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  1. I D Wacogne, Chief Resident
  1. Royal Children's Hospital, Brisbane

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One of the earliest tasks of professional development in a career in paediatrics is to pass some exams. The FRACP—Fellowship of the Royal Australasian College of Physicians—is entered by paediatric registrars here at a comparable stage to their UK counterparts. FRACP is harder than MRCPCH; well that is what my FRACP colleagues tell me, and who am I to doubt them? To compare the two:

There is no equivalent to MRCPCH part I. Access to the exam is limited by a requirement to have completed 3 years of approved training, with permission from the college, granted by the Director of Physician Training. This honorary (but high maintenance) college position held at each tertiary teaching centre acts as an effective filter to entry.

The written paper in March is multiple choice. A two hour morning paper covers medical sciences; the three hour afternoon paper examines clinical applications including investigations, practice, and therapeutics. Two thirds of candidates pass; you don't “fail” this exam, but you may be “not successful”.

The clinical part is four months later, in July. This is a long run up, with huge training commitments generated by the registrars.

Examination centres are widely scattered, and candidates are not examined locally. This may mean a 4000 km, £400 round trip—fortunately tax deductible. Examiners combine local co-opted consultants and a college appointed group who move around the country during the exam week. Examiners attend calibration sessions to assess their style of marking There are long cases and short cases, but no viva. On exam day, each candidate sees two long cases—an hour with the patient, 20 minutes with the examiners for each—and four short cases, each 15 minutes. They start at about 9 am, and finish at about 4 pm, during which time they are examined by four different examining teams.

Long case patients are chosen with multiple different issues. Before the exam, the examiners spend forty minutes with the patients, and are asked to use the supplied notes as little as possible. A mature attitude to the assessment, differentiation of problems and plans for management of the complex patient is expected. Each long case is marked out of seven and are weighted threefold compared with the short cases.

Short cases, with 15 minutes per patient, are markedly different from the 5 or 6 minutes in MRCPCH. This format deliberately avoids spot diagnosis, making the point that this is a show-off skill, good in medical company but of relatively little value in real medical life. The focus is on methodical examination of the patient, eliciting subtle signs, and careful discussion. The examiners use just one short case for the morning, and one for the afternoon, four candidates each session. They've had 20 minutes with the patient before the examination starting, and prefer to examine on their own findings rather than the supplied notes. They will “reject” unsuitable short cases too—something an organising registrar needs to be ready for!

Each short case is marked out of seven. The clinical exam is marked out of 70; candidates need 40 or more to pass. Unsuccessful candidates are granted one further attempt at the clinical a year later. Overall, about two thirds pass, and each year a medal is awarded to the highest achiever.

Exams occur once a year; a significant stress to everyone involved. For candidates, failure means a setback to career plans for a whole year. For centres training registrars it means chunks of the year when many junior staff are utterly focused on the exam, and points when large numbers of people are away from work, being examined.

What would I take from FRACP and MRCPCH? I would:

  • remove MRCPCH part I, and put in its place a human filter to say “you are ready, you are not”. Of course, the revenue would go, which in an ideal world would not be a factor

  • Have 10 weeks between the written and clinical exam

  • Have one long case only, lasting an hour and weighted appropriately

  • Have four short cases, but they would each last 15 minutes

  • Have a 20 minute viva.

  • Hold exams twice a year, with the results a month before a national application date for jobs.

And I'd negotiate worldwide peace while I was at it.

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