impede your learning and ability to fully engage with the preparation leading up to the examination. When this occurs, remediation may also include:
- Reflection on what learning you have missed during the period
- Catching up on missed clinical work and address pragmatically
- Thinking about whether your circumstances are affecting you so much that a period of interruption of studies might be more appropriate. You can discuss this with your educational supervisor, college tutor or mentor. Ultimately, if you have missed a significant part of the preparation, it may not be possible for you to catch up in the current round of examination and it may be better off cutting your losses and go for the next sitting but work done so far would not have been futile.
(Modified with permission from student support materials prepared by the Peninsula College of Medicine & Dentistry)