VIVA Exam Preparation with Alex Craven

Welcome to First Incision, the podcast about preparing for the General Surgery Fellowship exam. I'm your host, Amanda Nikolic. Welcome back to the second part of our interview with Dr. Alex Craven about preparing for the fellowship exam and what to expect. Today we are going to go over... what to expect, as well as tips and tricks for the clinical and viva part of the fellowship exam, as well as finishing up with Alex's top three.

tips of things that he wished he'd known before sitting the fellowship exam. I'm really grateful to Alex for spending so much time talking to me about everything that we need to know about the fellowship exam. He has a really great way of breaking things down and I hope you get as much out of this as I did.

For those who missed the last episode, we're going to start off with asking Alex to tell us a little bit about himself. Thank you. It is a pleasure to be here. I'm flattered to be asked and humbled to be involved. My name's Alex Craven. I am currently in my first year of Upper GI Anscoza Fellowship training at the Royal North Shore in Sydney.

Before that, I did a postgraduate fellowship in bariatric surgery at the Austin Hospital, and I sat and passed the exam in the first half of 2018, so a couple of years ago now. and finished general surgery training in that year. I don't know. I'm married. Two kids, 1613. That keeps me busy enough.

So let's get started with the clinical or viva exam. What can you tell us about this part of the exam? There's the clinical viva's. which are where you go to some strange hospital somewhere. There's only sort of two or three other candidates there. You've never been there before. It's really weird. It's kind of like it has all the hallmarks of showing up to a new rotation on the first.

day like that to me it like brought up a lot of oh my god i don't know this hospital and where the hell is radiology and all that sort of stuff so it's all a bit weird getting there And you kind of check in and you wait and there's only two other people and you're both sort of wishing each other luck and secretly hoping that you get the easy patients and they get the hard patients. And you do your vivas and your shorts.

on the same day in the same location with a lunch break in between and and so that is for me aside from the weirdness of going to a new hospital that is really the most normal part of the examination that to me felt a bit more like real life uh once i got in the room i sat down in front of some old guy and then some old lady that were kind of like some old guys and some old ladies I've been sitting down in front of all through my surgical training.

We had a bit of a chat and we swapped a couple of jokes before we got started. And then I asked them a bunch of questions and it was just like... The medium case for me, it was just a really weird inpatient admission. It was just like meeting someone down in emergency and asking all those questions and trying to get along.

It was very normalizing, relaxing, and pleasant, to be honest, which is a very strange thing to say about any part of this exam, but it was actually quite pleasant and comforting to do all of that.

And I think too, I don't know if it's just my examiners, but I feel like they also, you know, feel like they should be making the patient comfortable as well. So after the initial... history taking examination me presenting the patient it was just this lovely meandering chat about vaguely relevant um contents of general surgery

It really focused on day-to-day, real-life scenarios and was fine. And I had, I would say... not particularly bizarre long cases whereas some of the guys that went to RPA just had terrifyingly bizarre long cases but even when you talk to them and they had patients with conditions that none of them had heard of really this exam revolved more around yeah this is weird but you're a general surgeon how do you be a general surgeon and i

I think that practising those medium cases is weird and confronting on the wards with your bosses with each other. But... you just need to practice and i think if you're used to doing this then it doesn't really matter what the actual long case that you're faced with is you'll stumble on through And even in the most complex, weird, bizarre cases, you've got to get to the crux of the current problem. And it's really usually pretty something simple, you know.

You know, one of mine was this guy with all this bowel cancer stuff and this and that and blah, blah, blah. He'd had an incisional hernia and he clearly had a chronic mesh infection. And that was why he was still a patient of this hospital, which is great because it meant I could just kind of skate over all of the other complex colorectal stuff and just talk about mesh infections.

And, you know, my second case was the worst breast cancer I had ever seen or imagined invading everything, metastasizing everywhere. It was just a conversation about palliation. This isn't... This isn't complex. This isn't high. And then we talked about tamoxifen and chemotherapy. auxiliary clearance because we kind of felt like we should do something with the other 20 minutes but but that was my feel of that exam so i try not to get too worked up about that

With that exam, do you feel like what's your perspective on whether or not you should answer the question or whether or not you should try and steer the conversation towards something that you do want to talk about? I've sort of heard both sides of that. Yeah, I honestly couldn't tell you which I did, which means I probably wasn't trying to steer. I think steering examiners around.

is a very high level game to be playing. Because if you're not careful, it very quickly turns into not answering the question you've been asked. So I think... I'm not clever enough to steer examiners, so I didn't. Now, having said that, I didn't chase my tail down.

dark holes of lack of knowledge. I didn't deliberately talk about things that I didn't want to talk about. But I think the idea of steering examiners is one for... really extremely highly intelligent manipulative uber geniuses that you know should be bond villains um i think if you can do that in the

environment of the exam with the stresses and emotional overlays that that involves with the very unpredictable content and with in particular as we move on to the to the non-clinical fibres with the large amount of content that needs to be covered in those. Hat off to you. You're much cleverer than me and you're operating at a very different level to me. I think if I had tried to do that, it would have looked like avoiding questions and answering.

not answering questions that were asked. So, yeah. And with them moving to more standardised marking and things like that, I'm sure they just want to get out those tickets. boxes or get those boxes ticked and move you on to the next question. So you might steer them away from what they actually want to get out of you, I guess. Yeah. And I think that so in the clinical vivas, the examiners have a lot more freedom.

So in these virus, my two examiners sat down, met the patient, talked about the history, went through the investigations, and between them came up with a plan of what they thought was a sensible... range of topics to cover for that patient. So they had a list of stuff in front of them that they wanted to talk about, I'm sure. I don't think they would have been regimented about getting through all of it.

But they had a list of things that they thought were relevant and not. And it was probably guided by their own expertise to a certain extent. And so to then go and... try and play havoc with their preparations, remembering that really these are two general surgeons who are meeting another general surgeon.

to run through a list of what they think is relevant general surgery and then pass them on the exam because that's a hell of a lot easier than failing a candidate. I think just work with your examiners rather than against them.

I think it's safer. That's my feeling. Well, you've got pretty solid reasoning backing that up, so I'll give you that one. Sorry, the shorts. We didn't mention the shorts. Yeah, so the short cases are, that's just outpatient's clinic. It's a weird and scattered multi-specialty outpatient's clinic.

With similar time pressure, if anyone's worked in a public outpatient clinic, I don't know that it was that time pressured. I think I see much more patients in a public outpatient clinic than I would ever see in a 40-minute shorts exam. It was just refreshing to have them all lined up for once instead of calling them from the waiting room, really. All jokes aside, though, it is very quick, but that actually makes it easier because...

By the time you have done a fairly slick and complete examination of whatever body part you're examining, you only have a few minutes left. which really means you're going to get one or two questions. They're going to be very spotlight questions. They're going to be short list, quick description type. questions or maybe something that will touch on a controversy would you repair this lap or open and why you know really and that'll be it for per patient very simple simple things

And I think I was told that you had to know what everything was. I had two things. I didn't know what they were. There's a lump. I think it's retroperitoneal rather than intraperitoneal. It's big. I have no freaking idea what this is. The guy sort of said, good, because we didn't either. Here's a CT scan. So, but I think that what really helped me in that was a lot of, not that I ever encourage cramming, but a lot of cramming of.

examination technique. So really I don't think I practiced a lot of hands-on examination technique until very late in the piece but then just drummed it in and we just ran through all of those exams. so quickly because I think that the key to it is stopping your examination. You need to be able to go from start to finish and stop examining the patient in time to let the examiners examine you.

That's really the key to that for me is that you need to examine that groin hernia thoroughly, quickly, professionally, but in about 30 to 90 seconds. Same with the thyroid lumps, same with the parotid, same with the hand, same with the leg, same with the ulcer, same with the varicose veins, all of them. You just got to be able to do that in under two minutes flat, yet in a calm.

cool, not upsetting the patient kind of way. And then, yeah, honestly, my examiners were just more stressed about running out of time than they were about my performance. They just wanted to make sure that they got me through all the... all the patients, really. And so that's it. Clinics is just you admit two patients from ED and then you go to a really weird public outpatients clinic. That's all it is for the clinical survivors.

And then the non-clinical survivors. Oh, should we talk about those? Oh my gosh. Yeah, these ones, I think, this is the bit I found terrifying. I think other people might feel very differently and that's fine. There are three. The exam traditionally starts with the operative viva. That is deliberately chosen because it tends to be the one that candidates perform the best in. that the vast majority of candidates pass and therefore often does a lot of that.

choke inoculation we talk about so the college is actually under this as well they're doing a bit of amateur choke inoculation as well by getting you into a exam simulation environment called the operative viva that you have a very high chance of succeeding in and therefore less likely to choke through the rest of it so the operative viva

in my year, and I think this persists, was about six cases or scenarios that we went through, and two of them were a lot longer and more involved than the other four. So what did that look like? All the clinical vivas, you show up. with your name tag and you sit in a waiting room and there's this weird system where you have to enter before the last lot leave and you're not allowed to come into contact with them and then they have to stay

hidden away until the next group comes in, which I think will probably be even more pronounced now that COVID's around. But you show up at... You hand over all your goods and chattels. You're literally left with nothing but a name tag and a suit. And you meet your examiners outside the door and...

You've got a couple of minutes to go and you think you're going to have a chat and you don't because they're stressed and you're stressed and everyone's stressed. And then you walk into this room and you sit down at a computer you are looking. to the computer and in most cases you're flanked by an examiner on each side who are also looking at the computer but also at a folder they each have

that contains the content of the exam they have to work through. And then one of them will have a clock or it will be sitting on the computer. And that's the setup. So you're sitting facing a computer and there's an examiner on each side of you also facing a computer. I think when people talk about not being able to read their examiners, no visual clues, they weren't telling me anything I couldn't read there.

body language I think a lot of that comes from this environment because you're looking you're all looking at a computer sitting side by side and their heads are in folders there is no way and and I think that that feeling that the examiners are not trying to help you A lot of it comes from just the physical setup of the room. I would strongly suggest start practicing in that environment. It's really weird. The examiners will either have one of them...

running the exam. So keeping to time, getting you through the content, flicking through the slides for you or telling you when to flick onto the next side, firing questions at you while another marks you. or they'll take it in turns. So maybe either they'll take it in turn question by question, Or one of them will do scenario one, one of them will do scenario two, and then back and forth. That was more common, was a bit of back and forth between the two. I was...

Only in my final non-clinical Bible was I aware of the importance to the examiners of keeping up with the pace of the exam. And I think that a lot of the feeling that you're being harassed. hassled, rushed, peppered with questions actually comes from examiners very cognizant of the fact that their duty to you is to get through that exam from start to finish. And there's a fair bit to cover and you don't have much time and they must move you on.

For an examiner, that probably feels like, oh, man, we've got about 10 minutes on this, five minutes on that. If they babble on too much on that, I'll have to skip past the necrotizing fasciitis really quick, blah, blah, blah. What it feels like to the candidate from my point of view was...

Two people sitting on either side of you, peppering with you in questions, interrupting you all the time. Every time you start getting one of those sentences going that you know is going to really kick ass, you'd never get to finish it. randomly jumping from topic to topic. And that's very disconcerting and disorientating. And I think that often in our practice, we

again, focus on one area of content in our practice. And so we might derive, you know, let's do a practice Viva on anatomy and you'll... you know talk through the inguinal triangle and then you'll move on and talk through the anterior triangle of the neck and then you'll go on to talk about the thorax in the exam it kind of feels like you know tell me

two sides of the femoral triangle you seem to understand that well really the question was about the content so let's tell me what's in it and what's this attached to the you know what's this hanging underneath this person's jaw Oh, that looks like an enlarged submandibular gland. Good. Tell me the nerves are at risk during, you know, what do they call it? Extirpiation of the submandibular gland.

Then it's like, here's an esophagectomy photo and you haven't orientated yourself yet. You're still trying to figure out what's anterior and what's posterior, but what's this structure? And you say thoracic duct because it's always a thoracic duct, right? But that's the experience of the exam is that there is a lot. And so what's happening, I think, and I think we should talk to an examiner about this, but I think what's happening is they have a long list of stuff.

that those that have written the exam have said, look, these are the things that we need to cover in this section of the exam. deliberately planned in advance so that the whole of the syllabus is covered. The whole syllabus? Well, every area of the syllabus is getting what they consider relevant attention. What I only became aware of afterwards is the complexity of the design and marking of the exam in this regard, because there is a facility during discussion of results.

For the examiners to decide that although you may have shown insufficient knowledge of breast cancer in your medium case, you answered the written, on breast cancer well so that is not a grounds to fail you and there's all this sort of stuff going on in the background so so that content and getting through it is is quite important uh and so

working with your examiners and i think i don't want to be at all disparaging of all my examiners i think they all of course i think they did great they passed me but um i think that there was also a difference in the technical skill of some examiners in regards to running the exam in such a way that it felt relaxed.

yet efficient versus almost this badgering type scenario now that also could just as easily have been that the stuff i knew well i was relaxed and efficient in the stuff that i didn't i felt like i was being badgered because i was slow But that's, yeah, so I would suggest that when you're practicing these things, practice facing a computer with two people that you don't know standing, one sitting on either side of you, and then just...

changing topics very randomly and quickly and interrupting you as soon as you've shown that you understand something. Because that's what it felt like for all of these. So the operative happens first.

Two longer cases, and they were sort of case presentations where inevitably you needed to make a decision to operate and say what your operation would be. I think one of them was something like... and undifferentiated abdominal pain with signs of early signs of sepsis but stable uh so you know we talked about

merits of various imaging techniques and chose to do a ct and there was this sort of localized perforation of something and we talked about the differentials for that and then very soon afterwards we were talking about um a patient who'd failed non-operative management and what do you know when you open them up to deal with the diverticular disease you find a perforated cancer and so then really it was talk about what to do

in the situation of perforated malignancy of the colon and your options. Do you do a formal oncological resection? Do you... Pull out one stoma or two stomas. What do you do with the stump? And that was the topic. I think I had been taught that I would need to be very quick and slick in explaining whole operations in under three or four minutes. You know, I was very good at explaining how to do it.

complete thyroidectomy and under i pride in myself i can explain it from start to finish in three minutes there is no way i would ever have needed to do that in the examination ever um The majority of this exam was specific questions about intraoperative decision-making. What do you do if? explanation of specific parts of the examination. How do you identify the ureter? Tell me how you take the hepatic flexure down.

How do you approach Kelow's triangle? Tell me how you do this translystic exploration you've just talked yourself into. So there was that. After a couple of more involved ones, there were about four interoperative pictures or clinical pictures, if you like. that were a stimulus for a very quick discussion about an operation. So one of them was an image of an adrenal lesion.

And the examiners were very careful to make it very clear that they wanted to know the steps, theory only, of how to do an adrenalectomy. They were very clear about that. And so in those cases, so I think that a lot of our practice was around explaining operations start to finish, covering...

you know, in this lovely, eloquent way covering the pitfalls and the practical tips and the key parts of the operation. Whereas I think if I had my time again, I would focus on... being able to jump, knowing what the key pitfalls were and how to deal with each one, and knowing how to describe the key parts of an operation in one sentence.

And I think that's what I would have focused more on to prepare better for that exam. The pathophysiology and critical care and clinical reasoning part of the exam was horrible and terrifying, but that's just because I don't know this well or understand it and never have. So it wasn't my strong suit. But again, it was rarely... the long explanations I had practiced. It was a lot of lists. It was a lot of tell us the options here and which you would choose and why.

rather than explanations of pathophysiological processes. And so, again, practice changing tactics. This I found really hard mainly because at one minute you're talking about necrotizing fasciitis of the foot in a diabetic and then there's a face with a Merkel cell tumor on it. And then... I've got to know what happened after that. I completely derailed at that point and don't remember the rest of the exam. It sounds like it all goes so quickly as well. It is very quick and very erratic.

And then the anatomy viva is lovely. Terrifying because you like... You just don't want to fail anatomy, right? Like I said, surgical registrar, you just don't want that to be the one. But the anatomy viva, again, I remember it being a couple of long scenarios where we looked through a whole CT scan and traced arteries or pointed out structures and then a lot of clinical photos.

So sort of one or two sections where we explained relationships, where we explained operative significance of structures. how to avoid them, how to refine them, those sorts of anatomical explanation type things. And then very quick, what is this? What does it do? How do you avoid it?

Three questions, move on. Three questions, move on. Three questions, move on. Very much more spots. Essentially, I think, yeah, it was almost, think of it as the Viva version of two short answers and four spots, I think.

I want to be so thankful to you for the time that you've taken to really break down those individual parts of the exam. Because I find it really hard to know how to structure the way to study for this exam when I really don't know what to expect or what they expect from me in each of those different aspects of the exam.

Yeah, and I think that's why people doing this the second time around just smash the exam. Like they just walk out with the distinct knowledge that they've passed this time and it's all over. And I think that's it. The best preparation for any exam is sitting that exam. And probably the best you can do to imitate that is just simulation. type environment, but run by or informed by people who have actually been in that exam.

preferably people who have been in that exam twice. They are much better. People who have sat this exam twice are much more knowledgeable surgeons and better educators. So if that's any consolation to anyone out there that's worried about failing this exam, just fail it. You'll be better surgeon and educator.

an all-round human being by sitting this exam twice than you will if you skate through once. I realise I've put myself into the category of worse human being, but it's not the first time I've done that. Yeah, I think, though, that knowing each of these inside out is important, but more the feel of it is important.

You know, it's all very well to read the white book in and out and know what those words are. But I think there's a difference between that and the doing and the practicing and the deliberate practice of... The deliberate practice aimed at adjusting your performance in specific ways. So deliberate practice aimed at making your behaviour different rather than practice to...

And I think there is a type of practice aimed at getting feedback on where you are and how you're going and whether your content knowledge is sufficient. So I think that is... The practice you have with an experienced consultant where they ask you questions about whatever and give you content-based feedback along the lines of... you don't know enough about this or along the lines of, you know, the real controversy here is this. The it depends in this is X, Y, and Z.

That sort of contact feedback, that is one form of practice, and that is very useful. I think then what we do as fellowship candidates... is carry on with that same form of practice with each other. And the problem with that is by the time it comes around to exam time, the fellowship candidates are by far the most knowledgeable people.

in the hospital and therefore are just terrible people to be giving you content advice because their level of expectation is so far above the average consultant and therefore the average examiner. that you end up with all of this content feedback that is just unnecessary for you and wasting your time. I think the Practice within groups would be better spent on deliberate performance, changing your performance in specific ways. Getting rid of that.

you can do this you can do that and turning it into in this operation i do x i do y my options are i would choose to perform a primary anastomosis if a b c rather than well you could do a primary anastomosis or you could do this and you got to think about x kind of thing that sort of practice is something that

we should be providing each other as fellowship candidates rather than the content feedback practice, which is much easier to do. And it makes you feel great. There is nothing better than telling someone about something you don't know or giving them a better explanation to something. It just feels great.

me tell you how I explain Crohn's disease I'm so much better at you and it feels great but it doesn't help either of you and I think that that would be my suggestion about practice yeah I've been trying to make the study sessions more about what you can't do by yourself because you can

cover content by yourself you don't need anybody else there to do that but the reason you need to have a study group is so you can be practicing talking and practicing those techniques um and you've only got a finite amount of time with your study group to do that so we're trying to find ways to make it

more, I guess, like you say, goal-directed. I really like that term. So, yeah, you've given some really practical ways to try to do that, which is really fantastic. So, thanks. Yeah. And I think, you know, if you... You will have different goals. If you've got a good study group, you'll have different strengths, different weaknesses, different goals. So in our study group, we had the machine.

We had a marathon runner with a military background who was just the epitome of organization, dedication, and focus, who was always going to smash the exam. We had the... technique-oriented, content-poor sweet talker, which was yours truly. And then we had the details guy. And if he's listening, he'll know who he is. I would deliberately bait him by sort of blazing away with something like, oh, it doesn't matter what.

X, Y, or Z means or whether there's any randomized evidence for blah. And sure enough, a week later, he found the one randomized controlled trial done in Czechoslovakia that needed to be translated. in order to get the results and then you come back with it and so the deliberate practice for the detail guy was was cover the general first cover the basics first have a a good framework and the and and practice that and and the practice for the content poor uh technique focused sweet talker was

Answer the question that people ask you. Stop trying to beat around the bush and make sure that your well-structured answers actually have the relevant content in them. And there was no practice for the robot. He was just awesome. So, you know, there's nothing you can do about that. But that's, you know, the scenario is that you can actually work on these things and actually...

change each other's performance and bring your own strengths to someone else's weaknesses. And that makes you a good study group. When you talk about having a framework, did you come up with different frameworks for different? sort of topics or types of questions or did you find them somewhere like, you know, with the interview frameworks and things like that? Yeah. I think some we made up ourselves. Most.

We gathered from, I think there's already some in the white book that are quite useful and quite sensible. It's got to work for you. And the problem, yeah, so I think, yes, you should have some defined frameworks. You should have a defined framework for a trauma of any type, of course. A critically ill patient of any type, of course. But you should probably also have a pro forma for getting to a vessel.

that needs turning off you know there's usually there's usually one muscle in the way of pretty much any archery you might have to turn off in a trauma situation know what that muscle is and know whether you retract it medially, laterally, or divide it to get to the artery. That's sort of it. And so that, you know, that's it.

there should have a proforma for each section of the exam but also specific to the to the scenario in the exam so i think you need a different proforma for tell me how to do a right adrenalectomy to You need a performer for bleeding. You need a performer for leaking. You need a performer for not quite right three days after surgery.

I think that the more you practice these, you'll suddenly find out that what sounds like a lot of performance suddenly becomes not many. And so you go from having a performer for bleeding and a proforma for ureteric injury and a proforma for this and it becomes one proforma for intraoperative fuck up and you have another proforma for unexpected intraoperative finding

you know, be it a liver lesion or a hole in something or whatever. And so I think you do need some, but I think if you go out and look for the performers. and just start and don't alter them or combine them as you go. I think you're in trouble. And so I think there are heaps out there and you just pick the ones that suit you. but then melt it to your own. Probably the most helpful thing I did in this regard was the Moses course. I can't recommend that highly enough.

The Moses course is essentially, as far as I can tell, designed to provide... fellowship exam candidates, a great set of performers for dealing with intraoperative and postoperative issues, whatever they may be. And then DSTC gives you all the performance you need for all of the trauma stuff you'll ever encounter. And so those are two things, you know, just throw some more money at the college, obviously.

But those are the two things that if you're lazy, like me, and can't be bothered finding how to do these things for yourself, then showing up to DSDC and Moses covers that quite well. become an instructor in emst or crisp because that'll give you all the performers you need for those things um if you like or you can go out and find your own and i think your and the other thing is that

Yours doesn't have to match your study groups. There is no right pro forma. There's a wrong pro forma. You just have to be organized. And some of our approaches within our study group were identical and some were radically different. It didn't matter. We all passed. It's fine. Just need to have a approach so you don't joke. Yes, yes. So something to say. Oh, and it's okay to say I don't know. I think that would have saved me a lot of stress in the exam.

I think a phrase along the line of, I can't answer that right now, can we come back to it? It's terrifying and hard to say, but I think... You know, you can't say it to every question. But if you really hit that point and say, I can't answer that right now, can we move on and come back to it later? And you probably won't come back to it. It's a 20-minute exam and it was one point and, you know, they're not going to fail you on. Yeah. I had some...

particularly embarrassing choke points in my pathophysiology exam. And there's no way they were going to fail me on that. I get that now. I didn't get it at the time. I was convinced I'd fail my exam afterwards. But if you look back on it, one single answer is not going to be the do or die. To finish us off today,

I wanted to ask you, what are your top three things you wish you'd known before you sat the fellowship exam? Top three things. One is it is often very difficult to tell local doctrine.

from global truth. What do I mean by that? I found I was quite surprised at the exam preparation course when approaches to problems that I thought were set in concrete and could not possibly be done every way we're completely different to those done at say a hospital across the river or one interstate and i think that often we end up in study groups from within our own hospital network and so

It was a shock to a lot of us. It wasn't just our group that felt that way. It was lots of groups that said, oh, hold on. There's more than one option for neoadjuvant chemotherapy for esophageal cancer? Oh, okay.

you know oh you you know you can do this laparoscopically routinely oh that's interesting you know and and so i think had i known that earlier we would have cross-pollinated our groups set up some intergroup mingling even over zoom now in in covert times but but start doing some well-structured practice sessions with people from outside our hospital network i think i think that would have been very helpful um i wish i had known that

controversial topics, the only thing examinable about a controversial topic is why is it controversial? I think a lot of us fall into the trap of finding an area of controversy. that has existed for decades and thinking that in our study and research, we can tell people what the right way to approach that problem is. We can figure it out.

We're going to figure it out. The rest of surgery, there's 15 randomized trials in the period and there's still argument going on. But we're going to find the answer. We are going to find the specific answer to this problem. And it took me a long time to realize that really the examinable part of that is why is this controversy? What are the conflicting opinions here and what are they based on?

What are the advantages of option A? What are the advantages of option B? What are the advantages of option C? And what are the drawbacks of each? That's examinable. That is something that someone can ask you a question about and give you a right or wrong answer on.

right or wrong mark on you can be passed or failed based on that but if it's an area of surgery that remains controversial and and i would say also remember that the exam is is is written essentially at least a year in advance so unless the controversy has been solved at least two or three years ago even longer probably because then it's got to get out into

you know, the general knowledge of the general consultant in order to be examinable. So unless the controversy was solved five years ago, you really just need to know what the issues are that cause the controversy.

And stop trying to solve a problem in surgery that has existed for longer than you've been in surgery. And along the same lines, the third thing I would say that I... wish I'd known before I started the exam is hearing what a sensible well-read surgeon does is of far more value than a week in

up-to-date and online, particularly with common clinical problems or even rare clinical problems, knowing what someone who has seen this before... and who you think is a sensible and clear thinker, what they do with this problem and why, will just save you days of designing your own approach. to what is often a problem you will never see in your entire surgical career. And so I think a lot of time can be wasted knowing what exactly the right approach is to... The difficult duodenum.

Yeah, the difficult duodenal stump. Just ask an experienced GI surgeon what they did the last five times they dealt with it and what they think they'd do next time. what they think the crap options are and why and then just regurgitate that during the exam there's a lot of this sort of play acting it's it's hilarious that someone you know like

I'm two years out now. I am in a formal upper GI training program. What do I do with the difficult duodenal stump? I call someone that's seen more of them and ask them what the fuck they think I should do. But you can't really say that in the exam. Well, you can actually. You can actually say, I'll call someone who's dealt with more duodenal stumps than me. And the examiner will probably say, yeah, nice try and tell us what you do.

But these sort of difficult scenarios, just go and ask someone that you trust to give you good, sensible advice who has done the thinking for you and save yourself spending hours and days and weeks reading stuff you don't really understand the context of anyway.

Yeah, I was getting confused the other day with all the trials on esophageal and gastric cancer. So I just called my fellow and I said, hey, what's the situation? She goes, these are the trials you need to know. This is the summary. This is what you'll say. I was like, okay. Fantastic. Exactly, exactly. And then the thing to know there too is that you say, look, you know, this is what we do in my centre.

As long as it's within the realm of reasonable practice, no one is going to question you on that. It's a very sensible and efficient way to do your study. I just wanted to say thank you so much for coming on the program and giving us your time and giving us such amazing practical hints for preparing for the fellowship exam. That's all right. I hope that was helpful.

i feel like that went on a lot longer than i expected i hope that there's some practical stuff in there We're so lucky to have had Alex on the program to give us such an in-depth analysis of the different aspects of the exam, what to expect, some really practical hints on...

both preparing for the exam before we get there, as well as what to expect and how to deal with the stress of the day. He is pretty keen to come back on the program to do some other episodes on goal-directed learning and... how to approach practicing for the exam so that we don't choke as he's mentioned is a potential problem with some people sitting the exam I'm sure I'm not exempt from that so I really look forward to having him back on the program and I hope you got

as much out of that as i did and happy studying 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!