In 2016 I started work at Lismore Base Hospital after moving from Royal North Shore Hospital in Sydney. Having been involved in teaching and education, particularly at the resident and registrar level, I was keen to get involved in a similar scene in Lismore. It didn’t take me long to track down my old supervisor from my time as a trainee registrar in Lismore, Dr Adam Blenkhorn, who had been evolving the Basic Physician Training program over the years at Lismore. One of the key milestones he was keen to achieve was to run the national Physicians exam locally. This was no mean feat, but with the support of the new Department of Medicine, this aim is being achieved.
The physician clinical exam takes place once a year and is run over the last two weeks in July. Candidates begin preparation for this exam 18 months prior to it, undertaking rigorous training both on the job and academically. They work as the ward registrar rotating through relevant medical specialties, gaining skills and knowledge, whilst being responsible for the patients under their team and on the ward.
Simultaneously they begin their studying, dedicating most evenings and the majority of their weekends to the task, that is of course when they’re not on overtime shifts. They will often spend two weeks away at a dedicated course focused on only medicine and much of their finances are contributed towards focused courses to help them achieve their goal. In the year I passed my exam I had spent over $20k on dedicated activities. By March of the following year they are expected to have achieved a peak of knowledge that is adequate to see them achieve a pass in the written papers and move on to the clinical exam. This is another challenge entirely…
Between March and July candidates apply themselves to the task of honing their clinical skills to the sharpest point. No physician ever achieves a greater level of knowledge and broad clinical skill than immediately after successfully achieving passes in both of these exams.
For the clinical exam, candidates must go interstate to a hospital they have not worked at previously. To avoid biases they need to be a ‘blank slate’ to the examiners. This involves its own sense of terror: they have to travel out of town for the most important date in their career so far, with all of their clinical equipment. Will the plane be delayed? Will they allow neuro tips through airport security (yes)? Will they be able to find the hospital? What if they can’t find good coffee in the morning?
This is a terrifying exercise, but it is designed to give the candidate every opportunity to pass on neutral territory. All candidates are equal in this examination.
The clinical exam requires candidates to review two ‘long case’ patients and four ‘short case’ patients. A long case is a complicated patient with multiple active issues. An example might be a patient with cardiomyopathy with worsening renal failure and a new PE who is diabetic. A review undertaken of long case patients and their outcomes post exam and their estimated two year mortality rate was 30%.
Candidates are expected to review the history and examination of these patients with no notes or results and within an hour be able to synthesise a comprehensive summary of their issues, along with a detailed problems list and solutions.
The short case takes a different approach. Candidates have seven minutes to examine a patient on a specific system (i.e. cardiovascular) and using physical examination skills alone be able to report the relevant positive and negative signs that correlate to their provided diagnosis. Again patients often have rare or unusual diagnoses. Charcot-Marie-Tooth, HOCM, Muscular dystrophies are common fare in this part of the exam, along with more standard cases of Rheumatoid arthritis, Parkinsons and Aortic Stenosis.
So, over two weeks at the end of July, all around Australia and New Zealand, these clinical exams are held. Around Australia more than 3000 people are involved in running these exams, including patients, candidates, examiners, administrators and volunteers. The highly trained National examiners are included on every examination panel to ensure a standard is maintained.
The remainder of the examining panel is made up of local examiners who are from the region but have an interest in participating. The local examiners have spent time observing the exam in other centres and have been monitored acting as a preliminary examiner before being accepted. Every year all of the examiners attend a session ‘calibrating’ to ensure consistency.
If we now go back to 2016 with Adam discussing plans to run the Physician exam locally we can understand just what that request meant. It is not merely providing the College with an examination centre. It is not just about allowing more candidates to be examined. It is about participating in a national event. The pinnacle of physician training in Australia. It is about Lismore having something to offer on that national scene and inviting people to come and view that.
So where are up to in this endeavour? In 2017 and 2018 we ran a trial exam for four candidates from Prince of Wales Hospital, Sydney. We provided interesting and challenging patients for the candidates and the exam was well received. In order to proceed with running the formal exam in July, however, we need local examiners to become qualified. To date I, along with Dr Adam Blenkhorn, Dr Venkat Manickavasagam, Dr Joe Churton and Dr Joe Gormally have been accepted as local examiners, with more to train in the future.
The new Rural Training Hub has been integral in our ability to aim high with this project and a key part of that was the provision of a Medical Education Support Officer, Mrs Stacey Casagrande, who will provide project leadership to help us with this goal. The main goal is to maintain and enhance the medical care for the community through the development of a high quality local education and training facility for Physician Training.
We aim to run Lismore Base Hospital’s inaugural Physician Examination in 2019.