SAQ 2017.2 Question 6

Describe the effects of morbid obesity on the respiratory system.

The material to answer this is scattered through the recommended texts and most of it can be deduced if you have a reasonable general understanding of respiratory physiology. It’s also nicely summarised in Foundations on Anesthesia : Basic Sciences for Clinical Practice by Hemmings and Hopkins Chapter 71 if you can find a copy.

It’s Friday so instead of making this a TRUE/FALSE post I’ll talk about answering an SAQ using this question as the base.

One of the examiners gives the advice :

  1.  THINK OF A FACT
  2.  ASSESS ITS RELEVANCE AND RETURN TO STEP 1 IF IRRELEVANT
  3.  WRITE IT DOWN
  4.  RETURN TO STEP 1

This is great advice. Unfortunately a lot of exam answers have step 2 omitted. Step 2 is very important, and in the heat of the exam it is easy to forget it. I have had a sneak preview of the exam report and for this question the marking examiner commented that ‘Notably there were no marks achieved for describing the metabolic, endocrine or cardiovascular effects of morbid obesity’.

I would build on his advice and say an even better answer would be created by :

  1.  THINK OF A FACT
  2.  ASSESS ITS RELEVANCE AND RETURN TO STEP 1 IF IRRELEVANT
  3.  WRITE DOWN BOTH THE FACT AND WHY IT IS RELEVANT
  4.  RETURN TO STEP 1

For example with this question you could write : (note use of point form, common abbreviations and clear arrows showing direction of change – all acceptable and even encouraged by examiners)

  •  FRC ↓ or FRC ↓ so oxygen store ↓ esp with pre-oxygenation (does this decrease in FRC have other implications too?)
  • ↑ pulmonary blood volume or  ↑ pulmonary blood volume → ↓ compliance → ↑WOB   (this change in blood volume is also relevant to gas exchange, why?)
  • diaphragm displaced cephalad → why is this relevant to the preload of this muscle?

 

 

 

 

Evolution of an SAQ

A colleague wrote some evolution of a viva posts so I thought I’d give some insight on the development of an SAQ.

An SAQ is initially written by an individual and placed into a bank of questions. Once we decide to include that question in a paper a group of us will look at it and try to remove any ambiguity. An answer grid is then written (often not by the original author). An answer grid comprises the points we think address the question, with weighting to more important points and often with weighting towards answers which demonstrate understanding. Marks are allocated such that an excellent candidate could achieve full marks well within 8 minutes. Other examiners will then inspect and edit the grid – we are not expecting you to guess the thought processes of one individual. The grid is not set in stone, if a candidate writes correct and relevant points in their answer they will be given marks even if they are not in the final grid. The question is often re-edited at this stage to take out any more ambiguity or to to narrow or widen its breadth.

 

 

Study Tips: “I keep six honest serving men (they taught me all I knew); Their names are What and Why and When And How And Where and Who.” – Rudyard Kipling, The Elephant’s Child

The vivas are over for another year, which means that it is less than six months until the next written exam.

For those of you planning to sit the first exam in 2018 it is probably time to revisit your study plan to see how you are tracking.

For those aiming for the second sitting next year, it is time to put pen to paper and make a study plan and timetable.

Here is a list of  the types of resources you could include:

  • ANZCA Curriculum (Learning outcomes mapped to the primary examination) – here is great site
  • Online MCQ collections (a previous study tips post covered the Black Bank and also applies to newer collections)
  • Past SAQ papers (including examiner reports)
  • Operating theatre teaching – Rudyard Kipling can help with this one
  • Primary LO of the Day (a bit of recursive promotion)

  • Other internet resources (try googling ‘anaesthesia exam technique resources’)
  • Study notes from past trainees – bear in mind that the real benefit of study notes comes from creation not consumption
  • Exam technique resources
  • Psychology support – managing exam anxiety

If there are others you know about feel free to leave a comment below.

Tips for performing well in vivas

 

The viva invite emails were sent out this week. My commiserations to those who did not receive an invite, it’s a tough email to get. Different coping strategies work for different people but at least part of the right answer for most people would be to take a break to recharge yourself for a new approach to study.

For those who were invited, congratulations. You’ll find your knowledge, understanding and verbal fluency leaping ahead in this period – verbalising your understanding and being challenged on it is an incredibly effective learning technique. I think this is where the value lies in viva practice, not in gaining ‘viva technique’. Behind the scenes examiners become expert at ‘examining techniques’, you should become expert on the subject matter covered by the primary examination.

An ex-examiner colleague directed me to this reference the other day – Twelve tips for performing well in vivas – which I have shown to some other examiners and we all pretty much agree that much of the material is not relevant to a science viva as opposed to a clinical viva. Some may find some comforting tips in there though, and it’s worth while reading through to tip 12 which I think is very useful.

 

Evolution of a viva- Part 2

In Part 1 we formulated a viva and I ran through it with my shadow a few times. Now we need to properly ‘test run’ the viva. This entails doing it with trainees, candidates and other people preparing for the exam. I don’t test a viva that will be used in the next exam. But it is important to test a viva because you invariably learn things- eg. what you thought was a straight forward question may turn out to be ambiguous to candidates. You might find that your viva is too long (they are never too short) or too hard (God forbid). A really hard viva does no one any favours. I sometimes find that candidates consistently get a particular question wrong- I need to discern whether it is worth asking that point or not and often end up discarding that question. For example, I asked in a BIS viva what cells in the brain are responsible for producing the EEG waveforms. I wanted people to say ‘cortical pyramidal cells’ but no one did so I canned it. Getting bogged down half way through a viva because of one point is not a productive exercise.

There are other changes that result from testing. I often find I change the wording of my questions or prompts after test running a viva. The ultimate test is using it in the actual exam of course and a viva can even undergo changes during the course of an exam. Believe it or not we want to maximise the chances of the candidate demonstrating to us an understanding of a given viva topic. The challenge for the examiner is to find the best way to extract the desired information. Sometimes the exam experience is very different from that with my local candidates. I have certainly ‘decommissioned’ a viva after an unsatisfactory performance! It is always surprising and enlightening to see what aspects of a particular viva candidates find challenging. It is quite satisfying when candidates consistently do well with a particular viva. This doesn’t necessarily mean it is easy. Indeed the same viva may be done poorly in another sitting of the exam.

That is all I will say for now about writing vivas. But I will give you a little heads up. One of the disturbing  recent trends examiners have noted is that the vivas that were done poorly tended to be on core topics eg. core anaesthetic drugs, PK and PD, cardiac physiology, respiratory mechanics. This tends to reliably distress us examiners (“they should know that etc”) so there is a good chance these topics will be revisited in future exams.

Evolution of a viva- Part 1

Before you get your hopes up I will not be revealing the intimate details of a viva but I will attempt to convey some of the thought processes that are employed in the creation of a viva. I can only speak for myself here but I suspect my colleague examiners do similar things.

It begins with an idea (as do most things) which is often formed during the actual viva exams. I think to myself, “Gee the candidates don’t know much about basic propofol pharmacokinetics.” Often this thought is engendered as I watch a colleague examine on a particular topic. I like to examine on topics that satisfy a few criteria:

  • I think anaesthetists should know this stuff
  • The topic is clinically relevant (hopefully these two aren’t mutually exclusive)
  • I have seen a knowledge deficit about the topic in my trainees (if they already know it then someone else can ask them that!)
  • The ‘answers’ or responses I want need to be in the set texts (this can be quite difficult and has scuppered a few viva ideas along the way)
  • Another person with a FANZCA would at least understand most of what the viva was getting at
  • The nature of the topic lends itself to being asked in a viva format

Once I have the idea I write down what the main points I want candidates to demonstrate an understanding of are. (I also need to make sure there is a learning objective pertaining to the viva!!) Each viva topic is only five minutes long so the path to pass responses needs to be direct and hopefully short. Next I hit the books and confirm that the topic is adequately covered. Occasionally I discover that my understanding of the topic is at odds with what the books say! Not uncommonly I may have to look at six different books and it is frustrating for all of us if they say six slightly different things. Next I need to formulate the questions to get the information I want. Each viva should ideally start with a simple and brief question to allow the candidate to answer the opening question correctly and begin in a good frame of mind. So, for a propofol PK viva I might ask “What is the induction dose of propofol for a healthy unpremedicated 20 year old?” Subsequent questions need to flow on naturally from the opening question. I like a diagram or two in a viva but it needs to be simple and easily drawn. Sometimes it may be better to provide a diagram. It may be deliberately incomplete. Lastly I run through the viva myself a few times to check the timing and make sure the flow of the viva is alright. Then the real hard work starts. Part 2 will elaborate.

Study tip: Answering SAQs – make the most of your unconscious brain, but don’t let it fool you….

Ok, that title is a little cryptic, but bear with me….

We have probably all had experiences when we are asked to recall something which we are sure that we know (for me this is often a person’s name), but seems impossible to drag up from the depths of our brain. We give up and then the answer just pops into our consciousness. Perhaps this is your unconscious brain at work.

How can you use unconscious brain to your advantage during the SAQs? As soon as you read the questions your brain will start working on them. Make sure that you read all of the questions carefully in the first 10 minutes. Spend a bit of time carefully checking to see exactly what the question is asking, as you want to set your brain off on the right track. I will assume that you have studied well and have a good knowledge base. In spite of this, some questions may initially seem tricky: perhaps the information doesn’t spring to mind; you may not be sure how to structure the answer. That’s ok – don’t panic! Panic is shocking for your memory. Send these questions to the unconscious mind and get on with answering the questions you feel more confident with. When the time comes to answer the questions that you have set aside, hopefully your mind will have worked on them in the background and that knowledge will be easier to access.

Now for your second part – don’t let the unconscious brain fool you. This part applies to your SAQ practice. I suspect, and hope, that all of you are practising past SAQs. How do you do this? Here are some options:

  1. Do you select 6 questions at the start of your study session to write at the end?
  2. Do you choose some questions the day before to attack the following day?
  3. Have you put a whole lot of individual past SAQs in a box, from which you randomly pick a selection to look at and answer straight away?
  4. Do you have a friend/colleague put a set of questions in a sealed envelope to open and answer under exam conditions?

If you picked 3 or 4 – perfect! You are receiving a true reflection of how you could answer that question in the exam. The results may be confronting, but it will show your where a brush up is needed.

If you picked 1 or 2, I would contend that you are giving yourself an advantage that you will not have in the exam. You are giving your brain extra time to work on these questions even if you consciously try not to think about them.

There are still a couple of weeks until the next written exam. It’s not too late to give yourself some good quality SAQ practise. Any holes that you find in your knowledge should be easier to learn as this information is likely to have meaning for you.

Good luck everyone!! I am not sure that I will be back on the blog until after the written, but I wish you all of the best…..

….and just to finish, I couldn’t leave you photo free.

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“Brain” jellyfish, Mljet, Croatia

Study Tip: Describe, Explain, Compare, Discuss, Outline

I am sure you have seen these words at the start of short answer questions. Have you taken much notice of them? Do these words actually mean anything to you?

They are called action or reporting verbs and it is worth having a working knowledge of them.

Good answers to short answer questions usually have a structure. For example, an answer to a question about a drug might use headings like pharmaceutics, pharmacokinetic and pharmacodynamics. The detail under each of these headings will depend on the action verb.

The Anaesthesia Training Program Curriculum (v1.6) provides some definitions (p16) but there are other sources for example here and here that are more informative.

Having your own easy to remember definitions will help you in the exam. Here are a few to get you started:

Describe – What

Explain – How and Why

Discuss – Multiple Whats and Whys

Outline – An organised description, usually with big picture points

Taking more notice of the action verbs in questions can help improve the structure of you answers and earn you more marks.

Study tip: Remember information more effectively 

Why is it that some things stick in our minds forever and others we have to work so hard to retain?

The Ebbinghaus forgetting curve shows that new information is lost exponentially without revision. It looks terrifying….

The Ebbinghaus experiments were done on himself, trying to remember short sequences of unrelated letters – most of us would find that hard. It has no context and is not meaningful for most people ( except if you like remembering strings of random letters!)

We have seen previously on this blog, that one way to help with retention of information is to revise the information regularly. This is important and to be most effective must use  active recall

There are other ways that you can give yourself the best chance of remembering the information you are learning in the longer term.

  1. Add the new information to a frame of knowledge that you already have – try to build your new knowledge on to well established memories. This is not always easy to do if learning totally new concepts. This technique could be used to layer information into your brain. It is a technique used by at least one previous part one candidate (see the 5th comment)
  2. Make the information you are learning meaningful. This one should be easier to achieve. We remember things that we think are important much more easily than things we don’t (which may explain why Ebbinghaus’s curve looks so pessimistic). Find relevance in what you plan to study. Build up a list of questions during your day at work – why did the blood pressure drop on induction? what might have caused that dodgy sats reading? – and study to find the answers when you get home.  This technique has also been used with success (see comment 6 in the above link). You will be using the knowledge gained through studying for the Primary Exam throughout your whole career – it’s your job.
  3. Look after yourself. Good nutrition, regular exercise, plenty of sleep and some time to relax, will all help your brain to function at it’s best. Do not under estimate the importance of this

As promised  the flying frigate bird – it’s a bit hard to photograph a moving target, but I did my best!

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AR_ME 3.2 Discuss everything which could be construed as being related to anaesthesia

AR_ME 3.2 Demonstrate knowledge and understanding of the procedure including indications, contraindications, anatomy, technique side-effects and complications

This follows on from AR_ME 3.1 which is not examinable in the primary:

Demonstrate proficiency with:
 Vascular access
 Airway management
 Central Neuraxial block
 Other regional procedures
 Invasive monitoring procedures

T/F The Primary examiners have developed a sudden passion for anatomy.

T/F You are now required to know all about regional blockade when you sit for the Primary

dontpanic_1024

Whilst this is only my humble opinion rather than an official ANZCA publication:

Asking regional blocks would be a major change in the scope of the primary. A change of this magnitude would not be slipped into the exam without a clear announcement from the College. So I will go out on a limb, and say: You will not be asked about subjects which are not in the non AR_ME LOs.

The examiners do not write the LOs, but I believe that the two AR_ME LOs which relate to the primary have been inserted to make it clear that when you study for the primary you should consider clinical applications, and when you are practising anaesthesia you should understand its grounding in science. I think you would be quite safe to ignore AR_ME 3.2 & AR_ME 1.3 (Apply knowledge of the clinical and biomedical sciences relevant to anaesthesia), as long as you realise that you will be asked about the clinical implications of the subjects you have studied.

As I am accustomed to say, if you don’t know the dose of propofol in an anaesthetic pharmacology exam you are in the wrong specialty 😉