Ann. din. Btochem. 13 (1976) 399-402
How to Pass Examinations: a Personal View on Good Technique in Clinical Biochemistry Examinations ALAN
M.
BOLD
Clinical Chemistry Department, Queen Elizabeth Hospital, Birmingham, B15 2TH
Elementary faults in examination technique are commonly displayed by candidates who have worked hard for the examination. Advice is offered on answering multiple-choice questions and "essay" questions and on how to tackle oral and practical examinations. A candidate's preparation for an examination should include the submission of written work and the taking of a mock oral examination for critical assessment by a supervisor. Carefulwritingup of practicalwork in the home laboratory is important, so that faulty technique can be corrected early in training. Above all, stress is laid on the importance of mastering the technique of effective communication for success hoth in examinations and in later professional life. There is no substitute for hard work and a wellorganised programme of study for an examination. That said, it might be argued that for mature candidates the essentials of the technique of passing examinations are obvious. Unfortunately year after year similar elementary faults are committed-by medical students, medical and science graduates, and by experienced technicians. Successive formal reports and informal grumbles by examiners have a familiar ring, pointing to poor examination technique in the industrious student as well as inadequate preparation as a major cause of failure. The remedies, though obvious, still appear to need stressing.
learnt much from working and talking with a variety of examiners, though not all would necessarily endorse all my suggestions. MULTIPLE CHOICE QUESTIONS (M.C.Q.s)
This is not the place to debate the pros and cons of M.C.Q.s. They are widely used because they cover many aspects of a subject, in general correlate well with other forms of examination (Anderson et al., 1965; Young and Gillespie, 1972), and require minimal time for marking. There are fundamental limitations of M.C.Q.s., though it may be hoped that examiners have themselves learned from early criticisms and now set better questions ATTITUDE TO EXAMINERS (Gibson, 1969). Examiners are human. From time to time they Advice on tackling M.C.Q.s can be reduced to: may be inconsistent, unjust, or out of date, and (1) Familiarise yourself with the type or types of these defects are an unavoidable feature of exam- format employed in the examination you are taking. inations which are rightly criticised (Bull, 1956; Previous papers are not usually available but you Lennox et al., 1957). Pappworth (1975), who has are entitled to obtain examples of all types of question extensive experience of teaching candidates for the set. (2) Consider the general sense of the question. examination for membership of the Royal College Undoubtedly candidates who are unusually well of Physicians, is as usual stimulating and forthright informed are occasionally penalised by a slip-shod in painting a cynical picture of examiners. Those question, but they may contribute to their downfall who share his views will enjoy his positive but by an unnecessarily literal interpretation of the astringent comments. However, virtually every question. Doubtless words such as "usually", examiner with whom I have worked has been con- "often", and "typical" are imprecise and should not scientious and self-critical, and happier when be used, but when they are you should interpret as passing rather than failing a candidate. Like other best you can with common sense. (3) Guess sensibly. people examiners can become irritated by a candi- In some schemes marks are deducted for wrong date's foibles, among which I would class verbiage. answers. Nevertheless in some questions the possible Unlike Pappworth I have never met an examiner answers can easily be reduced to two or three. Again, who marks essay questions by weight. you may with confidence be able to eliminate all Each candidate must make up his own mind answers except one of which you know nothing; it about examiners; your decision on this dictates the would be reasonable to select it (Lennox, 1975). general approach to answering questions. Advice Whatever may be the ethics of examiners using a offered here is necessarily a personal view. I have system encouraging guesswork, a candidate will do 399
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Alan M. Bold
better on average by judicious guessing than by restricting answers solely to those questions which can be answered with certainty.
ORAL EXAMINATION
For some the oral examination is more unnerving than the rest of the examination. Few candidates believe it, but most examiners are well aware of the limitations of an oral examination (Waugh and Moyse, 1969). In my experience it is used to find extra marks, if possible, to pass a borderline candidate, and it is unusual for a candidate who has clearly passed the rest of the examination to be failed because of indifferent performance in the oral examination. The following points might help: (1) Avoid making a bad impression by slovenly appearance or wearing outlandish garments. (2) Answer questions as promptly as possible. Take a little time to plan your answer, but avoid appearing dim by treating the simplest question with suspicion and answering only after lengthy pondering. (3) Answer the main point or points of the question without prevarication. It is sound advice to keep talking as long as you can, provided what you say is relevant. It is most unwise to take a roundabout, verbose route to get to the point the examiner really wants answered. It is best therefore to give a brief answer to the question, and then expand on those aspects about which you are well informed. Donat gratuitously introduce subjects you are not prepared to discuss further. (4) If you can only answer part of the question, press on as far as you can; don't hesitate just because you don't know everything about the question. If you cannot answer a specific question, it is best to admit you don't know. (5) Don't hesitate to ask for clarification if you don't understand the question. (6) Sometimes you may make an error, or a slip of the tongue. Many examiners appreciate that you may talk nonsense in the stress of the moment and give you a chance to retract-"Do you really believe that?" While you should not bank on this as an indication to change your mind, at least treat it as a hint to reconsider rather than as a subtle trap to lure you into error. (7) Be courteous without being obsequious. If you seriously disagree with an examiner, make your point calmly and logically. (8) Never give up, assuming you have failed. Examiners attempt to make some allowance for nervousness. Also, occasionally examiners ask very good candidates, who arc bound to pass, difficult questions to see how they respond. Do not throw in the sponge just because you can't answer one or two questions.
"ESSAY" QUESTIONS
Although the rare single question to be answered in three hours should be treated as an essay, most so-called essay questions are nothing of the sort. The typical two or three hour paper, with say four to six questions to be answered, allows little time for the expansive approach of the essay. What is required is a succinct, structured account including as many relevant facts as possible. Lengthy introductions, long winded ness, padding with information which may be true but is irrelevant to the question as set, and unbalanced answers are probably the most common faults. Of course, good examination technique is of little avail to the candidate who simply does not know enough to answer the question, but some candidates fail adequately to communicate the knowledge they have to the examiner. I have attempted to summarise advice. (I) Answer every question required. It is extremely difficult to answer some questions so well that you compensate for omitting one question or leaving very little time to answer one question. This particularly applies when examiners employ a close marking system, in which, say, 40% might be a bad fail and 60% a very good answer. No marks can be given for an unanswered question. While it is unrealistic to spend exactly the same time on every question, you must allow adequate time to answer all questions. There can never be any excuse for failing to observe this golden rule. (2) Answer every part of each question. Frequently a question has two or more parts. Judge whether they are equally important or not, and adjust your effort accordingly. It is a serious error to omit part of the question. (3) Stress the important and the common. Too many candidates fail to profit from routine experience. Avoid undue emphasis on fascinating rarities. (4) Answer the question set; do not recompose the question to suit yourself. While not all examiners are equally successful in indicating precisely what is required in a question, the question is worded as it is for a reason. If you are in doubt take a commonsense rather than literal view of the question. If it is really ambiguous choose another question. Suppose for example, a question is worded, "Discuss recent advances in the understanding of calcium metabolism." It is true that the word "recent" is imprecise, and you must attempt to judge whether you should concentrate on say the last two, five, or 10 years. Nevertheless an answer which began with a historical survey and discussed at length work more than 10 years old would get little credit. In this question "recent" is a key word. If you don't know the recent advances, avoid the question, even if you
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A personal view on good technique in clinical biochemistry examinations 401
can write pages about the old advances in calcium metabolism. (5) Plan your answer. You must ensure that all important points are covered and roughly allocate time accordingly. If you can achieve it, a logical structure to the answer is desirable. Pappworth specifically advises against planning an answerthis is unconventional advice. It is imporant, however, not to devote more than three or four minutes to jotting down your plan. (6) Use specific examples when possible; do not waste time with vague generalities. You would get few marks for writing, "A wide variety of different types of error may occur if a 24-hour collection of urine is not made satisfactorily". Give examples: for instance, "A serious error may be introduced in making a 24-hour urine collection if an incorrect or no preservative is used, if some of the specimen is inadvertently discarded, or if at the start of the collection the patient does not empty the bladder." (7) Use acceptable means of conveying the maximum of information in the minimum of space. Unfortunately not all examiners agree on what is acceptable. As a personal opinion, standard abbreviations are acceptable-for instance, e.g., i.e., and standard chemical abbreviations such as ATP and cAMP which are widely used in scientific journals. When in doubt, if you want to use a word or chemical term repeatedly, the first time write it in full with your abbreviation in brackets. Lists, tables, figures, diagrams, equations, and metabolic pathways are helpful to you in conveying much information succinctly, and they also aid the examiner. It may be true, as Pappworth points out, that such devices help the examiner spot your errors and omissions. A careful examiner will probably find them anyway. (8) Do not pad with irrelevant information or empty verbiage. I believe that an answer of two pages with all the main facts will earn more marks than the same number of facts diluted over 10 pages. (9) Examination questions may be prefaced by a variety of words or phrases such as "discuss", "describe", "outline", "write a critical account of." You should attempt to interpret the distinction, though in practice the requirement is usually, "write all you can in the available time about ... , and a critical approach to any subject is always desirable, whether specifically requested or not. (10) Answering in the form of notes other than lists, tables, etc., is not recommended. However, if you do misjudge the time available, the use of notes, provided they are comprehensible, is preferable to leaving important points unmentioned. (II) Good communication is the essence of examination technique as of so much of modern
life. Work at avoiding those things that impair communication-an obscure, or loquacious style, or poor grammar. Bad handwriting may be hard to cure, though choice of a pen which assists legibility rather than expresses personality would help some people. (12) Conventionally candidates are advised to read through their answers. Pappworth (1975) advises against this and is surely right. It takes too long, you are unlikely to spot many significant errors, and the time would be better spent in writing. Obviously if you do have time to spare, it is profitable to check what you have written. PRACTICAL EXAMINATIONS
Although performance in practical examinations is largely determined by basic laboratory training and skill, few candidates do justice to themselves in the way they plan and write up their practical work. Comments will be restricted to clinical chemistry examinations. Advice may be subdivided into planning the work to do, and writing up the work completed. Planning
Study all the questions. Only experience can help you make an estimate of how long each section will take. It is helpful to draw up a rough flow diagram of the overall plan of campaign. You may sometimes be able to tackle each question sequentially, but plan your work so that any lengthy gaps (for colour development, electrophoresis, chromatography, etc.) are filled in either by writing up work completed or starting work on the next question. Good organisation, which usually derives from good practice in routine laboratory work, can enable you to write spectrophotometer readings directly into a neat table in your answer book, avoiding scribbling on scraps of paper. Where time and available glassware permit, perform all analyses in duplicate. Do not forget the precautions you would normally take in your home laboratory, such as use of a quality control serum (request this if it is not provided) or analysing diluted and undiluted samples in parallel for determinations such as urea, glucose, or certain serum enzymes, where extremely high values may occur. Writing up
Candidates too often ignore the obvious fact that examiners can mark only what is on paper. The frequent poor quality of written practical work may reflect poor training and practice in the routine
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402 Alan M. Bold laboratory work. The essential requirement is that the examiner can discover easily and unequivocally what the candidate has done. An answer consisting of, for example, a series of spectrophotometer readings, personalised hieroglyphics, and the statement "The serum rhubarbase = 102 U/litre" is worth little. Do not waste time writing down the method you have been given. Do make it clear what concentrations of standard solutions are used, what dilutions if any have been made to serum, and what procedures you have adopted that are not specified in the given method sheet. Calculations should be clearly set out. Brief explicit statements and comprehensible tables are required, not purple prose. To illustrate these points: Suppose a question had been set on determining glucose in standard solutions and plasma "Y" from a fasting patient, by Bloggs's method. Table 1 and Fig. I illustrate Table 1. Typical presentation ofunlabelled data Blank
.04 .1 .19 .24 .32
1 2 3
4
.4 .46
5 6 8 10
.56 .65 .8
ny"
Plasma Y
=
.06 .15 .2 .28 .36 .42 .52 .61 .76
10.85
the written practical work of an imaginary but not impossibly rare sort of candidate; the technical side of the work has doubtless been carried out well, but the writing up of this work is grossly inadequate. The examiner has to guess what the figures represent, and how the glucose concentration of "Y" has been calculated. In the graph the x and y axes are poorly labelled, and throughout there is a careless use of decimals and significant figures. No comment is made on the fact that the absorbance of "Y" is above that of the highest standard solution, and no interpretative comment is made. Too many candidates are so obsessed with spending as much time as possible on practical work that they leave insufficient time for proper presentation of their work, which is all that can be marked. Table 2 and Fig. 2, I suggest, represent a better approach to writing up essentially the same results, except that the candidate has had the wit to analyse a diluted sample of "Y" in addition and to request a
commercial quality control serum. (To save space, however, I have not recorded duplicate analyses.) There are many satisfactory methods of setting out the data other than that shown in Table 2 and Fig. 2-for example, the concentration of glucose in "Y" could be read directly off the graph-and if there were time the presentation could be expanded. The important point is that by the expenditure of a mere additional three to five minutes, the data are labelled, the calculation is explained, and brief relevant comments are added. Someone might complain that there is insufficient time for this sort of presentation. If so, in my opinion it were better to analyse, say, fewer standard solutions and devote the time saved to writing up the work properly. Occasionally a disaster occurs. A tube may be contaminated, a reagent or standard solution labelled wrongly, a test-tube or beaker may break, or one of your results may appear ridiculous. Don't panic. You may consult one of the invigilators. He will be more worried than you if a mistake in organisation of the examination has occurred. If there is no time to repeat the work, at least write down briefly what happened, comment that any "impossible" results appear ridiculous, and indicate what you would have done, given time . GENERAL CONCLUSIONS
The main requirement of all types of examination is effective communication of what you know to the examiner, verbally or in writing. Effective communication comes easily to few. A week-end spent reading, marking, learning, inwardly digesting and above all applying the precepts of Sir Ernest Gowers's The Complete Plain Words would be time well spent (Gowers, 1962). This book is entertaining as well as educational; it is an investment that will help not only in examinations but in document writing, so important in later life. You will also find much sound sense cogently expressed in an article by Scott (1973) primarily aimed at anaesthetists but of value for all examination candidates. Occasionally his advice conflicts with mine. In addition, therefore, to planning your reading in preparation for an examination, devote some time to mastering essential examination technique. In practical laboratory work, endeavour from the beginning to write up all work neatly, succinctly, and clearly. How often does one return to a work book months later to find the data of a crucial experiment incomprehensible for want of a few explanatory words! You should, nearer the examination, write at least a few questions under examination conditions and submit them for criticism to a senior member of the laboratory staff. It is also
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A personal view on good technique in clinical biochemistry examinations 403
QD.
2
3
4
7
6
8
9
10
Glucose
Fig. 1. Inadequately Illhelled graph. Table 2.
Suggested satisfactory brief presentation of practical work.
Reagent blank Glucose Standard 1.0 mmol/I 2.0mmol/l 3.0mmol/l 4.0mmol/l 5.0mmol/l 6.0mmol/l 8.0mmol/l 1O.Ommol/l " Y Plasma Plasma Y diluted 115 in saline Q.C. serum Comment:
Absorbance v. distilled water
Absorbance minus reagent blank
0.04 0.10 0.19 0.24 0.32 0.40 0.46 0.56 0.65 0.80 0.21 0.41
0.06 0.15 0.20 0.28 0.36 0.42 0.52 0.61 0.76 0.17 0.37
Beer's law appears to be obeyed up to a glucose concentration of 6.0 mmol/l, Since the absorbance for
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404
Alan M. Bold serum Y is above that of the top standard, "Y" has been calculated from the absorbance using Y diluted 1/5.
Calculation: Concentration of test = A A
X Concentration of standard x dilution
test-blank
stand.ard-blank
Using the absorbance for the 6.0 rnrnol/l standard which is on the linear part of the standard curve: ConcentrationofglucoseinY = 0.17 x 6.0 x 5 = 12.1 rnmol/l 0.42 1 Q.c. glucose = 0.37 x 6.0 = 5.3 mmol/l (quoted acceptable range = 4.7-5.6) 0.42
Comment: Judged by the quality control value, the method is working satisfactorily. The plasma is stated to be from a fasting patient-a value of 12.1 rnmol/l is very high; if this were confirmed the patient could be diagnosed as suffering from diabetes mellitus.
GLUCOSE STANDARD CURYE-BLOGGS' METHOD l1-8
1(1'2-197(,
Absorbances ill I ern ce ll , Ilfllrd 603 hlter , vs , distilled water
(J'7
(J.(,
U·5
A ()'4
U'3
0·2
O+-----,---.,....---r-----r---~----,-------r_-----___, 2·0 3·0 6·0 1·0 4·0 5·0 o 10·0 8'0
GLUCOSE m mol/litre
Fig. 2.-Suggested satisfactory graphical presentatioo of work.
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A personal view on good technique in clinical biochemistry examinations 405 useful if you can arrange with your supervisor for a simulated oral examination, which not only provides useful experience but may reveal annoying faults or mannerisms. I append some important "dos" and "don'ts" of examination technique. Some examination "dos" 1. Answer every part of every question required. 2. Emphasise the important. 3. Plan your answer to ensure balance-avoid major gaps. 4. Give appropriate specific examples. 5. Use tables, diagrams, formulas. 6. Use a pen which maximises legibility. Some examination "don'ts" 1. Do not rewrite the question. 2. Do not use vague generalities. 3. Do not use private abbreviations or jargon. 4. Do not pad with irrelevant detail.
I was tempted to provide a model answer. Unfortunately the constraint of limited time available inevitably makes any answer to an examination question a compromise. It is a matter of personal judgment what should be put in, what has to be omitted, and how much detail can be included in each section. There are many excellently written textbook and review articles which illustrate what can be done. I felt that the following model "nonanswer", entirely mythical but illustrating real faults, might be more instructive.
Write an account of the pathogenesis and laboratory investigation of hypokalaemia (1) The bulk of the body's potassium is intracellular, where it is present in a concentration of 125-150 mmol/1. The total body potassium, measured by whole-body counter or exchangeable 42K studies is about 350Q-4000 mmol. This is in marked contrast to sodium, which in plasma is present at a concentration in healthy individuals of 135-146 mmol/l, whereas its intracellular concentration is very low, maintained by active extrusion of sodium ions across the cell membrane by an ATP-dependent sodium pump mechanism. In potassium deficiency potassium ions are lost from cells and overflow into the urine, where they are lost from the body, the intracellular potassium ions being replaced by sodium ions and hydrogen ions (in a ratio of approximately two sodium ions to one hydrogen ion), this exchange being obligatory to maintain cation/anion balance. (2) Potassium is widely distributed in foodstuffs, and, being generally the major intracellular cation, is present in large amounts in most foods, particularly those rich in cells, whether of animal origin, such as meat, or vegetable origin, such as fruit and vegetables, so that dietary deficiency of potassium is unlikely to be a cause of potassium deficiency unless it is part of a generalised malnutrition, in which case it is most likely that deficiency
of other foodstuffs, notably vitamins such as ascorbic acid, thiamine, riboflavin, or vitamin D, or of protein necessary for providing amino acids required for synthesis of the body's own proteins needed for muscle and other cells, in the absence of which the serious disease known as kwashiorkor develops. (3) The main cause of the pathogenesis ofhypokalaemia is therefore usually excessive renal loss via the urine. The physiologically homoeostatic mechanisms controlling the urinary excretion of potassium are many and complex, reflecting the balance between the filtered load of potassium (i.e., the plasma potassium concentration x the glomerular filtration rate) on the one hand, and the renal tubular reabsorption of potassium on the other hand. The renal excretion of potassium cannot be considered in isolation but must be always related to urinary excretion of sodium since in the distal renal tubule sodium ions are exchanged for potassium ions. (4) The excretion of sodium is mainly dependent on the renin-angiotensin-aldosterone system. Renin is an enzyme stored by and released from the juxtaglomerular apparatus of the kidney in response to a fall in pulse pressure in the afferent arterioles of the juxtaglomerular apparatus. It acts on a substrate present in plasma, angiotensin I (a dccapeptide), to produce angiotensin II (an octapeptide), which in tum is metabolised to aldosterone, a reaction catalysed by the converting enzyme, an a2 globulin present in normal plasma. (5) Although angio II itself has very potent pressor activity (i.e., it tends to raise blood pressure by constricting arterioles), the main purpose of this system is to produce aldo, which causes increased renal tubular exchange of Na for K (in the distal renal tubule), the main effect of which is to tend to increase ECFV (since water accompanies the sodium iso-osmotically) and at the same time increase renal K loss in the urine. Thus it will be seen that the main factor controlling potassium loss in the urine is aldo. The most important cause of hypok is 10 hyperaldo (Conn's syndrome), the main features of which are hypok, BP + (usually moderate, malignant hypertension almost never occurring), non-resp alkalosis, with a raised pH (low hydrogen ion concentration), raised PC02 and raised standard bicarbonate, and usually no oedema. The plasma sodium cone tends to be raised due to the action of aldo, and is usually above 140 mmol/l, sometimes above the upper limit of normal. (6) The cause of Conn's syndrome is usually an adrenal cortical adenoma, though bilateral hyperplasia (of the zona reticularis) or adenomatous hyperplasia may occur in some cases and confuse the picture. It should be treated with surgery though it may be treated medically by long-term administration of a methyl tyrosine. (7) It is particularly interesting to note that a variety of drugs commonly prescribed in hospital practice may also cause hypokalaemia. Furthermore, recently research workers have produced evidence which raises the possibility that humoral agents other than aldosterone are involved in the control of sodium and potassium balance. Unfortunately biochemical investigations of hypokalaemia may occasionally produce equivocal results so that a therapeutic trial may be indicated. (8) Hypokalaemia of mild degree is not usually serious
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though it may cause vague symptoms such as weakness and malaise. Severe hypokalaemia however may be serious, since it can cause cardiac abnormalities with flattened T waves on E.C.G. and prominent U waves, and even cardiac arrest. It is important to treat hypokalaemia, since treatment is cheap and effective. Ideally, treatment should be by oral potassium chloride (commercial preparations include Siow-K) in adequate dosage; in emergency intravenous potassium should be given with caution. Sorry no time to finish. When this "model answer" was shown to students for comment, without prompting some commended it for its clarity and general excellence. More critical appraisal shows that it is both grossly defective in balance and likely to irritate an examiner. Examination candidates might benefit from scrutinising this answer and listing as many failings as possible. Above all they should consider why in fact it should get a bad fail mark. At the risk of stating the obvious, for the sake of anyone unable to appreciate why it is so bad, I append my personal commentary. The main defect is failure to answer the question set. The laboratory investigation of hypokalaemia is treated very superficially and replaced by largely irrelevant comments about potassium in general. Gastrointestinal causes ofhypokalaemia are omitted. Primary aldosteronism is emphasised unduly with almost total neglect of the most common causes of hypokalaemia, These defects are so serious that even if the answer were otherwise perfect it would still deserve a bad fail mark. In comparison, other faults in the essay are more trivial, though they should be avoided since the aim is so to present the candidate's knowledge that the maximum possible marks are extracted. Without attempting an exhaustive catalogue of every fault the following points should be noted. The opening sentence of any answer is specially important, setting the tone for the whole answer. It should demonstrate that the candidate has grasped the important issues of the question. Here the answer begins with a side issue. Better would be a definition of the problem, for instance, "Hypokalaemia may be defined as a condition in which the plasma potassium concentration is below 3.5 romoljl, though a cellular deficit of potassium may exist without hypokalaemia." The second paragraph begins with an excessively long and largely superfluous sentence full of subordinate clauses. Sentences should be short and grammatical construction simple; long complicated sentences should be left to authors like Thucidydes, who don't have to satisfy examiners. The third paragraph begins with a non sequitur
and illustrates a long-winded tautological style characteristic of the whole answer. The fourth paragraph would have been better illustrated with a simple diagram. Even the absence of a diagram, however, cannot disguise the fact that this paragraph is a muddled mixture of truth and rubbish, though it may appear convincing in print. The fifth paragraph, amidst a spate of unofficial abbreviations, stresses the interesting but rare Conn's syndrome out of all proportion to its importance in practice, without indicating how it is distinguished from, say, secondary hyperaldosteronism. The sixth paragraph illustrates the danger of guessing (zona reticularis and a methyl tyrosine), especially as knowledge of such details is not vital to the answer. Errors of this type can only irritate the examiner, or at least make him more vigilant for other faux pas. Paragraph seven contains some generally true statements which are so vague as to be worthless. The last paragraph covers some facts irrelevant to the question. The classic final futile excuse is never valid, especially when no attempt has been made to confine the answer to the question set. No reprints will be dispatched to correspondents not sending a stamped addressed envelope. REFERENCES
Anderson, J. Dykes, J. R. W., Lennox, B. Recognition and recall questions in "objective" examinations for medical students. Lancet, 1 (1965) 953. Bull, G. M. An examination of the final examination in medicine. Lancet, 1 (1956) 368. Gibson, A. L. Second thoughts on multiple-choice questions. Brit. J. med. Educ., 3 (1969) 143. Gowers, E. The Complete Plain Words. Pelican Books, London, 1962. 2nd revised edition by Sir Bruce Fraser, H.M.S.O., 1973. Lennox, B., Anderson, J. R., Moorhouse, P. A comparative trial of objective papers and essay papers in pathology and bacteriology class examinations. Lancet, 2 (1957)396. Lennox, B. Multiple Choice Question Tutor in Pathology, Heinemann, London, 1975. Pappworth, M. H. Passing medical examinations. Butterworth, London, 1975. Scott, P. V. On taking examinations. Brit. J. Anaesth., 45 (1973) 1158. Waugh, D., Moyse, C. A. Oral Examinations: A videotape study of the reproducibility of grades in pathology. Canad. med. Ass. J., 100 (1969) 635. Young, S., Gillespie, G. Experience with the multiple choice paper in the primary fellowship examination. Brit. J. med. Educ., 6 (1972) 44. Accepted for publication 11 March 1976.
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How to Pass Examinations: a Personal View on Good Technique in Clinical Biochemistry Examinations ALAN
M.
BOLD
Clinical Chemistry Department, Queen Elizabeth Hospital, Birmingham, B15 2TH
Elementary faults in examination technique are commonly displayed by candidates who have worked hard for the examination. Advice is offered on answering multiple-choice questions and "essay" questions and on how to tackle oral and practical examinations. A candidate's preparation for an examination should include the submission of written work and the taking of a mock oral examination for critical assessment by a supervisor. Carefulwritingup of practicalwork in the home laboratory is important, so that faulty technique can be corrected early in training. Above all, stress is laid on the importance of mastering the technique of effective communication for success hoth in examinations and in later professional life. There is no substitute for hard work and a wellorganised programme of study for an examination. That said, it might be argued that for mature candidates the essentials of the technique of passing examinations are obvious. Unfortunately year after year similar elementary faults are committed-by medical students, medical and science graduates, and by experienced technicians. Successive formal reports and informal grumbles by examiners have a familiar ring, pointing to poor examination technique in the industrious student as well as inadequate preparation as a major cause of failure. The remedies, though obvious, still appear to need stressing.
learnt much from working and talking with a variety of examiners, though not all would necessarily endorse all my suggestions. MULTIPLE CHOICE QUESTIONS (M.C.Q.s)
This is not the place to debate the pros and cons of M.C.Q.s. They are widely used because they cover many aspects of a subject, in general correlate well with other forms of examination (Anderson et al., 1965; Young and Gillespie, 1972), and require minimal time for marking. There are fundamental limitations of M.C.Q.s., though it may be hoped that examiners have themselves learned from early criticisms and now set better questions ATTITUDE TO EXAMINERS (Gibson, 1969). Examiners are human. From time to time they Advice on tackling M.C.Q.s can be reduced to: may be inconsistent, unjust, or out of date, and (1) Familiarise yourself with the type or types of these defects are an unavoidable feature of exam- format employed in the examination you are taking. inations which are rightly criticised (Bull, 1956; Previous papers are not usually available but you Lennox et al., 1957). Pappworth (1975), who has are entitled to obtain examples of all types of question extensive experience of teaching candidates for the set. (2) Consider the general sense of the question. examination for membership of the Royal College Undoubtedly candidates who are unusually well of Physicians, is as usual stimulating and forthright informed are occasionally penalised by a slip-shod in painting a cynical picture of examiners. Those question, but they may contribute to their downfall who share his views will enjoy his positive but by an unnecessarily literal interpretation of the astringent comments. However, virtually every question. Doubtless words such as "usually", examiner with whom I have worked has been con- "often", and "typical" are imprecise and should not scientious and self-critical, and happier when be used, but when they are you should interpret as passing rather than failing a candidate. Like other best you can with common sense. (3) Guess sensibly. people examiners can become irritated by a candi- In some schemes marks are deducted for wrong date's foibles, among which I would class verbiage. answers. Nevertheless in some questions the possible Unlike Pappworth I have never met an examiner answers can easily be reduced to two or three. Again, who marks essay questions by weight. you may with confidence be able to eliminate all Each candidate must make up his own mind answers except one of which you know nothing; it about examiners; your decision on this dictates the would be reasonable to select it (Lennox, 1975). general approach to answering questions. Advice Whatever may be the ethics of examiners using a offered here is necessarily a personal view. I have system encouraging guesswork, a candidate will do 399
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better on average by judicious guessing than by restricting answers solely to those questions which can be answered with certainty.
ORAL EXAMINATION
For some the oral examination is more unnerving than the rest of the examination. Few candidates believe it, but most examiners are well aware of the limitations of an oral examination (Waugh and Moyse, 1969). In my experience it is used to find extra marks, if possible, to pass a borderline candidate, and it is unusual for a candidate who has clearly passed the rest of the examination to be failed because of indifferent performance in the oral examination. The following points might help: (1) Avoid making a bad impression by slovenly appearance or wearing outlandish garments. (2) Answer questions as promptly as possible. Take a little time to plan your answer, but avoid appearing dim by treating the simplest question with suspicion and answering only after lengthy pondering. (3) Answer the main point or points of the question without prevarication. It is sound advice to keep talking as long as you can, provided what you say is relevant. It is most unwise to take a roundabout, verbose route to get to the point the examiner really wants answered. It is best therefore to give a brief answer to the question, and then expand on those aspects about which you are well informed. Donat gratuitously introduce subjects you are not prepared to discuss further. (4) If you can only answer part of the question, press on as far as you can; don't hesitate just because you don't know everything about the question. If you cannot answer a specific question, it is best to admit you don't know. (5) Don't hesitate to ask for clarification if you don't understand the question. (6) Sometimes you may make an error, or a slip of the tongue. Many examiners appreciate that you may talk nonsense in the stress of the moment and give you a chance to retract-"Do you really believe that?" While you should not bank on this as an indication to change your mind, at least treat it as a hint to reconsider rather than as a subtle trap to lure you into error. (7) Be courteous without being obsequious. If you seriously disagree with an examiner, make your point calmly and logically. (8) Never give up, assuming you have failed. Examiners attempt to make some allowance for nervousness. Also, occasionally examiners ask very good candidates, who arc bound to pass, difficult questions to see how they respond. Do not throw in the sponge just because you can't answer one or two questions.
"ESSAY" QUESTIONS
Although the rare single question to be answered in three hours should be treated as an essay, most so-called essay questions are nothing of the sort. The typical two or three hour paper, with say four to six questions to be answered, allows little time for the expansive approach of the essay. What is required is a succinct, structured account including as many relevant facts as possible. Lengthy introductions, long winded ness, padding with information which may be true but is irrelevant to the question as set, and unbalanced answers are probably the most common faults. Of course, good examination technique is of little avail to the candidate who simply does not know enough to answer the question, but some candidates fail adequately to communicate the knowledge they have to the examiner. I have attempted to summarise advice. (I) Answer every question required. It is extremely difficult to answer some questions so well that you compensate for omitting one question or leaving very little time to answer one question. This particularly applies when examiners employ a close marking system, in which, say, 40% might be a bad fail and 60% a very good answer. No marks can be given for an unanswered question. While it is unrealistic to spend exactly the same time on every question, you must allow adequate time to answer all questions. There can never be any excuse for failing to observe this golden rule. (2) Answer every part of each question. Frequently a question has two or more parts. Judge whether they are equally important or not, and adjust your effort accordingly. It is a serious error to omit part of the question. (3) Stress the important and the common. Too many candidates fail to profit from routine experience. Avoid undue emphasis on fascinating rarities. (4) Answer the question set; do not recompose the question to suit yourself. While not all examiners are equally successful in indicating precisely what is required in a question, the question is worded as it is for a reason. If you are in doubt take a commonsense rather than literal view of the question. If it is really ambiguous choose another question. Suppose for example, a question is worded, "Discuss recent advances in the understanding of calcium metabolism." It is true that the word "recent" is imprecise, and you must attempt to judge whether you should concentrate on say the last two, five, or 10 years. Nevertheless an answer which began with a historical survey and discussed at length work more than 10 years old would get little credit. In this question "recent" is a key word. If you don't know the recent advances, avoid the question, even if you
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A personal view on good technique in clinical biochemistry examinations 401
can write pages about the old advances in calcium metabolism. (5) Plan your answer. You must ensure that all important points are covered and roughly allocate time accordingly. If you can achieve it, a logical structure to the answer is desirable. Pappworth specifically advises against planning an answerthis is unconventional advice. It is imporant, however, not to devote more than three or four minutes to jotting down your plan. (6) Use specific examples when possible; do not waste time with vague generalities. You would get few marks for writing, "A wide variety of different types of error may occur if a 24-hour collection of urine is not made satisfactorily". Give examples: for instance, "A serious error may be introduced in making a 24-hour urine collection if an incorrect or no preservative is used, if some of the specimen is inadvertently discarded, or if at the start of the collection the patient does not empty the bladder." (7) Use acceptable means of conveying the maximum of information in the minimum of space. Unfortunately not all examiners agree on what is acceptable. As a personal opinion, standard abbreviations are acceptable-for instance, e.g., i.e., and standard chemical abbreviations such as ATP and cAMP which are widely used in scientific journals. When in doubt, if you want to use a word or chemical term repeatedly, the first time write it in full with your abbreviation in brackets. Lists, tables, figures, diagrams, equations, and metabolic pathways are helpful to you in conveying much information succinctly, and they also aid the examiner. It may be true, as Pappworth points out, that such devices help the examiner spot your errors and omissions. A careful examiner will probably find them anyway. (8) Do not pad with irrelevant information or empty verbiage. I believe that an answer of two pages with all the main facts will earn more marks than the same number of facts diluted over 10 pages. (9) Examination questions may be prefaced by a variety of words or phrases such as "discuss", "describe", "outline", "write a critical account of." You should attempt to interpret the distinction, though in practice the requirement is usually, "write all you can in the available time about ... , and a critical approach to any subject is always desirable, whether specifically requested or not. (10) Answering in the form of notes other than lists, tables, etc., is not recommended. However, if you do misjudge the time available, the use of notes, provided they are comprehensible, is preferable to leaving important points unmentioned. (II) Good communication is the essence of examination technique as of so much of modern
life. Work at avoiding those things that impair communication-an obscure, or loquacious style, or poor grammar. Bad handwriting may be hard to cure, though choice of a pen which assists legibility rather than expresses personality would help some people. (12) Conventionally candidates are advised to read through their answers. Pappworth (1975) advises against this and is surely right. It takes too long, you are unlikely to spot many significant errors, and the time would be better spent in writing. Obviously if you do have time to spare, it is profitable to check what you have written. PRACTICAL EXAMINATIONS
Although performance in practical examinations is largely determined by basic laboratory training and skill, few candidates do justice to themselves in the way they plan and write up their practical work. Comments will be restricted to clinical chemistry examinations. Advice may be subdivided into planning the work to do, and writing up the work completed. Planning
Study all the questions. Only experience can help you make an estimate of how long each section will take. It is helpful to draw up a rough flow diagram of the overall plan of campaign. You may sometimes be able to tackle each question sequentially, but plan your work so that any lengthy gaps (for colour development, electrophoresis, chromatography, etc.) are filled in either by writing up work completed or starting work on the next question. Good organisation, which usually derives from good practice in routine laboratory work, can enable you to write spectrophotometer readings directly into a neat table in your answer book, avoiding scribbling on scraps of paper. Where time and available glassware permit, perform all analyses in duplicate. Do not forget the precautions you would normally take in your home laboratory, such as use of a quality control serum (request this if it is not provided) or analysing diluted and undiluted samples in parallel for determinations such as urea, glucose, or certain serum enzymes, where extremely high values may occur. Writing up
Candidates too often ignore the obvious fact that examiners can mark only what is on paper. The frequent poor quality of written practical work may reflect poor training and practice in the routine
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402 Alan M. Bold laboratory work. The essential requirement is that the examiner can discover easily and unequivocally what the candidate has done. An answer consisting of, for example, a series of spectrophotometer readings, personalised hieroglyphics, and the statement "The serum rhubarbase = 102 U/litre" is worth little. Do not waste time writing down the method you have been given. Do make it clear what concentrations of standard solutions are used, what dilutions if any have been made to serum, and what procedures you have adopted that are not specified in the given method sheet. Calculations should be clearly set out. Brief explicit statements and comprehensible tables are required, not purple prose. To illustrate these points: Suppose a question had been set on determining glucose in standard solutions and plasma "Y" from a fasting patient, by Bloggs's method. Table 1 and Fig. I illustrate Table 1. Typical presentation ofunlabelled data Blank
.04 .1 .19 .24 .32
1 2 3
4
.4 .46
5 6 8 10
.56 .65 .8
ny"
Plasma Y
=
.06 .15 .2 .28 .36 .42 .52 .61 .76
10.85
the written practical work of an imaginary but not impossibly rare sort of candidate; the technical side of the work has doubtless been carried out well, but the writing up of this work is grossly inadequate. The examiner has to guess what the figures represent, and how the glucose concentration of "Y" has been calculated. In the graph the x and y axes are poorly labelled, and throughout there is a careless use of decimals and significant figures. No comment is made on the fact that the absorbance of "Y" is above that of the highest standard solution, and no interpretative comment is made. Too many candidates are so obsessed with spending as much time as possible on practical work that they leave insufficient time for proper presentation of their work, which is all that can be marked. Table 2 and Fig. 2, I suggest, represent a better approach to writing up essentially the same results, except that the candidate has had the wit to analyse a diluted sample of "Y" in addition and to request a
commercial quality control serum. (To save space, however, I have not recorded duplicate analyses.) There are many satisfactory methods of setting out the data other than that shown in Table 2 and Fig. 2-for example, the concentration of glucose in "Y" could be read directly off the graph-and if there were time the presentation could be expanded. The important point is that by the expenditure of a mere additional three to five minutes, the data are labelled, the calculation is explained, and brief relevant comments are added. Someone might complain that there is insufficient time for this sort of presentation. If so, in my opinion it were better to analyse, say, fewer standard solutions and devote the time saved to writing up the work properly. Occasionally a disaster occurs. A tube may be contaminated, a reagent or standard solution labelled wrongly, a test-tube or beaker may break, or one of your results may appear ridiculous. Don't panic. You may consult one of the invigilators. He will be more worried than you if a mistake in organisation of the examination has occurred. If there is no time to repeat the work, at least write down briefly what happened, comment that any "impossible" results appear ridiculous, and indicate what you would have done, given time . GENERAL CONCLUSIONS
The main requirement of all types of examination is effective communication of what you know to the examiner, verbally or in writing. Effective communication comes easily to few. A week-end spent reading, marking, learning, inwardly digesting and above all applying the precepts of Sir Ernest Gowers's The Complete Plain Words would be time well spent (Gowers, 1962). This book is entertaining as well as educational; it is an investment that will help not only in examinations but in document writing, so important in later life. You will also find much sound sense cogently expressed in an article by Scott (1973) primarily aimed at anaesthetists but of value for all examination candidates. Occasionally his advice conflicts with mine. In addition, therefore, to planning your reading in preparation for an examination, devote some time to mastering essential examination technique. In practical laboratory work, endeavour from the beginning to write up all work neatly, succinctly, and clearly. How often does one return to a work book months later to find the data of a crucial experiment incomprehensible for want of a few explanatory words! You should, nearer the examination, write at least a few questions under examination conditions and submit them for criticism to a senior member of the laboratory staff. It is also
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A personal view on good technique in clinical biochemistry examinations 403
QD.
2
3
4
7
6
8
9
10
Glucose
Fig. 1. Inadequately Illhelled graph. Table 2.
Suggested satisfactory brief presentation of practical work.
Reagent blank Glucose Standard 1.0 mmol/I 2.0mmol/l 3.0mmol/l 4.0mmol/l 5.0mmol/l 6.0mmol/l 8.0mmol/l 1O.Ommol/l " Y Plasma Plasma Y diluted 115 in saline Q.C. serum Comment:
Absorbance v. distilled water
Absorbance minus reagent blank
0.04 0.10 0.19 0.24 0.32 0.40 0.46 0.56 0.65 0.80 0.21 0.41
0.06 0.15 0.20 0.28 0.36 0.42 0.52 0.61 0.76 0.17 0.37
Beer's law appears to be obeyed up to a glucose concentration of 6.0 mmol/l, Since the absorbance for
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404
Alan M. Bold serum Y is above that of the top standard, "Y" has been calculated from the absorbance using Y diluted 1/5.
Calculation: Concentration of test = A A
X Concentration of standard x dilution
test-blank
stand.ard-blank
Using the absorbance for the 6.0 rnrnol/l standard which is on the linear part of the standard curve: ConcentrationofglucoseinY = 0.17 x 6.0 x 5 = 12.1 rnmol/l 0.42 1 Q.c. glucose = 0.37 x 6.0 = 5.3 mmol/l (quoted acceptable range = 4.7-5.6) 0.42
Comment: Judged by the quality control value, the method is working satisfactorily. The plasma is stated to be from a fasting patient-a value of 12.1 rnmol/l is very high; if this were confirmed the patient could be diagnosed as suffering from diabetes mellitus.
GLUCOSE STANDARD CURYE-BLOGGS' METHOD l1-8
1(1'2-197(,
Absorbances ill I ern ce ll , Ilfllrd 603 hlter , vs , distilled water
(J'7
(J.(,
U·5
A ()'4
U'3
0·2
O+-----,---.,....---r-----r---~----,-------r_-----___, 2·0 3·0 6·0 1·0 4·0 5·0 o 10·0 8'0
GLUCOSE m mol/litre
Fig. 2.-Suggested satisfactory graphical presentatioo of work.
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A personal view on good technique in clinical biochemistry examinations 405 useful if you can arrange with your supervisor for a simulated oral examination, which not only provides useful experience but may reveal annoying faults or mannerisms. I append some important "dos" and "don'ts" of examination technique. Some examination "dos" 1. Answer every part of every question required. 2. Emphasise the important. 3. Plan your answer to ensure balance-avoid major gaps. 4. Give appropriate specific examples. 5. Use tables, diagrams, formulas. 6. Use a pen which maximises legibility. Some examination "don'ts" 1. Do not rewrite the question. 2. Do not use vague generalities. 3. Do not use private abbreviations or jargon. 4. Do not pad with irrelevant detail.
I was tempted to provide a model answer. Unfortunately the constraint of limited time available inevitably makes any answer to an examination question a compromise. It is a matter of personal judgment what should be put in, what has to be omitted, and how much detail can be included in each section. There are many excellently written textbook and review articles which illustrate what can be done. I felt that the following model "nonanswer", entirely mythical but illustrating real faults, might be more instructive.
Write an account of the pathogenesis and laboratory investigation of hypokalaemia (1) The bulk of the body's potassium is intracellular, where it is present in a concentration of 125-150 mmol/1. The total body potassium, measured by whole-body counter or exchangeable 42K studies is about 350Q-4000 mmol. This is in marked contrast to sodium, which in plasma is present at a concentration in healthy individuals of 135-146 mmol/l, whereas its intracellular concentration is very low, maintained by active extrusion of sodium ions across the cell membrane by an ATP-dependent sodium pump mechanism. In potassium deficiency potassium ions are lost from cells and overflow into the urine, where they are lost from the body, the intracellular potassium ions being replaced by sodium ions and hydrogen ions (in a ratio of approximately two sodium ions to one hydrogen ion), this exchange being obligatory to maintain cation/anion balance. (2) Potassium is widely distributed in foodstuffs, and, being generally the major intracellular cation, is present in large amounts in most foods, particularly those rich in cells, whether of animal origin, such as meat, or vegetable origin, such as fruit and vegetables, so that dietary deficiency of potassium is unlikely to be a cause of potassium deficiency unless it is part of a generalised malnutrition, in which case it is most likely that deficiency
of other foodstuffs, notably vitamins such as ascorbic acid, thiamine, riboflavin, or vitamin D, or of protein necessary for providing amino acids required for synthesis of the body's own proteins needed for muscle and other cells, in the absence of which the serious disease known as kwashiorkor develops. (3) The main cause of the pathogenesis ofhypokalaemia is therefore usually excessive renal loss via the urine. The physiologically homoeostatic mechanisms controlling the urinary excretion of potassium are many and complex, reflecting the balance between the filtered load of potassium (i.e., the plasma potassium concentration x the glomerular filtration rate) on the one hand, and the renal tubular reabsorption of potassium on the other hand. The renal excretion of potassium cannot be considered in isolation but must be always related to urinary excretion of sodium since in the distal renal tubule sodium ions are exchanged for potassium ions. (4) The excretion of sodium is mainly dependent on the renin-angiotensin-aldosterone system. Renin is an enzyme stored by and released from the juxtaglomerular apparatus of the kidney in response to a fall in pulse pressure in the afferent arterioles of the juxtaglomerular apparatus. It acts on a substrate present in plasma, angiotensin I (a dccapeptide), to produce angiotensin II (an octapeptide), which in tum is metabolised to aldosterone, a reaction catalysed by the converting enzyme, an a2 globulin present in normal plasma. (5) Although angio II itself has very potent pressor activity (i.e., it tends to raise blood pressure by constricting arterioles), the main purpose of this system is to produce aldo, which causes increased renal tubular exchange of Na for K (in the distal renal tubule), the main effect of which is to tend to increase ECFV (since water accompanies the sodium iso-osmotically) and at the same time increase renal K loss in the urine. Thus it will be seen that the main factor controlling potassium loss in the urine is aldo. The most important cause of hypok is 10 hyperaldo (Conn's syndrome), the main features of which are hypok, BP + (usually moderate, malignant hypertension almost never occurring), non-resp alkalosis, with a raised pH (low hydrogen ion concentration), raised PC02 and raised standard bicarbonate, and usually no oedema. The plasma sodium cone tends to be raised due to the action of aldo, and is usually above 140 mmol/l, sometimes above the upper limit of normal. (6) The cause of Conn's syndrome is usually an adrenal cortical adenoma, though bilateral hyperplasia (of the zona reticularis) or adenomatous hyperplasia may occur in some cases and confuse the picture. It should be treated with surgery though it may be treated medically by long-term administration of a methyl tyrosine. (7) It is particularly interesting to note that a variety of drugs commonly prescribed in hospital practice may also cause hypokalaemia. Furthermore, recently research workers have produced evidence which raises the possibility that humoral agents other than aldosterone are involved in the control of sodium and potassium balance. Unfortunately biochemical investigations of hypokalaemia may occasionally produce equivocal results so that a therapeutic trial may be indicated. (8) Hypokalaemia of mild degree is not usually serious
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Alan M. Bold
though it may cause vague symptoms such as weakness and malaise. Severe hypokalaemia however may be serious, since it can cause cardiac abnormalities with flattened T waves on E.C.G. and prominent U waves, and even cardiac arrest. It is important to treat hypokalaemia, since treatment is cheap and effective. Ideally, treatment should be by oral potassium chloride (commercial preparations include Siow-K) in adequate dosage; in emergency intravenous potassium should be given with caution. Sorry no time to finish. When this "model answer" was shown to students for comment, without prompting some commended it for its clarity and general excellence. More critical appraisal shows that it is both grossly defective in balance and likely to irritate an examiner. Examination candidates might benefit from scrutinising this answer and listing as many failings as possible. Above all they should consider why in fact it should get a bad fail mark. At the risk of stating the obvious, for the sake of anyone unable to appreciate why it is so bad, I append my personal commentary. The main defect is failure to answer the question set. The laboratory investigation of hypokalaemia is treated very superficially and replaced by largely irrelevant comments about potassium in general. Gastrointestinal causes ofhypokalaemia are omitted. Primary aldosteronism is emphasised unduly with almost total neglect of the most common causes of hypokalaemia, These defects are so serious that even if the answer were otherwise perfect it would still deserve a bad fail mark. In comparison, other faults in the essay are more trivial, though they should be avoided since the aim is so to present the candidate's knowledge that the maximum possible marks are extracted. Without attempting an exhaustive catalogue of every fault the following points should be noted. The opening sentence of any answer is specially important, setting the tone for the whole answer. It should demonstrate that the candidate has grasped the important issues of the question. Here the answer begins with a side issue. Better would be a definition of the problem, for instance, "Hypokalaemia may be defined as a condition in which the plasma potassium concentration is below 3.5 romoljl, though a cellular deficit of potassium may exist without hypokalaemia." The second paragraph begins with an excessively long and largely superfluous sentence full of subordinate clauses. Sentences should be short and grammatical construction simple; long complicated sentences should be left to authors like Thucidydes, who don't have to satisfy examiners. The third paragraph begins with a non sequitur
and illustrates a long-winded tautological style characteristic of the whole answer. The fourth paragraph would have been better illustrated with a simple diagram. Even the absence of a diagram, however, cannot disguise the fact that this paragraph is a muddled mixture of truth and rubbish, though it may appear convincing in print. The fifth paragraph, amidst a spate of unofficial abbreviations, stresses the interesting but rare Conn's syndrome out of all proportion to its importance in practice, without indicating how it is distinguished from, say, secondary hyperaldosteronism. The sixth paragraph illustrates the danger of guessing (zona reticularis and a methyl tyrosine), especially as knowledge of such details is not vital to the answer. Errors of this type can only irritate the examiner, or at least make him more vigilant for other faux pas. Paragraph seven contains some generally true statements which are so vague as to be worthless. The last paragraph covers some facts irrelevant to the question. The classic final futile excuse is never valid, especially when no attempt has been made to confine the answer to the question set. No reprints will be dispatched to correspondents not sending a stamped addressed envelope. REFERENCES
Anderson, J. Dykes, J. R. W., Lennox, B. Recognition and recall questions in "objective" examinations for medical students. Lancet, 1 (1965) 953. Bull, G. M. An examination of the final examination in medicine. Lancet, 1 (1956) 368. Gibson, A. L. Second thoughts on multiple-choice questions. Brit. J. med. Educ., 3 (1969) 143. Gowers, E. The Complete Plain Words. Pelican Books, London, 1962. 2nd revised edition by Sir Bruce Fraser, H.M.S.O., 1973. Lennox, B., Anderson, J. R., Moorhouse, P. A comparative trial of objective papers and essay papers in pathology and bacteriology class examinations. Lancet, 2 (1957)396. Lennox, B. Multiple Choice Question Tutor in Pathology, Heinemann, London, 1975. Pappworth, M. H. Passing medical examinations. Butterworth, London, 1975. Scott, P. V. On taking examinations. Brit. J. Anaesth., 45 (1973) 1158. Waugh, D., Moyse, C. A. Oral Examinations: A videotape study of the reproducibility of grades in pathology. Canad. med. Ass. J., 100 (1969) 635. Young, S., Gillespie, G. Experience with the multiple choice paper in the primary fellowship examination. Brit. J. med. Educ., 6 (1972) 44. Accepted for publication 11 March 1976.
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