Success is sweet because the sacrifice has been so great

The week leading up to the final viva examination were awfully horrible days. I had taken annual leave to revise at home; but after 4 months of solid revision, I seemed to have completely and utterly run out of steam. I would get up at about 10am everyday, faff around for about 2-3 hours on youtube before finally forcing myself to sit down and stare at the books. The procrastination got so out of hand that I ended up having to eject myself from the house and its distractions to study at the nearest cafe. Nevertheless, the first couple of hours were always the least productive, and it would take me another 2-3 hours to learn the first topic of the day. My revision momentum would build up so painfully slowly, and I would only feel as if I was starting to get into the rhythm of things at about 7 or 8pm at night. The “real revision” then goes on till about 3 or 4 am in the morning before I decide that I have done enough for the day and probably deserved to go to bed.

Once in bed, I would proceed to “quickly” run through everything I learnt that day in my mind. The process was often not as quick as I had expected it to be, and regularly led to tangents whereby I would try and remember other things that I had learnt the day, week, or even month before. Going to sleep was never a conscious decision, and I was almost always led to dreamland only when the machinery that is my brain would “hang” mid-thought. Sometimes I would fall asleep, then suddenly jolt awake and begin to run through how I would anaesthetise a phaeochromocytoma, or a patient with chronic renal failure, or someone with hypertrophic cardiomyopathy (just checking if I had forgotten).

It was really a rough time that I thoroughly did not enjoy. The more I revised, the more things seemed to crop up that needed looking up. Learning about oxygen was never just about the gas itself. It would lead on to how oxygen is distilled from air, how it is stored, how it is transferred from the pipeline through the anaesthetic machine and to the patient, how it is measured. That would then lead on to a question on the oxygen cascade and oxygen carriage in blood. Which then brings us to the topic of indications for long term oxygen therapy, or hyperbaric oxygen therapy, and the effects of oxygen toxicity. Now, that is only on the topic of oxygen. Imagine expounding on every single other topic that is in the curriculum in the same way. My mind was completely and utterly saturated.

I remember evenings when I would feel so overwhelmed and anxious that my palpitations would kick off again. I remember the uncomfortable churning in my stomach as I struggled to cope with the knowledge of my lack of knowledge. I remember the one night when I prayed to God and sobbed my eyes out. It was all getting too much. I was physically, emotionally and mentally drained. My stamina was running out, but somehow I had to keep it all together. I must not peak too early, nor should I sink into a state of despair prematurely. I had to keep myself together and pace myself to reach peak form on the 24th of June.

Hobbo and I became a revision pair before the exam as well. Thanks to the wonders of technology, we could viva each other almost every evening via Skype. We tried to work through the past questions on the Coventry Final FRCA website, and sought to ask each other the harder & more unexpected questions that have previously come up. Somehow, we had to practice how to talk AROUND things that we knew nothing about. We had to dig deep into working things out from first principles, and learn to deliver an answer we are unsure of with an overwhelming confidence. I found that one of the hardest things to do.

I took the train down to London the day before the exam. En route, I worked through the College questions from the College guidebook. I managed 2 long cases, 2 short cases and 2 science questions… and then headache struck. The same headache I had when I was on the train down to London for my Primary viva 2 years ago. The headache that required me to close all my books and bury my head into folded arms on the table.

I eventually arrived in London and checked into my usual exam hotel at Studios2let. I revised a little more. I then headed off to Nandos for the usual pre-exam dinner, and as usual looked through R.Craig’s statistics notes as I ate. I must have gone through these exact same motions at least 3-4 times in the last 4 years. Anyway, I continued to do some more revision on one of the art installations outside Euston station that evening, and it was only after I had convinced myself that I could remember the Van Hoff’s equation for osmotic pressure that I decided it was time to head back to the hotel. More attempts at last minute cramming ensued, but I could simply put no more into my brain that day. I was completely spent, and all I was achieving was placing myself in a state of panic. I made the conscious decision to stop. Shower. Sleep.

The alarm clock rang. It was a signal to war. I got up and showered, packed, and prayed. As I cried out to the Lord, I could feel my teeth chattering, my hands trembling, my muscles stiffening up. Adrenaline and anxiety surged through me. The nausea I felt that morning made having breakfast a rather difficult and drawn out affair. I had no appetite to eat at all, but I knew I had to force this brain food down my gullet. Breakfast was followed by a long, slow walk to Red Lion Square with my luggage in tow. I did not feel good that morning- my head was not clear. I felt fuzzy. I knew I was not in top form. Had I gone past my peak? I contemplated this as I made my way to the college… and then something caught my eye. A passer-by emerged from a shop wearing a T-shirt emblazoned with the phrase “Success is certain.” That proved to be my motivation for the day, and I regarded that as a sign from God.

More palpitations, tachycardia, shortness-of-breath, and queasiness later, we were finally led to our exam. The morning exam was the clinical vivas. My long case was on an obese man with hypertension and a history of alcohol excess presenting for elective knee replacement. He was found to have an ejection systolic murmur and left ventricular hypertrophy on his ECG. I prepared my case as though he had aortic stenosis, only to be given an echocardiogram and cardiac MRI result during the exam itself saying that the valves were normal! So scrap aortic stenosis! Summon all knowledge on HOCM, on the spot! That was the route the exam went down instead.

My first clinical short case was on sepsis- fairly straightforward in my opinion.

The 2nd started with “What is Crohn’s disease? How does it present and how is it treated?” My heart sank- medicine! Flippin’ medicine! I’m trying to sit an anaesthetic exam here! Leave medicine to the medics! Anyway, I summoned everything I could remember about Crohn’s from my med school finals as a 4th year medical student 8 years ago. It was slightly painful. Thankfully, we moved away from general medicine and swiftly onto sedation practices for gastroscopies and colonoscopies. Not my hottest topic considering that I last looked up sedation guidelines 2 years ago- but it wasn’t terrible.

The final short case was on retained placenta. Great- I cover the maternity on-call ALL THE TIME so I should be hot on this. “What are your concerns pre-operatively?” I started with “the patient still has the physiological changes of pregnancy…” Nope, they didn’t want to hear that. “Bleeding.” What else? “Infection?” What else? I ran out of things to say. “How quickly does she need to come to theatre?” “Immediately if she is bleeding and haemodynamically unstable. As soon as is practically possible if she is stable- excessive delays should be avoided.” Not the answer they were looking for. “Within 75min?” They didn’t look happy. The examiner took me all over the place with this question, and kept coming back to “what are your other concerns?” I was so frustrated as I simply did not know what she was looking for. Thankfully, the final bell rang just in time to save me from the misery she was putting me through.

I left the morning exam feeling intensely dissatisfied. The exam just kept replaying in my mind, and the more I thought about it, the worse my performance appeared to be. I was convinced they had both given me a 0 for that last short case. That means I lost at least 4 marks just on that question alone. Assuming that I scored full marks for the other questions (which I was not sure I had), that gave me a budget of 4 marks to lose in the afternoon’s science exam- my weakest area, the very area that led to my failure the last time. That means I am likely to fail. Fail. Fail. Fail. I imagined having to undergo the hell that is revision and exams a 3rd time. I thought about how upsetting it would be to have to scrap my 30th birthday plans so as to revise for the December re-sit. I was miserable (even when eating lunch from my favourite Japanese fast food restaurant in London: Wasabi!).

After lunch, I went back to the college and sat in the lecture theatre for about an hour or so whilst waiting for the afternoon exam to start. I tried to put some last minute information into my (still fuzzy) brain. There were a couple of other candidates around me that afternoon, everyone desperately trying to keep it all together. Eventually, it all got a little bit too much. I needed to have a breath of fresh air, so I went outside to Red Lion Square and sat on one of the park benches there. I stopped myself from thinking about work, concentrating instead on how lovely and sunny it was, and how comfortable it was to feel the light breeze in my hair. Now and again a moment of panic would strike, and I would calm myself down by thinking of that “success is certain” sign I saw in the morning. Nick had also sent me a message that afternoon “Good luck Dr T! Keep going, you can do it!” YES I CAN. Keep the 3Cs J. Remember the story of the broken pencil. You are the worst judge of your own performance. Forget the morning, concentrate on the afternoon!

A gruelling 3 hours of waiting later, I went back to sit my afternoon exam. After putting my bag back into the locker, I thought “I should just quickly glance at the anatomy of the facial nerve…” Nevertheless, I struggled to find the appropriate page in my textbook… so I thought “oh screw it, I can’t be that unlucky.”

My anatomy viva started with “In which situations do we have to monitor cranial nerve function?” Flippin’ heck, I knew what they were going to follow up that question with. I kept my composure and started going on about monitoring facial nerve function in ENT surgery, 3rd and 6th nerve function in raised ICP, brainstem death testing, Guillan Barre Syndrome…” Then the question came “describe the anatomy of the facial nerve.” Great, I know nothing about it. I made some crap up on the spot, and even said that it exited the base of skull via the foramen magnum???!! (what an idiot). I was just about to lose it when I remembered some advice I received via email- move on! There are marks to be scored in later questions, don’t dwell on what you don’t know. So move on I did. We talked about the cranial nerves tested in each aspect of brainstem death testing, how recurrent laryngeal nerve function is monitored… we talked about loads of stuff, and even though I have never really encountered this question in my exam prep, I was surprised by how much I actually did know.

Then, the rest of the exam flew past and I knew I nailed the science. I was so thankful to God that nothing unexpected came up. We talked about the physiology of moving from the supine to lateral position in thoracic surgery, and causes of hypoxia in one lung ventilation. My pharmacology question was on drugs for diabetes and the treatment of DKA. I offered them 2 classification systems for insulin. How they are made (bovine, porcine or recombinant DNA), or how long their effects last (rapid, short, intermediate, long). They caught onto it and said “ok, so tell me about how insulin is made from recombinant DNA.” I had no idea, so I threw in any DNA-related jargon I knew. “I’m not entirely sure, but I assume that we hold the genetic code for insulin, and using codon-anticodon triplet matching, amino acids can be lined up in the correct order for expression of the insulin polypeptide.” Completely made that up, no idea if it is even true, but at least I think I sounded confident. They then wanted me to dig further into my knowledge as a foundation doctor from years ago and tell them about the times to peak effect and duration of action of each class of insulin. I wasn’t too hot on that, but could give vague timings based on memory. Finally, the physics question was on the safety features of vapourisers. I like the vapouriser topic, so didn’t struggle too much. I even offered to draw them a picture of the desflurane vapouriser! They asked about the effects of altitude on the functioning of vapourisers- something that I still cannot get my head around till this day, but I said what I knew (partial pressure unchanged, concentration decreased) and left it at that… I caught myself just before I went on to expound on my lack of knowledge.

I came away from the science exam feeling rather good. However, the dark cloud from the morning continued to loom over me as I sat in the Square Pig pub with Hobbo and Matt. The both of them were convinced they had failed. Honestly, they were so sad and angry. Hobbo had a different set of questions to mine and I can honestly say that he had a really bad set of questions. Apparently he had to tell them about the exact cytokines and local mediators and how their concentration changes in the presence of pulmonary hypertension (what??!). But the worst question has got to be “Tell me about Alzheimer’s disease and the drugs used to treat it” Are you for real?! An entire pharmacology viva on drugs for Alzheimer’s?? I’m not even sure that is in the curriculum. We have certainly not seen it in any of the anaesthetic textbooks. Hobbo said that he tried to direct his viva to talking about drugs for Parkinsons or drugs for depression, but they would have none of it. His examiner literally had to lead him to every answer “if they are very agitated what do you think they will need?” “If I told you that they are low in acetylcholine what do you think they may be on?” I felt sorry for him for having such bad luck.

1715hr eventually came, and it was time for us to return to the college for our results. I remember standing right outside the college’s glass doors panicking. I muttered under my breath “please let me see my candidate number on the grid, please let me see my number…” I paced up and down and back and forth feeling almost sick from the anxiety. Matt was worried sick too, and eventually came and put his head on my shoulders. That was when I whispered to him “shall we pray?” Matt nodded.

I’ve always known that Matt is a Christian, but we have hardly ever said much about Christianity or our faith to each other. That day though, I felt the overwhelming need to pray with him and for him. We have been through a heck of a lot of hell together for this exam. So there we stood, outside the door of the Royal College of Anaesthetists, heads bowed to our Lord and Saviour. 2 desperately anxious anaesthetists begging the Lord for peace.

And peace was bestowed. Almost instantaneously, I felt so much better. Through prayer, we were reminded that everything is in God’s hands. We need not fear nor tremble, for the Lord is sovereign over it all. That was possibly one of the most precious moments I experienced on that horrible day- the reminder that GOD IS IN CONTROL.

We eventually went inside to collect the “Success grid.” I peeled away from the others with my little sheet. I closed my eyes and took a couple of deep breaths. This was the moment of truth. Slowly, ever so slowly, I worked my way from the bottom of the grid upwards, scanning constantly for my candidate number…

AND I FOUND IT!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

Final SOE pass

I passed! I passed! I passed!

I turned around and saw Hobbo peering over at me. The moment I saw him, my face just crumpled up and I started sobbing and sobbing and sobbing. After trying to hold it together for the last few months, after all the fears and frustration, after all the sacrifices I have made, suddenly I have received relief. Hobbo hugged me. “Did you pass?” I nodded, and he held me even more tightly. With tears rolling down my cheeks, I looked up at him and asked “did you?” And YES HE DID!!! I was elated!! The Hobster and I have worked so so so so hard together. Right from the very start when we were building the structure of propofol from styrofoam balls and sticks, to our days revising for the primary viva exam at the women’s hospital, to the times spent working through final MCQ/SBA/SAQ questions with study gambling, through all the courses we attended together, failing the final viva exam last December, to the evening skype viva revision sessions we did together in the last few months… now we have both passed! Together! On the same day! Freedom is offered! I thanked the Hobbo for being my revision partner, and he said to me that “I couldn’t have done it without you either.” Such precious words.

We turned around to find Matt, and he had passed too! Group hug! We are now fellows of the Royal College of Anaesthetists. We are post FRCA. No more exams thank you very much. The thought of it, no more exams! This is all too good to be true. We are so elated. So joyous. So relieved. So thankful. Matt pulled me apart and said “let’s thank God together.” So there we stood, this time INSIDE the Royal College, as fellows, praising God and thanking Him for His goodness to us. Through the tough times when I was hospitalized with palpitations, and Matt needing a gastroscopy due to exam-anxiety related reflux, God has been faithful and led us through it all to this point. The point of relief. We are so thankful.

The people from the college then called out our names and candidate numbers so that we could form orderly rows. We listened to a retiring examiner give her speech to the newly appointed fellows (whoop! whoop!) and then proceeded to this strange college tradition whereby the successful candidates would go and shake the hands of all the examiners that day (they were all stood in a line). We were then offered the legendary glass of wine- the one that we’ve heard talked about so many times, the glass of wine of success. Not the finest of wines out there, but certainly the most expensive glass I have ever paid for– £2700 worth in exam fees alone (primary & final exams). That’s not even counting the money spent on books, courses, train tickets, hotel fees. Or my mental health and social life. That day, I had a change in mood… and it was only then that I realised how miserable I have been for the last 4 years. I had become so used to feeling so miserable that it seemed like the normal way to feel! Every single year had consisted of 3-4 months of exam prep, exam, rest for 2 months. Start revising for the next test again, exam, rest. And the cycle repeats. Now the cycle is broken. Thank God.

We were all so excited that evening. Matt was so excited that he even went on to (accidentally) smash his most expensive glass of wine onto the floor (silly thing)… but that did not put a damper on our spirits. We just could not help but address each other as Dr_____, FRCA. Whoop Whoop! It was a pleasure to sign in the register of the Royal College of Anaesthetists. Yes, my name is finally in the book. It is in the book! In the book! Whoop whoop! I was drunk on happiness and relief.

We took a tonne of photos that evening. Eventually, when we had savoured our time in the “pass room,” it was time to head back home. As we headed towards Euston station, we agreed that we will allow ourselves to relish in pride and maybe a little bit of arrogance that day and perhaps even the day after before getting back to reality (and humility of course). Because who are we? WE ARE CHAMPIONS!!!! There were so many smiles and laughter abounded that evening. Even our Burger King dinner at the train station tasted like it was manna from the heavens. This time, I wasn’t taking the train of shame back home- I was on the train for champions!

What a day to remember, and I probably will not forget this for a very long time to come.

Hallelujah, praise the Lord.