Examination Medicine: A Guide to Physician Training (3 page)

GVHD
graft versus host disease

HAART
highly active antiretroviral therapy

HBV
hepatitis B virus

HCC
hepatocellular carcinoma

HCV
hepatitis C virus

HDL
high-density lipoprotein

Hib
Haemophilus influenzae type b

HIV
human immunodeficiency virus

HLA
human leucocyte antigen

HMG-CoA
hydroxymethylglutaryl coenzyme A

HMSN
hereditary motor and sensory neuropathy

HNPCC
hereditary non-polyposis colon cancer

HPL
human placental lactogen

HPO
hypertrophic pulmonary osteoarthropathy

HSV
herpes simplex virus

HUS
haemolytic uraemic syndrome

HZV
herpes zoster virus

IBD
inflammatory bowel disease

ICD
implantable cardioverter-defibrillators

IDL
intermediate-density lipoprotein

IEPG
immunoelectrophoretogram

IGF-I
insulin-like growth factor I

ILD
interstitial lung disease

INR
international normalised ratio

IPF
idiopathic pulmonary fibrosis

IPH
idiopathic pulmonary hypertension

IPI
International Prognostic Index

IRTC
Independent Review of Training Committee

IVP
intravenous pyelogram

JVP
jugular venous pressure

KUB
kidneys, ureters, bladder

LA
left atrium

LAD
left anterior descending

LAHB
left anterior hemi-block

LAM
lymphangioleiomyomatosis

LBBB
left bundle branch block

LCAT
lecithin cholesterol acyltransferase

LDH
lactate dehydrogenase

LDL
low-density lipoprotein

LH
luteinising hormone

LIMA
left internal mammary artery

LNAT
learning needs analysis

LV
left ventricle/left ventricular

LVEDD
left ventricular end-diastolic dimension

LVH
left ventricular hypertrophy

LVOT
left ventricular outflow tract

LVPW
left ventricular posterior wall

MAC
mycobacterium avium complex

MALT
mucosa-associated lymphoid tissue

MCP
metacarpophalangeal

MCTD
mixed connective tissue disease

MCV
mean corpuscular volume

MELD
model for end-stage liver disease

MEN
multiple endocrine neoplasia

MGUS
monoclonal gammopathies of uncertain significance

mini-CEX
mini-Clinical Evaluation Exercise

MKSAP
Medical Knowledge Self-Assessment Program

MR
mitral regurgitation

MRI
magnetic resonance imaging

MS
multiple sclerosis

MSF
multi-source feedback

MSI
microsatellite instability

MTP
metatarsophalangeal

MV
mitral valve

MVP
mitral valve prolapse

NAFLD
non-alcoholic fatty liver disease

NAP
neutrophil alkaline phosphatase

NASH
non-alcoholic steatohepatitis

NEP
National Examination Panel

non-STEMI
non-ST elevation myocardial infarction

NSAIDs
non-steroidal anti-inflammatory drugs

NSTEACS
non-ST elevation acute coronary syndrome

NYHA
New York Heart Association

OAT
Open Artery Trial

OTPs
overseas-trained physicians

PA
plasma aldosterone

PA
posteroanterior

PAH
pulmonary arterial hypertension

p-ANCA
perinuclear antineutrophil cytoplasmic antibodies

PAP
pulmonary artery pressure

PBS
Pharmaceutical Benefits Scheme

PCH
pulmonary capillary haemangiomatosis

PCR
polymerase chain reaction

PDA
patent ductus arteriosus

PDA
professional development advisor

PET
positron emission tomography

PIE
pulmonary infiltrate and eosinophilia

PIP
proximal interphalangeal

PNH
paroxysmal nocturnal haemoglobinuria

PPD
purified protein derivative

PPI
proton pump inhibitor

PRA
plasma renin activity

PREP
Physician Readiness for Expert Practice

PTH
parathyroid hormone

PTLD
post-transplant lymphoproliferative disease

PTTK
prolonged partial thromboplastin time with kaolin

PUO
pyrexia of unknown origin

PVD
peripheral vascular disease

PVOD
pulmonary veno-occlusive disease

PY1
Postgraduate Year 1

RACP
Royal Australasian College of Physicians

RAD
right-axis deviation

RBBB
right bundle branch block

RDW
red cell distribution width

REM
rapid eye movement

RLS
restless legs syndrome

RIMA
right internal mammary artery

RNP
ribonucleoprotein

RV
right ventricle/right ventricular

SAAG
serum-to-ascites albumin gradient

SAC
Specialist Advisory Committee

SAM
systolic anterior motion

SE
supplementary examination

SIAT
Significant Incident Analysis Tool

SLE
systemic lupus erythematosus

STEMI
ST elevation myocardial infarction

SVC
superior vena cava

SVGs
saphenous vein grafts

SVT
supraventricular tachycardia

TB
tuberculosis

TIA
transient ischaemic attack

TIPS
transjugular intrahepatic portosystemic shunt

TNF
tumour necrosis factor

TNM
tumour node metastases

TOE
transoesophageal echocardiography

TPHA
treponema pallidum haemoglutination test

TR
tricuspid regurgitation

TSH
thyroid-stimulating hormone.

TTP
thrombotic thrombocytopenic purpura

TZDs
thiazolidinediones

UKPDS
United Kingdom Prognosis in Diabetes Study

UTHs
university teaching hospitals

VC
vital capacity

VDRL
venereal disease research laboratory

VF
ventricular fibrillation

VLDL
very-low-density lipoprotein

VSD
ventricular septal defect

VT
ventricular tachycardia

VVI
ventricular-ventricular inhibited

WC
ward consultant

WCC
white cell count

WPW
Wolff-Parkinson-White

CHAPTER 1

Basic physician training

I would live to study, and not study to live.

Francis Bacon (1561–1626)

There is nothing more rewarding and exciting than working as a consultant physician. Physicians are specialists who expertly diagnose and look after patients with complicated medical problems. They typically see patients referred to them for specialised advice and treatment by other doctors, and manage complex patients admitted to hospital. Accurate diagnosis is the key to optimal management outcomes in medicine, and when there is uncertainty or multisystem disease, colleagues turn to physicians for answers and guidance. As a consultant physician you will have the opportunity to change the lives of your patients for the better.

Physicians may work in
general medicine
and look after all patients with medical problems. They may be based in large regional hospitals or in general medicine departments in more specialised hospitals. Physicians may also train in
sub-specialty
areas such as gastroenterology, endocrinology, geriatrics and even cardiology. A lot of physicians now carry out interventional procedures such as colonoscopy or cardiac catheterisation, but still shudder at the thought of being a surgeon. Many physicians feel that their interventional work is an extension of their thoughtful diagnosis and skilled management of complex patients.

Training to become a physician may be perceived as long, complicated and difficult, yet it is a highly rewarding experience. Training requirements differ across the world, but particularly in Australasia, the United Kingdom and South East Asia, physicians are required to have a solid grounding in general medicine before they can begin sub-specialty training. In Australasia this means at least 3 years of work as a junior medical officer and registrar in hospitals, including a written theory examination and a clinical examination. Both the rotations and the hospital need to be accredited by the Royal Australasian College of Physicians (RACP) to be accepted for training purposes by the RACP. All trainees are required to complete formative (ongoing) assessments under the PREP (Physician Readiness for Expert Practice) guidelines, before completing training.

The RACP was established in 1938 with a core responsibility to train future medical specialists, including adult physicians and paediatricians. The RACP appoints supervisors who provide the training required before candidates may sit their exams. This period is called
basic training
. All registered basic trainees who have paid their fees are now members of the College and can vote in College elections (and you should, to shape the future of your College).

Success in the written and clinical exams (which are both barrier examinations) enables a trainee to enter
advanced training
in an area of specialty medicine. This usually takes another 3 or 4 years. Successful completion of advanced training enables the trainee to be admitted to the College as a physician and use the prestigious letters FRACP (Fellow of the Royal Australasian College of Physicians) after their name, often colloquially described as ‘getting your ticket’. There is currently no summative examination at the end of advanced training. In other countries (e.g. UK, USA), end-of-training examinations are required for subspecialties.

To be eligible for basic training in the RACP, candidates must have a medical degree, have completed an intern year (the first year after graduation), and have secured an appointment in a training position in a College-accredited basic physician training hospital. We predict with the surge in medical student training in recent years that these positions will likely become even more competitive.

During the core 36 months (full-time equivalent) of basic training, trainees work in different areas within accredited hospitals. There are certain requirements that they work in a variety of different medical terms before a candidate is allowed to sit the written examination. A total of 24 months must be spent in what are referred to as core training rotations, including general and acute medicine, and at least a year in the medical specialties (e.g. 6 months in neurology and cardiology – both highly recommended rotations if available). Up to 12 months can be spent in non-core training rotations. An Advanced Life Support course will be completed. Training supervision under the RACP is provided by the Director of Physician Education (DPE), a Professional Development Advisor, Educational Supervisors, and term supervisors on the wards (one per rotation).

The period of basic training in Australasia is closely supervised by the RACP and candidates must report their progress to the College regularly. A detailed curriculum is available and provides an excellent guide to the examination. The details of basic training are set out in detail on the College website (
www.racp.edu.au
). The specifics of training requirements differ minimally from Australia to New Zealand. Please refer to the website for all current information as the particulars do change over time.

For the trainee’s idle moments, another important recent innovation are the PREP assessments (
Table 1.1
). The mini-CEX requires trainees to assess a patient in their own hospital while being watched by an assessor. The trainee will be guided to a specific aspect of history-taking, examination or assessment. Before the trainee evaluates the patient, the trainee and assessor spend some time discussing what should occur. The trainee then spends 15–20 minutes with the patient and another 10–15 minutes afterwards with the assessor, again to discuss the performance. The idea is to simulate a normal clinical encounter in which a targeted history and/or examination are performed. A number of competencies are possible to assess in addition to interviewing and detecting physical signs in different exercises, including professionalism, clinical judgement, and counselling.