I will start with a confession. When I was a medical student, I remember the shock I received in my first year. I was no longer in a world with finite knowledge, a curriculum that had boundaries, with practice papers telling me exactly what I needed to know to pass the exams. Instead, I was in a world with infinite knowledge, a curriculum that was decidedly vague and practice papers that barely scratched the surface of what I needed to know to pass my exams. Yet, perhaps the last were the only saving grace akin to the straw that I could clutch while drowning in the sea of uncertainty. In short, I was clueless! I did not have any idea of how to approach anatomy, physiology or biochemistry that were so vast, varied and boundless that I struggled to learn how to study.

I failed miserably in my first exam. I was stunned into disbelief. Here I was, a top ranker in my school, considered to be a ‘clever one’ in the family, turning out to be an utter failure. I had to redeem myself. I did not know how? So, started my journey where I walked blindly in the dark alleys of medicine feeling my way through whilst discovering the simple, inane truth – all I had to do was to pass my exams, as my mother very eloquently put to me on a fine summer’s day.

This was a difficult proposition for me. You see, I had this nasty temperament, a very distracting vice, where I would start doing my readings and then surreptitiously, without my knowledge, I would drift away onto a tangent, trying to learn it in depth. This is analogous to clicking the links on a given webpage and in about half an hour waking up to the fact that you are no longer reading what you set out to read. A vice, that is admittedly incompatible with success in medical schools. I was torn. Between my desire to voraciously devour topics down to their nitty-gritty and my explicit aim of passing the exams, I had to choose one, in order to maintain my sanity. You can all guess the one I chose! I think that I was not the first and neither will be the last person to feel this way.

With passing time I realised that medical schools are so focussed on teaching what we should be doing that we are never taught when not to interfere. For instance, we are never taught when not to investigate or when not to treat. At the end of five years in medicine it was almost as if the curiosity had been beaten out of me. To quote Albert Einstein, “It is a miracle that curiosity survives formal education.” Luckily, I quickly recovered and bounced back to my normal self. I resumed my pursuit of the forever intriguing human condition of disease and health.

Having endured the mundane innumerable cycles of revisions and exams, I would like to offer some techniques to help not only pass your exams, but also to simultaneously keep the flame of curiosity alive.

In order to answer exam questions we must first learn how to ask questions. There are two ways of doing this:

1. A poor question, which merely tests memory – often a single step question and
2. A good question that tests your reasoning powers – often a two step question.

I shall illustrate this now:

1. What is the most common bacterial aetiology of community acquired pneumonia (CAP)?
   • Staphylococcus aureus
   • Haemophilus influenzae
   • Pseudomonas aeroginosa
   • Streptococcus pneumoniae
   • Enterobacteriacae

2.  

   2. A 62 year old man is admitted to the hospital with a one week history of cough, brown phlegm and fever. He had recently attended a conference where he stayed overnight at a hotel. He is found to have leukocytosis with a left shift, transaminitis and hyponatremia with acute kidney injury. The chest radiograph shows right basal consolidation. What is your first choice of empiric antibiotic therapy?
   • Amoxicillin
   • Cotrimoxazole
   • Co-amoxiclav
   • Doxycycline
   • Levofloxacin

As you can see, question 1 merely tested your factual memory rather than testing your understanding. Question 2, on the other hand, is a two step question. Based on the stem, you are likely to make a diagnosis of legionnaire’s disease for which the preferred empiric therapy is either levofloxacin or azithromycin. Do you see how it skipped the step where you made the diagnosis of legionnaire’s and instead went straight to testing your understanding of empiric antibiotic therapy in CAP? In other words, question 2 is testing the application of knowledge.

Now for the suggestions that I had promised earlier:

1. In your readings I would urge you to follow the thread of thinking demonstrated in question number two.
2. When you encounter patients at the hospital or clinic with a particular disease, use this to direct your readings. Contextualising your revision in this way burns the knowledge gained into memory.
3. Tying basic sciences to clinical medicine is the best way to study. In other words, understanding the pathophysiology helps in predicting the signs and course of the disease. It also helps in arriving at the diagnosis using first principles, which makes it more water-tight as you base your diagnosis on being able to explain all the findings seen in the presentation.
4. The next thing that I would like you to do, is learn the earliest sign seen in a given disease process. This focuses your attention to understanding the pathophysiology of disease, which not only helps in understanding the disease better but in the process helps you to become a better clinician. For instance, learning that one of the earliest signs that increases the likelihood of cor pulmonale is a loud P2, helps you detect it earlier (Sutton et al. 1968; Pilatis et al. 2000; WHITAKER 1954). Anybody can diagnose right heart failure when there is fluid oozing out from every pore in the body but doing it before this happens would mean earlier treatment, prevention of progression and a better quality of life for the patient concerned.

I understand that doing what I have suggested is not an easy task as there is always the proverbial ‘Damocles’ sword’ of exams hanging over your head rushing you to play catch up. In order to make it easier for you to walk the talk I have created this website where I will be covering all the major topics (of course with the caveat of time) separating them into three sections of black and white areas, grey areas and unknowns. The level of detail could be said to correspond to exam world (for the students), real world (for practising clinicians) and the world of innovation in medicine (for everyone) respectively. You are all welcome to explore any section as you like, at any level of detail that you desire, just by scrolling down.

Those of you, who are inspired by the gaps in our knowledge, as highlighted in every topic, can then discuss this in our forum. I hope this will re-kindle the fire of innovation in medicine that we desperately need. I hope you enjoy visiting this website!

Irfan

References

Pilatis, N.D. et al., 2000. Clinical predictors of pulmonary hypertension in patients undergoing liver transplant evaluation. Liver Transplantation, 6(1), pp.85–91.

Sutton, G., Harris, A. & Leatham, A., 1968. Second heart sound in pulmonary hypertension. British heart journal, 30(6), pp.743–56.

WHITAKER, W., 1954. Clinical diagnosis of pulmonary hypertension in patients with mitral stenosis. The Quarterly journal of medicine, 23(89), pp.105–12.