Guest Episode - The Fellowship Exam with Emily Olive

Welcome to First Incision, the podcast about preparing for the General Surgery Fellowship exam. I'm your host, Amanda Nikolic. Welcome back to a special episode of First Incision. We are joined today by Emily Olive, who is a successful candidate from 2020. So she's going to talk to us about the 2020 exam, the COVID exam.

including lots of insights into what it actually feels like to sit the exam, what was different about this exam, as well as heaps of tips and her experience and things that she wished she'd known leading up to the exam. There is something for everyone, including those that are sitting next week, as well as people who are just thinking about starting to prepare or are going to be preparing in a few years. I hope you enjoyed listening to this episode as much as we enjoyed recording it.

Welcome to the program I was hoping we could start off by you telling us a little bit about yourself So I'm, oh, I think probably the most important thing is that I'm mother to two children. I've got a five-year-old boy, well, sorry, nearly five-year-old boy, Hugh, who's just started prep. And I've got a three-year-old poppy, Penelope. And they're amazing, but I don't get to see enough of them. And if it wasn't for my husband, our whole world would just daily fall apart, I think.

I'm currently doing a general fellow year up at the Sunshine Coast. And that was because this is the hospital that got me onto training. These are the people that believed in me from the beginning. felt like when I got to the end of training, I wasn't done, I wasn't ready for subspecialty training particularly because I just felt like I didn't have down pat.

the sort of middle of the night operating, you know, like the strangulated hernia, the sick laparotomy, the sick heartman, those sorts of things. And I didn't want to be doing subspecialty training and stressing about the on-call component of that. because that comes with basically any job. And so I wanted to go back to a department who knew me and loved me, basically.

and would support me. And it's been great so far. I just get to sort of do what I want in a way in that I've got some independent operating lists. I do lists with bosses. I pick and choose which lists I want to do and what parts of those lists that I want to do. I do on call as much as I want, essentially, both in hours and after hours. And also it's meant that we've been able to come home and live in our house that we bought.

seven years ago that I've lived in for three months and it's on the beach and it's amazing so that's me I trained in Queensland and I moved everywhere through training which was Actually, awesome in the end. You've got to see lots of different parts of Queensland. I think that's me in a nutshell. Thanks for the introduction.

So I'm really grateful that Caroline put us in contact because you sat the exam last year, the first COVID exam. Congratulations. Thank you. So given you are so close to the exam, I'm hoping that you'll be able to.

tell us about what to expect and talk us through the different parts of the exam. But before we get into that, I was hoping you could tell us a little bit about what you wish you had known in the lead up to the exam or during your preparation for the exam before you started studying or before you got there. I mean, my biggest point was that I still remember basically, I think it was like March 2019 going,

My mental health is probably my biggest vulnerability, like anxiety, sleep, things like that. And I'm going to, from the outset, make that my priority. And so I ran and I meditated and I did yoga. And I did that like religiously because I just knew otherwise I was going to be like I've been for every other exam, which is a total basket case. I think for the written.

I don't believe that I placed enough emphasis on timing for the written. Everyone sort of talks about you've got to practice your answers to time. And yes, we did that, but I wasn't religious about it. And that was nearly my undoing, to be honest, during the exam, especially because they've removed the ability to write the exam. I think unless you have special consideration, everyone types. And I think most of us can type.

some of us not excellently, but on the actual day, there is no content I felt that I couldn't answer. All the questions are really reasonable. If I had all the time in the world, I could have given stellar answers. But you are so pushed for time that you don't get a second to think and consider your answers.

like you normally would. And I'm normally the kind of person that finishes an hour and a half to two hours early in an exam. And I check all my answers and I work out which one I got right and which one maybe not. So this one was down to like the last second and stop. So I think if I had to do it again, it would have not been because I hadn't have focused on the right content or depth. It would have been that I hadn't taken that timing component seriously for the written.

I don't think there was many surprises for the Vibers, to be honest. I think I just didn't, again, probably listen to the advice that I got given and believe it. Everyone says, oh, it's a discussion between colleagues and, oh, they're just trying to get you through.

They absolutely are. I stopped during my anatomy station and said to the two men examining me, you two are being... so kind because they were, you know, I would give an answer that was maybe 70% and they'd want a bit more and they would gently probe or I'd get something wrong and they'd say,

do you think there could be something else there? They weren't in any way being punitive or trying to trip me up at all. They were trying to gently get the knowledge out of me in as quick a fashion as possible. And the other thing to say is when you do a good viva, it's actually a really fun experience because you get to like demonstrate, look at all the hard work I've been doing.

But I don't think I'd really believed that beforehand because I just heard that from so many people and I thought, oh God, if I had to hear that again, I'm going to scream. But it's true. It's absolutely true. Like they were just trying to settle your nerves or something by saying that, but it wasn't the case. Absolutely. but you're going to get in there and you're going to get sort of...

pulled apart by someone or showing up or whatever. I bulldogged last year and I remember one of the pathophys questions was about choledocholithiasis and about why you would get a coagulopathy. And I was, you know, had my ear up against the door, of course.

And the examiner was asking, you know, why would you get a coagulopathy? And the examinee gave an answer and then it wasn't quite right. And they said, oh, well, could it have something to do with, you know, the blockage and the bowel not getting in there? And they really led them to the answer. And it was like, yes, the trainee knew it. Absolutely.

But they weren't trying to trick them. They were literally trying to help get the information out of them, which I was really surprised by. Yes, absolutely. At the end of the day, what they... assuming is that we've all worked incredibly hard that we all have that knowledge in there and that on the day you're going to be confronted by your own nerves and anxieties and that that information isn't going to be as readily achievable

or retrievable, I should say. What I would say is that the viva is so much more doable than the written because the written, it's you and a computer. and there's nowhere to go you know if you drop the ball during the exam then there's no one there that gently prompts you or guides you back whereas in the viva you're actually so well cushioned by two people who know the answer

Assume you probably know the answer and are trying to get you to that point. So it's just such a more enjoyable exam than the written. Can you tell that I'm scarred? Yeah, it sounds like it. I think that's what I'm most worried about. I'm most worried about the long questions and just...

Because you can't have that depth of knowledge about everything. And it probably is a little bit of luck on the day that you get asked that question about something that you just happened to have recently covered and know those little details about. That's how I feel at least. I think the long-written definitely are structured in such a way that they allow you to draw out lots of information. So it's not that they want a dissertation on the genetic.

component of something or other. They basically want to give you the opportunity to discuss widely on a topic. So again, there was nothing on those long answer questions that I was thrown by. It's more that I had so much stuff. to write that I ran out of time well I didn't run out of time but I could have run out of time but I think that's the way to be I listened to this excellent core course actually that's one of my tips for the exam preparation

I listened to a lot of different state core courses. WA particularly has amazing core courses. And there was a core course where they got one of the trainees to talk about he'd failed the exam. And then he passed it and they wanted him to talk about why did he pass the second time? And he said when he did it the first time, he walked out of the spot like, oh, that was a breeze. You know, one word answers, not a worry.

And he got the feedback that there wasn't enough depth there. And the second time he said he just wrote furiously. And he said, that's how you should be writing. You should be writing like you're going to run out of time and not walk out of there going, yeah, that's fine.

Oh, fantastic advice. I'll have to look up that core course episode from WA. So that does bring us into the next part of this episode where I wanted to talk to you a little bit about the different aspects of the exam. what it was actually like to sit those parts of the exam, any differences with the COVID exam, and then also if you have any particular tips or advice for each component based on your experience last year.

Well, I think by the time you go to sit the exam, you know exactly however many spots and then there's shorts. And this is the amount of time you should be spending on each question. And you've practiced so many of them that you really walk into it. quite well prepared from that perspective. The COVID exam was different in that it was a tight exam. They were incredibly sort of caught up in the rigmarole of being COVID safe, which added a layer of anxiety that was

predictable but also difficult to deal with because we were already stressed enough. As we were talking about beforehand, they temperature checked everyone. So we all made sure we had Panadol and Nurofen beforehand to make sure there was no way in hell we had a sneaky temperature. So the first paper you sit is the spots and that's meant to be 25 questions and they're meant to be fairly sort of short answer questions.

And there's a variety of different prompts. It might be just a written stem. There may be a clinical photograph. There might be a CT scan, single shot. And then you might have then sort of three or four questions to answer. I think you'll probably get a practice exam sent to you when you do sit. We certainly did so that we knew what the new format was going to be like. We were the first ones to sit at types and then it became only types.

Basically, you can type as much as you want. So there's not like a limit to how much you can put into a box. And I actually think typing is a bit of a benefit in ways because... Particularly if you're a bit flustered or you're not quite sure, you can jot down a few things like headings and then you can go back and you can fill them in, which is quite difficult to do if you're writing a paper.

So I think that's one of the advantages. And even if you do get time to check your answers, you can easily fill back in bits that you might have missed, add things in or think, oh, no, that actually just sounds like rubbish. I'm going to delete that and start again. So typing it makes it easier.

The hard thing I think about typing it, particularly for the spots, is that it's difficult to gauge how far through the exam you are. When you're writing a booklet, you've got a physical thing in your hands that you can kind of... you know fold a corner down and be like that's halfway I need to be at that spot by like you know 10 20 or whatever the time is so you don't run out of time there are there's clocks everywhere but

In the moment, you've still kind of got to be keeping an internal clock of how long you've spent on questions because it is so easy. Because you can type endlessly, you don't have that physical limitation of a page.

You could spend a long time on a question you know a lot about and run out of time for others. I think my advice for the spots as for the shorts is that if there are questions that you don't know, just quickly read them and go no nothing's coming right now move on for me that was one on mesenteric paniculitis but it was a ct scan that

I mean mesenteric paniculitis is vague anyway on imaging so it was a vague CT and I thought oh I think that's what it is but I'm really not certain and I spent a little while looking at the CT and then I thought enough. I'm not sure, I'm just going to keep going. And then I had time and I came back to it. But I think if you don't immediately have things to start on, you should just set it aside and come back.

And then the short answer. So there was a new question introduced, which is common to all specialties. So one of the seven questions. So orthopedics, cardiovascular, everyone does it. And for us, it was the impaired surgeon. You call your boss in and he's drunk, I think was the scenario, and then there's prompts to sort of talk about that. We...

as a study group, ran through what the potential scenarios could be. Like COVID was obviously very topical and they'd only recently written the paper. So they'd rewritten the paper in like June, July. So we thought, okay, that's totally gettable. But, you know, the usual things like the impaired practitioner and things like that. So I sort of had an answer, but not really. But I think it's just going back to that first principles. It should be something, though, that you should...

prepare for as a group and have some answers floating around in your head because I don't think it's something that you should really fail on. I think it's just that they're trying to sort of demonstrate. across all surgical specialties, a bit of non-clinical competence. Oh, that's interesting. I wasn't aware of that. That's almost like the things that you study for the interview. That's exactly right. It's exactly the same stuff. So I think...

I just regurgitated all that stuff that I'd talked about at the interview. And maybe you've had, through training, you've actually had experiences of those things and so you draw on that as well. So that question wasn't too difficult. But I think the thing was written. is that, well, I felt like there was nothing on those papers that I couldn't answer. It was all about time. And all of my mates felt the same way. You know, at the start of the exam, they say, oh, you can...

There's water up the front if you want it and you can, you know, put your hand up if you need to go to the bathroom. Like none of us had time for any of that stuff. And you said there definitely are clocks around that you can see so you can see what time you're up to. Oh, yeah. There's a clock on your computer. It's either a count up or a countdown clock on your computer and then there's one at the front of the room. But even still...

You sort of need to be like there's no like you're now you're approaching halfway. There's none of that. You know, you really need to know. And so because as a study group, we had practiced to time so much. We were at that point of just like... You knew what it felt like. Yes, exactly. I knew what it felt like to write a spot or a short to a certain amount of time. But even still...

It is so rough. And is there paper there? Like if you want to draw a picture or a flow chart, can you do that? There is, yeah. So there is paper. Again, I don't know that I spoke to anyone who used it. There's been past questions and it's on the different topical anticoagulants. And the second part of the question is come up with an algorithm for which ones you'd use when. And so I suppose that sort of question really lends itself to a flow chart.

I don't think we had any questions that really lent themselves to that. But yes, you certainly can and you just have to sort of say that this pertains to whatever question and it all gets submitted to be marked. And the pictures that they show you, are they pretty, like it's pretty obvious.

That's what they're trying to show you. I mean, I know you mentioned the paniculitis one, but was some of them a little bit borderline? Yes. We'll go on and talk about the Viva. There was definitely some borderline ones in the Viva. In the written, so there was the mesenteric paniculitis, which...

As I said, you know, that's a bit of a vague one anyway, but I suppose it was enough of a picture that you don't know that you're looking at needs enteric paniculitis. All you're seeing is a cross-sectional CT and I think the stem was like chronic abdominal pain or something like that.

The other one that was a bit difficult was a woman who'd had a big component separation operation and was like 48 hours down the track, very unwell, here's her CT. And also because you can't zoom up on the picture. So the picture itself was quite small and you could see everyone peering into their computer to try and get closer. It wasn't the best representation, I don't think. And again, you had to sort of go on an eye of faith about what you thought was going on.

which was an enteric injury leading to sort of an intra-abdominal crisis, basically. I've also heard that sometimes the questions can help guide you to what the answer in the picture is. Yeah. So read all the questions. Absolutely. And don't make, you know, this is just like exam technique 101, but like read the question properly.

So one of the questions was an ultrasound of a spleen with, I think it was a, it wasn't a cystic lesion of the spleen. It was a solid lesion of the spleen. And you had to talk about, you know, the differentials and management and things. And he just saw the ultrasound picture and went liver. And everything he answered on was for liver. He just didn't read that it was slain. And that's a really bummy thing to walk out of the exam, say, oh, we're not going to talk about it.

We talked about it and to know that an entire question is just gone.

So the next thing I wanted to talk about was the Viva exam, which is obviously the oral component of the exam. Did you want to run us through your experience again and any tips that you might have? Look, I actually really enjoyed the Viva. I thought it was a real opportunity to demonstrate to the examiners that I had learnt stuff and I...

and I could present myself, particularly when you think about how far you've come. You know, I remember the first time one of my bosses said to me at the beginning of step four, Emily, I'd like you to describe your operative approach for laparoscopic right hemicolectomy. And I was just...

I didn't even know where to start because it's not, we aren't used to using the language of surgery to talk to each other. We don't, oh, and then I carefully protected uodenum. You know, you write the operative note, you say to someone, oh, I did a right Hemi today, but you don't say. operative steps. So it was really gratifying to just demonstrate knowledge. And this will be the same for this year as well. You're being examined by people you know, which can be a good thing and a bad thing.

On every station, I knew people, at least one examiner. In some stations, I knew both of the examiners. I'd either worked with them, even if even just in the same hospital, or I knew about them, which for me was a positive. I felt like I was amongst friends in a way. I know they're not your friends, but they've invested in you and they've seen you go through and they want you to get through.

For me, that was a real plus. For other people, it wasn't. Not because they had bad relationships with their bosses, but because all of a sudden they were thrown by a question and they're in front of someone that they desperately want to impress. and they drop it. For someone I know, it was that they had sat the exam the year prior and failed and felt that they'd failed on a particular station with a particular examiner.

First station, first day of this exam, walk in, same examiner there. So I think because they are doing state-by-state exams, it's important to prepare yourself for the very real likelihood that you will be examined by people that you know. and have strategies for that. So the viva in Australia is over three days. So the first day is the operative viva and then pathophysiology. The second day is clinical one, which is two longs, and clinical two, which are all short.

And then the third day is anatomy. You spend a lot of the exam in marshalling. So the actual exams themselves go for 40 minutes. It's over in an absolute blink of an eye. But you have to be marshaled beforehand so that you don't see people coming out of the exam. You do the exam and then you're marshaled afterwards in a room to make sure you don't, again, meet people who are just about to go into the exam.

For several hours, you are in an exam environment that of that only sort of 40 minutes, are you doing anything productive? You just go into a room and you stay in that room and you are with... two examiners, plus or minus an observer. So there are people who are observing the exam because they want to become an examiner or they're observing the exam to make sure that it's a rigorous exam. So there's often someone standing in the corner of the room.

And basically the examiners take it in turns asking the questions and the other person is listening and marking. Technically, because... you might be examined by someone you'll know, they're usually, they're meant to sort of say, I know this candidate and they're meant to actually not examine you.

really can't happen in the era of COVID with state-based exams. So you will still be examined by people you know. You'll also be examined by people who are experts in their field, even though, again, that's not meant to happen. But again, it's just... the constraint of numbers. So I had one of the forefront people in breast oncoplastic surgery quizzing me on the various tissue reconstruction bilateral mastectomy and I was like, this is so intimidating.

I don't know. So the first session, the operative is meant to make you feel good about life because it should be the thing that we're all like good at. In saying that, I think we both... of New Zealand cohort and ourselves got doozy questions. Things that neither continent, I think, had really well prepared for. Well, the people that I spoke to anyway. So New Zealand got an APR, which is...

You know, like that's not really a general surgical operation, but you can see the main focus was on the mobilisation of the sigmoid colon and the rectum, which is totally fair game. But I think, and the perineal stuff, I think by the time you got to that, they were like, yeah, yeah, yeah, fine. We've got subtotal gastrectomy for gastric cancer, which again, you know, I think it's fair game, but most general, most trainees are not doing subtotal gastrectomies independently.

I, but I had never, I've never seen one. I've never done one. I have done distal gastrectomies as part of Whipple, but you are, again, hopefully you're so well prepared that you're just like, oh yeah. I mean, I know the content. I know I've got to take off the momentum. I've got to do a D2 lymphadenectomy. I know this has got to be my margin from the tumor. And also, they cut you off. You don't ever get to do your full...

appropriately consent and position the patient. You're in theatre, you've got the scalpel in the hand, they just want you to start talking. And once they've decided, I think that you've got the idea, then they go, okay, on to the next thing. So you're not talking through the whole thing.

And then the other short operative ones from memory were really straightforward. I think I got like an ingrown toenail. And then the next is pathophysiology. And I really loved that one because lots of short scenarios. And they're all reasonably gettable. And again, you got to sort of, you know, demonstrate your knowledge. The clinical was...

I think a lot easier. And I know a lot of people will say that, oh, the new exam format, it's not like the old one where you have to examine patients and things. And they're right in a way in that. You remove the uncertainty of a patient who is going to give you a vague history, going to have unreliable abdominal signs, and it just takes away all of that.

element of uncertainty, which can derail candidates, I think. You're just basically presented with the scenario in slide format. The examiners go through it. They'll ask you, what would your abdominal examination consist of? Or what sorts of things would be pertinent on history? And you sort of talk about those things, but really the meat is still in the clinical reasoning and management side of things.

So for my longs, we had a, that was the lady with the BRCA1 disease who ended up with bilateral mastectomies and what tissue implants. And I'm there going, oh my God. And then the second one was a complex prone patient. But again, the meat of it was really in her management, not in the history and the exam. And then the short clinicals were...

really like rapid fire. I think we had a head of pancreas cancer. We had a trauma gone wrong. And they just moved through the scenarios very quickly. In fact, it felt a lot like the pathophysiology side of things, to be honest.

rather than what the old clinical would have been, which was examine this lump. Okay, what do you think this is? Or whatever it might have been. I heard from some of the examiners as well that they really liked that format because it's really difficult moving between all of the different rooms and you have such limited time.

And like you say, the patients will do funny things. So in a way, it might be slightly better. Absolutely. And I think from the logistics of organising an exam, it must just be a weight off their shoulders to have to not bring... all these people in from the hospital. It also means, and lots of people said that to us, that a lot more exam content is examinable.

You know, you're not going to basically you could rely on getting a hernia and varicose veins. And what do I have in my outpatient clinic? Essentially, no acute stuff, because obviously that wouldn't necessarily be appropriate. But now you can have a trauma. You could have a very sick, unstable patient be your long clinical, which is great from a content perspective. And it also standardises it across Australia and New Zealand. Absolutely. Although...

You say that, Amanda, but so we would come out of every Viva station and my boys and I, my study group and I would sort of like come together and go, oh, what did you get us? And it's like a choose your own adventure. So I'm here having this in-depth conversation about what tissue reconstruction I would be doing for this patient, thinking, well, I've cooked this station, clearly, because I'm having to say too many times.

oh, look, this steps beyond my area of expertise and I'd have to refer to an expert oncoplastic surgeon. Most of my mates didn't even get asked about it. Wow. So they can still just ask you what questions they want. Absolutely. There's a huge variability in the content that gets asked.

There's key questions that they have to ask. If you're going fine, they race you through them and then there's all this extension stuff. But so many times we get out of there and people would have been asked stuff that other people hadn't been asked. I never even got to the spleen rupturing. What are you talking about?

And we all pass. So there is still a huge variability in what actually gets examined. I wonder if the examiners get bored asking the same questions. They want to talk about something different. Potentially. I mean, again, I suppose it has to be standardised, so they can't go too off-piste. But yeah, I think if they have someone who's all over an aspect of content, then yes, they can stretch them a bit further just to see. And look, one of my favourites...

bosses who's one of the examiners says it's so nice when a candidate teaches you something you don't know or they absolutely kill it because you're just watching this person in full flight as smart as they're ever going to be and it's like Go you. Let's ask you some more questions. Oh, that's nice. It's good that they do experience that.

Yeah, especially because they know you. So this one particular boss afterwards said he just felt like a proud father watching the candidates coming through who were all doing so well. He was like, oh, yes, you know. And then the final. The final day is anatomy. And I think we all compartmentalize. Well, I'm generalizing here. I think anatomy does tend to get compartmentalized into a future box.

I would encourage people to not put in the future box because I put it in the future box and the night before I'm like cramming things in and I mean I would say my abdominal anatomy knowledge is excellent and my head and neck stuff is okay but my limb stuff is oh and we had a lot of vascular.

So we had popliteal artery and the trauma question centered around the popliteal artery and the popliteal fossa. And more than I had sort of, I suppose, prepared for, there was angiography. So the prompts... predominantly radiology. There was the iliac, so the external iliac, so femoral triangle sort of stuff. The one that was... I suppose different, and this is coming back to what we were talking about on the written, is the quality of the imaging that you get shown is not necessarily great.

So we had a sagittal of a rectal MRI, like you'd see in an MDP for a rectal malignancy. And it wasn't great. And we had to talk through what T-staging would you say? Could you comment on the nodes? I want you to point out what's it potentially invading? Now measure it from the anal verge. How do you find the anal verge? Great.

clinically relevant stuff potentially a bit beyond that of a general surgical exam but that's okay but the quality of the MR wasn't excellent and that was a an overwhelming feeling from that station and I've heard you can't you can't scroll through the images anymore it's just a single no there's no no it's a single shot And so you really have to make of it what you can. And I know a few people said that they, during the exam, sort of got quite...

particularly by that rectal MRI one and saying things like, oh, this isn't a very good MR and I'm not sure what I can tell from this. I think you have to put all that aside, deal with what you've got in front of you. I think the examiners understand that sometimes... The images aren't perfect, but still have to carry on and give some...

give some answers. Because in real life we do just scroll through the images so you can sort of orientate yourself around what's around there. We do. You do. That's right. And so I think how it had been previously where you could scroll through.

did allow you. Talking to some examiners though, they said a lot of trainees would get caught just scrolling, scrolling, scrolling. And at some point you have to start talking and they'd almost get a bit hung up on the scrolling or use that as a bit of a...

time-wasting gathering activity. So I think this removed that completely. You just have to start talking. What did you bring with you for the marshalling parts? Because when I bulldogged the exam, they weren't allowed to bring their bags in. You're not allowed anything. Don't have any technology. Nothing. Yeah. No. Didn't have. I brought my tongue. I just did a lot of talking. I saw some people had flashcards and were sort of looking at flashcards. No.

You're not allowed anything. We weren't even allowed our watch. And I have old-fashioned analog. And actually... And this will probably come back to what we, I don't know if we were talking about this before the podcast started, some deliberate things that I did prepare for this exam. And one of them was meditation.

First viva, I went to a nighttime yoga class and I do this like meditative yoga and I thought this will put me in the right mind frame. And there was this quote from this Buddhist monk and it was around the breath. seeing the connection between the mind and the body. And so when the mind is racing and you can't concentrate, go back to the breath. I was like, this is amazing. Right before my viva. But I practiced a lot of that.

in the marshalling because there was a lot of nerves. Not only do you sit around waiting, they then line you up and you're in that line. We got delayed because the other thing is because it's happening nationally all at the same time, there were delays between different exam centres. So I think at one point Sydney was running behind and so we had to wait until Sydney had caught up.

So we were standing in this line like ducks for I don't know how long because I didn't have a watch. And I could just feel myself getting more and more and more anxious. And I just went back to... practicing my breathing, which might sound really twee, but I know some really good people who have become completely undone in this exam. And a lot of it is just managing your own anxiety and your own nerves around it.

It's all about the performance on the day. It is so performative. You have that knowledge and you don't want to let understandable nerves derail you from demonstrating all the hard work you've put in. I made that as deliberate a practice, that an exercise as I did any of my study because there is no point how much I crammed into my head. I could know all of Sabastin's and completely fall apart on the day and it would be...

total waste of time so I made that as much of my preparation as anything how did you factor that into your sort of your week did you have a routine oh I did yep do you want to share that yeah So as I mentioned at the beginning of the podcast, I have two small children and it was very difficult to see them.

So nighttimes, I would try and get home and be there for bedtime for them. And bedtime with small children can go until 8.30, 9 o'clock at night. And I would find myself with this rise of resentment to them that I'm not getting to study. having to try and put you two to sleep and so I just decided that night times were off anything that I got done of a night time was a bonus I might do a little bit of reading but that was it I used to get up at four o'clock every morning and

Three mornings a week, I would go straight to the gym and I'd listen to a podcast at the gym. I only wish your podcast was available at that time. I listened to Behind the Knife, which is good, but it's very American and the content's built to their exam, which I think is a lot more superficial than our exam. Or I'd listen to the Australian core courses. So I'd go to the gym and then I would go to work and I would study. We have a great study room at work.

Otherwise, if I didn't go to the gym, I'd just go straight to work at four o'clock in the morning because my son particularly, they're like bloodhounds. They can sense when you're awake. And even though our study in the house we were living in at the time was downstairs and barred by two baby gates. and a very high door, he would manage to get himself in there. Sounds like you needed a plan. Yeah.

And I was exhausted and I reflect now and I don't actually know how I did it, but I was so motivated to do it once and to put my family through this process once. And I was just like, this has just got to be ultimate sacrifice. So my brain works better in the morning.

I work better in the morning. That's when I did it. And night times, as you know, as a surgical trainee, it's so unpredictable. You could be caught up in theatre or have a sick patient and suddenly your whole evening's derailed. And I also used to find... After the kids had gone to bed, I'd be exhausted. Later in the piece, when we were getting more to the crunch time, we Zoomed. My study group and I Zoomed.

which was an amazing thing to come out of COVID, to be honest. So eight o'clock at night, we had a Zoom date. Whoever could make it would make it. So before the written, we would do a paper a day and we'd just go around the group answering our answers for the...

different questions and we would I don't know how to sugarcoat this we would just pull each other apart but you know to build each other up and then for the viva we would practice the different scenarios and questions and answer them so that became the nighttime routine and that was really good

Because we were struggling to commit to after-work meet-ups at the hospital. It was in my study group with myself and two other blokes with small children. And we just, like, you have to see your kids. At the end of the day, like, you can't. You can neglect your partner, you can neglect your friends, you can neglect your parents, whatever. You can't not see your children. So Zoom was great as a way to commit to regular study. Was all of your study group in Brisbane or were you...?

all in different places at that time to begin with we were all in Brisbane and then um one of our study group went back up to Townsville but predominantly we were all in Brisbane and look and I would say for people who are they're in the pre-contemplative or contemplative stages of getting together and working out what they're going to do to study for this exam is I would get a study group. It doesn't need to be big. It can just be one other person. You do not need to be co-located.

I think it becomes a bit of a popularity contest and it doesn't need to be. It just needs, it's almost a bit like a fellowship. You need another person or group of people to keep you accountable. They become so important to you. They pick you up when you're down. They keep you on track. They keep you focused. But also they...

provide context. You don't know. You could be preparing completely inappropriately. Your answers could be shocking. You need other people to listen to your answers and say, that was absolute rubbish. I don't know what you were talking about. I think something that I'm going to reiterate, when I listened to Alex Craven's podcast with you, he talked about being kind to each other and accepting good enough answers, which is something that we...

all listened to Alex's podcast and then went, oh God, I'm so sorry. Because we were all holding each other to such high standards. And, you know, someone would give a really adequate answer to something and we would just be like, oh. Well, you didn't mention this. And what about this? And it's just not necessary. It really pushed us forward, but you've really got to be kind to each other. It's a pretty horrible time.

I think we're trying to do more performance-based feedback. So really pulling each other up on when you haven't structured something rather than the content of what you're saying, because that's going to come, but it's about practicing saying it in the right way in that performance. That's right.

Yeah, look, we did the same thing because I think if you have practice till you're black and blue and you get a question in the Bible like we did, describe your subtotal gastrectomy, then you can just start talking because... There's generics, phrases that you've practiced saying and suddenly you're in a groove and before you know it, you're pulling things out that you didn't know that you know and it's all good. But if you haven't got that safe framework, then I think...

You could get really derailed in those sorts of situations.

I jumped forward to the exam without asking about preparation tips and things that you did, but it sounds like we've sort of covered that. Is there any other tips or tricks or approaches that you use that you think would be good to share? I don't know. There's so much content out there that it can be overwhelming. I think you write your own notes, you use someone else's notes. It's really an individual thing. I think, you know, try and get...

In the beginning, go for real depth of content. But towards the end, there are some really good, simple textbooks, which are good to sort of thumb through right beforehand, like textbook surgery, which is an Australian publication. There was a new edition January 2020. It's an excellent one-pager on everything.

Radiopedia is an amazing resource. If you need to know the answer to any of life questions, it's probably on Radiopedia. The core courses from around Australia, as I've mentioned multiple times, and I'll say it again, are awesome. They're the ones that you can listen to through the GSA website. That's right, yeah. And for any Queensland trainees particularly who are going to listen to this podcast, put yourself out there during core courses. I'm sure people got sick of the sound of my voice.

that I used for those core courses, like they were mock exams. And if people weren't answering, I was like, oh God, okay, I'm going to give my answer because you would rather look like a fool in front of your colleagues than fail on the day. I started by just getting a handle on the depth of knowledge and I used a variety of resources. The companion series was kind of like the backbone and then I added to it with a variety of other things.

And I think that the biggest thing is commit to it and commit to it early. You know, I sort of told myself basically that first rotation of step four, okay, from now on every day I'm going to do some study and I don't care what it looks like. I think when you overwhelm yourself with, I'm going to do three or four hours study every night, blah, blah, blah, you can really set yourself up for failure. But I just sort of said to myself, every day I'm going to do something. And then it just...

slowly built on from there and I think that's probably the biggest thing. Get started and commit to it and work as hard as you can because you never want to do it again. Podcasts are amazing. Not to just blow wind up your skirt, but I'm like, I'm blown away by what you've done. I just think it's just such great initiative. Awesome study preparation for you, but there was nothing like it. A lot of us commute.

Or we want to go to the gym and we want to feel not guilty about doing that. And so I think utilizing that time put on a podcast, just some like really nitty gritty things as well. I would say.

When you get closer to the written and the viva, you need to give yourself things to look forward to. So the weekend after the written, I went away with my little family. And then the week after the written, I did no study at all. And my study group and I, there was total radio silence. It was quite weird. By the end of the week, one of the boys was ringing me going, I haven't studied all week.

It's strange. It was really important to like just have some time. And there's a big gap this year between the written and the viva. So I think it's eight weeks or something. Yeah.

So you do. You need to take some time and restart. And then after the Viva, I had a week holiday planned. But pass or fail, I was going on that holiday. You need stuff to look forward to because you've basically... sacrifice everything good in your life for about 12 to 18 months you deserve it yeah absolutely this has been absolutely amazing I've learned so much chatting to you and it's it's actually so valuable just to have all those little perspectives even what it feels like to be

sitting there and where the timer is on the computer or, you know, how you actually feel in the exam is something I think that helps, like you were saying, with those nerves, just knowing a little bit about what to expect makes a big difference.

The other thing that I asked you about before you came on the program was something that you were interested in talking about and something that you were passionate about. And you mentioned mentoring and also women in surgery. Because I thought we could spend the last bit of this podcast having a chat about those things. Absolutely. Well, it's actually like this slow evolving concept of mine of mentoring.

I don't know about yourself, but I have a lot of people through surgery that I have latched onto that I think I love everything about you and I want to be you when I grow up. It's a bit of a passive process. as in they probably don't know that you're loving everything about them. What was really surprising in my final term as a trainee is one of my bosses basically took me aside and was like,

this is what I see for your career. This is what I want you to do. And I was like, oh my God, no one's ever done that. I've actually felt the whole way through my training, like someone was going to tap me on my shoulder and say, Emily, this is just not really for you. So to have someone like seek me out was really quite powerful and it really got me thinking. I've had a couple of friends leave surgery.

I myself contemplated leaving surgery after the birth of my first child because I just didn't want to go back to work and leave him and all the usual things. And it was only because I have an amazing husband who said, no, you have to go back. This is your thing. You love it. And I went back to a job where I was surrounded by people who love and value me. Did I sort of continue on?

So probably those two things coming together has made me start to really think about the whole idea of mentoring. And I would like to, although I'm just still working through the feasibility of this, set up. formal mentoring within surgery. Now, I know orthopedics do it. One of my mates had a mentor assigned to him when he first started training, which he really took up and loved. But nothing like that exists in general surgery that I'm aware of.

And I feel like a couple of things, there's some good people who end up quitting surgery because they get lost, disillusioned or overwhelmed by the whole process. And the second thing is... You sort of get through your training. A lot has been invested into you, but for a large number of us, there's then just this abyss of, okay, now what do I do? What should I have been channeling my effort into? What would I be good at? Where would I work?

And I just think that if you could marry people up, trainees with surgeons and have an actual formal process. Now, speaking to a couple of my bosses about this. obviously there would be people who wouldn't be interested in it. They'd find it a bit forced and a bit twee. But I actually think that even if it was only beneficial to a handful of trainees...

That's a handful of people every year who have a meaningful relationship with someone who's actually interested and invested in not just them on that term. but then growing to become a surgeon. It's so interesting because my colleague who's in Adelaide the other day is at a great hospital and he said that he got to the hospital and they had a meeting with him and they sat him down and said, so where are you up to?

in your training how many scope numbers do you have how many majors do you have what do you want to get out of this term let's move these lists around with this rotation because we can do an extra scope here we can do that here and let's get you to get out of this term what you really need to get out of it

to get you where you want to go. And he was telling me about this and was so shocked. He's like, you know, I'm in my fourth year of training and no one has done this before. And I was thinking about it and thinking no one's done that.

with me there's you're sort of just made to sort of fumble through and find your own path and absolutely i got to the end of training and i was like jesus i haven't got all my upper scope like i had to scramble to get all my upper scope so you can get through training one by fluke two without necessarily attaching significance to some key learning opportunities and three without ticking off the very basic things that you need to finish training look i agree with you

There's always that tick and flick that you might sit down with your fellow or your boss just to say, what do you want to get out of this term? But that's probably about as far as the conversation goes. Surgeon is not just a technical person. There's such great non-technical and communication aspects to it.

And I just think if you invested energy and time into people, you could create such better contributors to the surgical world. That's my goal. And also from a completely selfish perspective, it's also feeling like... At the end of the day, that you've got someone who's vested in you, that there's a path forward. Yeah. And to feel like you're being noticed and recognized.

through training and that you're valued. So if you do get to those, you know, divergent points that you feel like an option of continuing on is there and that you're going to be supported in that. That's right. Like I was really lucky and this is the thing that's been playing on my mind recently is...

I didn't quit surgery because I had great supportive factors around me. I had an amazing family, amazing husband, and I also had bosses who they didn't know it at the time, but they provided the environment that I needed to keep going. So if you don't have those things around you and you have all the things that we know weigh trainees down, then the balance can tip and good people leave.

And so if you could put in place some of those resilient factors and some of them are having bosses that you can ring and just say, you know, I'm desperately unhappy about this or I'm lacking direction here or I'm really struggling with this aspect of training. I've been lucky in that I've managed to attach myself like a barnacle to some really amazing surgeons. But not everyone necessarily likes that personality-wise. Or they might not have...

had those people within their training to sort of attach themselves to. And then you've got that missed opportunity, I think, to get someone through. And from a personal perspective, I think the other thing is there's not

a lot of female bosses like I haven't worked with that many you know especially in some of the specialties I've never had a female boss in that specialty so it's really sometimes hard to try to find a mentor or someone to guide you when you don't feel like they have a similar perspective to you So maybe that formal process where you could be matched up with somebody who is a bit more like you would be really valuable. Yeah. You can't be what you can't be. And I...

I'm really lucky in my current job, the Director of Surgical Services. She's a general surgeon. She's a woman. She's amazing. Two of my three current bosses are women and there are other females within the department. But that is... almost unheard of. You're absolutely right which brings me to my next passion which is women in surgery. It's interesting because I would never have described myself as a feminist until I had children.

Because I never saw myself as any different to my male colleague. I love my male colleagues. I felt like I never got actively discriminated against. Yes, I was a woman, but I just felt like I got on and got along just as well as they did. And then I had children and suddenly I realised that there are huge differences between men and women. And suddenly I felt this huge difference and I suddenly started identifying myself as a feminist.

and not in the bra-burning raging perspective, but just understanding that the world is set up for men. Sorry to all the men listening to this podcast, you're wonderful. But the world is set up for men and to try and be a woman, particularly in a very male domain area, it can be really quite difficult. In fact, it can be suffocating.

One of the greatest compliments I had the other day was one of my favorite bosses saying to me, Emily, how have you managed to keep your feminism? Because I'm always in like really bright, floral outfits. And I don't know, I'm a very female. And he was like, how have you managed to keep that? But I'm very passionate about being a woman in surgery, not trying to be a man. Do you know what I'm saying? And I had to really understand that when I was

on maternity leave. One, being heavily pregnant was really quite confronting because it's not a disability but you are at a disadvantage for essentially nine months, feel awful for 12 weeks and then you get morbidly obese. And you still have to take down the splenic flexure in a morbidly obese patient at 1am in the morning. So that's the first thing. And then the second thing is you then take off time. And I took off nearly 12 months with both of my children.

And that is a severe disadvantage. It's great that I did that for my kids, but you're just treading water in that time and then coming back and feeling de-skilled and like everyone's going to see you for the numpty that you are.

And then you've got to navigate the whole, you know, if you're breastfeeding, pumping and things like that, if you're working part time, if you're not working part time, you feel like you've got this constant pull to get the hell out of there to get home to your children.

Suddenly you go from being one of the boys and just doing everything that they do to being totally different. And I still want to be excellent at my job and I don't want to be like lesser. Do you know what I mean? But at the same time, I want to be a woman. And I want those issues to be front and centre.

And that wraps up our episode with Emily. It was so great to chat about all things exams, as well as mentoring and women in surgery, which are things that I'm also really passionate about. So I hope everyone listening to the program got something out of this episode. To everyone that's sitting the exam this week and the Viva in eight weeks, just want to say all the best of luck and I hope it goes really well for you.

Trust in the months and months of sacrifice and hard work that's gone into this moment. And I hope that this really feels like the victory lap on the back of everything that you've already done. It's time to close up. Thanks for listening to First Incision. If you have any comments or feedback, send us a message at firstincisionpodcast at gmail.com or follow us on Instagram at firstincision. Happy studying!