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Sorry guys: all doctors have to resit their exams!

MRCP time: the toughest questions on the planet, drawn from a large pool of knowledge from all aspects of medicine. Randomised in order, answers randomised. Testing pure brain power! The results are evaluated in the most rigorous statistical manner to assure that only questions that distinguish between candidates with different abilities make it into the final papers.

You might have heard that this year something odd happened. A number of colleagues who sat the Part 2 managed to crack a all of a group of difficult questions that only very few others did managed to get right. They were good in a big part of the exam. But: they were pretty average in another part of the exam that had been added to the final paper at the last minute. The exam board got suspicious: did they know the answers to some of these items? Had they seen the questions before? A thorough examination of the circumstances is still under way, but it seems that the successful candidates had just worked really hard and managed to memorise the right content.

As we were discussing this I had to reflect on this. My MRCP is a fair few years back. The written was much less fun then the PACES exam: For the latter I studied at the Kent & Canterbury hospital with the amazing Ian Sturgess. We were a tight nit group of candidates. We would study still 22:30 and them run down the hill to make it just for last orders at the local pub.

The written was a so tough. It had at the time a much less clinical flavour. But if we look at the make-up of the questions it doesn’t feel that way. There is cardiology, thoracic medicine, endocrinology, nephrology. It could not get more clinical than that. But the shape of the focus of the questions is about testing knowledge that only the best candidates hold. So inevitably the questions are something like: ‘Which of the following enzymes is reduced in activity in this or the other disease’. The questions are good at detecting who can memorise facts for example this one quoted from

A 32-year-old cyclist had noticed increasingly frequent flickering of his limb muscles, particularly the calves, and reported occasional cramps over 3 months. On examination, he had widespread fasciculations in his arms, forearms and calves. His deep tendon reflexes were normal, and he had no sensory signs. What is the most likely diagnosis?

A: benign fasciculations

B: McArdle’s syndrome

C: motor neurone disease

D: myotonic dystrophy

E: polymyositis

McArdle’s disease is part of a group of glycogen storage diseases which affects approximately 1:100.000 people ( In the UK approximately 1:280.000 patients is diagnosed ( The average district general hospital in the UK will therefore look after 1-2 patients with this condition. This does not make the condition harmless or impossible to diagnose. It is just not very common. The chances that the candidate will see a patient with this condition while he or she still remembers the answer to the questions is just over zero percent.

Moto-neuron disease is more common and affects up to 5000 adults in the UK at any given time. So this is a condition most candidates will see and have to care for. The treatment is complex. It often involves support for breathing and treatment is delivered within a group of health care professionals including neurologists, respiratory physicians, physiotherapists, palliative care specialists. It is all about delivering complex care for some very unfortunate individuals under difficult circumstances.

Talking about difficult circumstances. The NHS is likely to struggle even more this winter given that the number of colleagues from the European mainland is likely to go down and that we are facing major problems with frustrated and exhausted doctors and nurses at almost any level. Politicians have struggled to inspire clinicians to make the leap in innovation that many feel is needed to make the health service a robust and safe service.

In a recent meeting with senior colleagues at my local hospital I started to get a glimpse of why that might be the case. We were talking pressures, patient flow, rising numbers of emergency admissions. And I asked whether we have got data to show trends. And I was handed a chart. Now from my training with colleagues who trained at the Institute for Healthcare Improvement ( and with 1000Lives (  I know that the right tool for this questions is usually a process control chart. Unfortunately we did not have the data as part of a process control chart. Not did anybody quite seem to understand what a process control chart does.

Looking back at my observations from this years MRCP: the overwhelming majority of its questions are focused around diagnosing pathology and treatment of individual patients and NONE around diagnosing pathology and treatment of organisational problems. The exam sets a powerful signal of what we as senior physicians feel is key to delivering good care. At least half of this is about understanding disease. But the problems that stop us delivering good care every day require a different set of knowledge and skills. And we don’t test it.

If we emphasis the importance of Quality Improvement but don’t make it part of the most important exam of a doctors career, then this is such an important signal: If we want teams to work as teams, think patient centred, diagnoses problems in our services and start the right improvement treatment then this is what we need to teach and focus our exams on.

In the end it might boil down to ‘do what I do not what I say‘!

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