I Failed My Finals

'No matter what you do now, you will end up passing your finals anyway, so stop worrying about it. '

I can't even remember how many times i have repeated this line to all my friends who worries about the final hurdle of our medical education. Some got rather annoyed with me, asking me how could I be so sure of this. I just shrugged them off all the time. Never had i thought it will come back to haunt me. 

Well, I always have always managed to pass my exams. To me, it's a constant. No worries. The only variable is the grade. It has been like this all my life, almost (there were exceptions, but I shall leave that to another post). I have even stopped worrying about grades after getting admitted to university. At the end of the day everybody is conferred MBBS (Singapore). Only the few exceptional students who score distinctions in all 5 years get a mention of honours. That's beyond my reach. However I have been conscientious enough to make sure that every step i take, it is towards becoming a competent and safe doctor.

All these years, I have always assumed that I will graduate along with everyone else in the class. 

So when Naga called me 2 mornings ago, I wasn't at all prepared for the cruel irony that follows. That I have failed my surgery paper felt so unreal, so unreal that i kept on hoping that i would wake up and realise that this is nothing but a dream. I never woke up from the nightmare. Still haven't, i last recalled. 

I was so confident that i would pass my surgery papers. 

Apart from the Slides examination that i mistook the allocated time for 2 hours instead of 1.5 hours (I was left with a lot more questions than i should at that juncture but thankfully I managed to finish answering them all with my sympathetic overdrive), there was hardly any hiccups at all. I thought the clinical examination were a clear pass. I had very simple short cases that I could perform very well. Long case wise, it was less than stellar but i managed to present my history and physical examinations succinctly and coherently, giving the correct diagnosis with appropriate differentials, and the discussion went smoothly from investigations to managements. With every statements i gave supporting findings and reasonings; likewise for things that i ruled out. 

Unfortunately there were also instances that i could not answer well. 

"How do you test for L5?"

"By testing the EHL sir, according to the American Spinal Injury Association"

"How else can you test for L5?"

"Err.. Tibialis anterior, sir"

"Good. How do you ISOLATE tibialis anterior?"

"Err i am not sure how to isolate tibialis anterior from the other muscles that dorsiflex the foot" (Eversion is the answer i think, but that really is a bit chim, isn't it?)

"Is drug allergy important?"

"Yes sir, it is very important."

"Is it important in THIS PATIENT?"

(I thought I have just answered YES??!!)

i was told the golden rule in answering a question that was asked twice was to change course immediately. So without further consultation with my common sense i blurted out, "No."

I swore his eyeballs almost came loose from the sockets at that moment, and i immediately retracted my statement and apologized profusely. 

"Isn't blood pressure important in this patient? Why didn't you take the blood pressure?"

"Yes sir it is very important in this patient as he has a significant history of hypertension of x years duration, currently treated with 2 drugs, with no complications from the condition so far as well as no side effect from the medications. I did not obtain his blood pressure reading as the BP machine was faulty and i did not have enough time to hunt for another one down the corridor."

"Why didn't you get another BP machine?" he repeated. 

"I did not have enough time, sir. I thought I can refer to his clinical chart for his BP readings while i continue with my examination"

He does not appear appeased by my answer. 

"What else do you see on the X ray? Something you have mentioned just now?"

"Err.... secondaries?" (My differentials of neurogenic claudication from spondylosis or spondylolisthesi, vascular claudication from peripheral arterial disease, and secondary metastasis to the spine)

"Where is the secondary deposit?"

We were both peering very hard at the screen. It would have been a great photo if the screen captured our facial expression at that moment. 

"I do not see any, sir. They usually involve the pedicles and present as winking owl sign. I do not see any such sign here."

I think he was trying to hint at spondylolisthesis on hindsight, but i really did not see any anterior translation of any vertebrae. I did mention about wanting a oblique x ray for Scottie dog sign though, but he wasn't impressed. 

Other than that there was no more blunders that i can recall, apart from introducing Dr Suresh as Prof Thambiah to my patient. Haha. That surely wasn't that fatal a mistake, right? 

Anyway I came back to Singapore today. First thing i did after i put down my luggage in my room was to walk down to the Dean's Office to find out what's going on. Was told to approach the Surgery Dept instead. I had to wait for a week or two before they will finalize my appeal application, then the Head of Department or the Convener of the Final Exams will explain to me my shortcomings identified in the exams. 

That's a rather long wait, but the grimmer piece of news was that so far No One succeeded in their appeal. That the outcome always stay the same, makes me wonder what all the fuss about appealing is, why i even bother to appeal. 

Anyway I managed to talk to my previous tutor, and we discussed on what might have gone wrong. He reminded me of one reason that a student could fail - causing the patient pain. I recall that my patient was suddenly able to flex more than 70 degrees on straight leg raising when asked to demonstrate in front of the examiners, and i had to raise it to almost 90 degrees before he grimace. I then proceeded on to confirm with Lesague and Bowstring test. Was there any moment that i caused the patient pain without realising it? I really do not know now. I have a really uncomfortable feeling about this. 

I spent the last 2 days cracking my head on how i could have failed my surgery paper. I have mentally watched my long case being played over and over again in my mind, so many times that i was really exhausted at the end of the day that i could ACTUALLY sleep on both nights. Amazing feat isn't it. It's going nowhere, and it's getting unhealthy. Had been wearing a mask-like facies on both days that worried everyone at home sick, especially my mum. My best friend commented that i have sighed more times in the last 2 days than all the years he has known me. Even my dog stayed away from me. And for the first time in my life, instead of dropping me at the airport and drive off waving goodbye, my brother actually parked his car and sat with me for half an hour before urging me to board my plane. 

Now that i have realised how futile and wishful my appeal to the department was, i am more accepting of my failure. The change in mood came so suddenly that i found myself grinning and filled with optimism. (Hope it is not the first presentation of bipolar) Well, casting aside all the downside of a supplementary exam and the remedial posting that comes along, i actually get to be a student for another 6 months!!! Not that i really want it... But i am determined to make full use of the coming months. There were many things that i wished i had more time to cover and do when i was preparing for finals earlier on. There are other skills that i wish to acquire too. Suddenly it felt as if it wasn't too bad to fail. 

Now i sound more like myself. The endless supply of optimism. 

There's one HUGE regret though. The fact that i won't be able to graduate along with my close friends saddens me every time i thought about it. But then again, i can always borrow their gown and take photos together. Eventually my memory will fail and i will think i have graduated along with everyone. That is if my significant cardiovascular risk does not kill me before i grow THAT old...