• Dr Sally Ayesa

Levelling up your final exam preparation

When you are in the thick of exam study you become completely immersed - and when you are immersed, sometimes you can lose sight of the real goal. I know that in retrospect, for the most part I looked at the radiology exams as a barrier I had to break through, rather than taking a step back to consider why the barrier was there in the first place.

What is the point of the exam? Considering this question can be quite a useful tool in the latter stages of exam preparation. Your brain is swimming with mountains of hard earned knowledge, facts and practical skills which have been set out by a syllabus - which is really just a to-do list of topics. What can be lacking, however, is context. How does this shopping list of conditions and imaging findings fit into the vision of your future radiologist self, and the skills that you hope to possess.

I believe that the final bringing it together phase is the hardest part of exam preparation, as it isn't something you can read in a textbook or learn in a tutorial. It is something that you can only earn through practice, experience and (unfortunately) making mistakes.

Think about it like leveling up in a video game. I used to play a lot of Tetris, when you got a certain amount of points you would irreversibly be promoted to the next level which was faster and harder. It felt shaky at first, and often took you by surprise leading to a misplaced brick or two, but there was no going back. So you kept playin and soon enough you settled into the new challenge. Exam preparation can offer a similar experience, especially in the latter stages. You are all of a sudden in possession of a critical mass of knowledge, leading you to grow without you realising. The only tell is that all of a sudden you start feeling unsettled and making mistakes. It may last a few days or a few weeks, and can be mentally very difficult as it feels like you have taken a step back when in fact you have taken a step forward.

So how does putting the exam into context fit in with your final levelling up?

At the end, the greatest challenge can be putting together everything you have learned

Think big...

If you put everything aside - exams, training requirements - what do you hope to achieve, and who do you hope to be at the end of your radiology training? For me, I wanted to be a safe and competent radiologist. I wanted to get to a point where someone would be able to pick up something I had written and say "Oh, I know Sally - she knows what she is talking about." You might have a similar vision for yourself.

The best conceived exams and training schemes are "fit for purpose", meaning that they are written in such a way that they assess the key skills that one needs to achieve that broad end goal. In our case, that is producing that safe and competent radiologist who you would be happy to be working alongside you at your practice, or someone you would trust to report your mother's chest x-ray.

When you consider how eFilm and viva exams are designed, at their core they aim to model how you perform at your workstation with a live case in front of you. They are assessing how you manage when you assess films without the assistance and backup of your supervisors. In reality, exams are made of a series of collected (granted more difficult) cases from workplaces around Australia and New Zealand. What the examiners want to see is how well you handle these difficult cases - can you demonstrate a safe and competent approach? Can you suggest a sensible assessment and offer a sound management plan? Can you recognise the rare but important diagnoses which may significantly impact ongoing management? In short - how would you help this patient?

Think small ...

Transcending the exam on a single case level can be tricky for several reasons. In certain phases of preparation you can find yourself looking too hard for what you have just been reading about, or trying to squeeze a case into a diagnosis which doesn't fit. Common mistakes I see candidates make include over-explaining findings and bringing in rare or obscure diagnoses before the common conditions.

It is similar to writing an assignment. Earlier this year I had to write an essay on parathyroid imaging, capped at 1500 words. I researched and wrote and ended up with a 2500 word essay which I was really happy with, but not what my examiners had asked for. I found it hard to edit down, as a lot of interesting facts and things which I felt added something extra to the discussion had to be tossed. Similarly, you as a candidate presenting cases or writing eFilm answers have to fish out what is most high-yield and relevant.

The danger of over-explaining is that you can end up leading yourself down a rabbit hole, which is then difficult to climb out of. You can confuse yourself, or forget to synthesise the important piece of information you had detected some time earlier. During my viva preparation, one of my consultants showed me a case of a cerebellar lesion with a large amount of surrounding oedema. I became really hung up on trying to correctly describe the anatomical locations of where the oedema was and what structures were involved. At the end she said to me "You know, you wasted time there. The important thing was just the fact that there was oedema - so just say that."

When formulating differential diagnosis lists in exam settings, there is a temptation to look for the zebras instead of horses. The problem with this mindset is that you are tempted to throw out weird and wonderful first diagnoses, when you are perhaps looking at a more common entity such as sarcoidosis or lymphoma. To combat this, my advice is to apply the "middle of the night test". You are sitting alone at a reporting station in the middle of the night and the emergency department is on the line. What would you say to them? You might phrase it like, "Well it fits with this common diagnosis, but I am concerned about this life-threatening diagnosis with a differential of this obscure diagnosis". You wouldn't put the unlikeliest differential diagnosis first in life, so try not to do it in your presentation unless it is a lay down misère.

It takes a level of radiological maturity to be able to successfully edit description and craft a differential list on the fly and under pressure, and even in the exam you will not be successful every time (goodness knows I wasn't). If you can move into a reporting mindset for your viva presentations, and roll live cases and exam cases all into one, you are on the right track. And as I always say, if you are accidently slipping the occasional "full stop" or "comma" into your verbal viva presentation you are on the right track.

Final thoughts...

Radiology exam preparation is hard at the best of times and 2020 has added an extra degree of difficulty. During the rocky phases, and the times where you are 'leveling up', try not to be too hard on yourself. The whole experience requires great humility, and remember that you not only will make mistakes, but you need to make mistakes to get the most out of your preparation.

Look beyond the exam as that hurdle you need to jump over and then forget, and keep that vision of the mature and competent radiologist at the forefront. As a great radiological hero of mine is rumoured to have said "If you walk into the exam as a radiologist, you will walk out as a radiologist."

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