Nishs Guide To Final Year

Nishs guide to finals
2011
My guide to final year

1. Introduction
2. How shall I plan this year?
3. Whats the deal with the elective?
4. What about MTAS?
5. What exams will I have?
6. Do I need a tutor?
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7. What books shall I use?
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8. What courses shall I go on?
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9. How shall I use my firm time?
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10. Have you got anyone with signs please?
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11. What happened in my finals?
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12. Final thoughts
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Nishma.manek@imperial.ac.uk
2011
1. Introduction
Firstly, congratulations! You made it to final year! Fifth year is probably the toughest year in
medical school- in some ways it is harder than final year. You should be proud of yourself
that youre here- its now the final stretch after 6 long, hard years. And secondly
congratulations again- because by the very fact that youre making the effort to read this
guide, youre almost certainly going to pass your finals! I think that if youre worried enough
about passing finals to be reading this, then you care enough to take the advice below and
that youll receive from other people. And so youll care enough to do the work. And youll
pass. Simple.
So with that in mind, heres a guide Ive made with some general advice to passing finals.
Please remember that these are just some of my thoughts- its by no means the only right
way to do things at all, and everyone is different. Youll receive advice from so many people
over the course of the year. Some things will scare you, other things you wont understand,
and then youll take on board bits of whats left. You'll glance over at your colleagues and
freak out because they'll be doing something that you haven't done (yet). Someone will pull
out the most obscure diagnosis for an orthopaedic shoulder exam and others will know the
13th most common side effect of Digoxin. The most useful bit of advice I can give is that this
will happen, expect it and plan for it. Final year is your own personal journey and you simply
will be unable to follow in someone else's footsteps.
Remember that everyone works differently- what some people may advise may not always
be best for you. Try not to let people scare you. You might be feeling pretty calm now, but as
exams approach its almost inevitable that some advice someone offers or something you
hear your friends are doing will freak you out. You got here so far by doing your own workso if you know what works for you, stick to it. Have some confidence in your own ability to
plan your revision.
The point of this guide is to try and pass on the words of wisdom I received over the course
of final year and add to it a few things I think might help so that you dont make the same
mistakes weve all made. I was very lucky to have lots of help and support from people
above me like previous final years and SHOs who tutored me, and so I hope I can be of at
least some help to your year. (Try and remember to do the same for the year below you
when you get to my stage!)
Final year is a journey. Its definitely busy, and a least a bit stressful for most people. For
those of you who havent worked that much over the past few years- this year its not really
worth that risk. If you know youve had resits in the past, and are the kind of person to leave
things to the last minute, dont! Youve spent so long getting to this stage, and its the final
hurdle to becoming a doctor. Failing should not be an option- only 8 people in my year
failed. Its not like other years where you can resit if you fail by a couple of marks, and you
just slip back with your year as usual. If you fail, you cant start your job. You really dont
want to be in that group of 8. So think about working early, youll be thankful later on I
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promise you. Imagine that day in June when you go to the Reynolds with 300 other people
to collect your results envelope. You want to be able to scream and shout like everyone
else!
This year can be quite confusing and even a bit lonely at time if Im being honest. Its hard to
know what to do. Fifth year was hard because there was a lot of work to get through, but it
wasnt that difficult to work out what you needed to do. But now theres no big textbooks to
read like Impey, and no perfect strategy to passing.
For those of you who have got merits/distinctions in previous years, and know you always
work hard and worry about what everyone else is doing- keep working hard, but try to enjoy
it too. This year becomes purely focussed on passing finals, and that should be your main
objective. But its also about learning to become a doctor. The knowledge youll accumulate
over 1 year will be incredible. You might find it hard to believe, but people say you probably
wont ever in your life know as much as youll end up knowing by the time your finals come
around. You will wake up every day by the end feeling like there is a huge weight on your
shoulders, and I can almost guarantee that however calm a person you are you will have
several freak outs towards the exams. But you will get through it. Almost everyone does!
People become focussed on doing well- but remember all you really need to do is pass.
Anything extra is a bonus. When youre opening that results envelope in June, I promise that
all youll really care about is whether youve passed or failed. Whether you get distinctions
or not really doesnt matter when you come to start working.
The best feeling in the world is passing your finals. When youre feeling stressed or tired, sit
back and close your eyes and imagine that feeling. The feeling of six years of hard work
being over, and finally being a doctor. The four weeks off youll have before starting as an F1
will be one of the best times of your life. Youll change your credit card name to Doctor,
youll feel a certain sense of pride in being able to circle Doctor as your title when you fill
out a new form, youll feel incredibly pleased when your parents announce proudly to
everyone they meet that youre now a qualified Doctor, and youll spend a lot of money that
you dont really have yet. Look forward to that time now! There is a light at the end!
Dont forget to work hard but play hard too. If you start working really hard, and stop seeing
your friends etc you run the risk of burning out. Its a long hard slog, and you need your
energy and your friends around you. Come February, people will start working fairly hard.
But dont lock yourself up and go at it full pelt. Work by all means, but take regular breaks. If
one day things just arent going in dont feel guilty to take an evening or day off to
regenerate. You need to save your last energy for the final few weeks.
Finally and most importantly, please help each other out. Youre not working against each
other, you should all be working together to achieve this goal. You all came to Imperial to be
doctors, and you all want to come out the other end together. You cant succeed without
other peoples help, and dont forget to return that favour. Dont hog emails of good stuff,
dont forget to tell people about teaching or revision sessions that are happening, and dont
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try to scare anyone by going on about how much work youre doing or rumours you heard!
Pass on any advice you get or courses you go to, spread the word if you find a good patient
with signs in the hospital who might be willing to see another group of students, and tell
your friends if you find a useful clinic or enthusiastic consultant who wants to teach. It might
surprise you how insular and secretive people will become in your year. If this happens,
ignore them. Forget about the rest of the year, focus on yourself and what you need to do.
Good luck!
Ps. This guide is really long I know, but Im just trying to pass on everything I can whilst I
remember it. Dont read it all in one go!
2. How shall I plan this year?

Final year is a bit of a marathon. Its different to other years in that you have a long stretch
of revision time at the end- about 8 weeks. That doesnt mean you can leave everything until
then, because it really will fly by faster than you think and youll be grateful if you start
earlier. But my point is that you need to have some energy for the end or its easy to burn
out.
Personally, I didnt really do much before my elective (Group 2), and started working a few
weeks after I got back from around December. Most people will start around
December/January, or February if youre Group 3. If youre in Group 2 or 3 and you want to
start on something before you leave, I would suggest just some simple things like:
Start to contact tutors (see later section)- definitely worth getting on this early!
Writing up your examinations. This might sound a bit tedious but I think it helps if
you have them all written up again 3rd year style, especially with things like ortho and
vascular. Over the year people will give you all kinds of pointers, and if you have
them written in a word document you can add these as you go along. Also in finals
youll often get simple questions such as what are you looking for in the hands?,
what are the respiratory causes of clubbing?, what is Mcmurrays test? etc, so if
you have these written out it will help later. I have all these written up which I can
send you.
Practice each examination so you are happy it is perfected. This should be done on
your pillow/favourite soft toy/partner. Try doing the whole examination from
beginning to end in 2 to 3 minutes including what you will say and introductions, and
then repeat it over and over like learning lines for a play. The time to practice is not
with patients. Seeing patients should be for adding in the skill of spotting,
remembering and reporting clinical signs while performing your perfected routine. If
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you can nail your examinations before you start on patients, youll be in good stead.
Final year is a vicious cycle: if you can't examine then you can't find the signs. Make a
list of all the examination you need, including random things like cerebellar,
Parkinsons, speech, varicose veins etc, and start practising little by little.
Thats probably enough pre-elective work! Enjoy yourself, as fifth year was pretty tough and
you need time to recover. Also it depends which firms you have before your elective- some
things might be worth reading about whilst youre on the firm (e.g. renal- again see later
section). But in all honestly most of what you read pre-elective youll forget most things you
do now by the time you come back.
(For the really keen, pre-elective:
Medicine- if youre keen, there are common things which come up in finals which
you could start reading about. For example for cardio you could start getting familiar
with heart murmurs (again see my notes). Neuro is an alternative which is pretty
tough, so could be worth getting to grips with early.
Surgery- you could potentially start flicking through Surgical Talk. Its quite easy to
read and might help refresh some of the rusty things from third year.
Pharm- you could begin to look at Garry Pettets notes (again see later). Im not sure
how useful it will be because youll end up forgetting a lot, and in the end have to go
through it all again anyway...)
3. Whats the deal with the elective?

In my opinion, I wouldnt work too hard on your elective. I think its a great time to
reenergise, see a bit of the world and have fun. I did exactly that on my elective, and despite
some reservation before I left I definitely dont regret it. Even today I sit back and reflect on
one of the best times of my life.
By all means if youre doing something youre really interested in then it is a good chance to
get some hands on experience. But in terms of passing finals, the best thing you could do is
relax. When you come back the period after Christmas through to June will be pretty
stressful. Personally I found having amazing elective memories to look back on really helped
keep me going. And you soon realise once you start work how hard it will be to get a block
of time like that again to travel the world. Make the most of it now!
Any books that you take with you with the aim of revision will probably be left untouched
but will bug you on your shelf on elective. Remember the marathon that will start when
youre back, and give yourself a well deserved trip of a lifetime!
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4. What about MTAS?

MTAS is a pretty annoying source of anxiety in final year, but one of those hoops you have to
jump through. Ill try to give a few tips and pass on some advice of previous years.
Picking your deanery- personally, I think you should not try to second guess the
MTAS system. Pick the deanery you want to go to, and just put it first. Last year
(2010-11) NWT was undersubscribed, and had an average score of 60ish I think to
get in. Compare that to Oxford which had a score of 83! No one could have predicted
that. I think the year before us NWT was oversubscribed, and some people say it
comes in peaks and troughs. In my opinion you shouldnt try to have a strategy for
this- just put wherever you want to go first and cross your fingers!
Talk to other people from other deaneries. Lots of people in my year moved all
around the country and are having a great time. Its actually a really nice change
from being in London, so dont forget to think about life outside NWT if you havent
yet.
Dont worry about your quartile- people in fourth quartile can score in the 90s.
Focus on those questions.
If youre in group 2, dont worry. I was in group 2, and it was fine. We took a week
off from the hospital and were able to get on with it without any distractions. So its
no major disadvantage. The one thing I would say is try to arrange for some
F1s/F2s/SHOs to read over your form before you leave. Explain youre going away,
youll be emailing the form to them at a certain time, and would really appreciate
their help whilst youre away. Not all of them will be able to, so try to ask quite a
few! Buy them some chocolates before you go to say thanks!
And sort out your references before you go too. Another thing we found really
helpful was bringing an old laptop with us. That way we could download the form,
and just work on it in our hotel (where there was no internet) and go to the internet
caf every evening if we needed to. Bit easier than working on it all day in a hot and
noisy internet caf I think, especially if the connection isnt great.
Get hold of some other forms if you can. Ask around for some other forms of F1s,
and if possible find out how highly they scored. This will give you an idea of what
makes a good answer.
Start thinking of good examples- look at last years questions below, and try to think
of examples from your clinical experience so far that might apply. I dont think that
next years form will be that different, and sometimes the hardest part is thinking of a
good example for each question.
Print off the GMC Guide to Good Doctors and the Foundation Programme
Curriculum (or something like that). If youre going on elective for MTAS, print these
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off and take them with you. They have good buzzwords in it that are worth using in
your answers. The questions on the form reflect different areas within these guides
and it will help you understand what theyre looking for. You can paraphrase bits for
your answers, and make sure your examples fit well with these objectives. But be
honest on your form! I think a few people at random are asked to provide proof of
everything theyve said.
Organise people to read your form early- as I said before this is important especially
if youre in Group 2 elective. Personally I think F1s, F2s and CT/STs are the best
people to read the forms, as theyve just been through it themselves or are in the
process of filling out new ones.
References- again sort this out early. I think one is your personal tutor and one is
another consultant/GP.
2010-11 MTAS questions:

1) Effective team working can have a significant impact on the quality of the patient
experience.
Describe a clinical case you have observed where there has been a MDT approach to
discharge planning.
Describe how the interaction between the MDT impacted on the quality of the
patient's care.
What have you learned from this about effective MDT working
How will you put this into practice on as FY1
2) Describe a clinical situation which provided an opportunistic learning experience.

What approach did you take to consolidate and extend this learning?
Compare this approach to how you may follow up a planned learning experience
How will you use these experiences of learning to improve the quality of teaching
others.
3) You are the only foundation doctor on a busy surgical ward and you feel under pressure to
complete the tasks expected of you. A foundation doctor on another surgical team asks if you
will hold their bleep for the second time this week as they want to go to observe an
operation.
What would your initial response be to your colleague?
What factors would influence this response?
If you had to hold the bleep, how would you prioritise the tasks?
What additional learning needs does the situation highlight for you?
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4) Describe a clinical consultation that you have observed where the specific CULTURAL,
SOCIAL or FAMILY circumstances of the patient posed addition challenges.
Identify the techniques used within this consultation that contributed to this
patient's experience.
What other approaches could have been used in this situation?
What did you learn from this which you can apply to future clinical practice?
5) Essential attributes of an F1 are the ability to deal EFFECTIVELY with PRESSURE, and the
ability to PRIORITISE TASKS.
Describe TWO different PERSONAL achievements to demonstrate that you possess
both of these qualities, relating each achievement to a single attribute.
For each attribute, GIVE ONE SPECIFIC EXAMPLE of how your achievement can
contribute towards IMPROVING YOUR PERFORMANCE as a foundation doctor.
5. What exams will I have?

You might know this already, but just in case youre not sure these are the exams we had:
1. Written Papers:
1) Paper 1 (SBA) 150 Responses. 3 Hours
2) Paper 2 (EMQ) 200 Responses. 3 hours
Both had:
40% Medicine, including GP and Public Health

30% Surgery
30% Pharm
3) Paper 3 - Practical Prescribing. 1 hour Examination

2. PACES:
1) Medicine Stations (10 mins):
History Taking (22mins)

Abdomen
Cardiovascular
Nervous system
Respiratory
Short Cases (Could include: Skin, Eyes, Rheumatology and Endocrinology)
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2) Surgery Stations (10 mins):
History Taking (22mins)

Abdomen
Vascular
Musculoskeletal
Images/Instruments
Short Cases bed cases or sitting cases
There are a few things from this which I would point out:
Pharm (CPT) is worth just as much as surgery and almost as much as medicine!
Therefore do NOT neglect this! You will spend hours attending Barrys course and
preparing for surgery, but just remember that pharm needs just as much attention!
Do NOT ignore public health- I think we had about 10 questions on this in total in
our 2 papers. Might not sound much, but if you havent looked at it you cant really
guess this stuff and thats a lot of marks deducted for no reason. I would say go over
the slides for these lectures that you have in the practical medicine week, and theres
some good notes floating around which I can send you nearer the time, summing up
all the lectures. Thats all you really need to do- I just went through it once a few
days before the writtens. But just make sure you do it- people that didnt kicked
themselves afterwards for throwing away easy marks. Also I have some King College
MBBS past papers, and the public health questions in there were quite similar to
what we had. I can send you these too nearer the time.
If youre aiming for merits/distinctions- as Ive said before this isnt important.
However if youre the type of person to aim high Ill give this a mention. Something
that a lot of people in my year didnt realise until quite late on was that you only
need to pass the writtens, for which the pass mark is usually around 50-60% and
only a handful of people fail writtens each year. At the end of the year youre
awarded distinctions and merits, and for our year they were given like this:
Distinctions in CPT are awarded to approximately the top 20% in the Practical
Prescribing paper. Merits are awarded to approximately the next 10%. So note
that if youre aiming for a distinction in pharm, dont neglect practical
prescribing because distinctions were awarded on the basis of this paper
alone.
Distinctions in Medicine and Surgery are awarded to approximately the top 20%
in the Medicine and Surgery PACES. Merits are awarded to approximately the
next 10%.
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Basically distinctions in medicine and surgery are given on the basis of PACES alone. And the
writtens are fairly easy to pass. So my strategy was to spend about 70% of my time
preparing for Paces, which is much harder to do pass or do well in, and 30% was spent doing
past questions for the writtens- which is hard to do well in but remember you only need to
pass this, which isnt majorly difficult to do! Some people will argue that this doesnt matter,
and you should just focus on doing what you need to for both. Its totally up to you but Im
mentioning it because Im very grateful I found this out early, and the strategy I took worked
for me as I was a lot less confident with Paces than I was with writtens.
Just decide what you want to do, dont neglect anything too much because you just need to
pass at the end of the day. Check for your year how its going to be marked as it may not be
the same.
Writtens
Medicine
The questions for this are pretty similar to what we had in third year. My advice
would be to spend as much as your time practising questions as you can for
this- avoid reading too much and writing excessive notes. Just get hold of lots
of question books- see later section for book recommendations.
Use the Cheese and Onion and your main reference I think, you dont really
need much more than this. Honestly dont spend lots of time reading- just do
questions!
Surgery
The same goes for this. It wasnt too bad at all, definitely no surprises. Id say
the questions were similar to third year, with a few harder ones here and
there.
A lot of the surgery questions were repeated from Web CT in third year, so its
worth looking at these again. I think the surgery questions were a bit easier
than medicine, and Barrys book is really all you need for the writtens. The only
area I thought wasnt covered that well is Ortho, but this is done in enough
detail in Surgical Talk, so use that instead.
Also Barry does a mock SBA thing at the end of the year which is really useful,
and I think a few questions were repeated from this.
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Pharm
The pharm EMQs and SBAs were a bit easier than most people had imagined.
A fair few questions were repeated from Schachters slides and his book- you
have been warned! Easy marks!
In terms of how to prepare- I would concentrate on Scachters slides and
either Garrys notes/Podmedics notes (see later). I started going through all
the WebCT lectures too as I was advised to from previous final years. In all
honesty I didnt think they helped me much at all, and took an insane amount
of time and will-power to sit through. Its up to you, but I didnt think they
were worth the amount of time they took. Some are better than others- it
might be best to do Scachters book then just look at the lectures that cover
the parts you dont feel as comfortable with.
Practical prescribing
The other pharm paper you have is practical prescribing. Remember
distinctions in pharm were given out on the basis of this paper alone, so its
worth preparing well for! It consists of 5 calculations, 2 prescriptions you
have to comment on, and 2 prescriptions you have to write (by the way dont
waste time explaining why youre giving certain drugs for this bit, theres no
extra marks in it).
I cant stress this enough- all of the questions in our paper WERE REPEATED
from Schachters practice examples. DO THEM! Its so easy to prepare well for
this. There is a PDF by someone in our year called Sam Rainsbury of all
previous questions collated in one document. Get hold of this and just
practice practice practice. I only spent a couple of days preparing for this
paper in my revision time, and it was enough.
There are also 1 or 2 mock papers on the intranet- theyre not that easy to
find but dig around and you should come across them.
Also get confident with the BNF, looking up doses etc. I learnt a few of the
common doses (e.g. for pneumonia, ACS) so that in the exam I didnt have to
spend time looking them up. This paper is tight for time, the only one that I
found was! So make a mock paper for yourself and practice it under timed
conditions beforehand- I found this really helped me to work out how long to
spend on each bit.
When you get in the exam, highlight each point in the question and read it
very carefully! Then I made a list of each problem the patient had first, so I
didnt forget to prescribe something for each bit. At the end I looked over the
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prescription I had written as a whole, and checked for obvious interactions.

With the commenting questions its the same thing- make a problem list for
the patient and check each drug against the patients problems, before
looking at the prescription as a whole.
The calculations were again ALL REPEATED from his lectures, so make sure
youre comfortable with them before you get in the exam. Its worth doing
these first I think on the day, because theyre easy to do and you can get
them out the way quickly.
If Ive been too ambiguous so far...the questions WERE REPEATED from things
he will have shown you before!!! (this may not be the same for you, but just
in case)
Public Health
More questions than you will expect on this as Ive mentioned - so don't
leave revision to glance over the night before the exam (I know, it's just so
tempting to do!). As I said before, you only need a day or two in your
revision for this bit, but its time well spent. Go over the notes that
summarise all the lectures, look at the Kings questions on it from their
past papers and youll be fine!
6. Do I need a tutor?
Personally I think having a medical and surgical tutor is pretty important. Saying that, I do
know people who only had one or neither and did pretty well. So I guess it depends how you
work. Our group found them really useful in terms of finding you patients with good signs,
and watching you examine and present. It made me a bit nervous doing this, which was
great practice for the pressure of finals!
The group: Pick your people carefully. I think 3 people is best, 4 should be a maximum. Try
and choose people you work well with, not just your friends. Its helpful to have people in
the group that are quite keen and do reasonably well, because you will inevitably end up
comparing yourself to them and striving to keep up with each other. I didnt really watch
anyone else examine patients apart from those in my group, and I think looking back it
helped that they were all really good as it gave me something to aim for.
The tutors: Ideally you want someone whos done or about to do their MRCP or MRCS, and
someone with enough time to meet you once a week. I dont think consultants are really the
best people to ask- theyre usually really busy and not always sure of how Imperial finals are
structured. If you know any good SHOs/registrars in medicine or surgery, contact them
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ASAP. Ask other final years for anyone they know thats good. Whilst this is really difficult,
its worth trying to get 2 to confirm for medicine and 2 for surgery because one will almost
always back out just when you need them. We spent months looking for tutors, and ended
up only confirming both med and surg by late January.
The tutoring: We started tutoring from the end of January, and by the time the exams came
we felt pretty prepared. Id say make sure youre starting by February. If you find your tutor
keeps cancelling, whilst its important to understand that they are really busy people doing
you a massive favour and will inevitably cancel a few, dont leave it too late to get another
tutor. You dont want finals round the corner having only had a couple of sessions.
We found the best thing for our weekly medicine tutorials was if our tutor found patients,
and watched us examine and present before grilling us for a few minutes. This is more
realistic for finals, and will be invaluable practice for the day. Our tutors were great and did
things quite formally, getting the patients permission and then closing the curtains, only
asking the student in when the patient was ready to be examined. Each patient became a
Paces station, which was great. For surgery, we saw a lot less patients and lot more time
doing things with our tutor alone. I think this worked really well- going over all the surgical
exams first is useful because a lot of them are quite new (e.g ortho) and your patients in
paces are quite well (e.g. again ortho!).
Also get into the habit of doing images and instruments every other week or so- if your tutor
cant do this with you meet up as a group and do this between you by testing each other
before your tutor sessions.
7. What books shall I use?

Medicine
Cheese and Onion- an absolute must, and the latest edition too. This is pretty much
all you need for medical writtens. I didnt use much else. But bear in mind you dont
need to know lots of detail, and you skip the really dull pages like the different
shapes of kidney stones! This book goes into a lot of depth- youll soon learn when
you start doing questions what you can discard.
Baby Kumar and Clark- useful if you find C&O too dull, but personally I think the
above is a bit better for the exams.
Medicine at a Glance- a useful adjunct to help remember things, especially if youre

more a visual learner...but not essential.
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Surgery
Barrys course book- again an absolute must. Youll realise why as soon as you get it
in February (see courses section later).
Surgical Talk- you probably used this in third year, and it still a great book for surgery
finals. Id recommend using this alongside Barrys book to supplement your
knowledge, especially for ortho. I found it quite useful to read the relevant chapter
before Barrys course that week, but towards the end this didnt really work as I was
short of time! But its probably worth a try if you can.
Lecture notes- personally I didnt really use this except for the hernia section which
was pretty good. I found it too much detail, and dont regret it now. However some
people prefer this to Surgical Talk so just see what suits you.
Browses Sign and Symptoms of Surgery- this is great! Really useful for Paces too. I
didnt use all of it, but I liked the pictures (said like a typical girl, Im sorry). Its good
to use towards Paces time, because you can cover the captions and practise
presenting the pictures to friends. Also if youre worried you havent seen certain
things before like lumps or goitres, its a great resource.
Pharm
Garrys notes- some very helpful person a few years ago wrote these, and I can email
you them. Theyre pretty much all you need to know for pharm in conjunction with
Schachters lectures. I really dont think you dont need any actual books for pharm,
apart from a question book!
Podmedics notes- similar to the above but a bit more up-to-date and easier to read.
Just pick Garrys or these, you dont really need both.
Schachters Pharm book (The Final Hurdle)- this came out a couple of weeks before
our exams. It was a bit pricey but worth it I think. (Im selling my copy if anyone
wants it a bit cheaper!) If youre buying it new split it with a friend and just share it,
the questions wont take you long to do.
Paces
Medicine- Cases for Paces (Hoole)- a must- have! Carry this around with you on
firms early (instead of OHCM), and you can start looking at it early on. I got told
countless times that if you know this book inside out you will get a merit in Paces,
and looking back I think its true. It covers pretty much everything you need to know,
with a few gold star points too. Buy it now and you wont regret it.
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Medicine- 250 cases in clinical medicine (Baliga)- whilst this does go into a lot of
detail thats more suited for MRCP, if youre aiming for high marks in paces I think its
worth looking at. Ignore the random facts and rare cases, but I think it was really
useful for the common things like heart murmurs and resp conditions. The questions
that are asked in there might be a bit above what you might get, but if youre doing
well in the exam dont be surprised to get a few. If youre aiming to simply pass,
perhaps dont look at this book first. But if you want to do well I think its worth
getting out of the library early and referring to when you start seeing patients with
common finals cases. Youll learn a lot!
Surgery- Clinical Cases and OSCEs In Surgery (Ramachandran)- this is the equivalent
to Cases for Paces for surgery. I think certain bits go into too much detail, but its a
superb book for surgery paces. Things like vascular and ortho exams are covered well
in this. Again get it early and look at it as you see patients with various things.
Ask Dr Clarke- go on this website early, and find the reports of finals from previous
Imperialites. This stuff is gold- look at this early and youll get a great idea of what
Paces will involve. Our group collated the last few years (i.e. combined all past resp
cases, cardio cases etc), so I can send you that document if you want it. I found this a
fantastic help. Lots of patients get recycle year after year, and many of my friends
had cases they had read about from these reports. I think if you prepare well for all
the cases that have come up in the past few years, you wont go far wrong.
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Questions
WebCT third year questions- dig out old 3rd year EMQs and look at the WEbct
questions, a lot were repeated or at least of similar standard to what came up.
Onexamination or Pastest- most people sign up to one of these. I did, but to be

honest I didnt find it very useful and lost patience doing online questions. It depends
what you prefer I suppose, and the Pharm and Public Health sections were
reasonable.
Get ahead SBAs and EMQs- I did the surgery SBA and medicine EMQ books, and
found them pretty good. Great explanations and a similar standard to the exam.
Barrys SBA book- this book is really good, but pretty tough. The questions are a
great learning tool, but harder than what youll get in the exam. Quite useful to use
each week to see if youve understood his chapter for that weeks revision course.
The answers will give you good extra bits of info for paces.
500 SBAs in Medicine- written by a genius in my year, this book is really good for
finals. The explanations are great and the questions are a similar standard to finals.
Covers pretty much everything in medicine at a good level!
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Kings college past paper- I can email you this, its almost exactly the standard we got
in our exams, and some questions were even repeated from it. Especially look out for
the public health bit.
Other question books- if you still want more (!), just get hold of any final year
question books. There are lots at Marys and Charring Cross which are all pretty
good. But remember you only need to pass writtens, so personally Id spend more
time on Paces than trying to do every single question book ever written!
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Other useful resources
Open rounds- these are on the intranet. They happen towards the end of each year,
where a consultant and a few students (picked at random by the med school)
examine a patient in front of whoever turns up in the Drewe in Paces-style. They get
recorded and put on the intranet. I didnt have much time towards the end so only
looked at a few of these, but they were useful. I think theyre probably worth looking
at if you start early. Some are better than others, and theyre quite long. But youll
get to see lots of patients with common signs that come up in finals, and usually the
consultants who do them are finals examiners so you can see the kind of standard
they expect from a good candidate.
Surgical lectures- Barry organises a few surgical revision lectures at the end of the
year which are really good. I remember the vascular one in particular being good!
8. What courses shall I go on?

Everyone has their own opinions about which courses are necessary for finals. This is just
based on my experience. Courses are expensive and not always the most efficient way to
learn, but I found the following really useful and would highly recommend them:
Medicine
1. Ask Dr Clarke- personally I found this fantastic. There is a 1 day Medicine and 1 day
Surgery course, and I only did the Medicine one (about 50). His course guide is great
and during the day he takes you through all the common cases for finals in a fun and
interactive way. I would definitely do this!
There are other courses such as Dr Mirzas which I heard was really good, a 1 day course by
Meeran and the Elite course. I didnt do these so cant really give you any advice on them!
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Surgery
1. Barrys course- personally I found this brilliant. Its every Thursday from about 630930pm at Kings from February for 10 weeks. Ok its fairly pricey for a medical student
course at over 200, and I was initially not sure... mainly because I felt Barrys
anecdotes couldnt make up for the dent in my bank balance to start with!.
Id say about 80% of Imperial people go in addition to Kings students, and if I were
you I wouldnt think twice about it. I didnt have much of an opinion on Paraskeva
having never really come across him in firms until the course, but once it finished I
thought he was a legend and I definitely wasnt alone in that.
The course guide is great, he gives great tips on being an F1 too, and it really helps
structure your surgery revision. If you start revising surgery week by week according
to what Barry has/will cover that week, it will become more manageable. You learn
how to speak properly for the exam, and as youll soon realise, thats what really
matters! Also if you get a chance on the course to present/examine/be viva-ed, I
would take it if you can. If you can answer anything in front of 400 people and Barry,
the exam wont be so scary!
Sign up via the MDU website. You wont regret it. (And no, I dont work on
commission!)
Medicine and Surgery combined

1. Gillian Parks / Northwick Park - 50, 1 day course in May, about 40 places. This
rotates through different specialties rooms in groups of around 10, with a tutorial
format just focused on Paces. The stations were things like managing ACS and
common arrhythmias for cardio, how to elicit reflexes and use the opthalmoscope
properly for neuro, going over doing a breast exam, vascular exam, measuring ABPIs,
stomas, instruments, ortho exams and X-rays etc.
It has certain plus points: its only one day, and is a good opportunity to ask last
minute questions / clarify things before PACES (e.g. I didnt know how to do an ABPI
or the types of hip prostheses before the course), and the people that run it are
generally teaching fellows who are all absolutely excellent. But we also felt it was
very close to the exams. I guess you have to see for yourself where you are with your
revision at the time- if youre on top of things you might gain 3 or 4 good points from
the day but thats time well spent compared to being stuck in the library all day!
Email Gillian Park for more details / ask on A&E placement at NPH.
Gillian.Park@nwlh.nhs.uk.
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2. West Middlesex Paces course (finalsPACES- finals.paces@googlemail.com)- This course

was fairly useful. It was a weekend course very early on in the year, with 1 day for
medicine and 1 day for surgery. I think it was quite cheap at the time (50 for the
weekend) and as it was early on it was quite a nice gentle introduction to paces
preparation. Personally I didnt find the surgery one as good but the medicine was
pretty good. They take you through each station that comes up in Paces, and go over
common cases.
The main advantages are the course guide is really good, they drum into you the
importance of presenting well and how to do it, and the instruments station takes
you through the common ones that come up in finals and gives you a chance to look
at all the instruments in close up. So overall Id say its quite good, worth it for the
money and if you do it early, but not absolutely essential.
Mock Paces
These are amazing practice if you can get on them. As far as I know in our year there were
ones at Chelsea, Ealing, Hillingdon and a Muslim Medics one. They were all greatparticularly the Hillingdon and Muslim Medics (I didnt do Ealing so not sure about that).
Theyre all pretty much first come first serve/randomly allocated after you sign up- so just
monitor your emails carefully and try to get on as many as you can!
9. How shall I use my firm time?

Someone told me at the start of the year that if you have half a day off, examine 1 patient.
And if you have a full day off, go in and examine 2-3 patients at least. Although it wasnt
always feasible, I think thats pretty good advice. The temptation is to spend your
days/afternoons off relaxing or reading in the library. I think before Christmas relaxing is
fine, but reading in the library is probably not time well spent if you think about how your
exams are structured. Thats not to say dont do it, but I spent most of my free time
examining patients or if I was reading, reading Paces books rather than just the Oxford
Handbook or another textbook.
Final year isnt about carrying around massive textbooks and trying to quote every disease
under the sun! Its about developing sound examination techniques more than anything
else. Stick to perfecting the basics rather than worrying about the details.
Heres a few pointers which you might find helpful for specific firms. Also I think its handy to
do the pharm and emergency sections of the relevant firms at the same time e.g. when
youre doing cardio, read the cardio drugs and cardio emergencies etc.
Any free time within the firm, get reading on the bit that you dont have firms on e.g. resp
and GI etc.
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SCM
This is very much dependent on what you chose. If you chose something you want to
do as a career, take full advantage of finding out as much about that area as possible.
If not, then use your free time wisely. I had lots of half days, and usually tried to
examine 1 or 2 patients before I left. This was really useful, especially as I had it quite
early on so the wards werent full of students. I was very grateful later on in the year
that I had started to do this early.
If youve got your SCM later in the year you could also use your free time to read etc,
but examining patients is really important!
ENT
I had this the week before my elective and hardly went in as I was busy packing. I
would just use this week to examine patients/start reading/relax because its not
examined in finals.
Opthalmology
Remember fundoscopy is really likely to come up especially if youre at Chelsea for

finals. So dont waste this week- I wouldnt bother going to surgery etc, but aim to go
to 2 or 3 clinics and get used to the opthalmoscope. In Charring Cross you can
examine the patients with dilated eyes whilst theyre waiting for their appointments.
Just get used to finding the disc first and going through the routine, then try to
identify basic pathology like hypertension and diabetes. Annoyingly, retinitis
pigmentosa is another exam favourite but you may find it hard to find anyone with
this in the real world.
Read up on the common conditions that come up in fundoscopy in finals (use Dr

Clarke past reports for this, and read up the cases in the Baliga book). Ive got some
notes on these which I can send you.
Do the neuro part of eyes during this attachment too e.g. fields and cranial nerves
etc, as you have quite a lot of time and it will save you doing it later .
Renal
This is actually a really good week, and quite well organised at the Hammersmith.
Take this opportunity to examine lots of renal transplant patients- theres a really
high chance of this coming up in both med and surg finals. Examine patients for all
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2011
the little hidden gems they love you to find in paces- the scar, feel the kidney, detect
side effects of medications like steroids, previous scars from tessio lines, fistulae and
their complications, signs of the causes e.g. diabetic prick marks on the fingers.
Reading wise- its worth looking over the renal transplant sections in Baliga, Cases for
Paces and Ramachandran so that you can nail any renal transplant station. Also for
written you could read the renal section of OHCM, but you dont need to know too
much detail. A good way to do this is to skim the chapter and then attempt a few
renal questions online or in EMQ books.
Cardio
You just have a week of this. Probably the best thing to do rather going to lots of
clinics, is to listen to as many murmurs as you can. The main thing for finals is to tell
systolic from diastolic, and however much you end up stressing over telling aortic
stenosis from mitral regurgitation, you can still do really well in paces with just saying
its a systolic murmur, and why you think its more likely to be AS than MR. If you get
it wrong it doesnt matter! Dig out the heart sounds CD from third year to help.
Definitely read up on all the murmurs this week, or if you have this attachment late
on in the year this is worth doing earlier. For these I think the Baliga book is best. You
can get asked a fair amount in your cardio station if youre doing well, so its worth
knowing the 4 key murmurs in detail.
Try to get familiar with the other cardio paces cases that come up in finals during this
week- e.g. metallic valves is very common, pacemaker scars, CABG scars etc.
Definitely get to grips with the rest of the cardio section in OHCM and the
emergencies- common things asked about in Paces are heart failure, ACS and
infective endocarditis.
Read the Cardio pharm section too if you can.
In terms of seeing angios or echos- I saw one of each, and I wouldnt waste too much
time seeing many more. Youve only got a week, so try to focus on examining cardio
patients as much as possible!
Neuro
You have 2 weeks of this if its the same as ours. Get cracking with Neuro!! Its a big
area.
Hit the Neuro and Stroke wards of your hospitals. It doesnt matter if you do 20
stroke patients, its good practice to be able to appreciate hyperreflexia and
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2011
increased tone! Neuro signs can be subtle, the more you see the better youll get at
detecting them for finals.
By the end of the 2 weeks your neuro exams should be exam-ready! Dont be too
complacent here, youll be grateful later if your neuro exam is good by the end.
Again same drill with reading- refresh your neuroanatomy first (Crash Couse is good
for this), get on top of the common Neuro cases from the paces books (again Crash
Course and Baliga), and do the neuro drugs if you can too.
A&E
Clerk and examine lots of patients, it will be useful. Its also worth trying to present
your cases, with a differential diagnosis and management plan. This will be good for
your history station as well as for F1.
I liked this firm too because I finally got to grips with cannulas and taking bloodswhich is really important when you start F1.
I also found this a good firm to get in a bit of reading as it wasnt too busy. Try to
read through the main emergencies in OHCM as they can get asked about in paces
and writtens.
Theres lots of tick boxes to do in GP (audits, cases, special events etc) so dont leave
it all to the last week.
Try to see if you can get your own room and see patients. I had to push for this quite
a bit in my surgery, but when I got to do it, it was great. Observing can be useful too,
but a bit boring if thats all youre doing.
Its a good time to read up about the patients you see in the day, because theyll stick
in your mind. Also skim Dr Clarkes paces reports before you start, so if any patients
walk in with weird scars or conditions that you know commonly come up, you can
ask to have a listen or look yourself if they dont mind.
Generally GP is quite relaxed, so youll have time to get on with reading. Aim to do 1
of the chapters in OHCM that you wont encounter otherwise, e.g. GI and resp. Read
the paces things for these first in Cases for Paces/ Baliga, then skim the OHCM (you
dont need much detail!). If Barrys course has started, then start cracking on with
surgery too.
GP
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PWE
This depends a lot on your firm. I had vascular and resp, and both were really
relaxed. I spent my time off examining patients rather than shadowing the F1s, who
kept telling me to go home. In hindsight, it is worth spending some time shadowing
for when you start F1. I dont think you need 3 full weeks of this, but spend some
time both examining patients and following your F1 so you can see what the job
involves. Like I said I didnt practice what Im preaching here, but looking back I think
a bit more hands on F1-ing would have been useful at the time.
Take lots of bloods, do cannulas and ABGs too if youre asked- its great practice!
Practical medicine
It might seem pretty dull, but its worth attending the public health lectures,
Schachters stuff and the Paces advice lectures.
The public health stuff is always examined, and the questions just come from the
slides. Schachters calculations in the exam were ALL from his slides, so get to grips
with these this week! Paces advice- I found Dr Gabriels , Dr Levys and Dr Orchards
lectures this week really good.
That leaves about 5 or 6 others that I didnt attend that week... and from what I
heard it wasnt worth it. I had this week really close to exams, so if thats the case for
you it might be worth using some of your time to get on with work rather than going
to every single one. Try to get in the hospital and examine a few patients once that
week too, to keep things fresh.
10.Have you got anyone with signs please?

Finding signs will become the bane of your life/a bit of an obsession amongst your year by
the time the exams are round the corner. Mark my words. Start early! Heres a few tips from
my experience about finding patients with signs to practice on:
Medicine
Cardio- obviously hit the cardio ward for good murmurs but generally any Care of the
Elderly ward will have good ones too!
Resp, Neuro, GI- just hit the relevant wards. Stroke rehab is good for neuro, as are
neuro clinics.
22
Renal- after your renal attachment try to go back to the Hammersmith for half a day
and refresh your memory by examining a few renal patients.
Rheum- look out for RA on any elderly patient you examine! If youre not
comfortable with examining rheumatoid hands, it might be worth attending a rheum
clinic as its a really common case in finals.
Endo- I hadnt seen acromegaly etc before I went in, and I dont think you really need
to have. The patients you see will look like those on Google images!
Opthal- see you if you can attend a clinic nearer the time if youre not comfortable
after your attachment e.g. at Charring X. But even if you can get hold of an
opthalmoscope and practice on your friends and family, this is really useful! Then
dilated eyes will seem much easier in the exams.
2011
Surgery
Vascular- if you dont have a vascular firm, its worth hitting a few vascular clinics
and wards before the exams to get familiar with the scars and taking claudication
histories. Try Ms Rentons clinic at NWP, and Hardy Ward there has a lot of vascular
in-patients. Ms Renton also does a varicose vein clinic which is worth going to. Also
find out how to do an ABPI and practice before the exams, it can come up.
Ortho- if, like me, you didnt pay attention during Musc and Derm in fifth year, try to
attend a hip and knee clinic before exams. Its not essential, but I went to one at
Charring Cross for an afternoon and found it useful to practice ortho exams on real
patients. Other than that, keep practising the exams on your friends!
GI- this is mainly stomas and scars, which are the bread and butter of most surgical
units in the hospital so should be easy to find! Practise lots of stomas, theyre really
common in finals. Try and do a half day with the Stoma nurse. That way youll get to
see lots and learn about the complications etc. I know at NWP you can do this by
going to the Stoma nurse office in St Marks, and booking in with them. Its easy to
arrange and worth doing if you do it early on.
Shorts:
Varicose veins- see above under vascular. Also if you go to Theatre Admissions
Unit (pre-op) e.g. at NWP at 8am one morning (call the surgery secretary up via
switchboard first to find out what cases are on that day) then this can be a great
place to find varicose veins, hernias and groin lumps.
Hernias- definitely worth seeing, try to go to a general surgery clinic (Mr

Bhutianis at NWP is good for this, and hes very accommodating). Alternatively
try TAU at NWP or anywhere else.
23
Thyroid- worth getting to a clinic if you can. Theres an ENT head and neck clinic
at NWP which usually has a few thyroids, and also Mr Pallazzos clinic at
Hammersmith Hospital is really good for this.
Breast- I didnt go to any breast clinics but if youve got the time and feel you
want to, there are plenty around e.g. at Charring X and NWP. Might be worth it
to see some post-op mastectomy scars but not essential if you cant.
Ulcers- again not essential but the Tissue Viability Clinic at NWP was a great place
to see venous and arterial ulcers, although these arent very common in finals.
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11.What happened in my finals?

This is a rather long-winded account of what happened in my exams in case it helps. I think I
got quite lucky with my cases and examiners.
My Medicine PACES (St Marys)

Overall the examiners were so lovely- maybe I got lucky, but I couldn't believe how nice they
were.
SHORTS:
I had three examiners in a tiny little stuffy room which was a bit intimidating for my first
station! First I was asked to examine a gentleman's eye movements. He reported double
vision on lateral gaze bilaterally which was a bit confusing, but I noticed he couldn't quite
abduct his left eye. I decided to just have a stab and reported it as a sixth nerve palsy. My
questions were:
What do you know about 6th nerve palsies? (the main causes and how I would like to
complete the exam e.g. examine the rest of the CNs for CPA tumour, PNS for pons
infarct, and fundoscopy).
Why fundoscopy? (diabetic and hypertensive changes because these are common
causes of a 6th nerve palsies, and papilloedema for a space occupying lesion, and
even demyelination for MS)
What else would you like to do? (intracerebral imaging as the most worrying cause
would be a false localising sign)
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2011
They then asked me look at the hands of a second patient. I rather stupidly took a quick
glance and went into autopilot, asking him to roll up his sleeves and check his elbows and
look behind his ears. I also got a pillow from the bed to rest his hands on. Then after I had a
proper look I realised it wasn't arthritis, but spade like hands of acromegaly! I had never
seen acromegaly hands before, but they looked like any google image of acromegaly!
Apparently this same patient has been coming for 3 or 4 years, and theres another female
acromegaly patient who comes up too so worth learning about!
I asked if I could talk through what I saw, and I just went through everything in Dr Clarkes
book commenting on skin fold thickness, boggyness to suggest active disease, comparing the
size of his hands to mine (which was probably slightly stupid as I have tiny hands, but you'll
be amazed what you do when you're nervous!). I also commented that I couldn't see
wasting of the thenar eminence or carpal tunnel scars (in hindsight it would have looked
more slick to just do Tinels/Phalens to see if I could elicit it). I then described his face, asked
him to show me his teeth and stick out his tongue. For completion I said I'd like to ask him
for old photos, test his visual fields, and dipstick his urine. They then asked me to examine
his visual fields so I did that too. A whole host of questions followed about acromegaly
symptoms, questions I'd ask him in clinic, investigations and treatment (mentioned
Pegvisomant which they seemed to like!). I babbled the whole way through thinking I was
running short of time, but in the end they seemed happy enough to let me go at 7 mins! So
take your time if you need to!
HISTORY:
I had a young woman in the station, and was asked to take a history of how she initially
presented. I was also told she had had an operation recently, but to focus on the initial
complaint. It was a bit odd to be honest because I wasn't allowed to ask her the condition
she had- whereas I was under the impression that that would be the first question to ask in
the history station! Anyway she told me she had been admitted to A&E with diarrhoea and
vomiting on 6 occasions, so I asked lots of questions about that though I guessed she
probably had Crohns.
The examiner stopped me at 6 minutes and asked me for my differentials, which was a bit
odd. After I told her a few, she then let me go back to the patient and finish asking for extra
intestinal manifestations, family history etc, and about the operation she had which was a
total colectomy and end ileostomy. The examiner then asked a few questions about Crohn'ssuch as what the complications were, treatment etc. She also asked me whether I thought
the girl should be on iron and B12 tablets.
I still had 5 minutes left but she said I could ask any more questions to kill the time or go, so I
asked the girl a bit about living with the stoma...but really couldn't think of much else to ask,
so she encouraged me to leave! I was a bit unsure whether that was a good or bad thing, but
I got an A for medicine so I guess if that happens dont worry!
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CARDIO
My cardio examiner was the strictest of the lot, very stern faced and looked unimpressed
with everything I did. On inspection I noticed that the patient had visibly pulsatile carotids,
and so I expected to hear an early diastolic murmur of aortic regurgitation. But all I could
hear was a soft systolic murmur, so I presented it as aortic stenosis. I thought I might be
hearing the forward flow murmur in aortic regurgitation, but decided to stick with aortic
stenosis as there was no diastolic component! Good learning point- always ask for the blood
pressure! I usually do, but forgot with my nerves and other people afterwards said they
were told he had a wide pulse pressure and so presented it as mixed aortic valve disease.
The questions that followed were:
What are the signs of severity of aortic stenosis?

How would you investigate him? I mentioned looking for left ventricular hypertrophy
with the sum of the R wave in V6 and S wave in V1 of >35mm. He then asked me
whose criteria that was, and I just smiled and said I didnt know. The only time the
examiner smiled in the whole station was at that point, but he quickly recovered and
went back to being stone faced! I think if youre asked something that you know
youre not really expected to know, its better to admit it straight away rather than
try to waffle a response that theyll see right through.
What would you be looking for on the echo?
OK, imagine the patient has mitral stenosis now. (This threw me a bit, and I suddenly
wondered if I had got the diagnosis wrong, but I think he was just bored of talking
about aortic stenosis). What would you see in terms of clinical features of mitral
stenosis?
What is the significance of the pre systolic accentuation? (they are in sinus rhythm).
OK lets talk about infective endocarditis. How would you investigate someone with
this?
What treatment would you give?
Then as the bell went the external examiner decided to ask one: You mentioned
HOCM as a differential for AS. What can you ask the patient to do to differentiate the
too? (Valsalva manoeuvre or ask them to stand from squatting)
I left that station feeling a bit disheartened, but I think you just have to expect that some
examiners will be purposefully stern and others will be as nice as your mum. Try to just
ignore that, and imagine the stricter ones are just putting on an act- if you can try not to let
it affect you, youll come across more confident (easier said than done I know!)
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RESP
The examiner for this couldnt have been nicer in stark contrast! She reminded me of my
mum- literally put her arm around me as soon as I walked in, told me to examine and then
wed have a nice chat!
The patient was a thin elderly chap, with the most pronounced clubbing I had ever seen. I
had been a little worried before the exam about recognising someone who was subtly
clubbed, but this guy had drumstick fingers- you wont miss it. He also had incidental
Dupytrens. On auscultation I heard a few coarse crackles on one side, but definitely felt he
had reduced air entry and reduced vocal resonance on the other side. I knew it was unlikely
that he had a pleural effusion given that he clearly wasnt an in-patient, but decided to go
with what I found. I offered a pleural effusion and associated consolidation as a differential,
and given that he was clubbed this might be secondary to a malignancy. In hindsight I should
have stuck to a simpler diagnosis- bronchiectasis! But I couldnt put together the findings of
reduced air entry and vocal resonance. She didnt seem to mind though- asked me why I felt
it was a pleural effusion, and I think because I told her what signs were consistent with that
she seemed happy.
He also had a small scar on his back-it wasnt obvious how it was linked but I just mentioned
it, thinking it might be some sort of pleural biopsy scar.
The questions were:
How long should you ideally check for a CO2 retention flap?
What are the resp causes of clubbing?
If you could ask this patient one question to help you decide what would you ask? (I
found this a bit hard given that I still hadnt decided whether he had a malignant
pleural effusion or bronchiectasis, and floundered around with a few questions like
weight loss, haemoptysis, smoking history....but she still pressed for just one
question. So I decided she was hinting at bronchiectasis and went with the nature of
the sputum he was producing. She seemed satisfied but it was a bit of an odd
question!)
How would you treat bronchiectasis?
What are the complications?
What could be the cause of his scar? (turns out it was from removal of a skin lesion!)
As the bell went she patted me on the back and said well done. Such a contrast to the last
examiner who was staring daggers at me as I left! I thought the resp station hadnt gone
particularly at all because Id over complicated the diagnosis, and not really landed on the
right one until very late. But I did fine in the end, so it shows that getting the diagnosis isnt
always the most important thing. Or maybe I was just lucky with how ridiculously friendly
she was!
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2011
ABDO
This time I had an inpatient- cannulated, in a gown. The patient looked pretty ill- quite
drowsy and didnt say much. I felt quite bad about even examining him- I asked the
examiner if I should still continue, and he said the patient was a bit unwell after having so
many students prod him and roll him around so to be careful. It was a bit off putting as I felt
constantly worried about the patient, but tried to just do what I could.
He was obviously distended and had the most widespread spider naevi I had ever seen, like
a rash all over his abdomen. Always sit the patient up- I try to do this at the start so I dont
forget (he had spider naevi here too). The examiner was on his computer the whole time I
was examining, didnt even seem to look at me! Apparently he did this for everyone. I just
ignored this, in case he was watching without wanting me to realise and just carried on as
normal. The patient had a tremor too, yellow sclera, and his abdomen was very tense so I
couldnt for the life of me feel any organomegaly (probably just as well because I wasnt
confident about it anyway!). I did shifting dullness, but the patient seemed so unwell I tried
to do it quickly so he wouldnt be lying on his side for too long- bit of a mistake as it was
then negative. I presented it as chronic liver disease with decompensation, and possible
portal hypertension but negative shifting dullness. The examiner pointed out that I probably
hadnt left him on his side long enough for shifting dullness, so made me go back and do it
again. This time we left the patient on his side for a few minutes whilst he started asking me
questions!
Why does he have a tremor? (I suggested ethanol withdrawal, but he seemed to

want liver flap though it was definitely a very fine tremor which didnt fit with
asterixis)
What are the causes of ascites?
What are the 2 broad categories (transudate, exudates)?
What are specific exudative causes? What is an example of an infectious and
inflammatory cause?
What are the causes of chronic liver disease?
What investigations would you do?
How do we assess synthetic function of the liver? (INR, albumin, glucose)
What other investigations would you do? (ascitic tap)
What would you send the ascitic fluid for?
I left feeling a bit stupid about the whole ascites issue, but again I did ok overall so if youre
asked to go back and do something again (and a lot of people were at some point) try not to
let it put you off.
28
2011
NEURO
Final station, and the one I was dreading. Overall it wasnt too bad- there was an elderly
Caucasian chap on the bed with a walking stick by the bed, with his legs exposed. I was
asked to perform a lower limb neuro exam, but to skip the gait. He had increased tone
bilaterally, no clonus, weakness throughout, and hyperreflexia at the ankles. But I couldnt
get either of his ankle reflexes at all! This threw me a bit, but after testing with
reinforcement I had to move on. On testing for the Babinski reflex I found that one of his
plantars was upgoing, but the other was unequivocal. For sensation I started with vibration,
which was reduced bilaterally particularly on one side, and then did pin prick. The examiner
stopped me half way through pin prick and told me to leave the rest of the examination and
present (at about 5 minutes in). In any case for neuro I would suggest starting with vibration
and pin prick, and if youre short of time you could stop there if need be as youve already
tested a modality of the spinothalamic and dorsal column tract.
I presented it as a bilateral spastic paraparesis, but mentioned that I was a bit confused by
the absence of ankle jerks. In my head, I was panicking a bit about that but it turned out not
many people on my circuit could get them either- so try to just say what you found and
dont make anything up!!! She asked me what I thought about the plantars, and I decided
again to be honest and say what Id found. I finished by saying that I would like to check for
saddle anaesthesia and anal tone, examine the spine for scars, check for a sensory level and
look for features of multiple sclerosis (I remember this by the 4Ss of a Spastic paraparesisSclerosis, Saddle anaesthesia, Spine, Sensory level!). I also said I wanted to examine the
upper limbs and cranial nerves.
Questions:
So what is your overall impression?

What might be the cause of this picture? (I mentioned intrinsic causes such as
demyelinating (MS) degenerative (SACD, MND but that wouldnt fit with the sensory
loss), congenital (Freidrichs), or extrinsic such as a compression fracture or trauma.)
What else? (was struggling a bit here...mentioned inflammatory, infiltrative such as
sarcoid..)
What other broad categories are you thinking about? (infection?)
What infections do you know about that might cause this picture? (HIV, lyme
disease, syphillis)
What else? (HTLV-1?)
She then just stopped there and told me I could leave at 8 minutes. I was bit puzzled at the
questioning and didnt think that had gone very well- but on talking to the other candidates
on my circuit they had a similar experience with the same questions about infections, and I
did fine in the end so I think the lesson to be learnt is you never really know how youve
done when youve left the station. So whilst its easier said than done, try not to let your next
station be affected by your previous ones.
29
2011
SURGERY (ST MARYS)

Everyone always says the surgeons are nicer than the medics- to be honest, I found my
medicine examiners to be much nicer than I expected, so I didnt really imagine surgery to
be any better. But they definitely were far more friendly, encouraging and engaging and I
felt in surgery that I was able to show my knowledge more than in medicine. If you go off on
to the wrong tract they guided you to the right answer, and seemed a lot more impressed
with your efforts than medicine examiners. A lot of people come out of final year paces with
a newfound respect for surgeons!
I think the best thing to do for surgery is to practise with friends all the simple cases- and
particularly practise talking and asking each other questions because I felt that being about
to articulate your answers succinctly, accurately and particularly with the right terminology
was what they were looking for. I remember our surgical lead saying that everything that
comes out of your mouth should be gold (easier said than done under this much pressure)
but if you think before you speak and practise doing this a fair amount it will be easier!
Also remember particularly for surgery common things are common- so start these early
know the basic cases really well e.g. stomas, renal transplant, vascular scars, AAA, varicose
veins, knees, hips, scars, hernias, Dupytrens, neck lumps, rheumatoid hands. These WILL
come up, surgery paces in particularly is not there to catch you out. The questions they ask
are quite predictable- start early in the year and go and find these cases in the hospital.
SHORTS
The first patient the examiner asked me to see had a large swelling just below her twelfth rib
on the right. I hadnt really seen anything like it- so just tried to keep talking and described
what I saw (site diffuse swelling, spherical in shape, 3 by 4 cm, no punctum or overlying skin
changes, soft etc). Questions were:
What is your differential? (I suggested lipoma, then ran out then! Tried to say what I
thought it wasnt to buy time e.g. sebaceous cysts, hernia etc)
What else could it be? (said something about it being a sarcoma but really couldnt
think of what else was consistent with it)
What might it be if it was in communication with the pleural cavity? (he eventually
lead me to the answer which was an empyema but to be honest I didnt really
understand how it could be this)
What infectious cause might result in this? (again I said that the patient seemed well,
there were no signs of inflammation so I really didnt think it could be infectious but
he probed me for an answer so I said a cold abscess of TB)
Do you think she should have it removed? (he had confirmed it was a lipoma by then,
I said it depended on the patients wishes, the main problem was probably cosmesis
more than anything else)
30
2011
What might be the problems of removing it? (damage to surrounding structures- he

asked which nerves, and I didnt know so he said intercostal nerve damage which
might causes numbness over the area. I was starting to feel quite stupid!)
Is this a major or a minor procedure? (minor!)
What type of anaesthesia would she need? (local)
He then led me towards the couch where there was an elderly lady with an incisional hernia
over a midline laparatomy. She had several scars, and the skin looked very puckered and
tethered around the scars.
What is this? (incisional hernia)

Why do you think the skin looks like this? (maybe she had dehiscence of the initial
wound which was then sutured- he said this was right)
What are the risk factors for incisional hernias? (gave a rehearsed answer of pre-op,
operative and post op factors)
Which of these is the single most important factor? (I wasnt sure, gave a few
attempts but he said surgical technique was the most important)
Do you think it needs treatment? (depends on size of the defect and therefore risk of
strangulation, patient factors including patient choice, other co-morbidities)
She also has a Kochers incision why do you think they did an open cholecystectomy
for her? (adhesions would make laparascopic surgery difficult)
HISTORY
I had an external examiner for this who I liked instantly and was probably the nicest
examiner I had encountered in paces. The patient was a 70 year old Caucasian lady who was
incredibly friendly. She described how her only initial presenting complaint was one of
constipation, but she was taken into hospital for an emergency operation which resulted in a
stoma. After taking a thorough history of the presenting complaint and any post op
complications, the examiner stopped me at about 6 minutes and started asking questions. It
was similar to medicine in that I hadnt got round to the family history etc yet, but he didnt
seem too bothered.
He asked me lots of questions about what the procedure she had had was. It was more like a
chat, and he was extremely nice. I said it sounded a bit strange in that the procedure was
probably a Hartmanns procedure but she didnt have any symptoms of an obstructing
sigmoid Ca or perforation from diverticular disease which would be the commonest
indications. He kept encouraging me and in the end I felt like I was more just thinking out
loud than answering his questions properly. But I think its a good learning point that if
youre not sure of an answer, rather than staying quiet its better to articulate your thought
process as often there is no right or wrong answer.
31
2011
The rest of the station was spent asking me all sort of questions about colon cancer (turned
out shed had a rectal cancer which has found to be invading her uterus too at presentation,
so had had part of her rectum removed with an end colostomy and mucous fistula, as well
as a hysterectomy. They tried to reverse the stoma later but it failed). I cant remember all
of the questions but heres a few:
Why do you think they wanted to operate so quickly? (invading surrounding

structures)
How does bowel cancer spread?
What treatment might she need afterwards? (chemotherapy, radiotherapy)
What would you see in the bowel after radiotherapy that might make it difficult to
operate again (I wasnt sure about this- he said telangiectasia)
What would you see microscopically in the bowel after radiotherapy (a vasculitis)?
What do you think her staging was in terms of Dukes?
How would you monitor her post operatively for recurrence of the cancer? (MRI,
apparently you can perform a colonoscopy down the stoma too!)
What do you think is her likelihood of recurrence?
What influences the likelihood of recurrence? What other questions could you ask
her to determine her risk? (family history, talked about FAP, HNPCC, Lynch- would
want to ask about other cancers she may have had e.g. endometrial)
Why do you think they didnt do an end to end anastomosis in the first place?
Do you think we should attempt joining the two ends back together now? (I said it
would be important to consider patient choice, see how she was coping with the
stoma, but preferably leave it given that it is likely to fail again if it is under high
tension and the distal end is not long enough)
What would you look for as an F1 post op on her observation chart that may indicate
an anastomosis is failing? (High resp rate, temperature, pulse etc)
After what time frame post operative is an anastamosis most likely to fail?
IMAGES AND INSTRUMENTS

This station is the easiest to prepare for- go through all the images you get taught and you
really cant go far wrong. I didnt get asked many questions because for all the instruments I
just kept talking quickly through what it was, how to use it, indications etc. My instruments
were:
o Sigmoidoscope (where would you use this? What are its indications?)
o Proctoscope (picked up the Gabriel syringe to show him what I would use it with. He
asked me about treatment of fissures)
o Gabriel syringe
o Irrigation catheter (which port is used for what?)
o Urometer (what do you know about enhanced recovery programmes? Would we
accept a lower or higher minimum urinary output in enhanced recover programmes?
32
2011
I said lower, because the whole concept is focussed around getting the patient home
quicker)
With the images he didnt want to hear about the adequacy of the films etc, just spot
diagnoses. My images were:
o Air under the diaphragm
o He made me talk through my ABC management with this in reasonably detail.
o Causes?
o Treatment? (omental patch repair which can be open/laparascopic)
o Achalasia
o What is it?
o Treatment?
o Extradural haemorrhage
o Likely cause?
o Treatment?
o Which artery is damaged?
o ERCP with gallstones
o Treatment?
o What do they use to get them out (I wasnt sure, said a basket probably which
he seemed happy with)
o Complications of a sphincterotomy? (pancreatitis)
VASCULAR
The examiner asked me to examine the patients lower limb vascular system. I started at the
abdomen feeling for a AAA- the examiner hovered over me and asked me if I could feel
anything. I honestly couldnt feel a thing, and by that point Id decided it was always best to
just say what I found so I told him that whilst I was trying to feel for an expansile, pulsatile
mass I couldnt feel anything. He asked me to do it again, and by this point I guessed the
patient was supposed to have a AAA- but again found nothing and said so.
The rest of the lower limb exam was entirely normal. He asked me for my overall
impression- I said it was likely the patient had a AAA. He looked at me quizzically and
seemed surprised, asking for my reasons. I said, Because you asked me to feel twice, and
the rest of the exam was normal!. He laughed, and the rest of the discussion was focussed
on AAAs:
What investigations would you do now? (US, then CT if he was going for surgery)
What symptoms might he have presented with?
What is the commonest way for them to present (asymptomatic, picked up on
routine scan for another reason)
When do we intervene? (quoted UK Small Aneurysm trial, at greater than 5.5.cm,
symptomatic or growing at >1cm per year)
33
2011
What are the risks of not intervening?

What are the treatment options? (EVAR v open)
Why do we do one over the other? (EVAR has lower operative mortality rate, shorter
stay in hospital, lower transfusion rate, can be done under spinal or epidural
anaesthesia, but not everyone is anatomically suitable for an EVAR)
How would you decide? (patient choice as well as the above factors)
What are the other problems with an EVAR? (that we dont actually know much
about the longevity of EVARs compared to open repairs)
What if the patient had lung cancer? How would that influence your decision? (I
talked about the risks of anaesthesia...)
What one factor would be the most important thing to know about the lung cancer
to help in your decision? (I was still going on about operative risk but he sort of led
me to the answer which was prognosis of the cancer- i.e. if he wasnt going to live for
long there would be no point in intervening in his AAA)
ABDOMEN
This was another incisional hernia which I saw from the start. The lady had a midline
laparotomy incision and a scar in the right iliac fossa which looked like reversal of a stoma.
With the rest of the exam he moved me along pretty quickly at each stage, and asked a few
questions along the way e.g. what are you looking for in the eyes?.
The rest of the discussion focussed on the incisional hernia- I cant remember the details but
it was similar to my shorts case. He then asked me a bit about what I knew of different types
of hernia- all quite straightforward. He asked me what operation I thought she had, and I
gave a few options (e.g. anterior resection and loop ileostomy which had been reversed, or
Hartmanns and end colostomy which had been reversed but I wouldve expected the stoma
to be on the left hand side). The remaining questions were based around the operations I
had mentioned e.g. need for a Hartmanns etc. Im afraid I cant remember it all but the
questions werent too bad at all.
ORTHO
I was dreading this, but it was one of my nicest stations. Absolutely lovely examiner who
asked me to examine this elderly ladys knees. She had two vertical scars and some smaller
arthroscopy scars on both knees from previous replacements. The exam was fairly
straightforward- not many questions along the way and I just talked through it. The only real
findings were the scars and limited range of movement bilaterally. The questions were
nothing to do with the knee replacements!
This lady has a metal plate in situ in her tibia after a fall. If she came in pyrexial what
might be the causes? (main concern is septic arthritis)
34
2011
What investigations would you do? (e.g. joint aspiration)

What would you see on X ray? (not much for at least 10 days)
What is the treatment?
What else would be your differential for a sudden swollen knee? (e.g. gout, trauma
etc)
How would you investigate suspected gout?
What would see under the microscope of a joint aspirate? (negatively birefringent
needle shaped crystals)
What is the treatment of gout?
What are the side effects of NSAIDs?
She stopped me here at about 8 minutes and let me wait in the station for the bell to go!
So overall I think I got quite lucky with my cases and examiners. I think you need an element
of luck to do well, as youll realise from reading everyones different experiences. All you can
do is practise as much as possible, keep things simple and give it your best shot- the rest is
out of your hands.
35
2011
12. Final thoughts

I know this guide is a bit long and waffly, but I hope its helped. Final year is not as scary as it
seems, and you WILL pass. Remember this is the last exam youll do where the examiners
actually want to pass you! Enjoy it, theyre on your side for the last time!
You might be feeling a bit overwhelmed by everything. Like I said at the start, it will be a
weight on your shoulders especially during the last few months. But you WILL get through
it. And then the best month of your life follows remember!
In my eyes I think if you follow these main points youll pass with flying colours:
1. Listen to the advice of people whove been through it (not necessarily me)... but
dont let anyone freak you out.
2. Start early.... but dont work too hard or youll burn out.
3. Work hard.... but play hard too! Its your last year of being a student!
4. Help your colleagues, youre in this together
5. Enjoy it- youre actually so close to being a proper doctor!
Please pass this on to anyone you think might benefit from it. If you have any questions
during the year, feel free to email me and Ill do my best to reply.
GOOD LUCK!!!!!!!!!!
36

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Nishs guide to finals

My guide to final year

2. How shall I plan this year?

3. Whats the deal with the elective?

4. What about MTAS?

5. What exams will I have?

7. What books shall I use?

8. What courses shall I go on?

9. How shall I use my firm time?

10. Have you got anyone with signs please?

11. What happened in my finals?

12. Final thoughts

Nishs guide to finals

Nishs guide to finals

Nishs guide to finals

2. How shall I plan this year?

Nishs guide to finals

3. Whats the deal with the elective?

Nishs guide to finals

4. What about MTAS?

Nishs guide to finals

2010-11 MTAS questions:

2) Describe a clinical situation which provided an opportunistic learning experience.

Nishs guide to finals

5. What exams will I have?

40% Medicine, including GP and Public Health

3) Paper 3 - Practical Prescribing. 1 hour Examination

History Taking (22mins)

Nishs guide to finals

2) Surgery Stations (10 mins):

History Taking (22mins)

Nishs guide to finals

Nishs guide to finals

Nishs guide to finals

prescription I had written as a whole, and checked for obvious interactions.

Nishs guide to finals

7. What books shall I use?

Medicine at a Glance- a useful adjunct to help remember things, especially if youre

Nishs guide to finals

Nishs guide to finals

Onexamination or Pastest- most people sign up to one of these. I did, but to be

Nishs guide to finals

Other useful resources

8. What courses shall I go on?

Nishs guide to finals

Medicine and Surgery combined

Nishs guide to finals

2. West Middlesex Paces course (finalsPACES- finals.paces@googlemail.com)- This course

9. How shall I use my firm time?

Nishs guide to finals

Remember fundoscopy is really likely to come up especially if youre at Chelsea for

Read up on the common conditions that come up in fundoscopy in finals (use Dr

Nishs guide to finals

Read the Cardio pharm section too if you can.

Nishs guide to finals

Nishs guide to finals

10.Have you got anyone with signs please?

Nishs guide to finals

Hernias- definitely worth seeing, try to go to a general surgery clinic (Mr

Nishs guide to finals

11.What happened in my finals?

My Medicine PACES (St Marys)

Nishs guide to finals