Bell Ringer In Chief (For The Day)

I was given a day off on Friday from my rotation to help out at PACES, the clinical component of the MRCP postgraduate exams. I was lured by my supervisor with the promise of free lunch, a bell to ring, and the opportunity to examine the patients myself during the breaks between exam circuits.

The basic setup involves a series of patients or actors, usually nominally separated by not remotely soundproof curtains. It is not uncommon in these sorts of exams to be diligently listening for a heart murmur while all you can really hear is the person at the resuscitation station next door yelling, “Clear!” At semi-regular intervals, a group of candidates troops in, very well groomed and clutching their stethoscopes and tendon hammers, and spends the next couple of hours moving from station to station while examiners scrutinise their every move.

A clinical exam is by far the most nerve-wracking thing I do in any given year. I get terrible stage fright. I don’t get stage fright on stage, mind you, but I do in these.

I had a good time during the exam circuits themselves, dinging my bell and fetching supplies for the examiners and eating perhaps too much Quality Street. It doesn’t take much to make me happy. Clearly. In fact, I am slightly alarmed that they are planning to give a medical degree to a person who had that much fun dinging a bell for six hours.

The patients used for PACES are all volunteers, some recruited from wards around the hospital and others who are known to the medical staff as people with good clinical signs. The latter group might include, for example, patients with chronic disease or patients who have had operations that leave behind characteristic signs or patients who have congenital abnormalities. My grandfather had a number of chronic conditions and a number of interesting surgical scars, and he did this sort of thing on several occasions for medical school finals. I am told that the same two or three people with dextrocardia, an essentially benign congenital condition in which the heart points towards the right rather than the left, are volunteer patients in some exams every single year. They all seemed to have infinite reserves of patience and good temper, being poked and prodded by the candidates and then being examined by a steady stream of SHOs who will soon be taking a similar exam and, eventually, at the end of the queue, twelve or fourteen rounds later of ‘breathe all the way out’, cheerfully allowing me to do the same thing.

It was useful, and a rare and precious experience to see so much textbook quality medicine in such a short space of time. I’m grateful to the patients for their good humour, and to the examiners who were lovely and helpful and took time out of an incredibly busy day to do odd little bits of teaching.

And at this point in the year, perhaps the most useful part of the whole experience was to serve as a timely reminder about the importance of taking a deep breath, reading all the instructions, listening to the examiner, not making things up, and shaking off any mistakes before moving on to the next station. The simple things, but the things that are easy to forget in the throes of panic and that I know from my own experience can make or break an exam performance. In many ways, it was nice to see that the nerves never really go away. Sure, I may have entertained the odd fantasy that a switch would be flipped when I took finals and I would become cool and calm and collected and above such pedestrian things as stress and stage fright. (In my head, ‘after finals’ has taken on Narnia-like qualities.) But that was never going to happen, ever, and I actually found it reassuring that this is the same for everyone, including people who have long since been there and done that.

My registrar summed it up: “I’m nervous, even,” she said. “I passed this exam four years ago, but I’ve got exam nerves just from being in the room.”


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