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Helpful advice for MRCOG Part 2

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    Sujoy Dasgupta

    After request from many of my friends and peers from different parts of the globe. This is about MRCOG Part 2. (Will post on Part 3 later on). The long post is for those who are aspiring for MRCOG from outside the UK (Overseas Candidates).

    Passing the exam is difficult (of course, that’s why you are looking for it) but NOT impossible.

    Remember, it’s the exam based on UK system, so you have to adopt to that system. Because, they have not invited you to appear in the exam, rather it’s you who want to take it. To adopt to the UK system may seem difficult, if not impossible, but just think rationally while going through the guidelines and can talk to somebody who cleared the exam or working in the UK. Remember, talking to somebody who has recently cleared the exam or is currently in the UK, is of much help than somebody who is not. The exam system is continuously changing. Especially the current Part 3 exam is totally different from the previous Part 2 OSCE.

    Remember, everyone is not wearing the same shoe. Somebody can prepare within 3 months, some may take 3 years. Somebody may prefer (or get the opportunity) to take work-off, or somebody may not be so lucky. However, in the long run, you have to achieve this and that’s the goal. No matter, how long do you take to achieve this. Remember, most of you people have the highest post-graduate medical degree in your country and are not doing bad (may be not “well-established) in your place. So, MRCOG is like putting the feather on your cap. THERE IS NOTHING TO LOSE IF YOU TRY IT. However, it’s worthy to run after it, as it will improve your following skills (even you will see improvement, while preparing for the exam):

    1. Communication with your patients– especially manipulating angry, adamant and difficult patients, breaking bad news.
    2. Clinical knowledge– you can remain updated on your skills and patient care.
    3. Patient safety– needless to explain, as you know it better.
    4. More focussed on documentation.

    How to plan?

    Just think that you want to write MRCOG after your name and give a start. There is no need for formal planning or have a banquet party to declare that “I am preparing for MRCOG”. The less number of people, know about it, the better it is. “Work hard in silence, let the success roar”. Remember, Newton’s 1st law of motion. The most difficult part is to break the inertia. Just set a deadline, when you would like to appear in the exam. Once you fix the deadline, you must appear in it, no matter whether your preparation is complete or not. Say, today, you decide to appear for Part 2 in July 2018 but in May 2018, you feel that you need more time (as it can happen because of many other commitments in family, practice, health etc); still you MUST appear in July (think that you are going to waste that amount of money). This is important, to keep yourself in the inertia of motion with acceleration (Newton’s 2nd Law), to check your deficiency and also to know what types of questions are expected.

    What materials to collect?

    This is very much important. If it’s done properly, half the job is done. It’s up to you whether you are comfortable with soft copy or need printed format. The way I did it, by making separate folders in computer and the editing them to make charts, to highlight important points in Microsoft Word Format and then took print out of the copies and kept them in separate files. That’s to cut short a big guideline into a shorter one and then again further shortening it while reading.

    1. RCOG site– just download whatever guidelines you are getting. In order of importance are GREEN TOP GUIDELINES (GTG- the Bible for you), BEST PRACTICE AND GOOD PRACTICE GUIDELINES and SCIENTIFIC IMPACT PAPERS (SIP). Never forget to download RCOG CONSENT FORMS and RCOG PATIENT INFORMATION LEAFLET (PIL). All statistics from CONSENT FORMS and PIL are important and you cannot pass the exam without remembering them (no matter, how boring it would appear). PIL will also give you a touch of colloquial words, that they use in day to day practice. Remember, these are updated continuously. So, please keep a habit of looking at the site periodically.
    2. NICE guidelines– they are very few in number and are usually more pleasurable to read than GTG. Please read only those related to OB/GYN. There is NO need to read “Management of Coeliac Disease”
    3. FSRH (Faculty of Sexual and Reproductive Health), BASHH (British Association of Sexual Health and HIV) and BHIVA (British HIV Association) Guidelines on STI and contraceptives. Remember, sometimes there may be conflict between GTG and these guidelines, especially regarding figures. Again, keep in mind GTG is the Bible in that case.
    4. TOG (The Obstetrician and Gynaecologist)- Journal from the RCOG. You can get them if you pay subscription of RCOG (valid for 1 year). You have to go through TOG of preceding 3 (THREE) years before the exam. They are published 4 times in a year (so total 12 copies). However, sometimes, you may require older copies of some articles, which has not been covered in any guidelines or in recent TOG. Examples include Cystic Fibrosis, Asthma in pregnancy, Tuberculosis, AV Malformation of the uterus, Azoospermia, Polyhydramnios etc. If there is conflict between TOG and GTG, again GTG is the Bible (for example, NICE recommends only IVF in Unexplained Infertility, but TOG article says IUI can be tried. Your concept should be “No IUI, only IVF in Unexplained Infertility”)
    5. If time allows, few other guidelines, ESHRE (Endometriosis, POF), ESC (Heart Diseases in Pregnancy).
    6. StartOG– You are entitled to avail it if you pay RCOG Subscription (valid for one year). It’s a GOOD PRACTICE TO START WITH STRATOG. But BEWARE that it’s the guidelines, that you must focus on, NOT the StratOG. StratOG keeps all materials and guidelines according to chapter (Say, all guidelines related to ovarian cancer are in the same chapter in “Preliminary Reading”). But, that should not stop you from searching for guidelines in RCOG and NICE site, because some articles may not be found in “Preliminary Reading” of StratOG. So, first read the guidelines, and then have a look at StratOG. Read only things, that is not covered in guidelines. No NEED to read the same topic, which has been covered in GTG, from the StratOG. Again, remember, if there is any conflict, GTG is the bible. You can just copy and paste the materials from StratOG, as you cannot access it after your one-year subscription expires, in which case, you have to pay again. Remember, to practice SBA and EMQ from StratOG (at the end only, No need to see the “Initial Assessment”, see only “FINAL ASSESSMENT”)
    7. Books– The less you read the books, the better it is. Only 2 books are needed. The first one is “Handbooks of Obstetric Medicine” by Catherine Nelson-Piercy. This is again the Holy book for Medical Disorders in Pregnancy. Especially, look at the differential diagnoses as these often come in EMQ (Headache, Chest Pain, Dyspnoea, Convulsion in pregnancy etc. The 2nd book is Luselay and Baker’s “Obstetrics and Gynaecology”. Again, don’t read line by line (as it would be a luxury), just see the topics not covered anywhere else. Again keep in mind that GTG is the Bible. You can buy from AMAZON or if you are intelligent enough, just join whatever MRCOG groups are there in the FACEBOOK. There are lots of kind people to upload them there.
    8. Practice Materials– SBA and EMQ books. Again, the source is FACEBOOK or AMAZON. These books may be 2 types- some divided in chapters, some not. The first types can be helpful after you finish each chapter. Examples include- Andrea Pilkington/ Amitabha Majumdar EMQ, Ramalingam/ Palanivelu/ Brockelsby EMQ, Magowan/ Otify/ Shamy/ Pearson SBA, Neelanjana Mukhopadhyay SBA. The books where chapter division is not there, (but you must see them, because no such division is actually there in the exam) include Amanda Jones (RCOG) SBA, Shreelata Datta/ Tahira Mahmood SBA & EMQ, RCOG site (In the “Preparing for MRCOG Part 2 in RCOG Site) SBA & EMQ.

    Your nerve is already stretched after reading the list. Now, how you can summarize and keep in mind. As mentioned before, DIVIDE any guideline, TOG or StratOG or book articles into following parts:

    • Statistics Part– First, put all statistics from an article in one place. You can gradually understand, that few “percentages” are important (after reading the questions). But never forget percentages mentioned in PIL and the consent form
    • Clinical Part– If it’s history and examination, focus on DIFFERENTIAL DIAGNOSIS (like vulval skin disease, acute pelvic pain, headache in pregnancy etc). If it’s on investigations or management, focus on STEPWISE approach by making flow chart (“MUST” for CIN, PMS, Urinary Incontinence, GDM, Ovarian Mass)
    • Organization Part– Be very clear about MDT involvement (like urinary incontinence), Midwife vs Consultant led Obstetric care, Consultant involvement (Physically present or On call from home), Oncology (Cancer Unit vs Cancer Centre), place of delivery (Theatre vs Labour Room), EPU assessment, Day care surgery vs In patient care, involvement of Fetal Medicine Specialist (MCMA Twin, TTTS, SiFD), NHS funding in IVF (Only 3 up to 40 years of age), Risk Management (Incident Reporting in Shoulder Dystocia, Failed Operative Vaginal Delivery), Consent (Verbal Consent for delivery in Labour Ward, Written Consent for Trial in Theatre), Coroner’s Involvement in Maternal death or unattended stillbirth, NHS Stop Smoking Service, Child Safeguarding Issue in Female Genital Mutilation, Interpreter for Non-English speaking population etc.

    Try to Co-ordinate

    It’s important to keep your consent clear. While reading article on “Obesity in Pregnancy”, recapitulate the indications of Aspirin Prophylaxis in “Preeclampsia”. While reading Herpes Simplex infection, try to find out the difference in guidelines with Genital Warts. While reading “Epilepsy in Pregnancy”, recapitulate UKMEC for contraceptives in women using Lamotrigine and Phenytoin.

    Be very much particular about the cut off, because they are likely to screw you on these points. Remember whether the cut off means ‘more than equal to” or just “more than”. In thromboprophylaxis, age cut off is 35 years or more but for aspirin it’s 40 years or more. But Aspirin prophylaxis, the pregnancy interval is “more than 10 years” (Not 10 years or more).

    Be very specific about BIO-STATISTICS, LEVEL of EVIDENCES, ETHICS, TEACHING METHODOLOGY, ASSESSMENT and APPRAISAL. Never forget RISK MANAGEMENT and AUDIT. These are the parts, where the overseas candidates really struggle. Try to focus on what particular statistical test is needed in a very case, what type of epidemiological study would fit into it, what level of evidence you require here. Be familiar with formative/ summative, norm/ criterion based assessment. Be very clear about different teaching methods in different situations. Some UK LAW must be applied properly. Examples include Caldicott’s principles, Data Protection Act, Abortion Act, Female Genital Mutilation act, Fraser’s guidelines, Montgomery rules etc.

    Never miss questions on clinical genetics and the mathematical problems. Be clear about probability of carrier stage and affected in different mode of inheritances. Even after taking gallons of alcohol, keep in mind “The carrier incidence of Cystic Fibrosis in Caucasian population is 1 in 25”, because CYSTIC FIBROSIS is very favourite topic in genetics.

    Be familiar with some pictures. These include CTG, ultrasound, urodynamics, cystoscopic view, laparoscopic view (especially lateral pelvic wall), MEOWS chart, common surgical instruments, different diameters of maternal pelvis and fetal head. The exam question is in black and white and you sometimes require extraordinary imagination power to interpret the intention of the paper setter and the person who picked up the photo.

    The 2nd Phase

    Once you have done with all guidelines and few questions, have a look at the SBA and EMQ books and if you are comfortable with Hard copy only, take print out of the “Modified” (by you) guidelines and mark the points from where the questions usually come. Just you can make your study material more concise. Finish this phase at least 3 weeks before the exam (That may mean that you may have to keep some SBA or EMQ untouched). If you have time, have a look at Facebook Forum questions.

    Remember, for SBA, the requirement is “SINGLE BEST ANSWER”. All answers may be correct, but only the BEST one will give you the marks. If the question is “Most important risk factor for pulmonary embolism in pregnancy” and the answers are “multiparity, multiple pregnancy, previous surgery induced DVT, asymptomatic Antithrombin deficiency and family history of DVT”; then the correct answer would be “asymptomatic Antithrombin deficiency” because it carries the higher risk, although other answers may also be correct.
    In EMQ, never see the answers first. Read the question, form your answer and then see if your answer is there or not and then select it. If the question is “In a lady with OAB where 2 anticholinergics failed, what would be the next approach”, your answer might be “Botulinum Toxin”. But if the EMQ thread contains the answer “MDT Meeting”, the correct answer is “MDT”, NOT “BOTULINUM”, because botulinum can only be given after MDT review.

    The 3rd Phase

    Now, again have a look at the guidelines, with special focus on the parts (which you already marked) from where most of the questions come. If you have time, this phase can be repeated as much as you want. But NEVER think that, you will finish this phase and then you will fill up the form. NEVER AFRAID of the FAILURE. At the end of the day, everyone will see your suffix MRCOG, not the number of attempts.

    The 4th Phase

    The 4-5 days (preferably 1 week), before the exam is crucial. Don’t read too much. If possible, take a break from your work. IF you have to fly to another city or another country for the exam, this also takes lots of stress. So, concentrate on those parts.

    The Day of the Examination

    Have a sound sleep in the night before. Reach the spot in time. Keep some fruit juice with you. Both full bladder and hypoglycaemia can impair your concentration, so take care of them. NEVER forget to carry the admit card and photo identity proof. Concentrate on the exam and forget about the rest of the world. Put your details properly in the sheet. Fill up the OMR sheet as you read the question paper (DO NOT tick on the question paper and then transfer, because it will waste your time). If you face any difficulty (get ready, some questions will be DEFINITELY very HARD), move from it and complete the rest and then return to it. The answers are to be written with pencil and they will provide eraser, so you can change the answer anytime. (Probably, they cannot imagine the level of corruption that can happen with pencil in the third world countries). They will again take the pencil and the eraser after the exam (Probably they do not want to keep any remnants of the exam with you).

    There is no negative marking. So, it’s worthy to try each and every question. Give 60 minutes to SBA, 100 minutes to EMQ and 20 minutes to revision. EMQ takes time. If you guess an answer, the probability of being it correct is 1 in 5 for SBA, but its only 1 in 20 (usually) for EMQ. Remember, you have to PASS in all 4 parts separately (Part 1 SBA, Part 1 EMQ, Part 2 SBA, Part 2 EMQ)

    Any Courses required?

    There are different types of courses. Courses can guide you, but to pass the exam you need only one thing hard work. Remember, the traditional concept of knowledge matters, but the main essence of the exam is ORIENTATION. If you can feel that charm, you are in the track. Then the success is the matter of time and good luck. The most effective way to use this ORIENTATION, is to apply it in your day to day practice, as far as practicable.

    Some courses are meant for advanced level of preparation. That is, you can try them after your preparation is at certain level. They can help you to brush up. They are long duration or short duration. Some courses are extremely important for the beginners to have orientation and to give a good start. They can tell you what to read and how to approach. These are usually short courses and are worth trying. The rest is of course one and only your EFFORT.

    So, finally…….

    MRCOG is not the end of the world. Never forget to live your life just for an exam. Continue your work, surgery, clinics. Have time with family and friends. Check WhatsApp messages regularly and see your Facebook news-feed. There is no need to declare to the World that you are planning for MRCOG. If possible, discuss with your peers. Remember, they all are going through the same stress. Avoid discussion with negatively-minded people. Having said that, try to read whenever you have time and you feel it comfortable. Comfort is more importance. It does not look nice if you read throughout the whole night and in the next very morning you just fall down in the theatre (No “Risk Management” team will be there unlike UK). Maintain consistency. “Slow but steady wins the race”. At least some people passed the exam, without any UK experience. And believe me, they are just like you, they don’t have two brains or four heads.

    Remember, it’s the 2nd most difficult post graduate examination in the UK (after Royal College of Anaesthesiologists’ examination). So, NEVER compare yourself with your mates in the field of medicine or surgery (with due respect to all). When you feel frustrated (I ensure, you will !!!!), just imagine that you are taking the certificate from the RCOG President in the ADMISSION CEREMONY and that time you will thank yourself for having gone through difficult time. The sour journey results in a very sweet fruit and that’s only named as MRCOG. The one and only moto is NEVER GIVE UP.

    “Stop not, until the goal is reached.”

    Mr. Sujoy Dasgupta

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