Preface

‘MRCP; Member of the Royal College of Physicians … They only give that to crowned heads of Europe.’ *

A Short History of An Aid to the MRCP PACES

‘Remember when you were young, you shone like the sun … ’ †

At the beginning of the 1980s, Bob Ryder, an SHO working in South Wales, failed the MRCP short cases three times.‡ On each occasion I passed the long case and the viva which constituted the other parts of the MRCP clinical exam in those days but each time failed the short cases. Colleagues from the year below who had been house physicians, with me the SHO, came through and passed§ while I was left humiliated and without this essential qualification for progression in hospital medicine.

The battle to overcome this obstacle became a two or more year epic that took over my life. I transformed from green and inexperienced¶ to complete expert in everything to do with the MRCP short cases as viewed from the point of view of the candidate. I experienced every manifestation of disaster (and eventually triumph) recorded by others in Section F of this volume. By the time of the third attempt, I was so knowledgeable that I was out of tune with the examiner on a neurology case simply because I was thinking so widely on the case concerned. I believed at the time that I came close to passing at that attempt, although one never really knows and it was, after all, the occasion where I failed to feel for a collapsing pulse!** This was an important moment in the story because it was from this failure, along with the experience in the neurology case in my second attempt¶, that the examination routines and checklists, which are so central to this book, emerged. I finally passed on the fourth attempt whilst working as a registrar.†† During the journey, various consultants, senior registrars and colleague registrars tried to help in their various ways and amongst these, one of the consultants in my hospital, Afzal Mir, offered the advice that I should make a list of all the likely short cases and make notes on each and learn them off by heart. His exact advice was to ‘put them on your shaving mirror’. An important point should be made at this juncture. In order to be able to achieve this, one needed to attain the insight that it was indeed possible to do this. In those days there was no textbook for the exam, like the one you are reading, and there was no syllabus. Things had perhaps improved a little since the quote at the top of this Preface from A.J. Cronin* but nevertheless, the MRCP did carry with it an awe, a high failure rate and an aura that the exam was indeed one consisting of cases you had not seen before and questions you did not know the answer to. Indeed, many of us sitting it at the time would have found this a reasonable definition of the MRCP short cases.

A crucial part of my two or more years’ journey that formed the seed that eventually grew into the first edition of this book was the realization that, in fact, behind the mystique, the reality was that the same old cases were indeed appearing in the exam over and over again, that there was a finite list and, indeed, from that list some cases occurred very frequently indeed.‡‡ The realization of this led me to do exactly what Afzal Mir had advised (without the shaving mirror bit!). At the time there was a free, monthly journal that we all received called Hospital Update and it had a regular feature dedicated to helping candidates with the MRCP. In one issue the writer listed 70 cases which he reckoned were the likely short cases to appear in the exam and an eye-balling of this suggested it was fairly comprehensive.

And so I studied each of these 70 cases in the textbooks and made notes which were distilled into their classic features and other things that seemed important to remember and I wrote out an index card for each of the 70. Thus, the original drafts of the main short case records were penned whilst I was still sitting the MRCP.

Another major contributor to my final success with the exam was junior doctor colleague Anne Freeman. She had been on the Whipps Cross MRCP course with me prior to our first sittings of the exam and she passed where I had failed. Until that point, I think we would have considered ourselves equals in knowledge, ability and likelihood of passing.‡ I would describe Anne as being like Hermione Granger.§§ In her highly organized manner, she had written down the likely instructions that might be given in the short cases exam and under each had recorded exactly what she would do and in what order, should she get that instruction. She then practised over and over again on her spouse (Dr Peter Williams, to whom she is especially grateful) until she could do it perfectly without thought or mistake or missing something out, even in the stress of the exam.** I, on the other hand, was not like Hermione Granger. I could examine a whole patient perfectly in ordinary clinical life but had not actually thought through exactly what I would do, and in what order, when confronted with an instruction such as ‘examine this patient’s legs’ until it actually occurred in the exam.¶ And so eventually I did what Anne Freeman had done and the first versions of the checklists (for which I am especially grateful to my wife, Anne Ryder, who wrote them out tidily and then ticked off each point as I practised the examining, pointing out whenever I missed something out!) and primitive versions of the examination routines were born, again whilst I was still sitting the MRCP.

Having finally passed the exam, it seemed a shame to waste all the insights into the exam and the experience I had gained, and all the work creating the 70 short case index cards and the examination routine checklists I had created and practised and honed so laboriously – and so I conceived the idea of putting them in a book for others to have the benefit without having to do so much of the work or, perhaps, to go through the ordeal of failing through poor preparation as I had done. I shortlisted what seemed to be the four major publishers of the moment and on a day in 1982 was sitting in the library of the University Hospital of Wales penning a draft letter to them. At a certain moment I got stuck over something – I have long since forgotten what – and on an impulse went down to Afzal Mir’s office to ask him something to do with whatever it was I was stuck over. It was a defining moment in the history of these volumes. When I left Afzal Mir’s office, the project had changed irrevocably. I was a registrar, he was a consultant. He was extremely interested in the subject himself and my consultation with him ended up with the project being one with both of us involved and me with a list of instructions (consultant to registrar!) as to what to do next!

And so an extremely forceful and creative relationship began, which led to An Aid to the MRCP Short Cases. It was not that we worked as a peaceful collaborative team – rather the thing came into existence through creativity on a battleground occupied by two equally creative and forceful (in very different ways) people with very different talents and approaches. There are famous examples of this type of creative force, e.g. Lennon and McCartney or Waters and Gilmour.¶¶ Looking back, there is no doubt that without the involvement of myself and Afzal working together, an entirely different and inferior book would have emerged (probably the short 100-page pocket book desired by Churchill Livingstone – see below) but at the time I did not realize this and only thought that I was losing control of my project through the consultant–registrar hierarchy! My response was to bring in Anne Freeman, who I am sure would be very happy to be thought of as the Harrison/Starr or the Wright/Mason of the band!¶¶

Anne and I, in fact, also became a highly creative force through the development of the idea of surveying successful MRCP candidates to find out exactly what happened in the exam. It started off with me interviewing colleagues and this led to the development of a questionnaire to find out what instruction they had been given, what their findings were, what they thought the diagnosis was and their confidence in this, what supplementary questions they were asked, and their comments on the experience of that sitting. I distributed it to everyone I could find in my own and neighbouring hospitals, whilst Anne took on, with tremendous response, the immense task of tracking down every successful candidate at one MRCP sitting and getting a questionnaire to them! We asked all to report on both their pass and previous fail experiences.

Our overture to the publishers resulted in offers to publish from Churchill Livingstone (now owned by Elsevier Ltd) and Blackwell Scientific Publications (now owned by John Wiley & Sons) with the former coming in first and so we signed up with them. They were thinking of a 100-page small pocket book (70 brief short cases, a few examination routines, hardly any illustrations) sold at a price that would mean the purchaser would buy without thinking. The actual book, however, created itself once we got down to it and its size could not be controlled by our initial thoughts or the publisher’s aspirations. We based the book on the, by now, extensive surveys of candidates who had sat the exam and told us...