Written Exam Tips with Alex Craven

Welcome to First Incision, the podcast about preparing for the General Surgery Fellowship exam. I'm your host, Amanda Nikolic. Welcome to this special guest episode of First Incision. Today we are lucky enough to have Dr. Alex Craven on the podcast. I invited him to be a guest on the podcast because he has a great way of... breaking things down and explaining really practical ways to prepare.

He was actually one of the people who helped me prep for my interview to get onto the program. And he was super helpful then. So I'm sure we won't be disappointed with the way that he explained things and helps us prepare for the fellowship exam. This first episode is going to be based around his general tips preparing and sitting the fellowship exam, as well as touching a little bit on what to expect and tips for the written part of the fellowship exam itself.

We will have a second episode going into the clinical viva aspect of the exam. So keep an eye out for that one.

Thank you so much for coming on the program today. Before we get started, I thought I might ask you to tell us a little bit about yourself. Thank you. It is a pleasure to be here, 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. I think... The main thing I would say about myself in regards to the exam is I sat this exam two years ago, and this is an exam that changes every single year.

although it seems to evolve slowly over time. So what I have to say may still be relevant, but also some of what I say may be completely irrelevant to candidates. And in particular, I sat an analog exam. I sat a handwritten... written exam and there was really no technology other than a PowerPoint slide in front of me during the exam and I think that

if nothing else has changed. And so when I talk about, I guess, the feel and the environment of the examination, that's probably different now. And also I only sat one exam. It was my exam. It was unique to me and special to me. And I think that one of the things I found when I was studying for the exam, getting advice about the exam, is that often advice seemed very contradictory. And many people who I respected had...

very differing opinions about what is the right way to approach the exam, approach studying for it, approach answering questions. And I think it's worth remembering that the majority of people you speak to, unless they are examiners, sat one exam and that was their unique exam and that the advice they are giving you with the best intentions was specific to that exam they sat and it may not be

relevant to your exam so I guess it's up to you to choose how much of what I have to say is valuable to you and how much is not and also how much of what others say is valuable or not and feel free to Pick what you want and discard the rest. And I guess that's a good thing about or a good reason to ask lots of people so that you can get everybody's perspective and sort of put together your own approach to your exam.

Yeah, I agree completely and I think a big part of that is also choosing people who are a bit different from you. who think about things different from you, I think we tend to migrate as people, as registrars, as surgeons, towards people that kind of have the same interests as us and feel the same way, talk the same way, dress the same way as us.

And the most valuable insights you'll get in preparing for this exam and in life will be from people who come from very different backgrounds, who have different interests and different perspectives. And I think... Look out for those. Look out for people that challenge your way of thinking about topics because they come at it from a different angle because there is huge value in that. If nothing else, if you can figure out why two sensible people disagree.

on something then you're really getting to the crux of the problem and that's a valuable thing to have particularly those controversial topics that come up again and again and again if you can figure out why two very sensible rational well-read people, have strong opposing opinions, then you can answer that question. So I would agree heartily with exploring widely in searching for advice. Fantastic.

So moving on to why I asked you onto the program, in general, what tips or advice would you have for trainees about the fellowship exam? There's a lot I could. offer and say, and it is all mainly opinion. But when I look to the majority of candidates that sat with me and that I have met who have sat since, I don't think anyone... is not taking the exam seriously enough. I don't think anyone is not putting enough effort in.

What I think a lot of us end up doing is misguiding our efforts and working very hard rather than working very smart. One of the things that happens, it's a massive anticlimax at the end of the exam, if you get through, is that someone comes out and says, the college has found you satisfactory. They don't find you good. They don't find you... They don't even find you. Yeah. You're just satisfactory. And so I think we're all high achievers and...

We want to be something more than that, but all we're looking for here is satisfactory. And that is the ceiling of your efforts. Just have the good enough answer. It doesn't have to be the perfect answer. You'll always want the perfect answer. You'll never find it, but have a good enough answer for everything on the curriculum and you're there. In your study groups, stop worrying about who's got the best answer and make sure everyone's got a good enough answer. It is a very passable exam.

That is something that you will hear from all sorts of people who have sat it and who haven't. But look around you. Think of all the consultants you work with. Think about the ones who are a bit scattered, who don't explain things particularly well, who don't seem to be at all up to date with what's current in surgery. Think about the ones that are just plain a bit weird.

don't know how to communicate properly. Think about the ones that are far more interested in their extracurricular pursuits than they are about anything in the operating theatre. Think of all of those consultants. They all got through, every single one. So can you, simple as that. With that in mind, I would like to suggest that always remember this is not a pass versus fail exam. This is an exam that you pass now or you pass next time.

Every year, something like 70% of people get through on their first attempt and 90% get through within their first two attempts. And if you look at first three attempts, it's well over 95%. You know, really. Unless you consider yourself to be in the bottom 3% of all potential candidates, then you're going to get through. And with that in mind...

There's two questions to ask yourself. How do you make sure you pass now? Why is it that a lot of people have to sit this a second time? And when you ask them about that, they tell you how much more ready they were for the exam, how much better they knew the exam, how much easier it seemed. and how unprepared they felt they were the first time. And so try and figure out what is it about that second time around that makes those people float through the exam so easily.

who are the so-called failures that didn't do well the first time around. And I think the two things that they've done between those two exams to get through the second time is that their study becomes goal-directed. Rather than I'm going to read through this curriculum and then when I finish reading through this curriculum, I'm going to do some questions. There's none of that. When they attack that curriculum, they are deliberately looking.

for their weaknesses. They are deliberately trying to figure out what can I achieve from reading about this. They're not just let me read up about bowel cancer. They're reading about bowel cancer with the goal-directed intention of I am going to read about bowel cancer so that I can explain how I work up a bowel cancer patient. I am going to read up about right hemicolectomy so that I can describe the key steps and the pitfalls.

and move on. And so their study becomes goal directed. And I think that you don't need to sit the exam twice to be goal directed and focused in the way you approach the content. I say this because there is no... bottom to the curriculum. It is a bottomless pit. You can spend your whole life in that syllabus, curriculum, whatever you want to call it.

There is no, you know, everyone says, what is examinal? Everything in surgery is potentially examinable. You can spend your whole life waiting through it all. So. I think you need a goal-directed approach to that to stop you from wasting your time. And the other thing I think they do is that they deliberately practice. So they don't just practice exam questions to get some feedback on how to improve next time, but they practice exams.

questions in a deliberate way to change their performance in specific ways. What do I mean by that? They practice their exam questioning to do things like answer the question that's asked rather than the one that you assume. So when they sit down and practice their exam questions, you can actually do this yourself, have a practice session where all you do is focus on answering the question that's asked.

So if I put you on the spot, Amanda, and I say to you, where do you find the right ureter at right hemicolectomy? The anatomical landmarks for the right ureter at right hemiclectomy are the... Good. So let's stop and start again. So I didn't ask you what the anatomical landmarks are. I asked you, where do you personally find the right...

to the ureter at right hemicolectomy. And so your answer could probably start with something along the lines of at right hemicolectomy, I find the right ureter during lateral to medial mobilization. of the right hemicolon by staying anterior to the retroperitone, you know, whatever you want to do that. But that's a very different way to answer the question. Now, if I then ask you, how can the right ureter be damaged at right?

hemicolectomy i don't want to know the anatomical landmarks about that and and that's a very simple straightforward example but you can have practice sessions with the people in your study group to get rid of that behavior of trying to be smarter than the examiner, trying to answer what you think displays your knowledge best versus what the examiner has asked. And I think that a lot of candidates that have struggled...

and candidates who have had freak out moments, and I count myself amongst them in the exam, this is a key problem. So, and this is only one. And another way I think you can practice is... If you're given a quandary, the adage of any dilemma in surgery should be answered with it depends. Have a practice session where you answer with everything with it depends.

And then the next question, of course, is it depends on what? So if I ask you, you unexpectedly find a common bile duct stone at laparoscopic cholecystectomy, what will you do? It depends. It depends on what. And you can depend on whatever you want. But have a think about that. Because if you then ask yourself, it depends on what, then... It depends on does the patient have symptoms of cholangitis? Have they got evidence of biliary obstruction? Where am I?

Have they had a real myogastric bypass? Is this the only chance for that stone to come out? You know, it depends on a lot of things. And for any quandary, you can do that. And it becomes a bit of a fun exercise. you, by deliberately practicing these things and changing your performance in specific ways, you will create useful, effective habits in regards to question answering. That will be much harder to develop if you're just doing this ad hoc asking questions, answering questions.

And most of the feedback will be content-based, right? You know, you sit down with a boss and you say, oh, what did you think of my answer to that? Well, look, I don't think you adequately explain X, Y, or Z. most of the feedback. And if you can find someone that will give you good technique feedback, latch onto them and latch onto them early, develop your habits early, rather than trying to change the way you answer questions after you've been through the syllabus.

and already thought about this for three months. Set your habits early. That's really practical advice about how to structure sessions and develop a different way of thinking about just the content because it is really hard to come up with ways.

I guess, to do that in the study sessions. And we've struggled with, you know, how we should structure the study sessions and what sort of things we should do, question answers, you know, operative stuff. It's really hard to come up with that. So that's really handy advice, really. Yeah. Look, I think if I could have my time again, I would have done these. This is all fine for me to say. I didn't do any of this stuff. It's all stuff I've thought of kind of mid to late exam preparation.

The other thing, I think, while we're on the topic of this being a passable exam that you either pass now or pass later, the next question you need to ask yourself is, why might I need to sit this later on? Why might I need to do this again? And I've had the privilege and pleasure to meet with a number of... surgeons who sat the exam more than once and talked to them about these things. And what became very clear to me is it's our weak links that...

delay our transit through this exam, not our lack of areas of expertise. So no one has failed this exam because They couldn't quote the latest research. No one has failed this exam because they didn't know enough about the RET proto-oncogene. People have had to reset this exam. Because they hadn't adequately covered areas that were really quite basic and quite simple. And so when you look at that curriculum for the first time, when you're structuring this...

Sit down with your study group as well and be very honest with yourselves about where your weak spots are. I loved studying everything about the thyroid because I already kind of knew it. I was just finishing up on an upper GI endocrine term. And man, the stuff I learned about... MEN syndrome, and I could quote specific alleles. It was ridiculous of absolutely no help or use. But you get into this trap where you think, hey, I'm doing good study here. I'm learning a lot. And it is.

kind of interesting, particularly when you're trying to procrastinate from dealing with gaps in your knowledge. Find those areas that you're less comfortable with. I had no idea about chemotherapy and breast cancer and it took me a very long time to sit down and actually come to grips with that because everyone else seemed to know about it and so it was embarrassing.

to address that because I didn't want to show that I knew nothing about it so go and find those be very honest with yourselves and each other and find those areas where you're like I don't really understand this I don't get this and deal with that first Don't go through the curriculum in a stepwise, because if you go through it in a stepwise manner, you will devote a week to each section.

And the majority of that week will be refreshing yourself on the stuff that you know and understand because that's just more pleasant study to do. And that's not time well spent. something that you already understand better, has never helped a surgical candidate. Dealing with the areas they don't know well will. One other thing that I think causes people to seriously sit this exam is choking.

That is, and I mean that in a sporting sense, the choking I would define as performance that is severely below. Let me start that again. Choking I would define as performance that is well below that demonstrated previously by an athlete or an exam candidate.

That is when you know that answer but you just can't get it to the tip of your tongue or explain it properly. And then suddenly you're in this horrible place where... the next three simple questions just it's tumbleweeds drifting by and you know you're in trouble and most exam candidates have had this feeling where

You're just thinking, oh my gosh, the train is off the tracks. I am a grown man with a wife and kids and I am just floundering like... a scared child hit and and that is a horrible place to be and it ruins people's exams and if you talk

Again, a significant number of people who have had to resit this dam have had to do it because of choke events. It's not that they're... any worse than any other candidate it's not that they don't know enough it's not they haven't tried enough it's not that they're not eloquent enough it's just that they're in that horrible place and this happens to professional world-class olympic athletes this is not something to be embarrassed about

It is actually a sign that you are performing at your peak if you can choke. You have to be really good at something to choke at it. If you're not good at it, you can't choke, right? So the good news is that in... sports, the military, and life, people have looked at this and know how to stop it from happening. And the answer is generally simulation. If you put yourself in an environment that is of similar arousal or stress,

to the event and imagine it happening and then practice in that sort of environment, it actually decreases your chances of you choking. This is why the military scream at their... during basic training. This is why athletes who are practicing at the top level aren't just shooting free throws.

From, you know, within a quiet stadium, they're doing with people jumping in their face and yelling at them and carrying on. So get into simulation early. Create an environment that is as much like the exam as you can. Choose scary people to be involved in your simulations, people that you are either frightened of or either you respect and therefore are frightened of disappointing.

Involve them in your simulations and do it often. And the choke events just won't happen. As simple as that. So those are my in general advice for this exam.

One thing that we're all aware of, and it's part of choking and it's part of performance in the exam, is this really useful concept of the Yerkes-Dodson curve. And that's the one where performance is on the y-axis, stress is on the x-axis, and it looks like an upside-down u. And essentially, the idea being that...

at very low levels of stress or arousal, we don't do a very good job at stuff. When we're bored, we're not very good at doing what we're doing. And also when we are at very high levels of arousal.

such as in the middle of a surgical exam, in a grand final, in war, we make silly decisions or we perform well below our optimum. And you can really use this. And I think that... A lot of us think about it in terms of in the exam room, how do I keep myself out of that danger zone of the highly stressed area where I'm likely to underperform?

And there are lots of techniques for that, and you need to have some. I've talked about simulation so that it doesn't feel so weird. But, yeah, I had songs that I would listen to. While sitting around and waiting, I had things I would run through in my head that had nothing to do with the exam, just to bring me out of that space. And lots of people have similar techniques. You can find them all over the internet.

For the interview, I did power posing to make myself feel confident and calm. That's a perfect example. It's, yeah, you, and I... think if i had my time again i would have something to do in the exam room to bring me out of that space i don't know what that would be but i wonder if there would be something you could do

something you could have a technique for when you're in the thick of it you've got an examiner on both side of you and the wheels are coming off the tracks what would that look like what would that thing that you to be i'll give an example i always have as my shit stitch my bleeding stitch is always a fiber proline And the reason it's a 5-0 is because I yell out 5-0-5-0. And if anyone has seen The Wire, they'll know that that's a silly...

And as soon as I do that, someone in the room who's seen The Wire kind of groans like, oh, you're an idiot. And that brings me out of that shit, there's blood all over the floor moment. I don't want to suggest this routine for me, but...

But I do, and I deliberately have done this. And in any operation where I'm a bit nervous, a bit worried, things get a bit weird, I'll say, have we got a 5050? And it's got nothing to do with the stitch. It's got everything to do with getting Alex out of his... worry zone and performing better again flipping a mental switch for you exactly and so I wonder what I would have if I had my time again to get me out of that derailment so maybe that's something that you could

And people should look at doing, you know, is there a way to get you out of that headspace when you know things are going badly? But also what I was going to say about that is avoid the underperformance during your preparation because it's boring. when you're just reading through ways of this stuff. And I think the answer to that, to me, was making it question-based and practice-based. And I think until...

I started practicing questions, which I did sort of three months before the exam. Until I did that, I think my study performance was really poor. My knowledge retention was really poor. grasp of what was and was not important and my focus was really poor. And I think that had I started with problem-based, goal-directed learning from the start, I think I would have...

found my study more stimulating and therefore been better at it. And those questions, are they like those previous exam questions that have been photocopied and circulated everywhere? Is that what you mean or just getting other people to ask questions? Both. I think one really good...

thing to do with that bank of past questions because they won't repeat them. Everyone says, oh, let's repeat it. That's on the previous exam. Well, no, they don't. They twist it in some weird way so that if you regurgitate the previous answer, you'll muck it up.

But you look at that question and just ask yourself, how could this be asked in five different ways? I promise you any question on the exam, there are five different ways to ask that question. The question about... the anatomy of the liver with reference to its vascular supply.

anatomical abnormalities thereof we've all written this question like five times because it's kind of the easy one and you feel good about writing it and it will it will never come up the same again so questions you could ask about that would be the drainage of the liver. Or you could ask the same question with focus on the biliary tree. You could ask the same question or the segments or something else. Look at that question. The same with the thyroid nodule question.

Just change the characteristics of the patient. They're asking you about a three-centimeter nodule in the right thyroid. Okay, fine. What if it's a five-centimeter? What if it's a three-centimeter? What if the question is how you take it out rather than... How you work it up? What if the question is about a thyrotoxic patient rather than the benign nodule? Explore those questions and then suddenly you have a question bank that is much, much larger.

And actually more useful because in exploring those questions further, you will be more likely to adapt to whatever question happens on the day. So that does kind of take us into the next session where I wanted to talk to you about.

the different components of the exam because I feel like having an idea about the way they're going to ask us questions will help us make up ways to approach studying for the exam. So I was hoping you could break down each of the sections for us and then as well as telling us sort of what it is and what to expect, any tips that you have for each of the sections. And I wanted to kick off with the written exam in general and the spots.

So the written exam, I've got to warn you that I think like most candidates, there is a lot of fuzziness in there, probably because of that high stress, high arousal. scenario that we talk about i mostly remember being in a really quite terrible hotel and then a fantastic party long before we got our results like we all just went and

had a great time just to be out of the exam. They're my fondest memories of the exam. I remember all of that very well. The exam in itself is a bit of a blur, but the written is a very... collegiate friendly place to be. That's quite nice. You're all in the same venue. The experience of the actual exam is you all show up. You see a whole lot of people you haven't seen since, you know, the exam preparation course.

You're all in the same boat. You're all managing your emotional overlay in various ways. And it's quite lovely and friendly and nice. Not only that, but there'll be people there from other specialties as well. So you'll see, you know, people that you haven't seen for ages. You've worked with other hospitals. Oh, hey, you're sitting your exam, all this stuff. And it's just lovely. And then suddenly you're all sitting there.

realizing that the exam's about to start and there's a lot of money, time and pride on the line. And then it is a classic exam experience that you're in a... two foot by two foot desk that is well i'm sure exactly a meter and a half away from your next candidate on each side and in front and back You've got a few writing implements, a bottle of water and not much else with you. And there's a clock projected on the wall in front of you.

And then you sit there and you wait and you wait and then the exam booklets are handed out and you're terrified to touch it in case you get kicked out of the exam and then finally they let you start. And a couple of things. happen that you don't expect for me one of them was i completely forgot what time we started exactly i knew kind of roughly what time it was so it was kind of a mystery for me for the whole exam

exactly how much time I had left. Now, I knew I had the answer to within about 10, 15 minutes. What I didn't realize at the time is I probably could have asked the invigilator and they would have just told me, but... But so that's probably something to pay attention to if you're an idiot like me. The other thing is that it is one of those classic too much to do in too little time exams.

where it's very easy to lose focus, very easy to lose track of time, and extremely easy to spend half of the exam. answering perfectly that question you know so well and have practiced five times because there'll be half of the questions will be like that. You will know them very well. I think all of us that sat in that start of 2018 felt very strongly that was the trap, was time allocation. And that idea of strong link versus weak link.

you will get no extra points for making a good answer better. Like, yeah, you can get from the three to the four. Has that ever happened in real life? Probably not. But you certainly... the difference between a one or two and a three is massive. And so I think that's the trap. I don't know what.

you personally or anyone listening should do about that but I think you should have a plan for it I had an amount of time allocated to every question and that was it that was all the time i was going to spend on that question full stop no matter how well i knew it or didn't know it but that means practicing two things one it means practicing

a good enough answer for something you know well, as opposed to an excellent answer for something you know well, because a good enough answer is one that happens in about 10 to 12 minutes and stops. as an encapsulated answer rather than stops because you're only halfway through what you needed to put in there. It also means having a framework.

for hopefully making a good enough answer for something that you don't really know much about and so again those are the two things i would practice is is having a framework that will get an answer to a trauma type question when you don't quite understand what to do about the specific traumatic scenario. An anatomical question where you really don't know the anatomy that well.

intraoperative decision-making question where you've got no freaking idea what to do about the case in hand, you know, those sorts of things, but also if you can. beautifully explain the various options for the prophylaxis of breast cancer in a BRCA2 patient. Not doing so, but explaining it pretty well in 12 minutes.

rather than explaining it really well in 20 and then screwing up the rest of your exam. So that's the key to that one. Time management is everything. And the key is just start practising early. Those short answer questions, do they really just give you sort of an open-ended question or do they sort of direct you a little bit more? With mine, most of these were actually in about two parts.

The example is that the liver anatomy type question, there's a lesion in this segment. Please explain the segmental supply of the liver and how this applies to... It's blood supply for resection or whatever. So you've really got two things there. You've got chalice of the liver segments and that you know Cunard segments. And the second is what's the vascular supply to the liver? So again, answer the question that's asked. That's a trap.

I think, because otherwise you just lost time. Oh, we didn't talk spots, did we? Sorry, that was the short answer. We forgot. On the same day, you do the spots. So you do one in the morning, one in the afternoon. You have lunch in between. You get a booklet. put in front of you. And it's full of pictures, which are now quite good quality or were when I set the exam. I know there's been a lot of talk about crap pictures. Ours were all very good quality. So kudos to the college on that.

And each of them, almost all of them have three questions. Usually the first one is something along the lines of what is this? The second one and third one are usually. a list. What are the treatment options? What are the grades of this type of injury? What are the structures likely to be invaded? Whatever, usually a list of about four or five things.

And most of those lists will be single words to short phrases. Because you only have four minutes on average per question. Yeah, yeah. And it's really quick and really short. Again, this is the, of all the parts of the exam, this is the one where strong answers waste time. Good enough answers are the key. You know, what are the treatment options?

Rectal prolapse, list the four procedures, move on, done. When you start trying to explain yourself, explain your answer, just bleeding time. These spots are excellent preparation. for the vivas as well because they force you to cut the crap. And they force you to get really good at saying the bare minimum to get your point across.

And I would put it to you that if you actually answered most of the Vibers, as you would a spot, just by an incoherent list of stuff, you'd probably pass. So it's good practice for the rest. Things that helped me were use your inbuilt pattern recognition system. It is the best in the universe, the human eye. brain access is fantastic at recognizing weird shit and filing it away for you for later on. Use that. What I mean by use that, just look at lots of spots, lots of stuff.

Eight pictures of eosinophilic esophagitis down a gastroscope. Find all the weird stuff that you heard was on an exam once. Look at it. Do a spot about it. Move on. It's also great study for when you just can't be asked. Sitting down and going through spots is just probably... It feels like the least work because it is all just pattern recognition, which we're so good at automatically. Good bang for your buck. Yeah, yeah, absolutely. Again, in your goal-directed study...

If you look at a topic, ask yourself, how would I answer a spot question on this? If you can answer all the spot questions on this that you can think of, then that's all you need. Move on. Go and study something else.

And that's where we're going to leave this interview for today. I'm so grateful for Alex spending his time with us, giving us these amazing, really practical hints and tips for preparing and sitting the exam. And I hope you guys have enjoyed learning from him as much as I have. Keep an eye out for the next episode with Alex, where we're going to talk a little bit more about the written aspect of the exam. I'll talk to you next time.

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!