SOME FACTORS RESPONSIBLE FOR FAILURE IN FELLOWSHIP EXAMINATIONS IN SURGERY – A VIEW POINT

*Ajao OG, Ugwu BT
Department of Surgery, University College Hospital, Ibadan, Nigeria.
&
Department of Surgery, Jos University Teaching Hospital, Jos, Nigeria.
E-mail: ogajao@gmail.com

*Correspondence
Grant support: None
Subvention: Aucun
Conflict of Interest: None

Abstract

The major reasons for repeated failures at the Fellowship Examinations in Surgery are due to poor preparation and underrating the scope and depth of the expectations of the examiners. Attention to details and comprehensive answers to every question in the theory, clinical parts of the examination, viva voce and thesis are the linchpins to success. The answers should show mastery and up-to-date information of the subjects under discussion. Adequate preparation for fellowship examination should include reading the appropriate textbooks and surgical journals thoroughly, participating actively in clinical case presentations before peers and trainers, as well as searching the internet for current concepts in the areas of interest.

Key words: Surgery fellowship examination, Medical first degree, Surgical textbooks, Literature search.

INTRODUCTION

One reason for repeated failure in Fellowship Examination (FE) in surgery is because some candidates prepare for the examination as if it is a Medical First Degree (MFD) or MB, BS degree examination. There are certain fundamental differences in the approach of the two types of examination. But many postgraduate residents sitting for the FE are not aware of these differences in approach; strict adherence to these guidelines yields good results.

In the Medical First Degree examination, the subconscious attitude of the examiners may be, ‘Let him go’, if the error is of a minor nature. The thinking of the examiner usually is ‘after all he is going to train further in his chosen specialty’. So, the examiners tend to overlook some not-too-serious lapses. The net effect of this is that a just-below-average student may be successful in the MFD examination.

However, in the postgraduate fellowship examination the situation is the reverse. Subconsciously, the examiner is thinking, ‘How do I thoroughly assess him to identify his/her weaknesses or suitability? Is he adequate enough to be a member of my elite club? This is an exit examination. After this he will be a consultant and manage patients unsupervised. Can he make good life-and-death decisions on patients? Is he adequate for that?’ It is only when the examiners can not find an irredeemable fault in the presentations, and the answers to the above are in the affirmative, that the candidate is deemed to have satisfied the examiners in the examination. Therefore a slightly-above-borderline candidate may fail the fellowship examination whereas a slightly-below-borderline medical student may pass the medical first degree examination.

Though this approach may be regarded as subjective, it is a reasonable one at that, and the one that is familiar to many seasoned examiners of medical students and postgraduate residents.

The purpose of this paper therefore is to highlight factors that may be responsible for repeated failures in fellowship examinations in surgery. Some sections of the examination have not been fully discussed here because that is beyond the scope of this paper.

Our sources of Information for the review

In writing this review article we gathered information from various articles dealing with this subject from English literature. Our other sources of information included personal experiences, personal notes, oral information from our colleagues who were seasoned examiners. We also gathered information from the experiences of residents who had failed the examination at least once.

Preparation for the Examination

The expected answers to the questions in fellowship examinations are “the most appropriate” not necessarily the “correct” answers lifted from old textbooks1. For example, in considering the intravenous infusion to give a postoperative patient after surgery, one has to realize that the patient had been starved since the previous night and may not be able to eat for the next few days after surgery. So he needs, among other electrolytes, glucose to prevent or reduce negative nitrogen balance. If a postgraduate candidate says he will give Ringer’s lactate instead of dextrose-saline, the answer may be considered wrong because Ringer’s lactate contains no glucose, although it is ideal for resuscitation in emergency trauma in an accident patient where overnight fast is not involved. Ringer’s lactate solution should not be given to patients with gastric outlet obstruction or patients with sustained vomiting because of the tendency to metabolic alkalosis in these conditions. But if a final year medical student says the infusion should be Ringer’s lactate, the reaction of the examiner may be, ‘We- e- e- e- l- l he is relatively safe. At least he won’t kill the patient.’ And he probably will pass.

Another example is the infusion to give a deeply jaundiced patient the night before surgery to prevent post operative hepato-renal syndrome. If a postgraduate candidate fails to include mannitol after rehydration, his answer may be considered incomplete. But if a final year medical student mentions safe infusions even without mannitol, he or she may pass because the reaction of the examiners may be, ‘Well he/she has an idea that the patient should be hydrated’ So a cause of failure is because many fellowship postgraduate candidates do not give the “most appropriate” answers; they fail to realize that postgraduate examinations test the ability to integrate and analyze critically all the theoretical and clinical data concerning the index patient. Residents often give “answers that will not kill the patients” like medical students. This is the beginning of a negative outcome of the examination for the candidate. The countdown towards failure has therefore started.

Inadequate Source of Relevant Information in Preparing for Fellowship Examination Many candidates limit themselves to information in surgical textbooks while preparing for the fellowship examination. While relying only on textbooks for the medical first degree examination is adequate, this alone cannot be sufficient for fellowship examination because fellowship examination lays emphasis on the current medical findings. For example from the conception to the time it appears in print, it may take up to eight years for a good surgical textbook to be produced. This means that the information in a new textbook is, at least, a number of years old at the time it is published. Schwartz in the Bulletin of the American College of Surgeons wrote, “We are told that the doubling time for scientific knowledge is now only four years, which translates into rapid evolution of many aspects of surgery”2. Therefore, a textbook alone cannot be adequate to prepare for fellowship examination because it may not contain all the up-to-date information on the subject. It can be likened to the foundation and the walls of an uncompleted building. It is not habitable until it has been plastered, windows and doors installed and decorated with furniture. For example, in some surgical textbooks, entero-cutaneous (which may now be referred to as entero-atmospheric) fistula is still classified as “high out-put and low out-put” types. But many recent literature on the subject consider this classification obsolete and they now classify it based on new parameters3,4. Also the old popular Ochsner-Sherren method of delayed or expectant management of “appendix mass” is now considered not only obsolete but dangerous5. Current trends and evidence-based practice are the knowledge expected of any candidate at the fellowship examinations. In some old textbooks the treatment of obstructed hernia includes elevation of the foot of the bed, ice pack application and analgesics, all in an attempt to reduce the obstructed hernia. But this is now considered to be wrong; immediate surgical repair is what is advocated for good outcome as the trapped loop of bowel may be strangulated. Immediate surgical exploration is the best option whether it is deemed gangrenous or not. These textbook pieces of information may be acceptable for the medical first degree examination but they are not likely to be accepted for the fellowship examination because the candidates are expected to be current and they are regarded as potential teachers of medical students.

Therefore in addition to regular clinical presentations to peers and consultants, and reading the latest editions of surgical textbooks, to serve as a base, the candidate for fellowship examination must complement these with indexed journals, as well as search the internet for relevant information on current concepts for good outcome. This is sine qua non for success in the fellowship examinations in surgery.

Direct application of knowledge to the particular patient presented The fellowship examination emphasizes the ability of the candidate to deploy the appropriate knowledge and skills to solve the problems of the patient in question. Let us clarify this statement by this “extreme” example: a medical student was asked the differential diagnoses of a 25-year-old boy with possible appendicitis at his bedside. His differentials included: Mittelschmerz disease (ovulation pain), ectopic pregnancy, twisted ovarian cyst etc. Even though these may be considered as possible differential diagnoses of possible acute appendicitis, they cannot be the differential diagnoses for this 25-year-old boy! The candidate is simply reeling out the possible textbook differentials without aligning them to the patient in question.

Many candidates do a similar thing at the fellowship examinations although not as “extreme” as this. In one of the short cases at the fellowship examination, a 70-year-old man sat comfortably in a chair reading the news paper. This man had gynaecomastia that would be the envy of any 18-year-old girl! He also had an indwelling catheter. A candidate was asked to examine the patient and proffer the diagnosis. He got the diagnosis of gynaecomastia alright. But when asked for the cause of the diagnosis, he said, “Liver cirrhosis.” True, liver cirrhosis can cause gynaecomastia. But the patient was neither jaundiced nor had features of hepatic failure. Here is a black man in his 70’s looking well with big gynaecomastia and an indwelling catheter. What should come to the mind of the candidate first is carcinoma of the prostate on oestrogen treatment. Without this, the candidate showed that even though he probably knew all the causes of gynaecomastia, he had not “matured” enough surgically to “extract” the part of his knowledge that bears relevance to the patient presented. And therefore, despite all his knowledge of causes of gynaecomastia, he has not addressed his knowledge to help this patient. The examiner is not likely to be impressed by the fact that the candidate knows all the causes of gynaecomastia. He is expected to know that. What the examiner will want to know is that out of all the possible causes of gynaecomastia, can the candidate mention the most likely cause for this particular patient under consideration? To many examiners, to mention liver cirrhosis first will not be regarded as a correct answer. All these small but significant lapses are now building up gradually, and negatively, against the candidate.

Error in Long Case Presentation

The objectives of a long case presentation in the fellowship examinations are two primarily6: firstly, to arrive at the most likely diagnosis and secondly, to find other conditions in the patient being examined which may or may not be related to the problem the patient is complaining of1. So, when a candidate, after clinical examination says, “The main pathology is ….” He has unwittingly told the examiner that he has not fulfilled the second objective of a long case in the clinical assessment, and he is working to the answer of a pre-conceived diagnosis.

In clerking the patient, many candidates omit emphasizing “the medications the patient is currently taking” and a history of allergies in the patient to any medication or substance. So, what is the big fuss on “mundane” things like “allergies and medications”? The big fuss is that cases have been repeatedly reported of patients dying because of allergic (anaphylactic) reaction and because of lack of awareness of the treating physician of the medications the patient was taking before the administration of anaesthetics required for a surgical procedure. The patient may ooze blood uncontrollably from the surgical wound because it was not elicited that he/she was taking low dose aspirin along with blood pressure drugs. These are avoidable deaths that should not occur. So, when a candidate omits such important and simple information, some examiners will regard such a candidate as a “careless” doctor. Of course, no examiner wants to let lose to the public a “careless’ surgeon. The examiner might be his patient in future. Again this small significant issue is contributing negatively to the outcome of the examination for the candidate. Gradually, the negative perception of the candidate’s clinical competence is building up.

Presentation of a long case is to give precisely and concisely all the relevant facts of the case that will make arrival at the diagnosis obvious. This should not involve telling irrelevant stories about the patient. The presentation should not also sound like a medical report or a discharge summary of the patient.

Some candidates arrive at a diagnosis that the clinical findings do not support in any way. If there are no relevant positive findings or relevant negative findings of a disease in both history and physical examination, then the disease is not likely to be a part of the differentials. For example, a normal looking lady sitting down quietly without fidgeting but has a thyroid swelling is not likely to have thyrotoxicosis unless she is already takinig anti-thyroid medication.

To some examiners, “summarizing” a presentation seems to be a waste of limited precious time the candidate has for the examination and for assessment. Usually, some examiners ask for this when the candidate has presented a windy history in which the examiner gets lost in the presentation. No summary can make a bad clinical presentation a good one. It just reinforces the poor presentation.

After determining the likely differential diagnosis, the relevant investigations should be grouped into: investigations for diagnosis, investigations for the extent of the disease and the investigations for surgery and monitoring.

Short Cases Presentation

The short cases presentation is supposed to replicate the initial evaluation of a new case seen in the out-patient clinic. Usually at the fellowship examination, each candidate should be examined on about 3 or more short cases in the period allotted.

What may fail some candidates in this section is because of “manipulation” or “malingering” by the patient. Any postgraduate candidate who cannot detect this is not likely to be successful at the examination. As an example, a 55-year-old post-menopausal woman accidentally discovered a lump of about 5cm x 4cm x 5cm in her breast. But because many doctors, as well as medical students, have been examining her breast while on admission in the hospital, she decided she was not going to allow anymore examination of her breast. So, as soon as the candidate touched the breast, the woman “winced in agony.” The candidate later presented the mass (which turned out to be fibrocystic disease of the breast) as a “very tender mass” The mass that could be that tender is most likely to be acute breast abscess. But since this post-menopausal woman is neither lactating nor pregnant, she is not likely to have an acute breast abscess. If a candidate is unable to distinguish malingering from the real thing, he is not ready to be a consultant. But, in this case, if a candidate rightly shows that the mass is not tender, and that the woman is just making it up, he will get 10 (or P) which is a pass mark. But if the next candidate does not detect that the woman is malingering, he is not likely to get the same mark as the previous candidate. The next lower mark the second candidate can score is 9 (or P-) which is a failure.

The use of a measuring tape for a lipoma or a lump in the trunk can irk some examiners, because this is more of “acting” than examination. The reason is that the exact dimensions of such lumps neither affect the diagnosis nor the treatment for such lumps. It just indicates that the candidate is trying to waste time or trying to impress the examiner or just does not know when exact measurement is indicated in surgery.

However in orthopaedics cases where shortening of a limb, or the distance between the knees or ankles are required, or when the diagnosis of a unilateral leg swelling is required, or when the measurement of a head circumference in a suspected hydrocephalus is required, the use of a measuring tape is a must.

Incomplete answers to questions

This is one situation that generally gives candidates false idea about their performance. Let us illustrate this with this scenario. Candidate A is asked to give the differences between an umbilical hernia and a para-umbilical hernia. He gives five points for umbilical hernia: it is congenital, has a ring-like opening, does not usually cause strangulation, may not require repair, more common in the black race. For this he gets 10 (or P) which is a pass mark.

Candidate B, for the same question gives only 3 features of an umbilical hernia. Should he get the same mark as candidate A? The next lower mark for candidate B will be 9 (or P-) which is a failure. This illustrates how easy it is to fail the postgraduate fellowship examination. Comprehensive details and mastery of the subject under discussion are the key to a successful outcome in a fellowship examination.

Conclusion

Passing the fellowship examination in surgery is like performing surgery itself. Surgeons do not usually lose patients because of major glaring mistakes like transecting the aorta or forgetting to anastomose transected loop of bowel. It is the small but significant lapses that make the candidates fail, just like a surgeon adds to complications or loses a patient because he forgot an instrument or a piece of gauze in the abdomen of the patient. Or causing an entero-cutaneous fistula by carelessly catching a loop of bowel while closing the abdomen of the patient.

Since the close-marking system is the scoring method adopted in the fellowship examinations in surgery, all these minor lapses that may be regarded as “insignificant” in medical first degree examination make a great difference between 10 (or P) which is a pass mark and 9 (or P-) which is a failure.

Some of these ideas in our opinion may not have universal acceptance among the examiners. But if they improve on clinical performance and evaluation of candidates, then they are worth noting. And in any case, no candidate fails an examination by saying or doing the correct thing even if the examiner is not aware of the “correct” thing the candidate is talking about or doing.

References

1. Ajao OG. A guide for the examiners and examinees in surgical examinations. The J of Surgery & Surg Sciences. 2007; 1:1-5.
2. Schwartz SI. Message from the Editor. Bulletin of the American College of Surgeons. July 2001; 86(7):52.
3. McClelland RM(Editor). Small bowel fistula in Selected readings in general surgery. 1996; 23: 1-7.
4. Ajao OG. Enterocutaneous fistula – A review article. Saudi J. gastrenterol 2001; 7: 51-54.
5. Ajao OG, Adenuga, MO, Ladipo, JK. Colorectal carcinoma in patients age 30 years: a review of 11 cases. J.R.Coll Surg Edinb. 1988; 33: 277-279.
6. Ajao OG, Ugwu BT. Evaluating the evaluators in postgraduate fellowship examinations –A viewpoint. J. West African College of Surgeons2011;1:97-104.

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