PASSING ERPM, THE MYTHS, CONTROVERSIES & FACTS
Preface The ERPM or Act16 is an examination aimed at screening and absorbing foreign qualified medical graduates into the health system of Sri Lanka. As with many other examinations this exam is shrouded in mystery, controversy and scandal. The aim of this small compilation is to provide an idea on how the exam system works and emerge victorious to an unsuspecting candidate. Side by side information has been added on various methods used by the author in tackling this exam. It's appropriate to mention that these methods worked well for the author in passing ERPM in one attempt and the author sincerely hope that his effort would help students in repeating the feat. Wish you all the very best with ERPM.
What is ERPM? ERPM or Examination for Registration to Practice Medicine is an exam to absorb foreign qualified medical graduates into the health system of Sri Lanka. It's conducted by the Sri Lanka Medical Council. There has been a tussle as to who conducts the exam between SLMC & the University Grants Commission but however the rights have been awarded to SLMC as of Aug 2011. Exam has 2 parts Part A is Theory and Part B tests the practical aspect. Exams are conducted 3 times a year and are duly notified by SLMC at least one month in advance.
Part A
Part A This paper tests theory knowledge in Clinical (Medicine, Surgery, Paediatrics, Gynaecology & Obstetrics) and Paraclinicals (Forensic Medicine, Pathology & Community Medicine) The clinical paper is the same as the common MCQ paper that the local undergraduates face. It’s a very high standard exam with difficult but passable questions. As of now exams are being held thrice a year. April/May - Coincide with Colombo repeat paper August/September - Coincide with J'pura regular paper December/January - Coincide with Colombo regular paper N.B - There has been quite serious talk in town in reducing the number of sittings to two per year. The change is expected to occur from 2013 onwards.
Composition of the exam Each Clinical paper has 40 questions with 5 stems each of true/false type. For each correct answer candidate is given 1 mark. For each wrong answer one mark will be deducted. Negative marks will not be carried on so maximum a candidate could score from one question is 5 and the minimum 0. Paraclinical paper follows the same pattern except each subject has 10 questions of true/false type with 5 stems each. So each clinical paper is marked out of 200 and the entire paraclinical paper out of 150. Time allotted is 2 hours per paper for clinicals and 1 &1/2 hours for the paraclinical paper. All papers are held at a stretch with one paper per day except the last day where you will have a clinical plus paraclinical paper on the same day with a 2 hour break in between. Passing Part A The pass mark has been brought down recently form 50% to 44.5% and also you can pass on aggregate if you attempt all papers at once. So it is advisable to have a go at all papers at once. But one can still pass subject by subject. Pass mark for paraclinicals is 50% still (this mark was not reduced). So the ultimate goal is to score 431 out of 950. Remember the first attempt is your best so don't waste it.
Preparing for Part A Medicine is medicine and will not differ be it Sri Lanka, Nepal or Russia. The core knowledge that's being tested is already on books and what one has read during his or her medical student days definitely matter. Main things are getting used to the format and studying for the MCQs. I have mentioned below what I did during my preparation about 1 ½ months before the exam. 1. Get hold of MCQ's Question banks are available with local undergraduates or one can even get hold of some from senior students’ MCQ collection. Then start answering them. 2. Studying It's difficult to go through those bulky textbooks when time is most difficult to manage. So it’s advisable to refer shortnotes one has made during their undergraduate days. Nevertheless you can always easily refer following books for following subjects. Medicine - Oxford Handbook (if you master this book no need to worry about medicine) Surgery - SRB Textbook of Surgery (has all MCQ points but no concept) Short practice of Surgery Elsiver (Simple book with good concept) Gyn Obst - Randeniya sir's book Paediatrics - Illustrated Imp: Some theory aspects are modified according to local scenario so it's extremely important to read the local guidelines set by Health Ministry for all clinical subjects. Guidelines can be bought from the Colombo Medical College photocopy shop. 3. Classes For those who wish improve knowledge & confidence can do so by attending classes conducted by senior registrars. Classes are conducted all over Colombo. Going for classes by all means is not a must but will provide a good outlook about the exam. The writer attended the following classes. Medicine, Surgery and Paediatrics - Nobel academy at Sagara road, Bambalapitiya 0112505816 Gynecology and obstetrics - Dr. Jayan Jayasinghe's class at IAS Wellawatte +94714835527 There are few other renowned lectures who teach at other places and its upto the student to find out who are ideal for him/her. Medicine Dr Lalindra - Excellent teacher but can be naggy at times. Conducts classes at IAS Bambalapitiya Dr Charles - Slow and steady but gives excellent concept. Good for those who do not have much idea about medicine. Conducts classes at Nobel Academy Bambalapitiya
Surgery Dr. Shrishankar - A practicing and reliable surgeon (senior orthopaedics registrar). Conducts classes at Nobel Academy Gynecology & Obstetrics Dr. Jayan Jayasinghe - Very concise gives only MCQ points. His MCQ collection is sufficient to cover the syllabus. But he expects the students to know basics before coming to class so not suitable for those starting Gyn Obst from the scratch. Dr. ... - Conducts classes in the morning at Nobel. A practicing Gynaecoloist. Good for those with limited knowledge in Gyn Obst. Slow and steady and covers all aspects. Paediatrics Dr. Bala Gobi - Conducts classes at Nobel. Has a very simple and concise way of teaching. Finishes syllabus on time and does plenty of self made practice papers. Good for those starting from scratch. Dr. Daham De Silva - Ex-model turned consultant paediatrician. Good teacher and knows where students screw up! (He lectures at Colombo Medical College) He might not lecture for foreign students anymore as he's being inducted in to the ERPM examination board. He expects the student to know basic paediatrics before coming to the class. +94777748315 Para clinical Forensic Medicine and Community Medicine classes are a must for FMGs as the set up here is quite different. The writer did not attend pathology classes and it's in his opinion that pathology classes are not necessary as they test basic and clinical pathology. If you were sound in pathology during basic science days then no need to worry. Forensic Medicine Dr. Shanthanan - Teaches at Nobel Academy. He finishes the syllabus quickly without bullshitting around. Practices and discusses MCQs daily. He's the teacher of choice if you have limited time to prepare. Dr. Prashan - Conducts classes at IAS. A foreign grad himself, he knows where we lack. He doesn't distribute printed notes so it can be a real pain in the rump especially when copying down what he lectures for 4 straight hours. He discusses theory in great detail but drags classes almost right upto the exam date and can be very frustrating. Dr. Prashan’s class is suitable for candidates having ample time to prepare and also for those who have not studied Forensic Medicine as a subject during undergraduate days. 0718002632/0773099318 Community medicine classes are conducted by a Community medicine specialist at Nobel academy and his notes are more than required for the exam.
4. Self assessment Once the candidate has acquired satisfactory knowledge, he/she can time and do papers. Remember though for locals this exam is a ranking exam, for us it’s just a matter of passing or not. Hence this writer only ventured just above the passing level without aiming for the moon and falling back flat on the floor! This writer always attempted to obtain 120 correct responses. For the said purpose he would make it a point to get atleast 3 responses correct from each question running upto a total of 120 out of 200. This writer would never go beyond it unless he falls short of the target or questions are easy enabling him to mark beyond the benchmark of 120. In other words this exam requires some calculation as well. In summing up all above jargon; make sure you mark 120 answers with absolute certainty and beyond doubt for each clinical paper. N.B: The pass mark now is 89 out of 200 but still it is better to score above 50% in my opinion! 5. Answering MCQs Though not strictly followed the general makeup of a question is as follows. All questions have 5 responses of which 2 are very straight forward, one /two that require some thinking and the remainder requiring advanced knowledge. As an example take the following question which this writer attempted in his ERPM Part A surgery paper in August 2011. Q 1. In a solitary thyroid nodule which of the following indicate malignancy A. Nodule occurring in a child B. Multiple nodules palpated in the back of the gland C. H/O uptake of radioactive iodine on scan D. History of irradiation to the neck E. Patient presenting with Marfanoid features Out of the above options option A, C and D are clear and straight forward. Option B is tricky and needs thinking Option E Need advanced knowledge. Answers to the above: A – True. Young children and elderly have high chance of having a malignant thyroid nodule B – False. Multiple nodules being palpated indicate presence of a multi nodular goiter rather than a malignant nodule which is usually single C – False. Usually malignant nodules are cold nodules in majority D – True. Irradiation to the neck raises the chances of Papillary carcinoma E – True. Marfanoid features with mucosal neuromas are associated with Medullary carcinoma of thyroid
Likely there are some questions where you know all 5 options correctly and some where you don't know any. If you don't know the correct answer for any then mark all the options based on guesses as there's nothing to lose. If you know only one or two with absolute certainty then mark only them. Remember objective is to get at least 3 correct responses per question. Do not mark responses you're not 100% sure of! Don't be too greedy! Many mark all the responses irrespective of whether they know it correctly or not (or sometimes around 160 out of 200). As mentioned above it’s just a matter of passing for foreign graduates not scoring high up! (Its advantageous if you do manage to score high up but always strike a balance). As a principle the writer never ventured beyond 120 responses that he was absolutely confident of getting right. Hence this writer managed to score more than 110 in all clinical subjects without taking undue risks. Nevertheless it’s upto the candidate to decide upon. The paraclinical subjects are approached in a slightly different manner. As aforementioned you have to score 75 out of 150 (It’s still 50% for the paraclinical subjects). Community medicine questions are straight forward and are right from the theory books. Forensic questions are twisted but majority are answerable if you have common sense. Pathology correlates with clinical knowledge and little basic pathology knowledge. Candidate needs to be strong in at least one subject. One does not need to pass the subjects individually as compensation is possible. This writer’s personal experience in the August 2011 paraclinical paper sums up the situation. This writer did not have a good knowledge in community medicine and in the exam managed to answer only 18 out of 50 but did manage to answer 40 in forensic and 38 in pathology. Ultimately when results were published this writer had scored 92 out of 150 despite failing in community section.
6. Day before the exam Can be extremely hectic and stressful as there's always that unturned page left. For medicine just go through cardiology, renal, hematology & immunology sections of oxford handbook (writer feels that these are the sections where most questions are asked). For surgery, gynae obst and paediatrics notes will suffice. Don't cram all night. A good night sleep is essential. Make sure you follow the instructions given by the SLMC. 7. Day of the Exam Be on time and follow instructions clearly. Candidates are allowed to leave the examination hall at their own free will until the last 30 minutes after which you will not be allowed to leave till the exam finishes. (It’s alright if you can leave early because if you stay till the full time is up you might end up staying for another 30 minutes as you’re not allowed to leave until invigilators collect, cross check and approve all the answer sheets of all the remaining candidates and there’re lots of candidates!)
Count the number of answers you have entered after attempting all questions. Make sure that you’ve marked more than the stipulated benchmark. If the candidate falls behind the benchmark then he/she can go for answers based on logic or educated guesses. Unless that situation arises AVOID GUESSES! The time given is more than enough! This writer took 45 minutes to answer the first round and then revised the answers for a second and then a third before entering them on the answer sheet well within 1 ½ hours. DO NOT MARK THE ANSWER SHEET IMMEDIATELY! The unlikely event of changing an answer you’ve already marked on the answer sheet could be disastrous as the candidates are advised to mark ONLY with pen. Tipexing is allowed but can smudge the edges which can result in the computer not marking the entire question altogether. So enter your answers on the answer sheet after careful scrutiny. On the final day of the exam there’s a 2 hour gap between the last clinical paper and the paraclinical paper. This time can be put to great use by studying community medicine. This writer personally knows few candidates who passed community medicine through the flash memory of those 2 hours.
Part B
Part B Upon successful completion of part A he/she will be allowed to sit the practical section. Part B consists of clinical section viva, community medicine viva, forensic medicine viva and emergency viva. Preparing for the exam is tough as one need to study theory as well as examination technique but overall it’s easier to pass than part A. 1. Structure of the exam Clinical stations There are 6 clinical stations. Station 1 – Medicine Long case Station 2 – Medicine Short case & Paediatrics Short case Station 3 – Paediatrics Long case Station 4 –Surgery Short case & Gynaecology Short case Station 5 –Surgery Long case Station 6 –Obstetrics Long case There'll be short cases as well as long cases per subject. What's a long case? Long case tests the candidate's ability to take a relevant clinical history and discuss on further management. Candidate is given 15 mns and history has to be asked infront of examiners. There’re usually 2 present. There's one long case per main subject. Note: In some situations they ask to take a relevant history as well as clinical examination within 15mns esp in obstetrics long case. What's a short case? Short cases are very brief usually about 5-7 minutes. Candidate is asked to perform a relevant system examination infront of the examiners (usually 2). In most of the times the examiners will instruct on what system to examine and some may describe a clinical scenario and ask the candidate to examine the relevant system. Ex - This person was admitted with swelling of whole body and legs. Examine the relevant system - this will encompass cardiovascular system, abdominal examination and genitourinary system which is optional. Usually the examiner will prevent the candidate from examining the wrong system but it's better to avoid starting off from the wrong foot so be cautious. In Surgery usually there're 2 short case stations (sometimes 3). The time limit will be the same for all short cases hence the candidate should limit time to less than 3 mns per case in Surgery short cases. All other subjects have only short case 1 station.
Medicine and Paediatrics short cases are done together. There will be two examiners one physician and one paediatrician. Both will mark independently based on performance at both stations (medicine + surgery) not only on their relevant specialty. The candidate will not be given same systems to examine in both stations. (i.e. If you get cardiovascular system in Medicine you will get some other system in paediatrics) Note: In some short cases candidate is asked to take a brief history before examination. This happens especially in Gynaecology short case. Ex - Getting DUB as the Gyn short case. There will be no clinical findings except anaemia. How will you be marked in the clinical stations – Long cases? The candidates’ performance is assessed by two examiners. Each examiner is given a piece of paper with the marking guidelines. There’re check boxes pertaining to specific area in the history that examiner want you to ask! There are check boxes to the following rough subheadings of the history. 1. Introduction 2. Elaboration of presenting complaint 3. Hx of presenting illness 4. Past Hx 5. Family Hx 6. Drug & Allergy Hx 7. Social Hx 8. Menstrual Hx in females 9. Systemic review (lot of people miss this one but there's a separate check box for it) 10. Interaction with the patient 11. Demeanor If the candidate asks relevant information under each subheading then the examiner will tick each check box indicating that the candidate has asked questions satisfactorily. So the objective is to obtain ticks for all checkboxes and if the candidate does manage in doing so then he/she is sure to pass. Note: In paediatrics you get ANC Hx, Birth Hx, Development Hx and Immunization Hx in addition to above! Next comes the discussion part. Discussion is nothing but regurgitating theory so YES THEORY IS VERY IMPORTANT IN VIVAS! Once the allotted time is over the (a bell will be rung) the examiners will secretly (sometimes you might even be able to see) scribble the mark in a separate box at the bottom of the same paper. Remember if the candidate manages a perfect history then passing is a certainty! However if the history does end up bad then the candidate needs to have a sound theory
knowledge to compensate and maintain a good discussion. If both parts go well then the candidate can have a sound sleep at night thinking of a mark in the 60s. Note: The key to passing is making the examiners believe that you're special than other candidates or deserve to be passed than the rest. Try to ask or say something unique but relevant which makes you stand out! The writer had the fortune of striking gold in paediatrics long case. My case was a 9 year old child with PUO for 14 days and I asked the respondent about notification which the examiners duly noted and appreciated which made my passing in paedatrics long case a reality even before the discussion started.
How to prepare for the Part B? A. Get exposed to the clinical setting of the local hospitals Exposure to the hospital setting is of utmost important in part B preparation. The candidate has to be familiar with prototype cases from the 4 main specialties. There’re 2 ways of getting it done; the official way and the unofficial way! The official way is through the Sri Lanka Medical Council and the candidate has to request for a non-teaching base hospital in close proximity to his/her area. Majority of students go to these hospitals in the gap between the parts A and B. Following registration with the SLMC, the candidate is advised to attend clinical rounds at the designated hospital. Further information regarding this could be obtained from SLMC at time of registration for ERPM. However, the candidates must note that attending these rounds arranged by the SLMC is not a prerequisite or absolutely necessary to pass the ERPM. This scheme particularly avail the outstation students as they get better stations close to home but can be problematic for those who reside in Colombo. All applicants residing in Colombo are given placements at Homagama/Panadura base hospital which raises the issue of distance and travel time. Further, as quite a number of students apply, ward rounds can be particularly crowded. Though common cases are treated there, most of the complicated and rather good clinical cases are referred to tertiary centers. Ultimately days become monotonous with the same cases repeating. The remainder is the unofficial way, which this author used, of attending a ward under care of a consultant known to the candidate with expressed permission of the said consultant. The benefits include being able to see cases in a less crowded environment, better cooperation with the non-medical staff and freedom of movement i.e the ability to visit the ward in the evenings. This writer attended NHSL for Medicine, CSTH for Surgery, DMH for Gyn Obst. It was extremely difficult to obtain permission from reluctant and no-cooperative (or rather jealous) consultants to attend LRH for paediatrics hence this writer did not receive an adequate exposure in paediatrics.
B. What to do in wards In this writer’s opinion it’s not necessary to attend wards for months provided that you have received some clinical exposure overseas. Writer is known to some candidates who passed clinicals overseas just by demonstrating on dummies and not by interacting with patients. Also there’re candidates who are taking histories for the first time at ERPM. If that’s the case with a particular candidate then it’s advisable to remain in wards for a longer time. Otherwise this writer feel 2 weeks of honest work in each respective department suffice. However it’s upto the candidate himself to decide. Following guidelines should be adhered to at wards in general 1. Become part of a small study group – 4 would be ideal and wear white coats 2. A point should be made to cover all common cases atleast twice 3. Be mindful of the time and make sure the particular case is completed within the allotted time 4. Always present the case to another colleague maintaining eye contact at all times in clear English and a loud voice (Candidate with good clear English and good pronunciation definitely has an edge over the other candidates who are not well endowed with English skills) 5. Have yourself critically analyzed by a fellow candidate each time you take history or examine a patient (remember this is how you will be assed by the examiner so be critical of the performance to the utmost. “the more you get ashamed the more you learn”) and take all criticisms seriously (but do not think bad of your critic) 6. Make it a point that all members participate equally, avoid being selfish 7. Save time. Do not remain in the same ward for more than 3 hours 8. Be courteous to the staff (especially the nurses, interns and local medical students) 9. Build a good rapport with the intern medical officer. They’re the one’s who know what the good cases are! 10. It is not necessary to attend ward rounds. Majority of consultants do not bother to teach FMGs at rounds so it could be a waste of time Note: Cardiac cases may not be there at the wards. If the candidate wants to examine cardiac cases he/she can go to the cardiothoracic unit of the NHSL (ward 60 I think) and get permission from Dr. Ruwan Ekanayake, a consultant cardiologist. He was extremely helpful and granted us full permission to enter and leave at our free will. Best respiratory cases will be found at Welisara chest hospital. Just one visit will cover all respiratory system long and short cases. Neuro cases are found at all levels except for advanced cases like motor neuron disease, MS, myotonia dystrophica, peroneal muscle dystrophy etc which are found commonly at the Neuro ward at NHSL. One visit to the neuro ward would cover all these. All cases admitted in Gyn and Obstetrics wards are probable cases in the exam (there’re no good or bad cases in Gyn obst. All cases are good). Focus particularly on Rh –ve.
Remember the likelihood of getting normal pregnancy for the exam is extremely rare. All obst cases have multiple problems and nothing is absolutely normal. Practice vagainal examination (PVs) as much as possible. It’s a bit difficult for a male candidate to examine in wards so the best place to do PV is at the Gyn OPD where almost all patients are subjected to PVs and none complain. If the candidate has difficulties in finding an OPD, then he/she could attend the well woman clinics of the area with permission of the MOH. Master swelling, scrotal lumps, breast and thyroid examinations as they are common surgical short cases. All short cases can be seen in the surgery OPD. So remember in surgery for long cases go to wards for short cases go to OPD. Candidates can go to NHSL OPD in the morning around 6 AM and take cases before the consultant comes at 8 AM. Paediatrics is one specialty in which almost all consultants (and house officers, nurses and registrars) are snobs. They abhor FMGs attending ward rounds and OPD at LRH. When requested permission the hospital director sheepishly passes the ball to the consultants who flatly refuse. Ironically the only place to see congenital heart disease, thalassemia and cerebral palsy cases in Colombo is the LRH (they are the commonest cases). Desperate situations require desperate measures and we went to LRH sans permission once with an intern personally known to the writer and once with a preintern. On weekends the writer would visit the cardio ward during visiting hours without white coats, request permission from the parents who readily let the writer examine their children (there’re no house officers or nurses on duty during visiting hours and even if they do they tend to think that we are relatives. Do manage to conceal your stethoscope). Writer was chased away twice once by a house officer and another time by a nurse. One should be mindful of these especially while going to LRH and bear the insults meted towards FMGs. It is important to get input from a senior at the ward (SHO, registrar etc). The best bargain for a foreign student would be to present cases directly to the registrar or the house officer straightaway. This writer was fortunate enough to come across few good souls who volunteered to teach at particular wards. So if available use your contacts and get their help!
C. Study The candidates need to study theory as well as examination techniques. The students here follow Hutchison for clinical examination. They also follow some books written by few great senior undergraduates regarding long and short cases. Such books are available at the Colombo Medical College photocopy shop. For Medicine Long/Short cases – Notes are available at the photocopy shop For Surgery Long cases - Books are available at the photocopy shop For Surgery Short cases – Dr. Sudira Herath’s book
For Paediatrics Long/Short cases - Notes are available at the photocopy shop (including one compiled by Dr. Daham De Silva himself during his undergraduate days) For Gyn Obst Long/Short cases – Notes & history format made by Prof Randeniya are available at the photocopy shop For Emergency Medicine – Buy the book “A Guide to the Management of Medical Emergencies” from the Sri Lanka Medical Association bookshop at Wijerama Mawata. For Emergency Gyn Obst – Read Ministry Guidelines For Emergency Surgery – Read Ministry Guidelines For Emergency Paediatrics – Read Ministry Guidelines Long and short cases mentioned in these books are the ones normally given at any undergraduate exam. The book is beneficial as it has the theory discussion mentioned as well. These books are a must buy for those willing to study at home. In addition classes are conducted by senior registrars. Some of them are mentioned below Medicine Dr. Lalindra – Teaches long and short cases in the class while demonstrating. Also gives scenarios and practices history taking. Quickly finishes the list of cases. He also takes classes on emergency medicine. Once all classes are over he takes the students to his ward at NHSL (incognito) and let them practice cases. Dr. Charles – Conducts classes at Nobel Academy. Slow but gives a good concept. His classes are very interactive where he raises students and ask them to present cases. He also conducts emergency classes but doesn’t take students to his ward. Surgery Dr. Shrishankar – Conducts classes at Nobel academy. Discusses cases and shows possible short cases on power point. Covers emergency surgery as well. Gynaecology and Obstetrics Dr. Jayan Jayasinghe – Conducts classes at IAS Bambalapitiya. This writer felt that his long cases somewhat lacked in theory aspect compared to Randeniya sir’s notes. Discusses short cases in a very concise manner. Dr. Jayan completes emergency Gyn Obst as well. Paediatrics Dr. Bala Gobi – Took only one class for all short and long cases and didn’t do emergency paediatrics. Dr. Daham De Silva – Simply idled through the class asking the students to buy and read the set of notes he had made during his undergraduate days. He took 3 classes to finish the entire long/short cases and emergency paediatrics. He didn’t discuss short cases in detail. However he did mention where students screw up in vivas.
N.B: This writer feels that it’s not necessary to go for paediatrics classes. One can study at home provided that he/she has the long case book by Dr. Daham and the short case book from the Colombo Medical College. Emergency paediatrics need to be read from the Ministry guidelines except few topics such as paediatric surgical emergencies, neonatal resuscitation etc.. For neonatal resuscitation reading the publication “Guide to Neonatal Resuscitation” published by the Sri Lanka College of Paediatricians is a must. Some classes are conducted by pre-intern doctors who await internship. As of what this writer has heard, they give a student’s point of view of the exam. Writer cannot vouch for its success as he had not attended such classes in person. D. Time and practice Need for this is already emphasized above. There’re few senior registrars who bring ERPM students into wards of NHSL on weekends and conduct classes for cash. It’s strictly illegal to do so but however quite a number of students go for them (writer too attended few classes of such). They demonstrate examination technique first hand on patients and let each and every person try it on the patient. Then they discuss about the case. The advantage is that the senior registrar finds out the best cases from the entire NHSL and lets the students practice so its time saving. Also learning from an experienced clinician first hand is advantageous. The disadvantages are ofcourse the fee charged and the repetition of cases after a while. Writer feels that the same could be done by the candidate by himself if he has the permission from a consultant at NHSL. After all it comes down to the amount of practice received not the number of classes attended or amount of money spent. Writer has included numbers of such registrars’ in this document. If interested then candidates are advised to call and arrange a time for the class from the said doctor. The readers are implored to maintain confidentiality as undue publicity would be detrimental to the careers of these registrars. Dr. Weerasudan – Medicine SR 0718323601 Dr. Kamalatheepan – Paediatrics SR 0777725824 E. Para-Clinicals Preparation for the paraclinical viva is slightly different. Forensic Medicine Candidates do not need to know theory in detail but should have a basic idea about medico legal activities a HO might need to do. Candidates will be given pictures and asked to describe them and answer questions related to it or a pathological specimen or a bone to determine age sex or MLR & MLEF form to find out mistakes etc.
Viva classes are conducted by the same people who conducted classes for part A. Dr. Shanthanan – Covers up the required amount quickly and practices pictures and samples. This writer attended his class but however felt that the practice needed for picture interpretation and bones is somewhat less. Dr. Prashant – Though the writer did not attend he thinks that Dr. Prashan is the ideal person for forensic vivas. Practices lots of pictures, bones and specimens right from the JMO treasure trove. Points out at individuals who’re timid and reserved to stand up and answer. Everyone receives a thorough revision of forensic topics and makes he candidate feel confident. But as usual he conducts classes right upto exams which is quite frustrating. JMO classes – It is conducted by the College of JMO of Sri Lanka and is a must for the FMGs. They discuss core topics with lots of pictures, specimens and bones. Incidentally the same sets of examiners come for the ERPM viva so the candidate has the advantage of familiarizing with examiners before the exam. JMO CLASSES ARE IMPORTANT! Community Medicine Community viva is simply about beating around the bush with little theory from here and there without allowing the examiners to ask questions. Main thing is to give the examiners the impression that you’re interested in the subject and didn’t sleep in class during lectures. One can attend the class conducted at Nobel academy for CM. More than classes candidates should visit an MOH several times to familiarize with the system. The examiners will have a very bad impression on the candidate is he/she had not visited an MOH and a failure is inevitable(Writer knows candidates failed by a mere 1 mark at the exam). At the MOH office the students should have a face-to-face interview with the MOH and ask about the diseases prevalent in the area, her role in prevention, details about vaccines, reporting process, what to do in an outbreak of dengue/diarrhea/typhoid etc, disease notification, clinical activities of the MOH, duties of the MOH etc. candidates need to visit MOH office atleast 3 times (one should be to observe the clinics). Firstly call the MOH and arrange a date for the visit. While going to the MOH this writer feels that it’s better to take small groups, preferably 4, as the discussion becomes more interactive. Once the MOH visits are done arrange a visit to meet the area PHM through the MOH. The PHM should be asked about her role in maternal/child health in the area. This writer was fortunate enough to interview the kind hearted able MOH of the Delkanda MOH Dr. Leeda Fernando. She made the hateful subject of CM a desirable one. The writer had lengthy discussions with her on disease notification ad reporting which helped in the vivas. Writer advises people to visit her MOH as she’s very supportive of FMGs but to check her availability before going. Writer went and personally thanked her for her help in passing the ERPM. Through Dr. Leeda Fernando the writer met Ms Janaki the area PHM of Delkanda. Her help was also immense.
Delkanda MOH – 0112852718 Ms Janaki PHM - 0718045036 Things to take to the exam Equipment such as stethoscope, measuring tape, illuminoscope, watch with a second hand, gloves, light source, knee hammer, neuro kit (with tooth picks, cotton wool) should be taken. BP cuff is not necessary. It’s important to take soft toys for the paediatric examination. A minimum of 2 is required as the candidate is asked to gift the toy to the child. Do not offer children sweets. Passing Part B The clinical station can be passed on aggregate provided that the cumulative percentage of all long and short cases is above 50% (49.5% is not entertained). All vivas have to be passed individually with a percentage of 50% in each. Writer’s personal experiences in clinical section The writer faced vivas in January 2012 with results from either end of the spectrum. The candidate need not worry about lackluster performances in one station as he/she can compensate from subsequent stations. Clinical station 4 - Surgery Short Cases Writer received 2 surgical short cases. I. A trophic ulcer due to long standing DM Was asked to describe the ulcer; about types of ulcers, why the margin is sloping at one area, how can you treat it. This writer missed palpating pulses proximally and distally though he checked for sensation which was duly noted by the examiners and questioned. II. Tracheostomy 1st command was to observe the patient who was an elderly female. Next question was “what's the problem she's having now” to which the writer replied “hoarseness of voice with Tracheostomy in situ.” Subsequent questions were the types & indications for Tracheostomy, when do you change from cuffed to non-cuffed tubes, The golden question was “how will you manage this patient in the ward” for which I replied that I'll first give her a writing pad and a pen to write down complaints and a bell to summon the HO whenever required, followed by regular suctioning and cleaning. I was then asked about the frequency of suctioning and cleaning of the tube. Guess this writer hit the jackpot with this short case when the examiner said that this is what he expects from his HO.
Clinical Station 4 - Gyn Short case This writer was asked to take a brief history & examine the abdomen of a 55yr old woman giving a running commentary. They guided the writer whenever he felt confused (or rather exhibited confusion). She had a uterus the size of a football. This candidate was asked to percuss for the upper border, to comment about the size, to differentiate from an ovarian mass and come up with differentials. Ultimately the case was presented in line of endeometrial hyperplasia/Ca for which the examiners said that it was a fibroid. They asked the writer about subsequent management for this particular patient for which I replied TAH. Following that the writer was asked to justify his reason for the Hysterectomy for which I replied that the women’s significantly anaemic and is post menopausal which obviates the need of retaining the uterus. Last question was, unless complicated, when the sutures should be removed in a post hysterectomy patient and when should she be discharged; for which this writer could manage only a feeble mutter and that too incorrect! This write was let go after being grilled about the university in which he studied and being satisfied at his overall performance! Clinical Station 5 – Surgery Long case Was given 7 minutes for history, 1 minute for summarizing the history and another 6 minutes (till the bell rang rather) for the discussion. The case this writer got was a 62 year old female presenting with a 1 year history of PR bleeding with symptoms suggestive of anaemia, asthenia & altered bowel habitus. History was completed in about 5 minutes. Though requested to summarize the history, this writer opted to present a problem list! (Candidate can present either a problem list or a summary but problem list is easy to compile and express.) The writer was asked to give a probable diagnosis for which he replied “possible Colorectal malignancy of the sigmoid with synchronous lesions in the cecum” (the history was suggestive of such a diagnosis). Writer was then asked to support his diagnosis which was followed by the discussion which was a mere regurgitation of theory. Each examiner asked questions for 3 minutes for a total of 6 minutes. The questions this writer received were; how will you diagnose the condition? Investigations? Do you know any biochemical markers for this? How to stage the disease? (they asked me to describe the TNM and Dukes staging for which I replied that I’ve forgotten) Writer was asked about surgical management depending on location! What’s pancolectomy? And lastly how to prepare the patient for colonoscopy! Clinical Station 6 – Obstetrics Long case This is the station where this writer met his waterloo and hung up his head in shame! It started and then finished in disaster with perhaps the worst ever performance by the author at any given viva. This candidate was given 15 minutes for history, obstetrics examination and the discussion. 7 & ½ minutes were given for history as well as obstetric examination and for
summarization. The case given was a 24 year old P2C1 in her 2nd pregnancy who was Rhve . The worst possible scenario is getting a non-cooperative patient with the devil himself as the examiner and this happened to the author on this very day. Patient, perhaps out of fear of doctors, was not willing to come out with information this writer needed and gave her LRMP (Last Regular Menstrual Period) wrong. She made no mention (and I didn’t bother to ask) of a newer date given based on scans. Nevertheless the writer managed to cover important headings in history but didn’t ask further details on any possibility of Rh isoimmunization (a grave mistake). Time was limited and the examiner came up to the writer to signal that his time is up. Worth mentioning here is that there was no one at present observing my examination technique apart from the chaperone who was giving me tips every now and then. First the writer was asked to present the problem list the patient was having. This writer serially mentioned all problems found till the examiner stopped him when he mentioned about the pregnancy being post-dated (it was post-dated according to the patient’s LRMP). Examiner became furious when the writer told him the LRMP wrong and told the writer that she’d been given a newer date based on scans. He gave the new date and asked the writer to calculate the period of gestation (POG) which the writer got horribly wrong in the confusion. What followed was a series of insults and swears aimed at the writer and foreign medical graduates in general. To the writer’s dismay the other examiner was simply having a good laugh at the candidate’s predicament. Once the examiner exhausted himself from the banter, the theory questions started coming. The writer was asked to describe my management of this patient. When the writer told him that he’ll avoid oxytocics and ARM he flatly told the writer to tell him only what I’d do not what I’d avoid in a very arrogant manner. That let up to another round of abuses which went on till the bell was rung. This writer had effectively screwed up his obstetrics long case! Later this wrietr realized that he had not been the only victim that day. Spare the fairer sex endowed with the looks, all others had been blasted into oblivion by the very same examiner. N.B: Don’t be disheartened if you screw up a viva. There are many others who have done worse! Clinical Station 2 – Paediatrics Short case There were 3 paediatrics short cases the day this writer gave his exam. Usually the examiners will point out towards one. They had a Neonate, 5yr old child with respiratory distress & a 3 year old child with a cardiac problem. Writer was given the child with respiratory distress. The time allotted was 7 minutes for examination as well as discussion. After permission and quick rapport building with the mother this writer started examination from inspection; on which the child had obvious respiratory distress with flaring, recessions and rapid breathing. Next went on with auscultation skipping palpation and percussion as this writer feared that the baby might cry. The only findings noted were reduced air entry and movement on the right basal area without any added sounds. This writer could not comment about the vocal resonance though the percussion was slightly dull. Child did not have any IV cannulas in situ or a
mark of a pleural aspiration. The writer had 3 choices; either pneumonia, collapse or a pleural effusion. Child was quite active and afebrile. This writer switched on to pleural effusion and presented in line of it but made sure that no contradictory statements were made. In the end this writer mentioned that the “child’s having respiratory distress probably due to a pleural effusion which I would like to confirm with an x-ray”! The questions they asked were what are the types of effusions, age specific respiratory rates in children, how to detect exudate and transudate. Clinical Station 2 – Medicine Short case There were several medicine short cases namely; lower limb examination, upper limb examination (of the same patient), respiratory system examination. This writer received lower limb examination as the short case. The writer started with permission & a request for a chaperone as the patient was female. Followed the sequence of lower limb examination which revealed unilateral left sided UMNL type paralysis with hemi-sensory loss of all modalities! The examiners asked the writer to demonstrate the plantar reflex and the jerks. Was asked where the lesion could probably be whether in the spinal cord or above. The writer mentioned that the pattern of weakness is UMNL type so might have involved upper motor neurons. However this writer further mentioned that he would review history and perform a CT scan particularly focusing on the internal capsule area. Was asked why the writer would focus on that area for which he replied that internal capsule strokes typically affect the sensory neurons of contra lateral side as well as the motor neurons producing a clinical picture compatible with that of the patient. Discussion didn’t proceed further as the bell was rung. Clinical Station 1 – Medicine Long case The time allotted was 15 minutes with 7 and a ½ being for history and the rest for discussion. 2 examiners were present at that time marking individually. The case this writer received was a 72 year old female retired nurse complaining of low grade fever for 1 month, jaw pain and hemi facial headache. All in all it was a typical PUO case which made the history just a matter of completing the headings. The patient was extremely cooperative and threw everything at the writer. She was constantly mentioning about her jaw pain as if hinting to the writer that there must be something sinister related to it. However once history was completed the writer gave the open diagnosis of PUO with jaw pain and u/l headache! The questions thrown at the writer were; ddx of PUO? What investigations will you do in this patient? What will you suspect in this patient for which the writer mentioned TB. Next the discussion moved towards TB! The writer was asked about what type of TB would he suspect in this patient for which the writer replied probably post-primary pulmonary tuberculosis. Next was asked about the location of the disease in the lungs to which the writer mentioned that depending on the level of immunity the location will differ; namely better immunity will result in apical disease and poor immunity will result in basal disease. Next theory questions came on TB and about the clinical features one would expect in bronchiectasis and lung fibrosis! Just as the bell was about to be rung
they asked the writer if not TB then what other cause would result in such clinical picture for which the writer replied inflammatory causes. Writer was then asked to list the probable causes and his 1st choice was SLE and the examiners asked if the age is compatible for which the writer replied no. The writer was prompted to give examples for other inflammatory causes! Finally they asked the writer whether any procedures had been done on the patient which the writer had missed in the history. Then they mentioned that she has had a temporal artery biopsy and requested the writer to think about what inflammatory cause would warrant it in a PUO patient. When the writer was juggling up with answers with a blank look on the face the examiners simply informed the writer not to be afraid and that the case is a bit advanced for an undergraduate but however wanted to know whether the writer had heard of such conditions to award extra marks. After many clues and lifelines the writer finally blurted the Dx of polymyalgia rheumatica and was allowed to leave. Clinical Station 3 – Paediatrics Long case Again the same time limit was given and the case was a 10 year old child with fever and diarrhea for 2 weeks. The respondent was the aunt and not the mother (had to ask questions in social hx as to why the mother is not with the child at the moment) which lots of previous candidates had missed. The aunt was very cooperative and at one point listed out all the investigations done and mentioned that despite all those they still haven’t reached a diagnosis. Viola the writer’s immediate focus shifted on to PUO. However this writer ruled out dengue, leptospirosis and malignancy! The writer managed to impress the examiners by asking about notification done at the ward (PUO for more than 7 days should be notified) which they appreciated increasing the writer’s chance of passing the exam. Was asked what organisms cause fever and diarrhea? Can typhoid be a culprit (writer didn’t ask about possible typhoid exposure in history)? Next theory questions started coming in about typhoid and infectious mononucleosis; about detection and treatment. Writer’s personal experience in viva section The same examiners who came for the cases come for the vivas and 1st impression definitely counts. Emergency Vivas Viva section last for 15 minutes with 7 ½ minutes given for each section. Usually the examiners of both specialties (one from each specialty) would sit in the same place and poor performance in the 1st station would create a negative impression in the subsequent emergency viva. Medicine – Scenario was given about an elderly male coming to the ETU with fever, headache and patches all over body (meningitis picture) Was asked what investigations I would do and the initial management CSF picture of meningitis
Paediatrcis – Scenario was given about a 2 month old baby with respiratory distress. Was asked about clinical examination of the child, what signs will you look specifically in a child with respiratory distress? Initial management of this child? Oxygen delivery methods in children! Forensic medicine viva There were 2 examiners; one snobby female and a genteel gentleman. The gentleman taught us at ERPM JMO classes! Was given pictures and asked to describe! This writer received 3 pictures; one of a self inflicted stab wound to the chest of a female (was asked to describe the injuries on this one), another with bilateral raccoon eyes (was asked to list the causes of it) and the other of a decomposed body with a National ID by the side (was asked to discuss about identification in this one). The picture description part didn’t go well. The other examiner asked theory about the inquest procedure and asked what the writer would do if a patient gets admitted into the ward with multiple stab wounds! Community Medicine viva Candidate is given 15 minutes. Two examiners took this viva which became the most successful viva of the entire exam. The 1st question this writer received was where he studied from and what the most prevalent diseases there were to which the writer mooted TB! The examiners weren’t interested about TB (I was quite prepared to answer questions on TB) so I diverted the conversation into COPD! Then they asked about what causes COPD in the community to which I replied cigarette smoking and exposure to domestic smoke. They were extremely happy when I mentioned about cow dung burning as a source of firewood and its relationship to COPD. Then they asked the writer what he would do in his capacity to prevent COPD for which this writer replied that he would “target not those already with COPD but those who are at risk namely the unsuspecting school children who’re prone to develop the bad habit of smoking.” That was the passing point of the community viva. Next was asked about the levels of prevention. The other examiner asked about the EPI of SL. Asked whether the area that this writer lives has JEV coverage. Next question was whether the writer had visited an MOH and what were the activities conducted there! Lastly the examiner asked this wrier about statistics of SL (MMR, Life expectancy) and statistics of Nepal (where I studied) and what the reasons for lower life expectancy of females compared to males in Nepal.
Unknown facts about ERPM In Sri Lanka everything goes by merit and even the foreign students do have a merit order based on which they are given internship appointments. The cumulative percentages of both parts are used in the grading of candidates. The highest order of merit is given to candidates who pass both parts in one attempt (reason why it is important to attempt all papers/vivas in one go. Then the list is arranged so as to include candidates who have taken most number of attempts to pass in the bottom of the list. Those who are unfortunate to be in the bottom of the list get run down and far away stations during internship and post-intern period. So pass all exams in one go without being chronic. Candidates who pass part A in first attempt have an edge against others in the part B. Statistically ERPM completion rate is higher among those who pass part A in one go. The August 2011 Part A exam in which this writer sat saw 11 candidates passing part A in first attempt out of which 6 completed the Part B examination in January 2012 in their first attempt. Those who pass in the first attempt are allowed to sit for part B examination on the very first day thereby leaving 2 spare days to prepare for the Emergency Viva section after the completion of the clinical section which is less stressful for the candidate. There have been allegations regarding the transparency of the exam. On one occasion the ERPM part B pass list issued by the SLMC had 85 names whereas the merit list issued subsequently contained 87 names thus raising the issue from where the new names came from. In some cases there have been some malpractices but overall those who deserve to be passed pass where as the others get left behind. Writer has seen candidates who do not know about cranial nerves and those who tap the quadriceps belly when asked to look for knee jerk. Future trends in ERPM With the amount of attention this exam is receiving and the number of court cases pending, drastic change is likely to occur in the ERPM examination. The following have been proposed with regard to ERPM. 1. Standardization of the exam for all students foreign and local as they sit for a common MCQ paper This is being heavily debated in court and the final verdict has not been reached. 2. Decreasing the mark upto 40% This is less likely to materialize. Already mark has been reduced upto 44.5% and in this writer’s opinion that’ll put the standard of the MCQ exam in jeopardy. Even those who are blind will be able to score 40%! 3. Abolish the ERPM and conduct a familiarization course under authority of SLMC or any local university which is followed by an examination
The local medical fraternity will never agree to this policy. They might argue that local medical schools do not have a mandate to conduct private lessons via the university for foreign students. 4. Change the structure of ERPM. Namely omit true/false questions and have best of five type questions This point is also being heavily debated in court. 5. Recognize few overseas universities capable of a quality education and offer registration to its students sans examination The SLMC is also considering decreasing the number of exams conducted per year upto 2 from 3 at present as the local undergraduates have exams only twice a year. This policy is likely to materialize form 2013. At present a significant number of students follow medicine abroad which roughly amounts to 400 per batch. With the health ministry carder for medical officers diminishing gradually, the medical council might reduce the internship opportunities to foreign graduates citing priority to local undergraduates. If the current situation prevails there will be a time where there’ll be too many medical graduates in the country carrying placards forcing the authorities to grant them internship appointments!
End Notes What the writer has jotted down here is a rough outline of the monster we call ERPM. The suggestions are entirely based on writer’s own judgment and do not reflect the opinion of the SLMC or any one else. The writer sincerely hopes that this compilation would answer all queries candidates might have regarding ERPM. He does hope that his effort would be appreciated. He also requests those who find this small compilation useful, to circulate it among friends who are in need of advice. Writer has come across many selfish individuals while preparing for ERPM who’d misguide fellow students on purpose or withhold passing vital information regarding classes, clinics etc. He sincerely requests those who read this to help fellow students in passing ERPM without being selfish snobs. What goes around comes around. The writer wishes all readers success in the Examination for Registration to Practice Medicine/ Act16.
C.Y.A R.C 2004 A/L
