Addendum regarding the ANZCA Primary Exam Companion

Firstly, I want to thank all the people to date who have purchased my book. It has been well received and I earnestly hope it aids you in your quest to pass the exam.

The actual cover is reprised below- the back cover is a bit different from my earlier post.

Buy it from the Australian amazon site: amazon.com.au I have had several queries from people saying it has been out of stock- this is only on the American site. It has always been in stock on Amazon Australia. Interestingly I have sold quite a few copies in the US, Canada as well as the UK.

I have become aware of a couple of errors and have rectified these on the current version of the book that you would buy now. I would like to highlight these corrections for owners of earlier versions of the book.

• p27 100% oxygen- “The 47 refers to the the saturated vapour pressure of water at seal level at standard temperature…” This should be body temperature, not standard temperature.
• p166 pulse oximetry- my explanation of how carboxyhaemoglobin causes an elevated oximetry reading was a bit clunky. My revised explanation is reprised here: Carboxyhaemoglobin (COHb) has a similar absorbance pattern to oxyhaemoglobin so will tend to artefactually elevate the reading towards 100%. This is the simple explanation provided in the books, but it is more complex than that: COHb has a little absorbance of red light but none of infrared, so its presence alone should cause an elevated R ratio (AC₆₆₀/AC₉₄₀) which correlates with a reduced saturation! So why do the sats read high? The explanation is that CO binds very tightly to haemoglobin and there is reduced deoxyhaemoglobin present. A reduction in deoxyhaemoglobin causes a greater fall in AC₆₆₀ absorbance than AC₉₄₀ since it is a log scale and so the R ratio is smaller which correlates with an increased saturation value.
• Admittedly the above is pretty niche material but the perfectionist trainee should be satisfied. I also share with you what MAK95 (not MAC95) means.

The ANZCA Primary Exam Companion

The Cynical Anaesthetist has finally finished his long awaited exam primer book. It has been published on Amazon in both hardcopy paperback form and as a Kindle eBook. The paperback is $88 and the eBook is $70. The content is identical but there is a bit of colour in the Kindle version. The paperback is 263 pages long and A4 size. Obviously, the main incentive for writing the book is to help people pass the exam. I am totally biased of course, but I think this book will be a very valuable tool for you to use in your exam preparation. I asked a group of my colleague examiners to peruse and comment on the book prior to publication and have incorporated their insightful and much appreciated contributions. The cover and table of contents are reproduced below.

I have learnt a lot in the course of writing this book. The phrase “All killer, no filler” is apt. I have gone to lengths to include material that is very commonly asked in the exam and is poorly explained by the recommended texts. It is probably the book with the most comprehensive and up to date treatment of the encephalogram and BIS monitor. It also has quite detailed and comprehensive entries on the propofol plasma time curve and offset of a propofol infusion. The morbidly obese patient has been catered for. I can’t claim to have written a book without any errors in it, but have gone to lengths to do my very best to find and correct them. The SHORT AND SWEET section incorporates 500 short format questions and answers that traverse the entire breadth of the curriculum. They are similar in style to the QUICK QUIZ questions in Kerry Brandis’ The Physiology Viva.

As the title says, this is a companion book. It doesn’t claim to incorporate everything you need to pass the exam in a mere 263 pages. But it does plug quite a few gaps and represents the only book of its kind- a book written by an examiner for the ANZCA primary exam. I hope you find it helpful.

Exam Report- part 1

The exam report was released a couple of weeks ago. I and others have previously posted on why these are such valuable documents. As tempting as it is, examiners are now less likely to use the following phrases which have featured prominently in past exam reports:

• “…examiners were disappointed…”
• “…examiners were surprised…”
• “…examiners were disappointed and surprised…”
• “…lack of knowledge of core material..”
• “…relevant material is covered in all the reference texts…”
• “…candidates did not answer the question that was asked…”

This is despite the fact that all of the above comments are totally justified and every bit as relevant now as they were then!  Stating the obvious is deemed unhelpful in these politically correct climes.

Anyway, so what useful pearls can be gleaned from the exam report? There are lots of stats for you to look at- the overall pass mark has been remarkably consistent over the years. What is more interesting is that if you pass the MCQ and score 45% or less in the SAQ then you will almost certainly fail. I banged on about this in my post here: https://primarydailylo.wordpress.com/2018/08/16/saq-exam-tip-3/

The opening questions for each set of vivas are also published. I have banged on about these before as well: https://primarydailylo.wordpress.com/2019/03/15/vivas-the-opening-question/

Each SAQ has a report that was written by the examiner who marked that question (often it has been edited by the Chair so the best bits have been left on the cutting room floor but I digress). The SAQ report is most useful for the questions that were answered poorly. Firstly if a question has been really badly done then it is a good chance that it will be asked again. Secondly, hopefully the report gives an insight into why it was so poorly done- what were the common errors or omissions? Thirdly, and of intense interest to the prospective candidate, what was the desired response (aka the answer)? Often it is appropriate to give some components of a ‘specimen answer’. In that vein the latest exam report contains a specimen marking grid (aka answer- rejoice) for a SAQ asked in the exam. This example is provided to inform candidates about how SAQs are marked using the ‘holistic’ method. Remember you are aiming for a 3. (I’ve also banged on about this…)

The exam report is not an entertaining read as such, nor is it meant to be. Nonetheless there is potential – I will expand on this in tomorrow’s post.

 

 

Full of sound and fury, signifying nothing

It is quite possible to spend the entire ten minutes writing an answer to a SAQ and score zero. To avoid this, your SAQ (and viva) should consist of verifiable facts which are specific to the question asked.

Let us consider how we could achieve a zero score in the hypothetical question: “Write short notes on novifentanil”

We could start with a definition:

• Drug: a medicine or other substance which has a physiological effect when ingested or otherwise introduced into the body.

Now we can segue into some value judgements:

• Novifentanil is a useful drug.
• I recommend it
• It is cheap and readily available. (An answer often given in vivas: So are THC, crack and ice)
• Novifentanil is potent

We will now conclude with some statements which are worthless because they could be applied to (almost) any drug.

• The intravenous preparation is a sterile clear colourless solution
• When given intravenously it has 100% bioavailability
• When given orally it is absorbed in the gut and undergoes first pass metabolism
• It is metabolised in the liver
• Metabolites are excreted in the kidneys
• It acts on receptors
• Side effects include nausea, vomiting rash and rarely anaphylaxis
• Contraindications include allergic reaction

We could alternatively score high marks by covering the same issues:

• potent: Compare the potency with other drugs in this class. Does the potency have any other implications, such as altering time to peak effect?
• useful: What is it particularly useful for compared with other drugs in the same class?
• clear colourless solution: Why is it clear?
  • Is it intrinsically water soluble, is it an ionisable acid or base, is it dissolved in an additive such as propylene glycol?
  • What problems might the additives cause?
  • Is it safe to give it neuraxially?
  • Will it exhibit ion-trapping?
• first pass metabolism: Does this imply anything about whether or not the drug is effective orally?
• metabolism: It is very easy to get lost in the metabolic pathways. Some of the important things to figure out are:
  • are there any active metabolites
  • is there any genetic / drug interaction consequences of the pathways which are used? What will this imply in patients with liver disease? If it is metabolised by an enzyme such as CYP3A4 where you probably won’t see many interactions this is also important. (There are some exceptions to this such as St John’s Wort.)

• excreted renally: Does it have active metabolites? Is it excreted unchanged renally? Is it reabsorbed or secreted? If none of these, how is it affected by renal failure?
• receptors: state which ones and what effects these cause
• Side effects:
  • are they different or the same as other drugs in the same class?
  • are there any specific side effects which you need to mention?
  • are there any class specific side effects that this drug does not exhibit?
• I recommend it: are there any specific indications for which it is recommended?

SAQ Exam Tip #4

The most important thing is to answer the question.

Another statement of the obvious. Thank you cynical anaesthetist!

How many times does the exam report contain the phrases “candidates didn’t address the question”, “candidates responses contained irrelevant information”, “candidates only addressed one part of the question”?

No matter how obvious or intuitive it is to answer the question, candidates still make this very basic error far too often. It would undoubtedly be the commonest problem I encounter while marking practice (and actual) SAQs.

Some examples again from recent papers:

Discuss the potential adverse effects of suxamethonium– Don’t tell me what sux is or classify it. Don’t tell me what it is used for or how it works. Tell me about adverse effects.

Outline the hazards associated with the use of CO2 absorbents within a circle breathing system and how the risks can be minimized- Don’t tell us how absorbents work. Don’t tell me why they are in a circle circuit, tell me what the hazards are. If the question has two parts to it like this one, then if you just answer one part you can’t hope to pass the question. Half of the marks are for detailing how the risks can be minimized. More commonly if a question has several components it will be explicitly detailed how many marks relate to each part.

Outline how hyperventilation may reduce intracranial pressure– this is not an invitation to write down everything you know about intracranial pressure or cerebral blood flow or bang on about the Monro-Kellie doctrine at the expense of everything else. Nor do you want to tell the examiner what propofol does to intracranial pressure.

Compare and contrast the pharmacology of ephedrine and norepinephrine– a profoundly depressing thing is to realise you’ve compared adrenaline and noradrenaline which wasn’t asked for…. Yet this error was still made.

Resist the temptation to define every component of the question. Sure, if you’re asked about CSHT then you need to define it but if you’re asked a question about adverse effects of opioids then you don’t need to tell me what opioids are or what they are used for. Cut to the chase.

Vallecula posted recently about making the most of the perusal time https://primarydailylo.wordpress.com/2018/08/03/reading-time-make-it-count/ and I strongly endorse those comments. Read the questions when you are fresh and underline the key components. Jot down the main points. Answer the question that is asked. Answer every question.

Good luck (not that luck has anything to do with it).

 

SAQ Exam Tip #3

You are aiming for a 3.

I am not trying to be obtuse. I am referring to scoring 3 out of 5 for each SAQ. As you know we are marking SAQs out of 5 using a ‘holistic’ grid. A mark of 2 equates to 40% and 3 equates to 60%. The grids are non-linear; i.e. get 0 if you write nothing, get 1 if write a little that is mostly nonsense, get 2 if you write a few relevant points and no major errors or write lots of points including several with errors. A ‘3’ is a pass and contains most (not all) of the relevant (main) points for a SAQ without major errors. A ‘4’ represents a very good answer incorporating significant detail and we can all dream about getting 5s.

The diagram above (histogram) comes from the most recent exam report and makes a very important point. I suspect you would get a very similar diagram if you used data from previous exams. Although the majority of candidates achieve the invitation mark for the vivas (40% or average of 2/5 for each question), the majority of candidates don’t actually pass (>50%) this component of the paper. To pass the exam overall you need more than 50%, so if you go into the vivas with just over 40% you need to score almost 60% to pass. Of course the candidate who achieved a just adequate SAQ result is unlikely to over achieve in the vivas.  Consequently, most of those who failed the exam are in the 40-45% band above. If you go into the viva with 60% then you have an impressive buffer and I suspect none of those candidates failed the exam (I don’t know for sure but you get the gist).

You should get a 3 if you do all of the following:

• Answer the question that was asked (see Tip #4 tomorrow)
• Address the main points of the answer
• Don’t commit major errors
• Attempt every question on the paper- a blank paper is a crime
• Have attempted the question before– practiced it as per Tip #1.

You should be able to fit all the pertinent points on one page of paper, micrographia notwithstanding. It can be helpful to ask yourself- what is the clinical relevance of this question? Why is the examiner asking this question of anaesthetic trainees?

SAQ Exam Tip #2

If you draw a diagram make it a good one.*

Another rather obvious tip from the cynical anaesthetist you might say. However, every year the same sorts of errors are made by candidates with regards to the use of diagrams.

Some SAQs will specifically ask for a diagram. In this case your diagram must be correct- draw a nice big diagram that takes up at least half the page and label it clearly. Unlike the vivas this is your chance to have axes and units all detailed correctly with the curves or waveforms looking precise. Remember you just have a black pen so practise differentiating multiple curves if that is relevant eg. washin curve for three different agents. If you are not sure about something then best leave it out. There are two good UK exam primer books that deal with every possible diagram you could be asked to do: Graphic Anaesthesia and Physics, Pharmacology and Physiology for Anaesthetists. Of course the diagram must ultimately come from one of the set texts. Many candidates compile a set of diagrams that are examined frequently. Equipment SAQs lend themselves to diagrams.

Most SAQs won’t specifically ask for a diagram but a diagram may enhance your answer. If the diagram is not directly relevant to the question and/or incorrect then it will detract from your response, not enhance it. If your diagram is illustrating just one point or could be replaced with a phrase or line of text then it is probably best to leave it out. Then you don’t detract from your response with a potentially incorrect or poorly drawn diagram that took you two minutes to draw.

A few examples of good and bad use of diagrams from recent papers:

Describe the respiratory response to hypoxaemia in both the awake and anaesthetized patient– a discussion of the hypoxic ventilatory response is clearly relevant here and producing the diagram of PaO2 vs Minute Volume ventilation is a good idea. The diagram is simple, easy to draw and can be used to address the question well- drawing the normal curve and showing how it changes in the presence of anaesthetic agents.

Describe the clinical effects of NSAIDs including mechanisms through which they exert these effects– seems candidates are incapable of answering a SAQ on NSAIDs without producing the generic flow diagram showing the synthetic pathway beginning with membrane phospholipids. Many candidates attempt to produce this diagram which is not relevant to the question and takes up half a page and precious time.

Discuss the potential adverse effects of suxamethonium– please don’t draw the structure of sux. Again, it is not relevant and quite hard to do. Similarly diagrams relating to its mechanism of action are similarly unnecessary and tedious to produce. This SAQ is best addressed by churning out a list of adverse effects with a few lines between each one and then going back filling in detail until your ten minutes are up.

Describe how the large daily volume of glomerular filtrate is altered by the kidney to form a relatively low volume of concentrated urine– while the counter current mechanism is certainly relevant to this question, producing a diagram that explains the mechanism is quite difficult to do. Many candidates attempted drawing nephrons and counter current loops which invariably didn’t enhance their answer. Better to briefly describe the mechanism- you get marks just for writing down the term!

Compare and contrast the action potential from the sinoatrial node and a ventricular myocyte- although it doesn’t explicitly ask for a diagram clearly producing accurate diagrams of the two potentials would go a long way to passing this question. This is a question where if you don’t know the correct diagram you are in a world of pain. Core topics expect and demand a good degree of detail.

Explain the reasons why a pulse oximeter may give incorrect readings– resist the temptation to talk about how a pulse oximeter works. Resist the temptation to trot out the Beer-Lambert law. Resist the temptation to draw the diagram of wavelength vs extinction coefficient or the oxygen dissociation curve or SpO2 vs R value. Although the different absorption spectra of different forms of haemoglobin are very relevant to causing ‘incorrect ‘readings, that is a tough diagram to get right. Better to list the reasons and briefly explain each point than devote yourself to reproducing an unreasonably difficult diagram.

*No diagrams were used (or harmed) in this post.

 

 

SAQ Exam Tip #1

The written exam is fast approaching. I didn’t need to tell you that! In this series of SAQ exam tips I want to focus on a few things in order for you the candidate to get the best possible results.  Most of these ‘tips’ have been mentioned in previous posts by my colleagues and they have certainly all been broached in the exam webinar. Regardless, I think it will be beneficial in the final lead up to the paper to have these tips in the forefront of your hippocampus.

The first tip is you must do lots of practice SAQs. Yes, this is stating the obvious but bear with me. Perusal of previous exam reports will demonstrate that many SAQs are repeated. SAQs that are done particularly poorly have a tendency of being asked again. There is very likely to be half a dozen physiology questions, half a dozen pharmacology questions, an anatomy question and an equipment question. There is only one stats question that has been asked of late and it has been asked several times so you should have a fantastic prepared answer for that one. If you haven’t attempted the SAQs for the last four exams (60 SAQs in all) then you are handicapping yourself.

When you are doing prac SAQs it is best to try and replicate exam conditions: ten minutes per question, don’t look at them prior, use a black pen only, take your watch off and have a clock on the wall to look at. I have a dozen sets of 6 question papers which I use with my trainees. Each paper takes one hour to do and because I have set them the trainee doesn’t know what the questions are. Almost as useful as doing the practice papers is getting them marked immediately after attempting the questions.  The feedback is invaluable.

• What score did you get? (Tip #3 addresses this in more detail)
• Did you actually answer the question? (Tip #4 addresses this in more detail)
• Is it legible? Is it understandable?

If you have done a poor response then you need to go back to the books and compose a specimen answer for yourself.  Doing lots of SAQs will help find holes in your knowledge and hopefully inspire you to rectify them while the SAQ is still fresh in your head. In this week leading up to the exam most of you will have already done a considerable pile of prac SAQs. If you haven’t already done so I recommend getting a study partner/ friendly consultant/ your significant other to set a full practice exam (15 Qs) for you. Then get someone to mark it.

A full exam is 165 minutes long and quite exhausting. Doing a full practice exam helps test (apart from your knowledge) your time management skills, ability to prioritize and may find another little hole that you didn’t realise you had.

 

Reading your feedback in 2018 – part 2

More personal opinions and interpretations, this time on the SAQ feedback.

All the SAQs are now marked or scaled to out of 5 so in this section you are given your score for each question and your total score. In this section you need 40% to be invited to the vivas, that is a total of 30, or an average mark of 2 (borderline). I would also define a 2 as ‘the candidate has not demonstrated that they are performing at the level required in a specialty exam but rudimentary knowledge has been displayed and the examiner feels, based on that performance, that the candidate is worth inviting to the vivas to demonstrate their knowledge and understanding further’.

My hypothetical candidate will be invited to the vivas based on their SAQ score but they have a lot of ground to make up in the viva examination. This will be difficult but it is doable. Study is often more dynamic, interactive and effective leading up to the vivas.

I suggest you classify each SAQ based on

• topic
• whether it asks for factual material only, or integration
• whether it is clinically based

For example, question 7 in this exam asked to justify the dose of propofol used in different scenarios and requires integration of knowledge in a clinical setting, while question 8 in this exam just requires you to set down what you know about IV metoprolol.

Is there a pattern in your performance?

Question 15 scored 0 which suggests poor time management.

 

Stress

 

Stress: A state of mental or emotional strain or tension resulting from adverse or demanding circumstances.

Is it a bad thing?

I recently attended a management course that concentrated on resilience in the workplace. Learning how to identify stress in your life and identify it in others is at the crux of this course. The above slide was put up and my mind immediately travelled to performance in the primary examinations. Examinations are stressful, but is this a bad thing?

The above graph looks different for everyone but displays some important points. The yellow section is where people perform best. It is called the “optimum stress” area and is where you want to be when you sit the vivas. You are tense yet motivated, your senses are heightened and you are prepared for the challenge ahead.

At the Olympics, what separates good athletes from extraordinary athletes is often their ability to perform in high stress situations. Most of the athletes are very similar in their fitness and physique, and it comes down to performance on the day. Two people with very similar skills and training can perform drastically different when faced with high-pressure situations.

Everyone has warning signs about when they are moving into the overload category, and when fatigue is becoming exhaustion. In this overload area, we tend to do less of our normal, healthy coping mechanisms (e.g. exercise) and our performance starts to decline. This overload of stress has been linked to impaired performance in military and in civilian populations.

Resilience: The capacity to recover quickly from difficulties; toughness.

The good news is that you can get better at identifying and managing the stress you inevitably feel when facing difficult and uncertain situations. Identification and management of stress, and building of resilience, is possible. The trick is to manage your stress and keep it within optimal levels in order to perform on the day. If you don’t have the tools in place to keep your stress in check, you’ll under perform on the day of the exam.

The key thing to understanding this is that you are indeed facing uncertainty—the outcome of your future has not been decided. It’s up to you to develop the beliefs and mental toughness that will get you through the next few weeks, and perform well on the day of the viva.