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I looked into her anxious eyes and could feel her need to talk. The child sitting placidly on her knee was beautiful. The love between them was obvious and it was clear this was a special and precious child. “It's just that with the Blalock shunt in, I feel I have to be more careful with him, even if he just seems to have a cold.” I didn't know what a Blalock shunt was, but I knew this woman half expected me not to know and would patiently explain it to me. She did. “You see, Doc, he was born with Fallot's tetralogy and one way of overcoming that is to join up the artery that goes to the arm to the one that goes to the lungs. That way the lungs will get a decent blood supply and that does for a while.” We talked more about the difficult and traumatic times there must have been when her young son was having cardiac surgery, and how well he seems to have done since then.
I was doing a general practice locum then. It was a dark December evening and even though it was late when I got back home to Greystones that night, I took out my Harrison's Principles of Internal Medicine, and looked up all about Blalock–Taussig shunts, the intricate surgery required, and the subsequent findings in adult life–that is, endocarditis and possibility of pulmonary hypertension.
Five years later, at 34 years of age, there I was struggling with Part II MRCPI. It was only my second attempt, so I wasn't unduly panic stricken. I had done a mediocre paper, the oral exam had been touch and go, descending sarcastically into my “ability to differentiate a Q wave from a Mexican wave!” I knew I was on thin ice by the time the clinicals started. I was really pleased when the major case turned out to be a woman with multiple sclerosis.
My MD in immunology had touched on some exciting theories on the pathogenesis of MS. So, after a thorough social and medical history and physical examination, I was ready for the examiners to be suitably impressed.
Unfortunately, however, the “conversation” degenerated into anatomical minutiae and I spent an awkward time trying to respond to inquiries as to the whereabouts of the plaque in the spinal cord that was causing the sensory deficit in her left leg. The two “armchair” neurologists plunged deeper, wallowing in my obvious discomfort. The last straw was when one of them asked me about proprioception which I had completely omitted to do! Their shock and disbelief at such an omission turned to disdain when I offered to “do it now.” It was plain that in their opinion I should never even be allowed to shop in Kildare Street, never mind get into the college itself. All four of us, the patient included, breathed a sigh of relief when the bell finally went. However, I had paid my money and was entitled to go on and do the short cases. The surprising thing is that instead of being crestfallen, I was actually quite calm and collected, and looking forward to the next challenge. Perhaps the knowledge that I thought I had no chance of passing lightened the gravity of the next stage of the exam—I don't know.
Two well known professors took me in hand and as we approached the first case it was obvious they had had a bad day of it. “Examine this man's pulse.” I did, feeling both right and left radials (as you do in exams). The left radial pulse was absent. I noticed an ancient sternal scar and a raised JVP. I started the usual differential. It was cut short by a “YES, YES, YES, but what's the diagnosis?” My next sentence changed my life forever. “He has a Blalock–Taussig shunt in, professor.” Well, the two of them beamed with delight at obviously having found at last a candidate worthy of their attention. “What is a Blalock–Taussig shunt?” I explained with the details fresh in memory as if that consultation had only been yesterday. “You listen to his heart and tell me what you hear.” Even before the stethoscope hit the chest, I knew I was going to say there was left parasternal heave and a loud pulmonary component to the second heart sound suggesting pulmonary hypertension which is a recognised complication in patients who have had this procedure. Professorial delight knew no bounds and I was whisked majestically along from short case to short case, many of which could be manipulated to allow me refuge in immunology, GU, and HIV medicine. The complicated psoriasis led on to psoriatic arthropathy and sexually acquired reactive arthropathies, the fundal examination to CMV retinitis and other HIV complications. The chest complaint in a young man beautifully led into a discussion of HIV related lung pathology. I could do no wrong. I was obviously just the tonic these two worn out, exasperated examiners needed at the end of a long day in the Mater Hospital, Dublin.
As I left the hospital, I remember thinking to myself there will be some shenanigans sorting me out when it comes to the round table end of day assessment. I subsequently heard that there was indeed some heated discussion. My examination photograph had to be produced to be certain that I was the same candidate that had been examined by both parties. Professorial weight finally won the day and I squeezed under the door of Number 6 Kildare Street.
Did I deserve to pass that exam? I have done maybe a handful of full neurological examinations (including proprioception!) since passing, but I have looked into thousands of anxious eyes of patients who needed to talk, and I've been there for them. I think I deserved to pass.
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