These are neurologists crossing the border, Learning the genes and the prevalence order, Causes of twitch, of vision poor, The heredo-degenerative, and the rule of four.Apologies to WH Auden
This is a personal view about how to approach this thrilling exam, which is your final gateway to the world of a Consultant Neurologist. This is a view based on experience and the gems passed on to me from many colleagues who have been successful throughout the years with some tips and information provided by Professor Shorvon on ‘Cramming for the Exit Exam’ Pre-course workshop of Neurology run by UCL Institute of Neurology. When my child asked me what thrilling meant, I explained “Exciting, but a little bit scary”.
The best time to do the exam
This is a decision which only you may take. Statistically you are giving yourself a better chance when you leave it a little later in your training. It can work either way. Passed early, you’ve covered the curriculum and can spend the next four years consolidating and refining that knowledge, and keeping up with the demands of your e-portfolio. Later in your training, it provides an opportunity to tie up all the loose ends, to polish off your knowledge and get into the Consultant mind-set. Only you can know which is better for you.
When to start studying
Think tortoise not hare. This is an abstract type of exam, and will not only require you to recognise most neurological syndromes, and their differentials (see the mimics and chameleons articles in Practical Neurology, and the Bare Essentials). You will also need to be able to apply that knowledge practically and in a way that is relevant to your clinical practice as a Consultant. So know more than first line management, for common diseases, and the complications of the different treatments.
I would recommend that you take notes in every clinic, with every interaction, every CPC or Grand Round. Even one learning point per session will be priceless further down the line. Take notes as if you are doing it for someone else to read later (you are, future you!). With this in mind, that helps you to make more focused notes. I was a late adopter of the smartphone/iPad resource of making notes (hence piles of beautiful yet half filled notebooks gathering dust on my bookshelf) but loved it. After every on call interaction.
The little nuggets gleaned (and in later years saved on my iPhone) helped to hook the ‘dry’ text into my brain with every bit of learning. Ideally combine this with eportfolio reflections.
Get out the curriculum and have a look. It is helpful to do some questions at the beginning. That will give you a clue as to where your main knowledge gaps are. Spot the nooks and the crannies that are dusty for you, and carve out more time than you might expect to review these – not all the subjects are weighted equally (see the table below for weighting of subjects).
We all work long days and many of us have family commitments, undisturbed hours in the library we may once have enjoyed are but a distant medical school memory. Reading on the ‘Tube’ (squished, standing), or listening to podcasts (the AAN/neurology or Lancet Neurology) and at work, when time allows, is needed. Late at night when you’d like a nap, 20 minutes can be squeezed in. Help is at hand in the form of revision courses (list below), online modules (Ebrainjnc), twitter tips (@abntrainees) and attending all the local teaching sessions your job will permit. I found YouTube an invaluable resource, for example EEG education.
My best friends throughout this were Practical Neurology and ACNR. If I ever felt saturated, desaturated or overwhelmed with the enormity of this beautiful intricate magical specialty, then a light hearted debate on clinical signs, or an unusual case was enough to draw me in again, to absorb me. These should be your companions to learning. They are up to date, and written by people who ‘practise what they preach’. There are nuggets and insights and clear guidance.
Because the authors are people who love their subject, and use their knowledge from a practical point of view, they will hold your hand throughout this process of learning how to manage neurological disease. There are many interesting case reports, and thoughts about neurology. Every year a quirky little diagnosis will slink its way into the exam (Ciguatera, anyone?), and I can only imagine the smiles or sinking heart depending on whether you remember how an article ended.
Other essential foundations to your knowledge include guidelines from NICE, SIGN, and, of course, the ABN. This is a UK exam, and you need to know these by heart (or well at least). The diagnostic criteria for most neurological illnesses (GBS/CIDP/MND/MS/dementia/Parkinson’s/headache syndromes) should be a good starting point, then in the course of your clinical work, you can observe how the specialists apply these, and ‘square the circle’ for patients who do not meet exact criteria.
Membership of the ABN is assumed, but also joining the AAN (at trainee level) is relatively inexpensive and allows access to their bank of questions and their comprehensive Continuum text-books, which are brilliant at any stage of training. They also have a great collection of questions which you can do online. Ebrain is another excellent source of learning material and the questions provided are from previous exams (see the Royal College of Physicians website too).
Imagine you are the on call Consultant now. As a Registrar you formulate a diagnosis and know first line treatments, but as Consultant you will need to know how to refine that diagnosis, and interpret investigations (imaging, neurophysiology, visual field testing) usefully. Lists are essential (causes of ataxia and neuropathy, movement disorders in young people, progressive myoclonic epilepsies). An overview of the range of short term and long term treatment options, dose adjustments, complications of treatment, when to switch or stop. When you view your study from this perspective, then you will get the true value of it. This is not ‘just another hoop’. This is your chance to clear the decks (make this your number one priority), to devote yourself to progressing and finessing your knowledge so you are ready for the next stage. To get the most return for your study, think clinically.
For me, reading was not enough, there was annotation, drawing, recording lists onto my phone for commuting. I found memory cards really helpful. Teaching others what you have learned always demonstrates your confidence with the topic. Study groups can boost morale and be a motivating factor if you can find the time.
I loved our local Grand Rounds. Nothing brings the list of something like progressive myoclonic epilepsies into clear focus like the knowledge that you may have a microphone in your hand one day, and a friendly Professor asking you to remind the room of that list. It’s unfashionable to say it, but a little edge of fear helps me to remember things more clearly than anything else.
Ultimately when the hour draws near, it is good to come back to the questions. The subjects are not equally weighted. The exam itself takes place in several centres where people may simultaneously be taking their theory of driving test. Apparently it can be ambiguous about when the exam begins, the clock starts ticking.
Relax. Examiners want you to pass (if you’ve done the work). The questions can be complicated and seem obtuse. Sometimes it helps to take a step back. If it looks like X and it sounds like X, but there’s one little anomalous detail. Then, is it X? This is your time to be a clinician. Is the anomaly a little clue to the diagnosis, or red herring? I cannot tell you, but looking back, I am sure that some anomalies are there to make you question your certainty (which is what real life medicine is like) but make a decision based on your “gut instinct”. Sometimes they are there to prompt you towards another diagnosis. The skill in this exam is being able to differentiate between the two.
The point is, you need to go into this exam with a calm disposition. Breathe, read carefully, see the clues. Do not go down the rabbit hole – if this is a soft sign of another diagnosis (positive ANA), but all the clues are pointing to a much more likely diagnosis (clinical and radiological picture of NMO), then it’s probably the one you think it is.
The examiners are people who love their specialty and expect you to know how to identify and manage their patients so they will give you clues and unlock the door to the right answer. Marks can be lost by overthinking.
Think about this exam, not as a barrier to your career ahead, but as your chance to finally bury yourself deep in your subject, and hopefully to emerge from the chrysalis of revision notes as a nascent Consultant Neurologist, maybe even getting a chance to write a few questions of your own one day.
I hope this is helpful, and I wish everyone the best of luck!
Professor Shorvon facts:
- Exam consists of MCQ – best of 5 (all plausible)
- 200 questions in 2 papers• No negative marking – so guess if not known!
- Not like ABN self assessment – avoids ambiguity
- Also ‘extras’ (eg ethics)
- Mainly case scenarios – can be ‘unworldly’ in the sense of not common situations
- Will include data interpretation (neurophysiology, neuroradiology) and therapeutics
- Pass mark not fixed (currently) typically around 56% (113/200)
Exam knowledge & UK specific guidelines
- Royal College of Physicians
- UK guidelines: https://www.nice.org.uk/guidance/published?type=cg http://sign.ac.uk/
- Question weighting
- Royal College of Physicians
- Sample questions
- Comprehensive Review in Clinical Neurology: A Multiple Choice Question Book for the Wards and Boards: 1 Jul 2011
- Neurology: A Queen Square Textbook, Second Edition (Author: Charles Clarke and Robin Howard)
- Clinical Neurology, 4th Edition Paperback – 30 Dec 2011
- Practical Neurology (especially the bare essentials and the ‘mimics and chameleons’)
- Leading edge neurology for the practising clinician Read ACNR’s course reviews and previews.
- Birmingham movement disorders course
- Cambridge Dementia Course
- ILAE Oxford Epilepsy
- Edinburgh Neurology course
- Keele Neuroinflammation course
- Keele Headache course – Read a review of the 2014 course in ACNR
- Liverpool neuroid course ACNR review here