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Introduction to the Written Exam

Congratulations on embarking upon one of the most difficult but rewarding of career paths, that of internal medicine. Perhaps you see yourself as a budding neurologist or daydream about leading an adoring team on a fascinating general medical ward round. Maybe you will reach nirvana catheterising a left anterior descending artery. Maybe you enjoy working out a target weight for haemodialysis. Perhaps you’ve ruled out surgery (not crazy about detailing the boss’s Audi), anaesthetics (big syringe, small syringe), radiology (too dark) and general practice (too general) and it comes down to internal medicine for adults or children. Internal medicine is not the career choice for everyone. The job of a long‐suffering medical or paediatric registrar with the relentless on‐call roster, permanent eye bags and a cynical outlook becomes even less attractive with exam stress. Please remember that you will be a consultant a lot longer than you will be a registrar. Your training will not last forever, so think of the career you want to have at the end of your training as well as the thorny and intense journey travelled to get there.

Historically, it has been rather straightforward getting a basic training post in medicine and paediatrics (a desperate phone call from the head of department the night before the job started worked for me). Times are changing. Before being eligible to even think about sitting the Written Exam, the trainee will need to have completed the requisite number of mini‐CEXs and done some concerted navel gazing with the PREP programme. Paediatric trainees will have had a taste of exams with the Diploma. You may even have had (Shock! Horror!) an interview; if one is coming up then check out Chapter 35 for medical interview tips.

Upcoming changes

The FRACP Written and Clinical Examinations are held but once a year. It has been thus, despite conniptions, since the dawn of time. This book is written on the premise of an exam in February (for adult medicine); in fact, entire departments are aligned to this date like Stonehenge is to the solstice. There are plans afoot for a twice‐yearly Written Exam. This is partially why old exam papers have been removed from the College circulation. We are not sure when this change will come, but there will be a transitional period between the old and new systems. Please keep your ear to the ground as this change may directly affect you.

Why Does The RACP Have a Written Exam?

The FRACP Written Exam is infamous for an enormous syllabus and intense focus on the minutest of details. The thought of this exam sends many prospective physicians packing to alternative careers. Another off‐putting factor is that the examination, unlike many other specialties, is only held annually. High stakes. High stress. The preparation takes most candidates 8–12 months. Add study into the life of a busy medical or paediatric registrar and it is a miracle anyone sits at all.

While looking at old questions makes all newbie candidates clutch their heads in their hands, there is a method to the madness. The year of preparatory study lays the groundwork for advanced training, sharpens the mind, creates a robust knowledge base, increases confidence and improves performance at work.

The proportion of candidates passing the exam varies from year to year, and from region to region, but is generally above 50%. In the Auckland region, for example, the pass rate has risen from 50–70% a decade ago to over 80%. This means the majority of registrars, who commit to sacrificing almost a year of their life, put in the hard yards, work in a supportive hospital and revise properly, can hope to pass the Written Exam in their first attempt or, failing that, their second. Auckland paediatric trainees are even better off with a highly organised training programme, reflected in a 92% pass rate.

When is the Best Time to Sit?

Tricky. There is no perfect time in anyone’s life. Candidates have sat (and passed) whilst heavily pregnant, newly postpartum, in the middle of house renovations, moving interstate and training for triathlons. Even so, it is crucial to weigh up the rest of your life goals before signing up.

A cautionary tale to those who have a burning desire to surge ahead and get that Written Exam over and done with as soon as possible. We have observed that candidates who allow for 1–2 years in addition to the minimum allowed by the College have an edge. These registrars handle work stress better, have more clinical experience to help with tricky and obscure Written Exam questions and perform to a higher standard for the Clinical Exam. Your registrar years will whizz by very quickly. Take another year now – no shame in it, might even do you some good. Also, once the exams are over, you want to be able to move straight into advanced training without having to spend another rotation doing more of the same work.

How Long Does It Take to Prepare for the Written Exam?

The exam is always in February for paeds and adult medicine. One year (i.e. starting in March the year before) is about enough time to get through the material. Some people start earlier, but find it difficult to keep up momentum. There are anecdotes of candidates who ‘did no work until the November Sydney course’ and passed, with tales of ‘studying smart, not hard’ – we don’t believe them! The Law of Mass Effect states the harsh truth – the more time you put in, the more you learn. In Chapter 3 we will give some pointers to efficient and effective revision. This is a high‐stakes, high‐calibre examination. Give yourself plenty of time to prepare.

Am I Ready to Sit This Exam?

If you’re not sure that you want to sit just yet, consider sitting in with an existing study group and see how you fit. Canvas opinion from local registrars who have passed (and failed) recently. Finally, if you’re still in a quandary, it can be useful to ask your ward consultant or educational supervisor if he or she thinks you’re ready. Once you have decided to sit then the best approach is to hurtle wholeheartedly into revision. The best strategy is to commit to sitting, work hard and pass the first time. Candidates with multiple half‐hearted unsuccessful attempts are even more distraught than those poor souls who slog their guts out, have a bad exam day and fail. If you haven’t made your mind up by July whether to sit the following year, leave it for another year as there may not be enough time. There is no shame in this decision and it will probably pay off, as that extra year will mean more experience (as long as the procrastination ends eventually!). Remember – better to sit once and sit well.

Decision Made. Sitting the Written

Congratulations! You are not put off! It is important to know what you’re up for. Before we embark on the intricacies of how to pass, may we introduce you to the exam itself.

How Does the RACP Write the Exam and Come Up With All Those Questions?

Without giving away trade secrets, we will attempt to describe how the exam is set. Knowing how the exam is written helps you tackle it. There are four RACP exam committees.

• Adult Medicine Written Exam Committee
• Adult Medicine Clinical Exam Committee
• Paediatric and Child Health Written Exam Committee
• Paediatric and Child Health Clinical Exam Committee

The two Written Exam Committees do things slightly differently but the overall premise is the same. Both committees have representatives from every medical subspecialty known to the College/humanity. Each member of the committee formulates a number of questions that they think should be included in the exam. Other College fellows are able to submit questions also. The committees meet and all submitted questions are reviewed and agreed upon, revised or rejected. By September of the prior year, the exam is set in stone. So anything in a journal after the end of September is unlikely to be examined.

The brief of question writers is to come up with an MCQ that is set at the level of a trainee at the end of basic training. Not a subspecialist. Not even advanced trainee level. For example, you are not expected to know every single monoclonal antibody in existence, but it is fair game to be asked about the complications of TNF inhibitors.

For those who have sat the exam before, or who have already started studying, you may be quietly laughing (or perhaps crying) to yourselves at the thought of that last question you spent four hours trying to solve being allegedly set at basic trainee level.

Structure and Schedule

Here is the format of the exam. It is the same for paediatrics. It is worth noting that, especially in Paper 1, questions can be very similar if not identical across the adult medicine and paediatrics papers.

Morning

Paper 1 – Medical Sciences: 70 questions; time allowed: 2 hours

Lunch break (where no‐one really eats that much)

Afternoon

Paper 2 – Clinical Applications: 100 questions; time allowed: 3 hours

Most questions are in A‐type multiple‐choice format, meaning the candidate chooses the single best answer of the five options given, and shades the...