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Chapter 10 General guidelines for

exam technique

OVERVIEW

This chapter summarizes the general rules for any exam. Many of these are simple, but
we know from many students that they are often overlooked. The majority of this
chapter will be read quickly, and we believe it will make a lot of sense. You should
reread it a week or two before your first set of exams, and possibly later sets as well. In
Chapter 11, we will attempt to apply these general principles to the specific exams that
you will most likely encounter during your time in medical school.

Introduction
This chapter contains both good and bad news. The bad news is that,
contrary to popular belief, clever exam technique will not allow you to pass
medical school exams without doing any work. The good news is that proper
exam technique will allow you to use what you know to your advantage.

Getting ready for the exam

Understanding the exam's format and rules
Students who struggle frequently tell us, 'I had no idea what to expect
from the exam.' Although it may appear obvious, you should spend some
time learning about the exam, including its structure and format. How
many questions, how much time, and what kinds of questions will be
asked? This information is essential for your preparation. There will be
official information such as exam
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briefings and written information are important, but informal information

such as 'there was much more anatomy than I was expecting' or 'I didn't
realise the questions would expect us to explain pathology in terms of what
we knew of anatomy and physiology' will be invaluable to you.
However, keep in mind that these are highly subjective assessments. At
one institution we know, third-year exam performance would oscillate: one
year, many students would fail the clinical exam, but few would fail the
written; these students would then spread the message that the clinical
exam was extremely difficult and 'no one ever failed the written,' and the
following year, students would come well prepared for the clinicals but
poorly prepared for the writtens. This resulted in a fairly predictable 2-year
cycle. As a result, you might try to talk to students a few years above you
and try to reach an agreement on their advice. Consider some useful
questions to ask, such as:
● What happened during the exam?
● What went differently than you expected?
● What would you change about your preparation if you had to take the exam
again?
You can practice mock exams if you know the format of the exam.
You could use previous papers, questions from books or the Internet,
or even write your own (see our previous discussions about writing
questions as you study in Chapter 2). As we discussed in Chapter 9,
perform under exam conditions, particularly exam timings. Use these
practice papers to both practice technique and as a diagnostic tool. If you
get a question wrong, don't just memorize the correct answer; instead, go
back and revise that section again. Assume you get a question about one of
the diabetes treatments wrong; this probably means you need to go over all
of the diabetes treatments again, and maybe even make sure you
understand everything about diabetes.

Special circumstances
Every institution has a policy in place for extenuating circumstances. You may
not want to consider it, but imagine something terrible happening to you
around the time of an exam: perhaps a family member becomes ill, or water
begins to pour into your flat, forcing you to camp out on a friend's floor. In
these cases, your institution may consider your circumstances when
evaluating your results. Examples may include (depending on the institution):

● If you do not show up for an exam, it is usually considered a fail,

reducing the number of additional attempts at this exam and leaving a
blemish on your record.
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If you have a good reason, the exam board may agree to treat your next
exam sitting as your "first sit."

● IIf something terrible happened to you around the time of the exam,
and your score falls just short of the pass mark, the exam board may
look at your extenuating circumstances and agree that they prevented
you from demonstrating your true level on the day of the exam.

When things go wrong, the last thing you want to do is look up the
regulations and paperwork for extenuating circumstances. Gather these
papers well in advance of the exam and keep them somewhere safe; you
may not need them, but you or a friend may be grateful for your
preparation one day.
While discussing extenuating circumstances, we should make a few
points. First, exam boards aren't impressed by frivolous claims: if your
hamster died two months before the exam, they're unlikely to care. They
are only interested in knowing if there is a legitimate reason why your
performance on the day did not reflect your knowledge and skills. Similarly,
if you have a long-standing problem that has affected your work, for
example, recurrent hospitalizations for asthma and chest infections have
meant that you missed most of the teaching this year, and then you fail the
exam, they may conclude that you didn't have the knowledge and skills
required to pass the exam because of all the time you lost, and thus you
should have failed. If you were in A&E all night the night before the exam
with an asthma attack and wheezed your way through the exam after a
sleepless night, they might conclude that your mark should be a little higher.

The university's learning support unit suspected I had dyslexia and referred
me to an educational psychologist, who confirmed it and wrote a report for
the exams office. I now have more time in written exams and feel
significantly less stressed.
Gustave, first-year medical student
Obviously, any claim you make must be truthful, and you must be able to
provide written evidence to back up your claim. Don't lie about anything. If
things are going wrong for you in the run-up to the exams, remember that
the school would prefer to know sooner rather than later, and that people
are in place to help and support you (see Chapter 8). Most extenuating
circumstances policies are only effective if you notify the school of your
difficulties prior to the exam, never after the results are released.
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Taking lessons from the past

The last thing to think about before the exam is your previous experience.
How did previous exams go? What are your strong points and weak points?
If you frequently become overly nervous before an exam, you should plan
what you can do about it months in advance (see next section and Chapter
8). Similarly, if you find a particular exam format particularly difficult, you
should actively plan how to address this prior to the exams. Some of the tips
in the following sections may be useful, as may the various courses offered
by your school. Students who say things like, "It's funny, but I never do well
in multiple choice exams," don't get much sympathy!

Having to deal with nerves

Before an exam, everyone gets nervous. This is normal, and a little
adrenaline will probably help you perform better. If you have followed the
advice in this book, you should have learned the course content and revised
it as you went along, using deep techniques that ensured understanding and
effective recall (Chapter 2), you will have revised well (Chapter 9), and you
can rest assured that you are well prepared.
Of course, some people become extremely nervous before exams, and in
addition to the advice given in Chapter 9 (revision), there are some simple
tips to follow on the day.

● Arrive early for the exam – The last thing you want to feel on exam day
is panic that you won't make it in time. Arrive at least half an hour (more
if you are traveling a long distance) before the exam begins.
● Only converse with people who will make you feel good about the exam
– Stella Cottrell's (2006) advice is crucial. The advice given by Louise
below is an excellent example of learning from experience.

I failed my first year exams because I was too nervous - I showed up and
stood outside the exam hall with all my friends, and listening to them talk
about everything they had learned made me panic, and during the exam all
I could think about was how little I had prepared, rather than the questions
in front of me.
Every exam I've taken since then, I've arrived early but waited quietly in a
nearby seminar room or café, glancing over my notes and practicing yoga
breathing, and finished on time. Since then, I haven't failed an exam.

Lewis, newly-qualified doctor

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● People sometimes experience exam anxiety – there are always one or

two students who panic when they see the first question. Some
students rush out of the exam room. This is called stage fright, and it
occurs every time an actor takes the stage, a lecturer enters the lecture
theatre, or a student turns over the exam paper. If this happens to you
badly enough that you get up and try to flee, don't worry; it's happened
before and the invigilators should be well prepared. Make sure you have
an invigilator with you and allow them to speak to you. You're likely to
interrupt their friendly pep talk halfway through and ask if you can
return to the exam. When you look at the questions again, you'll notice
that some of them don't seem so bad!

During the examination

Exam instructions should be read
How many questions should you answer, and when should you answer
them? You should have known this information a long time ago and
practiced timings in the mock exams you took, but double-check that
nothing has changed. Keep an eye out for simple mistakes that you might
make. 'Answer three questions from Section A, four questions from Section
B, and one question from Section C,' for example, is a recipe for disaster.
Write 'THREE QUESTIONS' in Section A, 'FOUR QUESTIONS' in Section B, and
'ONE QUESTION' in Section C right at the start, so you don't get thrown out
during the exam.

Examine the question

This may appear to be a patronizing point, but as examiners, we have seen
hundreds of examples of students failing to read the question and thus
failing to demonstrate what they know. Table 10.1 contains some examples.
Carry a pen with you and draw a box around, underline, or otherwise
highlight each of the key words or phrases (see Chapter 2) in the question;
examples are listed in Table 10.2. One word of caution: you may not be
permitted to write on the question sheet, such as in a clinical exam where
other students will be looking at the same question sheet. Our advice
remains the same, but instead of writing on the question, imagine that you
are - which words or phrases would you highlight?

Prepare your response

Depending on the type of exam, you may have more or less time to
plan your response. If you are answering essay questions, you may
have plenty of time to plan. Short-answer questions could
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Table 10.1 Examples of students who did not properly read the questions

Q1 The following are classical features of
left heart failure (multiple choice question)
Q2 Please teach this patient how to use
these inhalers and explain how each one
works (OSCE question)
Q3 List four causes of clubbing, each
originating from pathology in a different
organ (short answer question)
Q4 Doctors make populations less healthy –
discuss (essay question)
Q5 This patient complains of intermittent
yellowing of the skin, please conduct an
abdominal examination and present your
findings to the examiner – you have
5 minutes (clinical examination/OSCE
question)
Student reads ‘right’ heart failure, and
gets each answer wrong
Student just teaches how to use the
inhaler and misses out on half the
marks
Student lists only three causes, or student
lists four causes originating from lung
disease only
Student only gives one point of view
(so does not ‘discuss’). Student focuses on
health policy (and not ‘doctors’). Student
focuses on treatment of disease (‘health’
does not only
refer to the absence of disease)
Student spends 4 minutes trying to take
a history from the patient (no marks) and
only manages a very brief examination,
and doesn’t have time to present

Table 10.2 Exam question examples of highlighting key points

Q1 The following are typical symptoms of left heart failure

Q2 Please instruct this patient on how to use these inhalers and explain how they work.
Q3 List four causes of clubbing, each of which is caused by pathology in a different organ.
Q4 Doctors reduce population health - discuss
Q5 This patient complains of intermittent skin yellowing; please perform an abdominal
examination and present your findings to the examiner within 5 minutes.

warrant a minute of planning, and in clinical examinations you may only

have a few moments to plan (for example, when introducing yourself and
gaining consent in an Objective Structured Clinical Examination (OSCE), you
might include in the plan '...I would like to run through how to use these
inhalers and also cover how each one works...' Is that all right with you?...'
We will go over planning in greater detail when discussing each exam
format, but the key point is that you should avoid jumping into an answer
without first thinking about how you will approach that answer.

Manage your time wisely

One of the most common exam mistakes is running out of time and thus
failing to answer every question. You must be precise with your timing.
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Missing 10% of multiple choice questions due to time constraints will

reduce your final grade by up to 10%. Not answering one of four essay
questions will result in a 25% reduction in your final grade; the math is
simple, but people still do it. Two issues contribute to students not
finishing on time. One is planning: we recommend writing key time points
into different parts of the question paper (we call these 'time-posts') and
practicing your timing in mock exams. Consider the following example: The
majority of marks ('easy marks') are obtained during the first half or two-
thirds of the time spent on each question; after that, additional marks
become increasingly difficult (in terms of time) to obtain.

Assume you have 10 minutes to write about the clinical presentation of myocardial
infarction (heart attack), and you will receive 10 points. This is one of ten short answer
questions you must answer.
You could answer the question using the categories 'classical presentation' and 'non-
classical presentation.' You write about classical presentations in 5 minutes and get 6
easy points. After you've written all of the obvious things, gaining extra points
becomes more difficult. You get another mark after the next two minutes, and one
more after the last three minutes.
You have an 8/10 after 10 minutes and it is time to move on. You could keep going on
this question, racking your brain, but it might take another 5 minutes to get to 9/10, by
which time you've missed out on the six 'easy' marks on the next question.
8/10 on all ten questions equals 80%. 9/10 on seven questions and 0/10 on the
remaining three (due to time constraints) equals 63%.

You must be strict with yourself regarding timing; when you run out of
time for that question, move on. If you have time, you can always return to
it at the end. Even if you don't know much about the answer to a question,
it's better to take a shot at it and get maybe half a mark for that question
than to spend that time on a question that you know more about and get
maybe one extra mark. Answer all of the questions that have been
assigned to you.

Following the examination

Many students congregate outside the exam hall, discussing the
questions. Some students benefit from this, while others benefit from
watching a colleague look through the books and punch the air,
exclaiming, 'Yes, another one I got right!'
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every minute or so can be inconvenient at best and disastrous for one's self-
confidence for the next exam at worst. So take a step back and treat yourself
to something nice.
Find some time on the exam day to sit down and write some reflections -
what went well, what helped, what didn't go so well, and what led up to this.
Make a plan for preparing for the next exams based on your reflections, and
stick to it. It could be as simple as bringing an extra pencil, or as insightful as
Louise's example above. You might want to discuss your thoughts with the
other students in your study group. They may have some additional ideas
that would be beneficial to you, and yours may be beneficial to them. The
key message here is to learn from your mistakes and to keep improving.

Messages received from the other side

As examiners, we have four key messages to share with you. They remain
true and relevant whether you believe them or not (and you won't believe
them all). They are related to the assessment's purpose, the examiners'
motivations, empathy for the examiners, and the noble art of question
spotting.

Understand why you are being evaluated

Assessment serves several functions. These include acting as a hurdle (to
ensure that you know enough to progress into the second year, or that you
are skilled, knowledgeable, and safe enough to graduate as a doctor),
providing feedback (for example, to help your academic writing skills
develop or to highlight your weaker areas to you), and providing feedback
on the course (if three-quarters of the year don't know the names of the
heart valves, there is probably something wrong with the course).
Students frequently lose sight of why they are being evaluated. Most
institutions' final exams are designed to ensure that graduates are
knowledgeable, skilled, and safe enough to practice as first-year junior
doctors. Some students believe that finals are much more important and
attempt to study at a hyper-advanced level, which may result in difficulty
covering all the bases. Worryingly, some students believe that finals are much
less important, and their focus is solely on finding a 'trick' to passing the
exam, 'performing' well on the day, and learning only the topics that they
believe will be covered. These students, who are usually not prepared to be
doctors, perform poorly. We have discussed depth versus breadth in your
studies elsewhere in this book (Chapter 2), and knowing the purpose of the
assessment will help you decide how deep to go in your exam preparation.
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Examiners are here to assist

Contrary to popular belief, examiners are not out to catch you. A great deal
of effort is put into making the exam as fair as possible, identifying every
single way that a student might get the short end of the stick and devising
ways to prevent this from happening. If a question simply asks you to list four
causes of something, there will be no points for a fifth cause, and the
examiners do not want you to list all of the treatments as well. There are no
hidden messages or things to decipher between the lines.
The examiners genuinely want you to succeed. They will work hard to elicit
the best performance from you in order to assist you in receiving the highest
possible grade. Ironically, this may include asking you difficult, sometimes
impossible questions to see how you respond. You may think these difficult
questions are 'unfair,' but give them your best shot; you might be surprised by
the results.

Transference
Transference is a clinical psychology term that describes when a patient
believes their therapist or doctor is feeling the same way they are. This is
something you will notice in your own life. When you were embarrassed,
you probably assumed that the rest of the world was as well. A good
example is purchasing condoms for the first time from a chemist or
supermarket. You are likely to believe that everyone is staring at you, that
the person behind the counter is thinking about you, when in fact, while this
may be the first time you have ever purchased condoms, it is the ten-
thousandth time they have sold them, and they are unlikely to be
consciously aware of the fact.
The same thing happens during exams: students enter the exam room
nervous and hypersensitive. Everything revolves around these students. An
examiner yawns, sending a personal message to the student (in reality, the
examiner was up all night with a new baby and had just sat through 99 other
students performing the same skill over and over on a hot summer day).
Many students may be thrown into the exam as a result of this transference,
their anxiety levels spiraling out of control.
Control is all about recognition. If you know that the feeling in your gut is
just transference, and that everyone around you is feeling the same way,
you can smile and let it go. If you ever have the opportunity to be an
examiner yourself, even for a mock exam, take it. Understanding the
examiner's point of view is extremely beneficial.
My medical school staged a mock OSCE in which I played the candidate and
was an examiner in the second half. I wasn't expecting it, but being an
examiner taught me a lot more than I expected.
Titouan, fifth-year medical student
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Examiners are also human

Examining is frequently tedious and boring. It's not fun to mark essay after
essay on the same topic, or to try to spot key points in short-answer
question after short-answer question, or to listen to 150 students in a day
ask a simulated patient how much alcohol he drinks and whether he has
ever considered cutting down. If you understand this, if you can put yourself
in the shoes of the examiners, you can make their job easier and help them
spot the marks you deserve.
Make sure your responses are simple to understand. If your handwriting
is terrible, work on improving it and writing important points in capital
letters to make them stand out. Consider the following two responses to a
short-answer question.
Q6 Describe the early clinical manifestations of a myocardial infarction (heart
attack) (10 points)

CLASSICAL PRESENTATION A myocardial infarction can cause

Symptoms
● Chest pain – classically CRUSHING,
CENTRAL, may RADIATE to left arm or
chin. NOT RELIEVED by nitrates or rest.
● Associated symptoms – SWEATING,
NAUSEA, VOMITING, collapse,
breathlessness
● Past history – may have past history of
ANGINA, or OTHER CARDIOVASCULAR
RISK FACTORS
(cholesterol, raised blood pressure,
arterial disease)
Signs
● May look GENERALLY UNWELL –
sweaty, tachycardia, in pain
● BLOOD PRESSURE up or down or
normal
● May present with CARDIAC ARREST
ATYPICAL PRESENTATIONS
● Atypical chest pain (‘indigestion’)
● FEVER +/− HEART FAILURE about 12
hours post MI
● CARDIAC ARREST
chest pain that is not relieved by
glyceryl trinitrate. There may be
times when there is no pain. Patients
may vomit and appear generally ill.
Pain may or may not be present, and
it may be mistaken for indigestion. It
is typically central, radiates to the
left arm or chin, and is described as
crushing, though there may be no
pain at times. History obtained from
the patient or their relatives may be
suggestive of an increase in
cardiovascular risk factors, and
blood tests may have revealed
previously raised cholesterol, raised
blood pressure, or angina. Blood
pressure may be high, low, or
normal at the time of a myocardial
infarction. Undiagnosed myocardial
infarctions may present later with
fever or heart failure.

● ASYMPTOMATIC MYOCARDIAL
INFARCTION – found at screening at some
later date
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Assume you are marking both of these responses, and you have a marking
scheme that lists all of the key words that will earn the candidate a mark
(and will probably rather look like the answer on the left). As a result, the
candidate on the left has made your life easier, and ticking each key point is
simple. The marks in the script on the right are much more difficult to spot.

Question spotting and planning

As a student, one of the authors spent countless hours poring over past
papers for recurring themes and patterns, creating charts and graphs, and
attempting to outwit the examiners. If a topic came up every other year and
didn't come up last year, it would almost certainly come up this year. This is
a popular pastime among medical students, with days or weeks spent
attempting to forecast the future. Some graduates go on to play the stock
market, creating similar graphs of share prices, but the majority of us
realized sooner or later that it was all for naught!
Examiners use a process known as blueprinting to determine the content
of an exam. During this process, they examine the curriculum content and
ensure that the exam (or exams) samples a broad range of the curriculum
that is expected to be covered by this stage of your training. The blueprint
gives more weight to important things, so there will be more questions in
this category, but the blueprint ensures that everything that should have
been covered can be covered in the exam. This is why it is critical for you to
consider the exam's purpose: it will give you an idea of the likely content.
Now for the bad news. They look to the curriculum to build the blueprint
of the exam, but they also look to previous years' blueprints of the same
exam; they will know if a certain question tends to come up every other
year, and they will know that the students know. To avoid alternate years of
students failing to learn the topic, they may decide to include it in a
'unexpected' year or leave it out for a couple of years.
Really dedicated examiners will even consult the blueprints of previous
exams that you have taken and will be taking to ensure that there is a good
spread of topics, with important topics (diabetes, heart attacks, etc.)
appearing frequently and rarer/less important topics appearing less
frequently but still appearing on occasion.
If you want to guess the exam content, make sure you understand the
purpose of the exam and the level expected. You will be able to list the
important and common topics that are likely to come up - you must be well-
versed in these - as well as the less common topics that may come up - you
must know enough about these to be 'good enough' at the level of the
exam. Making more specific predictions than this is a waste of time that you
could be studying.