quite dramatically from your time at A2 level. The pass rate depends on the scoring system and most are standardized.Throughout medical school you will be bombarded with different types of assessments—probably more so than your friends in other faculties. Although this may seem like a terrifying thought, it does actually provide a valuable motivation to stay on top of the curriculum as you go along. Do not end up cramming your revision into a few weeks before the end-of-year exams are due to begin. It is best to keep up with your workload! Assessments will take many forms from practical exams, to clinical OSCEs, to MCQ papers. This chapter will focus on the written exams that you are likely to encounter at medical school.
It may sound like a silly question, but passing exams allows us to:
• feel a sense of achievement and worth in terms of knowledge gained (needed to counter the stresses of medical school)
• gain a good ranking for job allocation
• possibly achieve honours or distinctions
It is worth noting that not all medical schools have the same systems of examination:
• You will find that the quantity of subject material quite dramatically from your time at A2 level. The pass rate depends on the scoring system and most are standardized.
• Medical school is crazier than school and college with crazier workloads but also comes with crazier fun. Although it is used countless times, the phrase ‘work hard, play hard’ is fully adopted by every medic. It is a cliché for a reason!
• It is important to realize that while in school it may have felt like you were pitted against your peers, whereas at medical school your personal performance is all that counts. You are all in the same boat in a tough course whereby ~8% of students drop out within the first 2 years. So please help each other to succeed, practise, and become good doctors.
MCQs involve a question with five possible answers to choose from. Each stem may also require a true or false answer. Some students feel that they are easy as the answer is right in front of you. However, others struggle with the process of elimination.
MCQs generally predominate in medical school summative exams, and so it is really important that you practise this type of question.
Example: which of the following statements about schwannomas is true?
a) They represent peripheral nerve tumours (T/F)
b) Treatment is excision (T/F)
c) They arise frequently in motor nerves (T/F)
EMQs involve a clinical scenario with more than five options to choose from. This reduces the ability to guess an answer and it gets trickier to use the process of elimination.
Example: Medical School Council, example questions, EMQs 
www.medschools.ac.uk/MSCAA/examplequestions/Pages/EMQs.aspx.
SAQs require the student sitting the examination to reproduce knowledge without having any options to choose from. The answers required are usually short as the name suggests and can be anything from a few lines to half a page. It is important to identify exactly what the question is asking to gain maximum marks.
Example: Medical School Council, example questions, SBAs www.medschools.ac.uk/MSCAA/examplequestions/Pages/SBAs.aspx.
These require the student to be able to answer all the points addressed in the question in an ‘easy-to-read’ and logical format. This can be quite tricky in a time-pressured examination and therefore it is a good idea to pre-plan an essay format or practise these questions (see 
p. 980).
The PSA is an important examination which has recently been introduced as either a summative or formative assessment in many UK medical schools. It tests a soon-to-be-doctor’s ability to write new prescriptions and calculate drug dosages, among other skills, usually in the final year.
It is important to find out whether your university marks its exams positively or negatively as this will sway how you answer the questions. Positive marking means that you will gain 1 point for answering a question correctly and 0 points for answering incorrectly. Whereas, negative marking means that when you answer a question incorrectly, a point is deducted. Therefore, if your exams are negatively marked you should avoid answering questions that you are unsure about. If not, guess away!
A fair number of assessments are classed as ‘formative’ where marks may not contribute to the end-of-year result. However, ‘summative’ assessments count towards your end-of-year mark (see Table 51.1).
Table 51.1 Formative vs summative exams
If calm is not an adjective your peers would use to describe you, remember: it is possible to learn this skill. Remind yourself that there is always enough time and that rushing is not necessary. It is very important in medical school to learn how to switch off. Some possible ways to feel rejuvenated consist of exercising, meditating, listening to music, as well as participating in a social group. Being able to recognize when you are becoming stressed is an essential attribute—work on this first and then work out how to counter it. This will also hold you in good stead when you start life as a doctor.
Believing in yourself is really important. When you head into an exam, realize that there is nothing else you can do at that point, you have worked hard and you have the ability to pass the test—so get your head down, focus, and think positively. Confidence is important throughout medical school and when you begin practising as a junior doctor. If you are worried about a patient, speak up; if you think a drug has been prescribed wrongly, have the confidence to mention this to one of your team members. Medicine is about working together and using the opinion of everyone on the team to decide the correct management for the patient who is your priority.
No matter what people say or how they act, everyone at some point will experience the feeling of having no idea what they are doing and being totally and utterly lost—you are not alone although there will be plenty of times when you will feel isolated. Working together and chatting through worries and concerns is an important part of the medical school experience, just as much as all the fun times you will have with your colleagues!
Developing a good exam technique is a valuable skill in medical school and the earlier you can decide what works best for you, the better. Knowing all the facts is only part of what is needed to pass an exam. If you can enter an examination room prepared, knowing exactly how you are going to answer the paper, you are more likely to stay calm and avoid stress (which only makes our brains cloudy). It will also help you to feel more confident about the task in hand. ‘Exam technique’ can be split into three stages: before, at the start, and during the examination.
Find out about the types of questions and the exact content covered in this exam. All universities provide this for their examinations so remember to check far in advance. This will help you prepare your revision.
Practise, practise, practise! Doing practice questions from textbooks, revision books, websites, and ones that you have made up with friends is a brilliant way of preparing. Do not leave this to the last minute as doing practice questions can reveal what you know well and where your deficiencies lie—not something you want to find out the night before an exam! It also allows you to feel confident when entering the examination room. Remember to ask around for older students’ or lecturers’ opinions on what type of practice question and resources would be most useful. There is often a range on offer and there is no point wasting your money on something that would be irrelevant. Some students start their revision using practice questions and identifying where deficiencies in their knowledge lie—and then revise those particular topics.
Whether you are the type of student who does little and often throughout the year or the type to leave the majority of learning until the end, note that 4 weeks is not enough. Aim to have a revision plan sorted at least 2 months before any major exams—this gives you lots of time for revision preparation. Learning early makes life a lot easier but remember to have fun too. The best medical student works hard, is dedicated to learning and to their patients, but also knows exactly how and when to de-stress and relax. It is also handy to ask your peers for any tips or tricks that they can offer about the exam.
This allows you to decide how much time you should spend on each question and will mean that you do not suddenly realize that you have only answered half the questions with 5 min to go! You can either plan beforehand how long you have per question, or just make sure that you have covered around half the questions by half time.
Pens, pencils, rubbers, rulers, sharpeners, a watch—it is vitally important to turn up on the day with the correct equipment to sit your examination. No one wants to be walking into an exam and find out they have forgotten a rubber and their best pencil—preparation is the key to avoiding stress! If an exam is longer than 2 hours some students find that their concentration wavers and a sugar boost/hydration is helpful—so consider taking in some chocolate and a bottle of water. 2% dehydration may 
around a 20% decrease in concentration! Also if you have a lucky charm or a mascot, do not forget it and do not be embarrassed—you will not be the only one bringing one! Make yourself as comfortable as possible.
This may not be something you feel you need to do, but some find that preparing everything the night before a very clear and serene head in the morning!
It is best to wake up early, have a light breakfast, take a shower to calm your nerves, and perform any other rituals you need to focus on the exam ahead. Never underestimate the amount of stress that exams may cause you and consequent mistakes that you are likely to make if you submit to the pressure.
This sounds obvious, but it is best to double check your exam venue and make sure you know the route and how long it is going to take for you to get there. There have definitely been pre-exam scares and a last-minute dash to the correct venue a minute before an exam was scheduled to start. Some people prefer to arrive in just about time so that they can avoid last-minute ‘stress-heads’, but make sure you do not arrive late.
You may want to use a toilet break to de-stress part way through an exam, but there is no point being half-way through a tricky section and being distracted by the call of nature.
Place your watch somewhere visible or note where the clock is, have your spare pencils and rubber handy, and make sure your desk does not wobble. Most examination centres require your student card for their identity check. Place it at the top corner of your table so the invigilators can see it without disturbing you during your exam.
A great way to sit an exam well is to know what section you should be hitting at what time—or at least know when you should be half way through.
This bit is a faff but you want to make sure it is done and dusted instead of wasting the first minutes of the written examination. There have been instances where candidates have forgotten to fill in their details which delays marking or may make your exam void.
Some students start at the front, others at the back, and others with certain sections—weird but something to consider! It is wise to spend the first couple of minutes inspecting the entire exam paper and start tackling the sections that you find easier. This way, you start building up your confidence and allow more time to answer the more challenging sections.
A tip that applies to all of medical school, but especially during an exam. Do not worry about people who seem to be going faster than you or turning to a different part of the booklet. Just make sure you answer the questions on every page and do your own thing.
Make sure you stick vaguely to those pre-planned timings. Do not rush through without thinking about a question, otherwise you will just have to completely redo it later! Calmly think through questions and if you are stuck, mark it so that you know to come back to it later before moving on.
Try not to panic, you have done your revision and you have made it into medical school—much like everything else so far in your life, you will get through this too!
It is ever so important to know what the question is asking—many a mistake is made by misreading or misinterpreting questions. It may feel at times that you are meant to read their minds, but try to establish what exactly the question is trying to ascertain from you.
If everything seems to be going wrong and you hit a brick wall, do something about it rather than giving up! Take a toilet break, have a sip of water or a bite of chocolate, or even take a step back to breathe. Your brain probably just needs a moment to regroup before focusing again.
Forget about it! Nothing you can do now, is there? Revise for the next exam and try to redeem yourself if you think you performed poorly. If you have finished all your exams, then simply celebrate, relax, and continue with your normal life which was put on hold during your revision period.
An MCQ is a question that asks the student to select the correct response from a list of four or five answers. A slight variation on this type of question is the SBA question. This type is slightly trickier and asks the student to select the ‘best’ or ‘most appropriate’ response, even though a few of the options may be partially correct and similar. MCQs generally predominate in medical school summative exams (especially in the first few years), and so it is really important to practise this type of question.
• Do lots of practice questions—the more you do, the more familiar you will be with this style of questioning.
• Try to avoid learning straight facts and instead attempt to attach some understanding and meaning to the knowledge you acquire.
• Often MCQs ask the student to apply the knowledge they have learned to a particular scenario—quite tricky if you only have superficial knowledge of a subject!
• Decide how you want to answer the questions. Are you the type to go through quickly once then recheck your answers? Or do you prefer to answer the question once properly and then avoid returning to it?
• Work out how long you have per question.
As with most things in medical school, it is important to work out your own way of answering an MCQ. However, here are some general tips:
• As with any question in a written exam, it is very important to read the question and then to establish exactly what it is asking (you may need to reread the question at this point). Misreading or misinterpreting the question is very common, especially in a time-pressured exam. This is where practice will help.
• Unless a particular answer jumps right out at you, using the process of elimination allows students to work their way calmly through questions. Do not be surprised if you find yourself playing ip-dip-doo between the last two answers though, this happens to everyone! An educated guess is an incredibly valuable tool, as long as your exam is not negatively marked.
• If you are really stuck, make a mark next to that question and leave it until the end of the exam—you just need some more time to mull it over at the back of your mind. Sometimes answering related questions to the topic that you are stuck on helps you to remember associated facts.
• Sometimes these questions can involve a lot of reading and so this is something you will need to prepare for. It is important to stay focused and relaxed to avoid having to reread the question numerous times.
• With SBAs, the trick is to not worry that more than three answers are correct which can be daunting, but to imagine yourself in that clinical situation, and work out what you would do initially or what is the most important thing.
• Establish a good pace for answering questions—it is important not to rush but also to avoid wasting time on a questions worth very few marks overall.
• Trust your instincts—often your gut instinct is going to be correct. Avoid changing too many answers after having completed the test. It is common to doubt yourself.
• Be on the lookout for double negatives, these can confuse anyone!
• Be on the lookout for flippant descriptions such as ‘None of the above’, ‘Never’, ‘Always’ which are usually the incorrect answers.
• Questions will often ask you to select the ‘most likely’ diagnosis or ‘most helpful’ investigation in a particular case, where more than one answer might be plausible. Try to narrow down the decision to the most plausible two or three answers when it is best of five.
• Remember, the answer is directly in front of you! You just have to spot them and there is a 50% chance of getting it right.
Which cells produce insulin (true or false)?
| a) Alpha | (F) |
| b) Beta | (T) |
| c) Delta | (F) |
| d) Theta | (F) |
| e) Gamma | (F). |
A 72-year-old man has sharp, central chest pain which is worse when he inhales. His heart rate is 105 bpm, BP 120/70, and temperature is 38°C. His past medical history includes ischaemic heart disease with a recent myocardial infarction. What is the most likely cause of the chest pain (choose one)?
Answer: D (pleurisy with mild-grade pyrexia post recent MI).
An EMQ is another type of question in which the correct answers are listed among incorrect answers on the page in front of you. It differs from an MCQ in that there are usually more than five options to choose from, often 10–14 options in an alphabetical list.
• Work out how long you will have per question.
• Again, learn around the facts, memorizing words and facts will not help in these questions!
• Work out the answer to the question before looking at the options.
• Use the process of elimination.
• Read the question to ensure you know what you are answering.
• If you are finding a question really tricky, mark it and then move on.
• Work out how long you have per question.
EMQ options:
For each of the following chest pain clinical scenarios, select the correct diagnosis.
A. A 75-year-old woman presents to the ED feeling sweaty and short of breath. On questioning, she reveals she feels as though something is constricting her chest but there is no pain. She is diabetic. ECG shows V1–V4 ST depression with raised troponin.
B. A 60-year-old obese lorry driver presents to the ED with ‘awful burning’ as well as sharp, central, and epigastric chest pain which began following a large meal. The ECG shows sinus rhythm.
C. A tall gentleman, with noticeably long arms and IHD, presents to the ED with severe chest pain, also felt between the scapulae. He begins to describe the pain and is noticeably SOB and subsequently collapses in his bed and becomes unresponsive.
Answers: A4 (silent MI in diabetics and elderly).
B3 (eating-related acid reflux).
C2 (connective tissue disorder/Marfanoid poor collagen quality dissection).
An SAQ is a question which carries a range of marks (usually 1–6) for a simple, concise answer. These questions can catch people out and it is very important to clarify how many points can be allocated for each question and exactly what the question is asking you to do. This type of question is less common than MCQs in medical school; however, you may still encounter them. It would be important to find out if your medical school will accept bullet-pointed answers, or prefers answers written in short prose.
• There is no substitute for knowing your subject matter.
• As always: practise, practise, practise! This type of questions may be trickier to practise but a great way to work around this is to create questions with friends and you can try to answer each other’s.
• Work out how long you have per question.
• Always look at how many marks the question carries. This tells you exactly how many points need to be made and how much detail you will need to include in your answer.
• Read and reread the question to determine if it is asking for one answer or multiple answers. It is handy to underline important words so that you remember to answer all parts of a question (e.g. state/describe/list).
• Look out for whether the question is asking you to write in words, give a numerical answer, or even possibly to draw a graph or picture—people can often be caught out by this.
• The best SAQ answers are concise and simple. Waffling does not give you any extra marks, and may even cause you to lose time and marks if incorrect.
• Always attempt the question even if you are unsure to improve your chances of gaining some, if not all, marks.
• Which hormones in the menstrual cycle rise between days 10 to 14? (3 marks.)
• Describe the features of the cells of the respiratory epithelium, name the type of cell, and explain why these features are necessary for its function. (6 marks.)
An essay question involves writing a concise but structured answer in prose to a given question. The answer sheets for these questions often only permit a certain space for your answer and so it is important to plan exactly how you are going to answer the question before you write anything on the page. You can use extra pieces of paper to map out thoughts or write bullet points as aide-memoires before writing the essay—this way, you will not forget any of your points and will have a structure. Essay questions in exams are time pressured and quite stressful, so it is important to practise this type of question beforehand.
• Practise, practise, practise!
• Perfect your own essay format: think about a logical order to answering questions, including an introduction and conclusion, and a simple outline to follow.
• Work out how long you have to plan, to write, and to proofread your essay.
• Guess what questions could be answered with an essay and brainstorm ideas of what you could include—also a handy way to improve your knowledge throughout the year!
• Think about your essay format while doing essays which are not time pressured throughout the year—lots of preparation is needed before a stressful examination situation.
• Use good examples to support any points that you make. Evidence is always needed to back up any point you make.
• Have an introductory and a concluding paragraph even if it is two sentences—this looks professional and will improve your mark.
• Spend a minute or two formulating a rough plan before you dive in. Having an essay plan is incredibly useful, you could try to use scrap paper to write down the important points to cover along with a reminder to write an introduction and conclusion.
• Rules of three: those who study the arts are more exposed to writing essays for their assessments. The general structure consists of the ‘three Ps’: three parts consisting of a paragraph for the beginning (introduction), middle, and end (conclusion) and dividing the middle into another three parts (e.g. objectives, methodology, results and discussion) or three paragraphs. Each paragraph should consist of three or four sentences with simple and succinct statements. There is no time or marks available for waffling.
Describe the menstrual cycle, describe the pathophysiology driven by sepsis, explain the process of carcinogenesis, describe the role of the immune system in sepsis, etc.
This is another nationwide mandatory requirement for final year clinical students looking at their ability to prescribe. The examination is online and involves MCQs and some SAQs. It will take place at some point during your final year (that is, if your medical school has introduced it). Topics covered include:
• writing a prescription for an example patient
• calculating medication doses
The specialities covered include medicine, surgery, elderly care, paediatrics, psychiatry, obstetrics and gynaecology, and general practice. The examination lasts 2 hours and you are allowed to use the online BNF or the paper version to answer the questions.
• Find out when you will be taking it. The test requires at least a few weeks to prepare—knowing your date in advance will allow for this.
• Do the practice papers online. These practice papers vary in difficulty level and therefore it is very important to complete them all, at least a week before the real exam—there is lots to be learnt from these!
• Try to get access to prescribing modules online for practice.
• Get familiar with your BNF. You will use the BNF (either the online version or the book) during the exam and so the slicker you get at using it, the better you will ultimately do. This examination is very time pressured. Also a great tip is to work out which sections are on which pages—there are rather handy antibiotics and palliative care sections, as well as appendices at the end (e.g. drugs to consider in breastfeeding patients).
• Watch people prescribe and learn how to do this as soon as possible in clinical years. As soon as you become a doctor, you will be hounded by everyone to write up prescriptions; the more you have observed this as a medical student, the less scary it is as a doctor! Also, it will make this exam a lot easier.
• Summative vs formative? Find out (1) whether your medical school requires you to sit the PSA and (2) whether the results are formative or summative. It is crucial to be a good prescriber and therefore passing the PSA is very important, but it is nice to know whether the score is counted into your final year mark or not.
• Stick to your planned timings. It is very rare to find a student who tells you they had spare time in the PSA!
• Do not rush the calculations.
• Read the question properly. As with all other written exams, make sure you avoid making a mistake when reading the question.
• Use the BNF to its full advantage. Your life will be a lot easier if you start using and flicking through the BNF early on during medical school. There are amazing chapters with lots of knowledge (e.g. the antibiotics chapter and the palliative care section)—learn where these are and the exam will seem a lot easier! At least you will know where to exactly find the relevant information when under immense pressure.
• Will warfarin interact with amoxicillin?
• Yes it will through the CYP450 pathway. Look up the warfarin ‘inducers and inhibitors’.
• Write a prescription for a patient requiring rescue medication following an exacerbation of COPD:
• Some things to consider include IV fluids, back-to-back 5 mg/2.5 mL salbutamol nebulizers (with at least four times daily maintenance doses), 500 mcg ipratropium bromide (Atrovent®) nebulizers four times daily, 40 mg PO prednisolone once daily for 5 days, 5 mL saline nebulizers PRN, antibiotics (doxycycline, amoxicillin, co-amoxiclav (Augmentin®) if exacerbation is caused by infective aetiology, etc.
• Singer. Pocket Prescriber. CRC Press. 2015
• British National Formulary (BNF) and BNF for Children. www.BNF.org. Available in print, online and app
| Aberdeen University | www.abdn.ac.uk/medical/electives/elective_information/download/73/Preparing_for_the_Prescribing_Safety_Assessment_plus_answers.pdf |
| British Medical Association | www.bma.org.uk/advice/career/applying-for-training/prescribing-safety-assessment |
| Prescribing Safety Assessment Guide for Foundation Doctors | www.yorksandhumberdeanery.nhs.uk/sites/default/files/remediation_training_guidance_for_trainees.pdf |
| Medical Schools Council | www.medschools.ac.uk/our-work/assessment/prescribing-safety-assessment |
| PSA – sample questions | www.prescribingsafetyassessment.ac.uk/resources |
| Pastest | www.pastest.com/medical-student-prescribing-safety-assessment/exam/ |
| On Examination | www.onexamination.com/exams/student/psa#QuestionBrowser |
| Prepare for the PSA | www.prepareforthepsa.com |
| Pass Medicine | www.passmedicine.com/student/index.php?gclid=EAIaIQobChMI1tGrpYr13QIVQed3Ch03cQ-KEAAYAiAAEgLpgPD_BwE |