Thoughts and Advice

The FRACP Written Exam

by Charco Azul




2011 Charco Azul. Some rights reserved. This work is
licensed under the Creative Commons Attribution-
NonCommercial 3.0 Unported License. Under the license this
work may be copied, distributed, transmitted and adapted as
long as proper attribution to the original author is included.
To view a copy of this license, visit
http://creativecommons.org/licenses/by-nc/3.0/
or send a letter to Creative Commons, 171 Second Street,
Suite 300, San Francisco, California, 94105, USA.

Published January 2011.

ISBN: 978 1 4467 8831 8
iii

Contents

Preface v

The Exam
Introduction 2
What is the pass mark? 8
The Questions 12
2010 Questions by Topic 13

Exam Resources
Why Journals? 16
Which Journals? 24
Finding Journal Articles 27
Other Resources 32
Exam Preparation Courses 40

Study Technique
How To Not Fail 48
Memory: Introduction 57
iv

The Testing Effect 61
The Spacing Effect 65
Practical Applications 72
More Memory Tips 77
Motivation 79

Afterword 85
v

Preface
This rather short book contains my thoughts on the
Fellowship of the Royal Australian College of
Physicians (FRACP) Written Exam. The content has
been adapted from the website www.fracpexam.com
which I built shortly after finishing the exam in 2010.
I can give no endorsement for the information here
other than I passed the written exam comfortably in
2010 at the first attempt. I also passed the clinical
exam. But that was luck.

I have tried to include all the things I wish I had
known when I started basic physician training. None
of this is guaranteed to make you pass of course, but
perhaps it will make you feel a little more in control
of the process. There are plenty of ways to get
through this exam, some easier than others. You
should be skeptical about what you read here, none
of it is intended to be taken as gospel. The exam
format and basic training structure is undergoing
vi

modification all the time, so be mindful that some of
this information may be out of date by the time you
read this. The text assumes you have access to the
past FRACP exam questions.

If you are still deciding whether or not to do
physician training, I would counsel against reading
any further. Would we do anything in life if we knew
exactly what we were getting into?

Please note that I have no affiliation with the Royal
Australian College of Physicians, nor does the college
endorse any of this books content. Neither am I
affiliated with any of the products or services I
discuss. I have not been paid or offered any other
incentives to write anything here. It is all is my
personal opinion, and is probably wrong.

I can be contacted at www.fracpexam.com or via
email examfracp@gmail.com. Charco Azul may or
may not be my real name.




The Exam

2
Introduction
So you're going to be a physician. It is a good choice
for those interested in using their brain to help
people, rather than making money or destroying the
planet. There is only one small problem. the
FRACP exam. It took me a fair while to understand
exactly what sort of undertaking this exam was. The
last exams I did were in University, and in hindsight
didn't seem so bad. The FRACP exam however is a
post-graduate exam and as such, differs from
University exams in several unfortunate ways. I have
listed some here for your enlightenment or
otherwise.

1. There is no real curriculum. The college
provides a curriculum of sorts, but it is not detailed
enough to be very useful. What to study then? This
seems like a hugely important question when you
start studying, but the answer is fairly mundane. Most
people end up studying some kind of internal
3
medicine overview such as the FRACP lecture series,
MKSAP or attending a 2 week preparation course.
After that, further study is guided by past exam
questions, reading journals, question banks (e.g.
Harrison's MCQ) and asking consultants what they
think is important. Textbooks are neither necessary
nor sufficient.

2. It is not a level playing field. In University,
everyone was in much the same boat, having been
taught the same stuff by the same people. This is not
the case here. Everyone is subject to a different set of
advantages and disadvantages. Some candidates have
young kids, others are single and live with their still-
doting parents. It is important to realize that
everyone has some kind of advantage. Don't get
bogged down in coming up with reasons why you
think you will fail.

3. Guessing which questions will be on the exam
doesn't work. When I was sitting the exam everyone
4
was sure there would be a question about progressive
multifocal leucoencephalopathy and biologic agents.
There was no such question of course. There is only
one way to predict which topics will be
examined: reading journal articles. There are
definitely questions from journals, it is not merely a
vicious rumour. Not only that, there are some
questions which require you to have read a specific
line in a specific journal article. I think that journals
are neglected as a study resource.

4. You have to study for a relatively LONG time.
It is vital to appreciate this point. University style
study methods, which typically involve a lot of
cramming, are poorly adapted to 2 years of
preparation followed by one apocalyptic exam. See
the sections on study technique and memory for
some ideas on how to cope with this.

5. The study material is bottomless. This is an
unprecedented time. Sitting on the couch with your
5
laptop, you can access a very large portion of all
recorded medical knowledge. Some of you will try
and study all of it. I would recommend against this.
In general I have found that the major problem is
achieving sufficient breadth of knowledge rather than
depth. Try and keep this in mind as you find yourself
reading about ways to prevent fungal outbreaks
during hospital construction works or memorizing
the base pair sequence of the HIV genome.

6. It is difficult in the beginning. When starting
out, the task seems insurmountable. You are
confronted with 1700 past exam questions, some of
which contain words you have never heard of and
investigations you never knew existed. In the
beginning, nobody else knows how to interpret
oesophageal manometry either. It will get easier.

7. The exam is psychologically taxing. I for one
wasted a large amount of time either studying in a
halfhearted fashion, or simply not studying at all
6
because I was convinced that I would fail. Life is
better if you can avoid this. Looking back, all it did
was waste time and cause burn-out. I hate to say it,
but you have to try and be positive. The benefits of
being positive are not trivial:
You get more study done with less effort.
You will be less burnt-out by the end.
The process will be less stressful for your
friends and family.
You will hate your job less or even not at all.

8. The written exam is difficult, but not
genuinely difficult. Negotiating peace in the Middle
East is genuinely difficult. Nuclear non-proliferation
is genuinely difficult. Flying to Mars is genuinely
difficult. I consider the clinical exam to be genuinely
difficult. In all these examples, certain situations can
be out of your control, multiple people are involved,
unforeseeable factors are at play, and despite trying
as hard as possible, the result is far from certain.
7
Although the written exam is of course quite
difficult, I think ultimately you are in control of your
result. It can be passed with the right preparation.
Take heart from this, and worry about the clinical
exam and the nuclear holocaust later.
8
What is the pass mark?
In 2010 the pass mark was 85 out of 150. The
bottom mark was around 50 and the top mark
around 130. The average mark was around 90. Apart
from the pass mark all these figures are approximate
and based on the graphical representation the college
gives you as feedback post exam. The college does
various complex things to calculate the pass mark.
The impression I have is that not all questions are
treated equally. Some questions that are considered
to discriminate between good and bad candidates are
weighted more heavily, but that is speculation.

The exam mark is out of 150 rather than 170 because
there are 20 questions repeated from past years that
are not counted. 2010 was the first year they did this
and the process will be the same in 2011. I think this
highlights the point that going through all the past
questions and studying them in detail is becoming
9
less valuable. I only reviewed the last two years' past
exam questions in any great detail.

Thinking about your mark is only useful in giving
you an idea of what to aim for. Taking 2010 as an
example, you needed 85 out of 150 to pass. It is likely
that an average candidate will be reasonably sure of
the answer to about 25 questions. That leaves 125
questions to get the remaining 60 points necessary to
pass, meaning you need slightly less than 50% of
those 125 questions. Another way to think about it is
that if you can narrow the possible answers down to
2 for those 125 questions, chances are you should get
50% right. Unless you always choose the wrong
answer.

To summarise: you are aiming to narrow the
possible answers down to 2 for the majority of
questions in the paper, plus be reasonably sure of the
answer for perhaps 1 in 5 questions. This should be
sufficient to pass. Further study and practice are
10
useful only in improving your chance of choosing the
right answer. Aiming to answer each question with
certainty will only lead to disillusionment. In going
over past questions with colleagues or consultants
you will soon appreciate that the answers are often
not clear cut. Your goal is to be able to guess right a
little over half the time. Some may say this is a nice
analogy to making decisions as a physician.

This perspective may be unpalatable to some. There
is this quixotic notion that during basic training one
should study to become a good physician and not
just to pass the exam. This assumes that (A) you are
motivated to study very hard, for years, without the
exam breathing down your neck and (B) the exam is
a fair and honest assessment of your readiness for
advanced training. I will leave you to consider the
validity of these assumptions. All I can say is I
learned more studying for this exam than I have at
any other time of my life and there is no way I would
11
have studied with the same application in the absence
of the exam.
12
The Questions
As I said in the introduction, predicting which
questions will be on the exam and studying to those
areas probably doesnt work. Candidates have been
predicting there will be a host of questions on
monoclonal antibody therapeutics for years, all to no
avail.

Below is a breakdown of the questions from each
topic area in the 2010 papers. This isnt my
classification, it comes on the feedback sheet you get
from the college after the exam.

It is worth noting that there are more psychiatry than
clinical epidemiology questions. I spent no time
studying psychiatry, and a lot of time studying clinical
epidemiology/statistics. Having said that, statistics
questions are fairly standard e.g. calculating
sensitivity and specificity, whereas psychiatry
questions seem rather random.
13

2010 FRACP Questions by Topic
Cardiology 13
Endocrinology 12
Thoracic Medicine 12
Haematology 11
Neurology 11
Rheumatology 10
Clinical Pharmacology 9
Geriatric Medicine 9
Immunology & Allergy 9
Medical Oncology 9
Gastroenterology 8
Nephrology 8
Clinical Genetics 7
Intensive Care Medicine 7
Infectious Diseases 6
Psychiatry 5
Clinical Epidemiology 4
Dermatology 0
Palliative Medicine 0








Exam Resources
16
Why Journals?
I think journals are overlooked as a study resource -
they are the one place from which questions are
directly taken. These questions are often difficult in
that they require very specific knowledge you are
unlikely to have without reading that particular
article.

An example is the infamous amyloidosis question,
question 32 in the medical sciences paper in 2008. I
cant reproduce the question for copyright reasons. It
is about the identity of the protein components of
amyloid plaques. This question appears to come
from the editorial Advances in the Treatment of
Amyloidosis. Rajkumar SV and Gertz MA, N Engl J
Med 2007, 356(23):2413-2415. The article contains
the following sentence:

Studies of compounds that bind serum
amyloid P component (SAP), an essential
17
constituent of all forms of amyloid
deposits that constitutes 5 to 10% of their
weight, suggest the possibility not only of
depleting SAP from the fibril but also of
causing regression of amyloid deposits.

Ill leave it to you to look at the real question.

On reviewing the 2010 paper, there were 18
questions that seemed to be very closely related to a
journal article from the preceding 2 years. I will list in
the next few pages the references to journal articles I
think gave rise to questions. Some of these
associations may occur by chance of course, but it
gives you an idea of the sort of articles you should
read. Notice that all these articles are review articles
or editorials. In my experience, it is not necessary to
read actual trials in detail for the exam.

You have probably also heard rumours that the
college uses journal articles from the last 2 years or
18
so before the exam to generate questions, and the
listing here supports this. The newest article is from
October 2009 which is perhaps a bit late (this may be
a chance association), the oldest June 2007. Most of
the articles are from 2009.
19
2010 Medical Sciences Paper
(Paper 1)

Silverman EK, Sandhaus RA. Clinical practice.
Alpha1-antitrypsin deficiency. N Engl J Med. 2009
Jun 25; 360(26): 2749-57. Review. PubMed ID:
19553648.

DuPont HL. Clinical practice. Bacterial diarrhea.
N Engl J Med. 2009 Oct 15; 361(16): 1560-9.
Review. PubMed ID: 19828533.

Nelson MR. From research and guidelines to the
consultation: five ways to improve blood
pressure management in clinical practice. Med J
Aust. 2009 Jul 20; 191(2): 111-2. PubMed ID:
19619100.

Reece EA, Leguizamn G, Wiznitzer A. Gestational
diabetes: the need for a common ground. Lancet.
20
2009 May 23; 373(9677): 1789-97. Review. PubMed
ID: 19465234.

Krum H, Abraham WT. Heart failure. Lancet. 2009
Mar 14; 373(9667): 941-55. PubMed ID: 19286093.

Tess AV, Smetana GW. Medical evaluation of
patients undergoing electroconvulsive therapy.
N Engl J Med. 2009 Apr 2; 360(14): 1437-44.
Review. PubMed ID: 19339723.

Cooper LT Jr. Myocarditis. N Engl J Med. 2009
Apr 9; 360(15): 1526-38. Review. PubMed ID:
19357408.

Young GB. Clinical practice. Neurologic
prognosis after cardiac arrest. N Engl J Med. 2009
Aug 6; 361(6): 605-11. Review. PubMed ID:
19657124.

21
Jeruss JS, Woodruff TK. Preservation of fertility in
patients with cancer. N Engl J Med. 2009 Feb 26;
360(9): 902-11. Review. PubMed ID: 19246362

Leitz N, Khawaja Z, Been M. Slow ventricular
tachycardia. BMJ. 2008 Jul 3; 337: a424. doi:
10.1136/bmj.39489.687894.DE. Review. PubMed
ID: 18599467.

Pamer EG. TLR polymorphisms and the risk of
invasive fungal infections. N Engl J Med. 2008
Oct 23; 359(17): 1836-8. PubMed ID: 18946070
22
2010 Clinical Applications
(Paper 2)

Tapson VF. Acute pulmonary embolism. N Engl J
Med. 2008 Mar 6; 358(10): 1037-52. Review. PubMed
ID: 18322285.

Lucey MR, Mathurin P, Morgan TR. Alcoholic
hepatitis. N Engl J Med. 2009 Jun 25; 360(26):
2758-69. Review. PubMed ID: 19553649.

Boden WE, Taggart DP. Diabetes with coronary
disease--a moving target amid evolving
therapies? N Engl J Med. 2009 Jun 11; 360(24):
2570-2. PubMed ID: 19502646.

Fraser WD. Hyperparathyroidism. Lancet. 2009 Jul
11; 374(9684): 145-58. Review. PubMed ID:
19595349.

23
Nava S, Hill N. Non-invasive ventilation in acute
respiratory failure. Lancet. 2009 Jul 18; 374(9685):
250-9. Review. PubMed ID: 19616722.

Casaburi R, ZuWallack R. Pulmonary
rehabilitation for management of chronic
obstructive pulmonary disease. N Engl J Med.
2009 Mar 26; 360(13): 1329-35. Review. PubMed ID:
19321869.

Lim W, Eikelboom JW, Ginsberg JS. Inherited
thrombophilia and pregnancy associated venous
thromboembolism. BMJ. 2007 Jun 23; 334(7607):
1318-21. Review. PubMed ID: 17585161

24
Which Journals?
The college exam guidelines give a list of journals
that one should read:

Annals of Internal Medicine
Internal Medicine Journal
The American Journal of Medicine (not JAMA)
The British Medical Journal
The Lancet
The New England Journal of Medicine
Medical Journal of Australia
New Zealand Medical Journal

Not all journals are created equal however. In order
of exam relevance, I would rank them as follows:
1. The New England Journal of Medicine
2. The Lancet
3. Internal Medicine Journal, The British Medical
Journal
4. Medical Journal of Australia
25
I read no articles from the Annals of Internal
Medicine, The American Journal of Medicine or the
New Zealand Medical Journal, and I must say, this
didnt seem to affect my performance much. I am
aware of at least one question from older exams that
came out of the Annals of Internal Medicine
however.

It is a myth that reading journals means reading
clinical trials. Thankfully, most questions seem to
come from review articles or clinical practice articles
(see previous section for examples). Questions that
do originate from clinical trials in general do not
require much detailed knowledge other than the
major result of the trial or some safety issue
identified with the treatment.

Finally, if you cant bring yourself to read journal
articles, the New England Journal of Medicine has
continuing medical education questions. Some
26
candidates found these useful for answering
questions in the exam. See here:
http://www.nejm.org/continuing-medical-
education/
27
Finding Journal Articles
I never sat down and read every review article in
NEJM from September 2007 to September 2009, as I
didnt really have time. My usual practice was to
search for review articles on a particular topic
amongst the journals listed by the college (see
previous section). For example, if I wanted to learn
about sarcoidosis, I figured the highest yield method
would be to search for any review articles rather than
reading UpToDate or in desperation, a textbook. I
have outlined here how to do this in a semi-efficient
manner, should you like to do the same thing. To get
a closer look at the pictures, links and search text, see
the website at:
http://www.fracpexam.com/2010/09/journals-3-
finding-articles.html

1. Go to PubMed MeSH at
http://www.ncbi.nlm.nih.gov/mesh
28
2. Search for your topic of choice, in this
example sarcoidosis.
3. Select the appropriate search term from the
results list.
4. In the Send to drop down list above the
results area, select Search Box with AND.
See below for how it should look.
29
5. After doing the above a box with
Sarcoidosis[Mesh] in it should appear. Paste the
following text after the search term in the box.
This will search in all the college listed journals.
You can copy and paste the below text from this
document, otherwise see the corresponding entry
at the website.
AND ("The New England journal of
medicine"[Jour] OR "Lancet"[Jour] OR
"BMJ"[Journal:__jrid2274] OR "Internal
medicine journal"[Jour] OR "The Medical
journal of Australia"[Jour] OR "The American
journal of medicine"[Jour] OR "Annals of
internal medicine"[Jour] OR "The New
Zealand medical journal"[Jour])

30


6. The screen should appear as above. Click the
Search PubMed button.
7. The search results should appear as they do on
the next page. You can filter the results to be
review articles only by clicking on the Review()
link under Filter your results: on the top right
hand corner.
31

32
Other Resources
Apart from journal articles and review courses, which
Ill discuss in a later post, there are various other
resources that I found useful. Some of these were
books, and I have listed these below. Note that we
pay a fortune for books in Australia, and I found it
much cheaper to order them from overseas rather
than buy them here, even with shipping costs. You
could also use the library of course.
Ganong WF. Review of Medical Physiology. 2005,
22
nd
ed, Lange Medical Books.
Has the right amount of detail. I used it to read up on
physiology concepts necessary to understand clinical problems
such as hypopituitarism.

Hancox B, Whyte K. McGraw-Hill's Pocket Guide
to Lung Function Tests. 2005, Australian ed,
McGraw-Hill Book Company Australia.
Great book. Covers it all for interpreting lung function tests,
plus blood gases and cardiopulmonary exercise testing. Has
33
example problems. Very practical, light on theory and
equations.

McDermott MT. Endocrine Secrets. 2009, 5
th
ed,
Mosby.
Bit American, but good if endocrinology is a weakness for you.

Champe PC, Harvey RA. Lippincott's Illustrated
Reviews: Biochemistry. 2008, 4
th
ed, Wolters
Kluwer.
Good overview if you need to revise the basics of DNA
replication, lipid/cholesterol synthesis etc. Has quite a few
clinical correlations (e.g. mismatch repair defects and cancer).

Lumb AB. Nunns Applied Respiratory
Physiology. 2005, 6
th
ed, Elsevier.
Very detailed (and expensive), which I found necessary to
understand some respiratory physiology like the concept of
oxygen delivery, VQ mismatch, shunting.
34
Birkett, D. Pocket Guide: Pharmacokinetics
Made Easy. 2009, Australian ed, McGraw-Hill Book
Company Australia.
Virtually all you need for pharmacokinetics. Short, which is
an advantage. Has example problems.

West, SG. Rheumatology Secrets. 2002, 2
nd
ed,
Hanley & Belfus.
Has detail on diagnostic patterns and management issues I
couldnt find elsewhere, worth looking at if you are weak in
this area.

There are a few Australian websites which
disseminate detailed guidelines on various conditions,
and these can be useful. They are usually under the
education/guidelines/training/professional
information section of the website.

Australasian Society for HIV Medicine (Also
good for viral hepatitis)
http://www.ashm.org.au/
35

Cardiac Society of Australia and New Zealand
http://www.csanz.edu.au/

NHMRC guidelines
http://www.nhmrc.gov.au/guidelines/health_guideli
nes.htm

Gastroenterology Society of Australia
http://www.gesa.org.au/

Australian Society of Clinical Immunology and
Allergy
http://www.allergy.org.au/

The Thoracic Society of Australia and New
Zealand
http://www.thoracic.org.au/

36
Other sites I found useful:

UpToDate Youve probably heard of this one. Well,
if you learn everything in UpToDate, you would have
a good chance of passing not just the FRACP, but
every post-graduate medical exam on earth. It takes
discipline to use effectively however, otherwise you
can spend many hours clicking on the next link and
learning nothing. I used it to study small, slightly
more esoteric topics like the use of
immunosuppressants in pregnancy, the role of
complement in glomerulonephritis, or diarrhoea in
HIV patients. The pathophysiology sections are
often very good also.

Harrisons Online I dont want to give you the idea
that textbooks are completely useless. I used
Harrisons online because I found it easier to manage
than the ominous weight of the hardcopy. The
upside of the online version is that you can search it,
there are updates, and you get 1000 review questions.
37
The downside is that one years subscription costs as
much or more than the hard copy. Again, dont try
and read the whole thing, I think thats a waste of
precious effort.

DermNet NZ (http://dermnetnz.org/) Good
dermatology site, although do take note of the zero
dermatology questions in the 2010 exam.

Johns Hopkins ABX Guide
(http://hopkins-abxguide.org/) Infectious diseases is
a little bereft of decent resources. This site has
concise info on clinical problems in infectious
diseases (e.g. brain abscess), various pathogens and
antibiotics. Requires free registration.

Biopharmaceutics and Pharmacokinetics
(http://www.boomer.org/c/p4/) Fairly maths heavy
pharmacokinetics site, if you are into that kind of
thing. Can be useful in trying to puzzle through the
more calculation intensive pharmacokinetics
38
questions in past papers. There have been fewer and
fewer of these sorts of questions lately. I do not
remember doing any difficult calculations in the 2010
paper.

Some people use the Medical Knowledge Self-
Assessment Program (MKSAP), now up to
version 15. It is an internal medicine overview, which
also has a lot of multiple choice questions. These
arent really FRACP exam type questions. It is
probably a good option if you are the sort of person
who wants to grind away for a period of at least 12
months. The questions are advantageous in that they
test whether you have learned the material properly. I
looked at it briefly and in my opinion, it is not
sufficient as a stand alone resource. Going through
the questions only and not all the course material is a
good option.

The college has a lecture series called the Physician
Education Program, which I would also recommend.
39
You will get an email about it after you register for
physician training. It is something largely passive you
can do in the first year of training. To be honest, in
the 6 months before the exam, I found I was too
busy to sit through more than a few lectures. Exam
relevance is patchy at times, so remember there are
no prizes for watching every minute of every lecture.
Aside from the exam however, the lectures are a
unique resource, as they are delivered by experienced
physicians and physician-scientists currently
practising in Australia.
40
Exam Preparation
Courses
There are some great written exam preparation
courses out there. They give you something to work
towards, which is important in an otherwise very
lengthy lead up to the exam. It may seem ridiculous,
but having two weeks off to go to a course is the
only guilt free holiday you get. I will discuss here the
three courses I attended, all of which I found to be
very useful.

Immunology4BPTs (Sydney)
http://www.immunology4bpts.com/
Held over a weekend in Sydney each year at
Westmead Hospital. Put together by David Fulcher,
a real life Professor of Immunology, physician and
college examiner. I found this course to be very
worthwhile. It is clear that much effort has been
made to gather feedback from candidates and
41
optimize the content and format of the lectures. It
covers the fundamentals of the immune system,
immunodeficiency syndromes, allergy and
unexpectedly, has a brilliant section on HIV. In fact,
they pretty much cover almost everything you need
to know about HIV. There is a good discussion of
advances in biologic immunotherapies such as
basiliximab, CTLA4 agents etc. Content is very
digestible. There is a quiz at the end. Supplied full
colour lecture notes are excellent and constitute an
immunology textbook without the waffle. The course
is also good fun, and actually has some healthy food
options (unusual on the preparation course circuit).

DeltaMed Written Exam Preparation
Course (Melbourne)
http://www.deltamed.com.au/
This is also a very well run course and has been going
for a long time. There are 10 days of lectures during
weekdays over two weeks. It is an intense period, but
is also a break from the grind of your work-study-
42
sleep lifestyle. The powerpoint slides of all the
lectures are given to you on paper each day, along
with some practice MCQs. There are several
kilograms of notes to take home afterwards. The
content is a mixture of basic core material and
discussion of hot topics. In general they get the
balance right between these two. The lecturers are
mainly physicians. Many are heads of department and
research leaders, but there are also some senior
registrars and fellows. I wouldnt be put off by this,
as the registrars lectures are often the most detailed
(the 200+ slide diabetes lecture is a case in point).

At the end of the two weeks is a 70 question mini-
exam. All the marks are collated and a distribution of
scores published, so you can see how you went
compared to everyone else. The year I went to
DeltaMed, we finished late on the last day which
severely restricted the time for the mini-exam,
leaving less than a minute per question. The point
here is that the mini-exam is not exactly an objective
43
measure under exam conditions of how you are
going to do in the real thing.

A question that everyone asks is can you pass the
FRACP exam if you only study review course
material? First of all, what study means exactly is a
crucial point. If you hope to just cram all the
DeltaMed notes alone, I would say you are definitely
at risk of failing. If you study the notes in detail,
make sure you are actually learning what you are
studying, fill in areas that are lacking from other
sources, practice past exam questions and participate
in a study group, I would say that you have a good
chance - especially for certain topics, and especially
for the clinical applications paper (Paper 2).

The ability of DeltaMed to act as the primary or even
sole study resource varies with the topic. The
Cardiology lectures were fairly comprehensive I
thought, but the Neurology lectures less so. This is
not a problem with the course as much as it is with
44
trying to learn Neurology, which has a profusion of
small to large topics you need to know in varying
detail.

A recent development is that DeltaMed is happening
much earlier in the year (September 19 30 in 2011),
whereas the New Zealand and Sydney courses occur
later in November as they always have. You need to
tailor your approach to which course youre
attending. Feedback that I have from colleagues
suggests that no one course is particularly better than
the other.

Some people attend a review course in their first and
second years of basic training. I think this is probably
unnecessary. Enjoy your holidays in first year while
you still can.
45
DeltaMed MCQ Weekend
(Melbourne)
This is held at the end of January, about 4 weeks
before the big day. The format is two days of short
lectures which start off with 20 or so multiple choice
questions on a particular topic for you to attempt,
followed by a lecturer discussing each question in
turn and giving some background to the answer.
There is an identical course held in Sydney a week
after the Melbourne course.

I thought the practice questions in this course were
all good exam style questions, and in fact one of the
practice Cardiology questions was virtually
reproduced in the real written exam in 2010. The
function of this course is to boost your knowledge in
highly examinable areas just before the real exam,
and it serves this purpose well. There is another
mini-exam at the end and the distribution of results
is later published for you to see where your score lies,
if you dare to do so.












Study Technique
48
How To Not Fail
It is important to be honest with oneself about this
exam, especially when it comes to study technique.
You will realize very quickly that time and effort are
precious, scarce commodities. By the end I found
that effort rather than time was the limiting factor in
my preparation. This is doubly true for the clinical
exam. You need to make each bit of study count.

I spent many hours worrying about failing. Not so
much whether I would fail, but rather whether I was
the sort of person destined to fail. In the end, I think
that there are two reasons why people fail. But first
of all, here is my list of fake reasons candidates make
up to convince themselves they will fail:

A lack of intelligence.
Eradicate this kind of thinking as soon as possible
and focus on the idea that with the right preparation,
any human can pass this exam. Other species may
49
have trouble, although a chimpanzee in a suit has a
good chance in the clinical.

Super-intelligence or extreme nerdiness of other candidates
Again, this kind of self-defeating rhetoric is a waste
of time. Nobody finds this exam easy. Nobody is
born understanding conditional probability in genetic
pedigrees. There are only the prepared, and the
unprepared. No other distinction matters.

Being too busy at work
Were all busy. Trying to find reasons why you are
the most disadvantaged candidate in the southern
hemisphere achieves little.

Not studying enough in medical school
Nothing I learned in medical school helped with this
exam. Maybe that does mean I didnt study enough in
medical school. Either way, I think what you did in
medical school is largely irrelevant to this exam.

50
Not having done a rotation in a particular specialty
Not a problem in my experience.

Now for the real reasons why I think failure occurs.
Note that both of these issues can be fixed, whereas
none of the fake reasons are amenable to
modification.

1. Not doing enough study.
This may seem obvious, but unfortunately only
becomes clear in retrospect. Sacrifice is necessary.
Everyone will tell you that work-life balance is
important, but I never had a good sense of what this
meant. Most of the people I know who passed spent
at least the 3 months before the exam studying
constantly, only taking breaks to work, sleep and
engage in some kind of brief semi-regular leisure
activity, like going for a jog or out to dinner. In the
last couple of months I basically studied until I
couldnt study anymore. By the end I had 3400 flash
cards based on: 300 journal articles/guidelines, the
51
preparation courses, UpToDate, Harrisons online
and the text books listed in the Other Resources
section. That many flash cards are probably
equivalent to something like 400 pages of (succinct)
written notes, with 10 or so facts per page.

Time management is not my strong point. I am sure
there are candidates out there who with discipline
and dedication, balance large amounts of high quality
study with an active and full life. I just havent met
any of them (Perhaps they are all in New Zealand?).
Im not disciplined. I didnt waste any time
pretending that I would transform myself for this
exam. I knew that I would be doing the bulk of my
study in the last three months, and I managed to
secure a whole 4 weeks of holidays just before the
exam. I probably did something like 250 hours of
study during that month, and by the end I was nearly
insane and 12 kilograms lighter. I would not
recommend this approach unless you lack discipline
52
and are an incorrigible procrastinator. Even then I
would not recommend this approach.

2. Wasted study.
Some candidates fail, and dont know why. The
reason is probably studying the wrong material or
studying ineffectually. It is the most concerning
problem and the one that can sink you even if you
work hard. The key to avoiding it is feedback. The
number one problem with this exam I think is the
lack of feedback about your progress during the
prolonged preparation period. How else can an
apparently intelligent medical professional who
works hard possibly fail this exam, barring illness or
personal crisis?

As offensive to your scholarly sensibilities as it may
be, the first question you should be asking yourself
all the time is: Am I studying examinable
material? Here are some ways to get feedback about
this, none of which are rocket science.
53
Past exam questions: The most important of
course. You should always study in close proximity
to the past questions. The actual content of the old
questions is not as important as getting a feel for the
types of questions they ask and the necessary breadth
and depth of study required to answer them.
Remember that past questions do not count towards
your mark anymore. I would counsel against saving
up a past paper to do as a practice exam close to the
real thing, as I think there is far greater value in
perusing the questions earlier.

Study groups: Universally considered to be useful,
however some group dynamics can be a set back.
Small groups are better, and by that I mean four
people or less. I only had one other person in my
study group (in other words, we were a study pair),
and it worked very well. Youre chance of getting
everyone in the group in the same room together is
inversely proportional to the number of people in
your group. Aside from much needed support and
54
motivation, a good group can provide you with
feedback on how your own study is going.

Consultants discussing past MCQs: I found this a
useful exhibition of how to think about questions.
You may have to organize this yourself if there is no
precedent at your hospital.

Topic based MCQs: MKSAP has questions broken
down by subtopics. It is possible therefore to study
something like scleroderma, and then go and do the
MKSAP MCQs on scleroderma. This is useful to
some degree, but the MKSAP questions are
dissimilar to (that is, easier than) the FRACP MCQs,
so dont be lulled into a false sense of security. The
Harrisons review questions are broken down into
broad specialties such as Nephrology or Cardiology,
which is a bit less useful.

The second question you should be asking yourself
constantly is: Am I studying effectively? Are you
55
remembering the material, and are you learning it
sufficiently well to apply it to answering questions (or
treating patients)? Whole books have been written
about how to learn, and Im not going to try and go
into it here in detail. It can mostly be summarized as
you dont learn very much just by reading, so try and
do something with the material like writing summary
notes, asking questions, reworking it as a diagram,
discussing it with your study group, drawing a mind
map, reminiscing about all the patients you could
have managed better with this new found knowledge,
doing MCQs about that particular area and so on and
so forth. In the end, the best way to obtain feedback
on your study effectiveness is to test yourself on
what you have studied recently.

I think most people have their own reasonably
effective study methods by now, and dont have too
many problems in understanding the concepts. The
critical thing for this exam is to add in feedback. The
best way to obtain feedback on your study
56
effectiveness is to test yourself on what you have
studied recently. It turns out that testing yourself has
many benefits, particularly with regards to long term
retention, but more on that in the coming sections.

57
Memory: Introduction
It is necessary to have a rigorous and efficient
approach to remembering. It is an unpleasant feeling
to study something in detail only to find that down
the track you cant remember much at all. There is
no doubt you do have to remember a lot. Perhaps in
medical school (Australian ones anyway) you could
get through by mainly learning the concepts and
looking thoughtful in PBL groups, but not here. And
virtually everyone complains that they are forgetting
most of what they are learning when preparing for
this exam. Candidates accept this as inescapable,
invoke tentative diagnoses of early dementia and
continue studying in the same fashion.

However, there are some lessons from psychology
research on memory that I found helpful in studying
more efficiently. I will try and summarise these here.
My only qualification for this is the research on
memory I undertook while I was procrastinating
58
before the exam. I am not pretending to have done a
detailed literature review by any means, nor do I have
any expertise in psychology whatsoever. Ideally
therefore you should examine the provided
references yourself. This article at the New York
Times online: Forget What You Know About Good
Study Habits
1
also gives a good overview.

I should start by distinguishing between recall and
understanding. Learning requires a mixture of both. I
don't think there is any doubt that you have to spend
the necessary time to understand a particular
concept. There is little hope in recalling the features
of type I renal tubular acidosis for example, if you
have not taken the time to understand the physiology
behind it. In general, I don't think most people have
great difficulty understanding most of the material
necessary for the physician's exam, although some

1
http://www.nytimes.com/2010/09/07/health/views/07mind.html

59
areas are notorious in this respect, such as genetic
pedigrees.

On the other hand, I think many trainees, myself
included, have trouble remembering things. For most
of my life, I haven't worried too much about being
able to recall information in the long term, assuming
it to be something that happens automatically while I
am doing real study. Memorization to me meant rote
learning (e.g. writing things out a hundred times,
doing 'look-cover-write-check') and that was
something I used to do in grade 3, not in university
or post-graduate life.

This attitude is wrong however. Remembering
requires devotion and attention all its very own. It
won't happen by itself. How good is your memory of
something if you look at it once? The answer is: as
bad as the next person's. Experiments with
memorizing nonsensical groups of letters first
performed by the 19th century German psychologist
60
Ebbinghaus revealed that recall decays steeply down
to a rate of 10 - 20% or less after a week
2
. This is
probably even lower if you are an exhausted, sleep
deprived doctor. Studying for the exam obviously
doesnt involve memorizing nonsensical groups of
letters for the most part, but the point is that briefly
studied, unfamiliar material not linked to other
information will be forgotten very quickly. The
realities of forgetting are not compatible with a study
program where you only look at something once or
twice and hope to remember it for the exam in
several months. I should acknowledge the old
training page of the Australian and New Zealand
College of Anaesthetists for initially pointing this
concept out.

In the next section, I will discuss in more detail two
important discoveries about human memory that can
improve the efficiency of a study program: the
testing effect and the spacing effect.

2
ber das Gedchtnis, 1885
61
The Testing Effect
The essence of the testing effect is as follows: If you
want to remember, you have to practice
remembering.

Now, what does this exactly mean? Say you read a
text and find the indications for treatment of
hyperparathyroidism. You read it two or three times,
then move on. The next day, or maybe in a week you
may read the article again, and there it is, the list of
indications for treatment of hyperparathyroidism,
looking quite familiar by now. Then you don't look at
it again until the exam.

Thinking about it, you have never actually practised
remembering/recalling the indications for treatment
of hyperparathyroidism. You could look at the list
everyday for the rest of your life and never practise
remembering it. Remembering is not looking at
something and basking in its familiarity. That is
62
recognition. Remembering, which I will refer to as
recall for the sake of clarity, is the process by which
you extract some piece of information from
'memory' in response to some need, which could be
the need to manage a patient or the need to answer a
question in this exam.

By changing one small thing however, you can
improve your long term retention and study
efficiency. Instead of looking at the list to revise it,
ask yourself: What are the indications for treatment
of hyperparathyroidism? The difference may seem
trivial, but by doing the latter and testing yourself,
you have to actually retrieve the information.
Research shows that the simple act of retrieving the
information improves long term retention, and this is
the so-called testing effect. The seminal paper
regarding this effect was published in the journal
Science
3
(if you don't read journals much, Science is
one of the most important basic science journals in

3
Karpicke JD, Roediger HL. The critical importance of retrieval for
learning. Science 2008, 319:966-968. PDF at http://goo.gl/I2oi6
63
the world). The paper showed that by incorporating
testing of every memory item immediately after
studying a list of items, participants achieved 80%
retention after one week, compared to about 35% for
those that were not tested on each item. This was
regardless of how many times the list items were
looked at.

When I first employed testing as a revision method, I
was somewhat perturbed to find that most of my
study was going down the drain. I wasn't retaining
the vast majority of what I had studied. My usual
method of studying was masking this, because I was
never actually testing my ability to retrieve
information until I had it tested for me in an exam or
some botched clinical encounter. Apart from
improving long term retention therefore, the testing
effect has the additional benefit of providing
feedback (before the exam) on how well you are
learning. This is key if you want to avoid failing due
to ineffective study.
64

This discussion is largely drawn from the book
chapter: Roediger HL, McDermott KB, McDaniel
MA. Using testing to improve learning and
memory. In Gernsbacher MA, Pew R, Hough L,
Pomerantz JR. (Eds.) Psychology and the real world:
Essays illustrating fundamental contributions to
society. 2011, pp. 65-74, New York: Worth
Publishing Co. (PDF at http://goo.gl/jPgTi). I
strongly encourage you to have a read of the above. I
wish I knew this stuff 25 years ago.
65
The Spacing Effect
The testing effect indicates that the best way to revise
something is to test yourself. But how often should
this testing take place?

First of all, the best time to try and recall something
is when you have started to forget it
4
. Another way to
put this is you gain the most from practising recall if
that recall is difficult. Of course, the natural reaction
when you have difficulty recalling what you have
already learned is despair. However, the research
suggests you should be pleased if you have half-
forgotten something, as this is the ideal time to revise
it. So-called 'error free' repetition where you haven't
forgotten anything has a greatly reduced impact on
long term retention. As counterintuitive as it may be,
revising as early and as frequently as possible is NOT
ideal.

4
Roediger HL, Karpicke JD. (in press). Intricacies of spaced retrieval:
A resolution. In Benjamin AS (Ed.), Successful remembering and
successful forgetting: Essays in honor of Robert A. Bjork. 2011, New
York: Psychology Press. PDF at http://goo.gl/hONza
66

There is no definitive conclusion on the optimal
schedule to make recall attempts
4
. There are three
options when scheduling revision:
1. Don't revise at all (more fun, but not
recommended)
2. Revise material at equally spaced intervals (e.g.
every 5 days from the learning event)
3. Revise material at expanding intervals (e.g. 5,
15, 35 etc days from learning event)
The research suggests that there is not too much
difference between options 2 and 3, as long as the
first recall attempt is difficult
5,6
. Therefore, when
doing expanding interval repetition, the first recall
attempt should not be too close to the learning
event, even though that sounds illogical. Note that

5
Roediger HL, Karpicke JD. (in press). Intricacies of spaced retrieval:
A resolution. In Benjamin AS (Ed.), Successful remembering and
successful forgetting: Essays in honor of Robert A. Bjork. 2011, New
York: Psychology Press. PDF at http://goo.gl/hONza
6
Karpicke JD, Roediger HL. Is expanding retrieval a superior method
for learning text materials? Memory & Cognition. 2010, 38:116-124.
PDF at http://goo.gl/iY6m6
67
when you are trying to learn a large amount of
material, equally spaced recall starts to become
impractical.

It has also been shown that after attempting recall,
getting feedback by viewing the correct answer
improves long term retention
7
. You should also
continue to revise questions even if you feel you
know the answer well. Treat memory like playing an
instrument. Being able to recall requires you to stay
in practice.

Interestingly, a Polish engineer called Piotr Wozniak
made many of these discoveries about the spacing
effect by trial and error and experimenting with his
own memory
8
. He created an algorithm designed to
space repetitions in an optimal fashion, and this has
been incorporated into computer flash card software
designed to simplify the process. Essentially the

7
Kang SH, McDermott KB, Roediger HL. Test format and corrective
feedback modulate the effect of testing on memory retention. Euro J
Cog Psych. 2007, 19:528-558. PDF at http://goo.gl/XN6Es
8
http://www.wired.com/medtech/health/magazine/16-05/ff_wozniak
68
algorithm employs an expanding schedule of retrieval
attempts, but spaces the first retrieval attempt to
make it more difficult.

The spacing effect has been found to operate in rats
9
,
and a tyrosine phosphatase that mediates the effect
has been discovered in flies
10
.

In addition to memory, the spacing effect also
applies to learning per se. Is it better to spend 20
minutes today learning the steroid hormone synthesis
pathway, or to spend 10 minutes today and 10
minutes in 3 or 4 days time? The answer seems to be
the latter. Therefore, setting arbitrary limits like I
have to finish this chapter by 2 am.' probably doesnt
help much. Trying to learn everything in one session
is called 'massed learning' in cognitive psychology

9
Sisti M, Glass AL, Shors TJ. Neurogenesis and the spacing effect:
learning over time enhances memory and the survival of new
neurons. Learn Mem. 2007, 14:368375.
http://www.ncbi.nlm.nih.gov/pubmed/17522028
10
Pagani MR, Oishi K, Gelb BD, Zhong Y. The phosphatase SHP2
regulates the spacing effect for long-term memory induction. Cell.
2009, 139:186198. http://www.ncbi.nlm.nih.gov/pubmed/19804763
69
parlance. Learning something over a series of
sessions is called 'distributed learning'. Cramming is
an extreme form of massed learning. I hope you've
realized by now you can't cram for this exam.

The spacing effect has been applied to medical
education
11
. There are a variety of studies showing
that education programs employing the spacing
effect are better than massed learning in urology
residents and consultants
12,13
, help medical students
learn physical examination
14
, and have persistent
although modest effects at 2 years after being
applied
15
. The methodology of spacing varies

11
Larsen DP, Butler AC, Roediger HL. Test-enhanced learning in
medical education. Med Ed. 2007, 42:959-966. PDF at
http://goo.gl/lNTem
12
Kerfoot BP et al. Randomized, controlled trial of spaced education
to urology residents in the United States and Canada. J Urol. 2007,
177(4):1481-7. http://www.ncbi.nlm.nih.gov/pubmed/17382760
13
Kerfoot BP et al. Interactive spaced education to assess and
improve knowledge of clinical practice guidelines. Ann Surg. 2009,
249(5):744-9. http://www.ncbi.nlm.nih.gov/pubmed/19387336
14
Kerfoot BP et al. Interactive spaced-education to teach the physical
examination: a randomized controlled trial. J Gen Intern Med. 2008,
23(7):973-8. http://www.ncbi.nlm.nih.gov/pubmed/18612727
15
Kerfoot BP. Learning benefits of on-line spaced education persist
for 2 years. J Urol. 2009, 181(6):2671-3.
http://www.ncbi.nlm.nih.gov/pubmed/19375095
70
somewhat in these trials. In one method, a question
illustrating a learning point is presented at time zero,
repeated one week later and then four weeks later. In
another, the question would be repeated at 7 week
intervals. The most elaborate study was recently
published
16
. It was a randomised trial of the authors
own version of spaced learning. Instead of presenting
a bolus of learning materials all at once, questions
with learning points were sent out in a spaced
fashion over the course of a semester. It showed that
utilising the spacing effect improved long term
retention and had greater learning efficiency, albeit to
a modest degree.

Harvard University has created a website called
Spaced Ed
17
which offers spaced learning programs.
Their system presents questions with some
associated educational material and feedback on your

16
Kerfoot BP et al. Online spaced education generates transfer and
improves long-term retention of diagnostic skills: a randomized
controlled trial. J Am Coll Surg. 2010, 211(3):331-337.
http://www.ncbi.nlm.nih.gov/pubmed/20800189
17
http://www.spaceded.com/
71
answer. If you get a question incorrect, it is repeated
in 8 days. Correct questions are repeated after 20
days. If you get the question right twice, the question
drops out from the revision schedule.

To summarise: the spacing effect provides a
guiding principle for optimizing revision and also
learning. There are a variety of ways of implementing
the spacing effect which can provide different levels
of long term retention. In the next section, I will
discuss how I applied the testing effect and the
spacing effect to preparing for the FRACP exam.
The best method for a particular individual requires
some experimentation on their part, but I think that
more intensive revision schedules like the one I
describe below are better for this exam, where a large
amount of material has to be learned.
72
Practical Applications
To recap, my interpretation of recent memory
research is as follows:

1. To recall something, you have to practise
recalling it by testing yourself.
2. The best time to practise recall is when you
have started to forget.

How to apply these two principles in practice?

I used a free computer flash card program which
incorporates the above effects. It is called
Mnemosyne
18
. It runs on Windows or Mac OS. The
program allows you to write a series of question and
answer pairs. You can leave a question 'unlearned'
and look at it again later in the day or the next day.
Once you feel you know the answer, it enters into
the repetition phase. The program will automatically

18
http://www.mnemosyne-proj.org/
73
space out learned cards for you to look at again
according to Wozniak's algorithm which marries with
what recent research has shown is optimal. The idea
is to open the program every day and go through the
day's cards. The window brings up the question
without displaying the answer. After trying to come
up with the answer, you click a button to show the
answer. The program also allows you to grade how
difficult it was to recall the answer. Difficult
questions are repeated sooner and easier ones later to
try and keep things efficient. There is some
randomisation involved, but usually a question will
come up for the first recall attempt 4 - 5 days after
learning. The program can deal with you missing a
day or several weeks even, although the number of
cards for you to revise builds up pretty quickly.
Questions/answers can include pictures as well as
text.

I didn't write any notes much. I would read a text
and write question/answer pairs in Mnemosyne as I
74
went. This was the most efficient way to study that I
could come up with. The other great thing about this
system is it takes care of planning revision for you,
and becomes something routine you can do every
day at any time. You can also keep the revision
schedule going after the written exam until the
clinical or even beyond - Wozniak's algorithm is
actually designed to continue throughout an entire
lifetime! Be warned though, it takes inhuman
motivation to continue this after the exams are over.

The downside to this system is you have to study
with a computer all the time. It is also difficult to
draw your own diagrams/flow charts. I got around
this by drawing a diagram on paper and then
referencing it as the answer to a flash card. The other
problem is that all your work is stored on the
computer, which is subject to technical failure. You
MUST back up the flash card library regularly (I used
an external USB hard drive). This is NOT negotiable.
Losing all your thousands of cards (and there will be
75
thousands) 1 month before the exam is a stress you
do not need. The most reliable way of backing up
would be to a remote source, such as a USB drive
you keep in your car for example, or by uploading
the flash card library file to a free online storage
service, such as Dropbox
19
.

Another downside to this system is that you can get
lazy and just go through writing questions without
really learning or understanding the material. Flash
card programs are mainly a revision tool, not a
learning tool.

Mnemosyne is not the only spacing effect flash card
program. Others I know about are Anki
20
and
SuperMemo
21
. SuperMemo is Piotr Wozniak's own
program. It is not free and is much more complex to
use than Mnemosyne. There are online flashcard
services that incorporate the spacing effect, such as

19
http://www.dropbox.com/
20
http://ankisrs.net/
21
http://www.supermemo.com/
76
Flashcarddb
22
. Be mindful however that websites
can shutdown at any time without warning, and any
content you upload there may not be secure. Smart
phone apps for Anki and Mnemosyne are available,
check their respective sites for more information.

22
http://flashcarddb.com/
77
More Memory Tips
Don't reread. If you want to learn something, just
read it over and over again right? This strategy is not
supported by evidence. Several studies indicate that
rereading is not an efficient study method and
produces poor long term retention compared to
other methods
23,24
. You would be better off reading
something once carefully and spending the rereading
time formulating questions, drawing a diagram,
lecturing your dog, relating it to other material and so
forth. Not sure if highlighting or underlining adds
much to rereading (although I know many of you are
very devoted to highlighting). Personally I don't see
the benefit of daubing thousands of important facts
in exactly the same lurid yellow.


23
Weinstein Y et al. A comparison of study strategies for passages:
Re-reading, answering questions, and generating questions. J Exp
Psych: Applied. 2010, 16:308-316. PDF at http://goo.gl/isWYG
24
Callender AA, McDaniel MA. The limited benefits of rereading
educational texts. Contemporary Educational Psychology. 2008,
34(1):30-41.
78
Draw pictures, remember better. This may seem
obvious, but there is robust research to support this
fact
25
. So draw diagrams and flowcharts, and seek out
resources that have pictures such as NEJM reviews.

Exercise. Aerobic exercise improves cognitive
performance, attention and memory
26,27
. This is
remote from the exercise, so you don't have to study
right after jogging to get the benefits. Getting fit is
also something positive you can take away from the
period of exam preparation, rather than just
exhaustion and bitterness.

25
Shepard RN. Recognition memory for words, sentences, and
pictures. Journal of Verbal Learning and Verbal Behavior. 1967, 6(1):156-
163.
26
Lambourne K, Tomporowski P. The effect of exercise-induced
arousal on cognitive task performance: a meta-regression analysis.
Brain Res. 2010, 1341:12-24.
http://www.ncbi.nlm.nih.gov/pubmed/20381468
27
Smith PJ et al. Aerobic exercise and neurocognitive performance: a
meta-analytic review. Psychosom Med. 2010, 72(3):239-52.
http://www.ncbi.nlm.nih.gov/pubmed/20223924
79
Motivation
I should be disqualified from writing about
motivation. I couldnt even get motivated enough to
write this, someone had to force me into it. All I can
offer is a description of my failed attempts at
motivating myself. In hindsight, my multiple false
starts, relentless procrastination and fanciful time-
wasting may contain some lessons about behaviour
change. I stole all the real ideas about behaviour
change in this section from a presentation by the
Stanford Persuasive Tech lab which can be found at:
http://www.slideshare.net/captology/stanford-
6401325

1. One day one of my senior colleagues said to me,
You want to get motivated for this exam? Ill tell
you something. If you fail then you will spend
another year as a basic trainee. Pass first time
however and you will become a consultant one year
earlier which means getting paid at least an extra
80
$100,000 for that year. Think about that! I did think
about it, and it did not motivate me in the slightest.
Lesson: Behaviour is not connected to the
part of your brain that deals with rational
thought. Elaborate justifications for studying
hard and getting your act together may not
have much impact.

2. At the start of 2009 (the year before I sat the
exam) I took a whole month of annual leave. I had
not done any serious study before this time, or even
thought much about the exam. My plan was to spend
the whole 4 weeks studying, building up to a furious
pace that I would continue over the next 12 months
until the exam. During the 4 weeks I studied for a
total of 30 minutes.
Lesson: Where to start with this one? First
mistake was I tried to make a quantum leap
from doing no study at all to studying at 100%
capacity. Humans dont seem to respond to
this kind of colossal change very well. Would
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you ask your binge eating, alcoholic, chain
smoking patient to give it all away at once?
Success is more likely in achieving small
incremental goals. Second mistake was I didnt
really appreciate that no behaviour happens
without some kind of trigger. When you wake
up in the morning, you need something to get
you started studying. Just deciding to do it
does not work. Later on the trigger for me was
looking at the days flashcards, which quickly
became a habit. Social triggers can work
particularly well, which is why a study group
can be a good source of motivation.

3. Sometimes I would drive home blasting Led
Zeppelin on the CD player and shouting at myself I
can do this. I can pass this exam. I WILL study. I
WILL BE GOOD. I WILL I WILL I WILL. I
would then go home and proceed to do no study at
all.
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Lesson: Consider carefully whether the will
to succeed is really a concept that holds water.
After expending much willpower over the
years, I think it may not actually exist.

4. One of the things I used to waste a lot of time
doing was just surfing the net aimlessly. I decided to
get a computer stopwatch and see how much time I
was wasting. This stopped me from surfing the net
so much, but instead of spending the new found time
studying, I started rereading my childhood comic
book collection.
Lesson: Here I was trying to stop a bad
behaviour in the hope that good behaviours
would fill the void. This is like hoping that
Bono will become the new leader of North
Korea when Kim Jong Il dies. In practice you
are more likely to succeed by actually getting
started on good behaviours rather than
avoiding bad behaviours. There is an endless
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supply of bad behaviours out there, better to
stick with the ones you know.

5. Endocrinology was one of my weak areas. I really
wanted to learn Endocrinology. I told myself this
every day for about 9 months and never got started.
Lesson: Broad, open-ended goals rarely
succeed. How does one learn Endocrinology
after all? Try and set specific tasks such as
review guidelines on inpatient management of
diabetes or learn the pathophysiology of
obesity. The more specific the better.

6. I really want to be a physician. I want to be good
at my job. I want to contribute to society. I want to
get on and pass these exams. Why the hell cant I do
any study then? What is wrong with me? Am I
broken?
Lesson: I may well be broken, but if you are
having trouble getting started on something, it
probably means the task is too difficult. Find
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ways to make it easier, rather than deciding
you are an unmotivated, hopeless sod.
Organize triggers, set specific goals, take
smaller steps.
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Afterword
Thanks for reading. I hope you have found some of
this helpful. Keep things in perspective and help your
colleagues if you can.




I hope for nothing.
I fear nothing.
I am free.
- Inscription on the gravestone of Nikos Kazantzakis