To a medical student the final examinations are something like death: an unpleasant inevitability to be faced sooner or later, one’s state after which is determined by the care spent in preparing for the event.
The examinations of the United Hospitals Committee are held twice a year in a large dingy building near Harley Street. It shares a hidden Marylebone square with two pubs, a sooty caged garden, an antique shop, and the offices of a society for retrieving fallen women. During most of the year the square is a quiet and unsought thoroughfare, its traffic made up by patrons of the pubs, reclaimed women, and an unhappy-looking man in sandals who since 1931 has passed through at nine each morning carrying a red banner saying ‘REPENT FOR YE DIE TOMORROW.’ Every six months this orderly quiet is broken up like a road under a pneumatic drill. Three or four hundred students arrive from every hospital in London and from every medical school in the United Kingdom. Any country that accepts a British qualification is represented. There are brown, bespectacled Indians, invariably swotting until the last minute from Sir Leatherby Tidy’s fat and invaluable
Synopsis of Medicine
; jet-black gentlemen from West Africa standing in nervous groups and testing their new fountain-pens; fat, coffee-coloured Egyptians discussing earnestly in their own language fine points of erudite medicine; hearty Australians, New Zealanders, and South Africans showing no more anxiety than if they were waiting for a pub to open; the whole diluted thoroughly by a mob of pale, fairly indifferent, untidy-looking British students conversing in accents from the Welsh valleys to Stirlingshire.
An examination is nothing more than an investigation of a man’s knowledge, conducted in a way that the authorities have found to be the most fair and convenient to both sides. But the medical student cannot see it in this light. Examinations touch off his fighting spirit; they are a straight contest between himself and the examiners, conducted on well-established rules for both, and he goes at them like a prize-fighter.
There is rarely any frank cheating in medical examinations, but the candidates spend almost as much time over the technical details of the contest as they do learning general medicine from their text-books. We found the papers set for the past ten years in the hospital library, and the five of us carefully went through the questions.
‘It’s no good wasting time on pneumonia, infant diarrhoea, or appendicitis,’ Benskin said. ‘They were asked last time. I shouldn’t think it’s worth learning about TB either, it’s come up twice in the past three years.’
We all agreed that it was unnecessary to equip ourselves with any knowledge of the most frequent serious illnesses we would come across in practice.
‘I tell you what we
ought
to look up,’ said Evans. ‘Torulosis.’
‘Never heard of it,’ Benskin said.
‘It’s pretty rare. But I see that old Macready-Jones is examining this time, and it’s his speciality. He has written a lot of stuff about it in the
BMJ
and the
Lancet
. He might quite easily pop a question in.’
‘All right,’ I said. ‘I’ll look it up in the library tomorrow.’
My chances of meeting a case of torulosis after qualification were remote, and I wouldn’t have recognized it if I had. But to be well informed about torulosis in the next fortnight might make the difference between passing and failure.
Benskin discovered that Malcolm Maxworth was the St Swithin’s representative on the Examining Committee and thenceforward we attended all his ward rounds, standing at the front and gazing at him like impressionable music enthusiasts at the solo violinist. The slightest hint he was believed to have dropped was passed round, magnified, and acted upon. Meanwhile, we despondently ticked the days off the calendar, swotted up the spot questions, and ran a final breathless sprint down the well-trodden paths of medicine, snatching handfuls of knowledge from the sides where we could.
The examination is split into three sections, each one of which must be passed on its own. First there are the written papers, then
viva voce
examinations, and finally the clinical, when the student is presented with a patient and required to turn in a competent diagnosis in half an hour.
On the morning the examination began the five of us left the Bayswater flat early, took a bus along Oxford Street, and walked towards the examination building in a silent, sickly row. I always found the papers the most disturbing part of the contest. They begin at nine o’clock, an hour when I am never at my best, and the sight of other candidates
en masse
is most depressing. They all look so intelligent. They wear spectacles and use heavy fountain pens whose barrels reflect their own mental capacity; once inside they write steadily and sternly, as though they were preparing leaders for the next week’s
Lancet
; and the women students present such an aspect of concentration and industry it seems useless for men to continue the examination at all.
I went with a hundred other students into one of three large, square halls used for the examination. The polished wooden floor was covered with rows of desks set at a distance apart that made one’s neighbour’s writing completely indecipherable if he had not, as was usually the case, already done so himself. Each desk was furnished with a card stamped with a black examination number, a clean square of pink blotting-paper, and a pen apparently bought second-hand from the Post Office. The place smelt of floor-polish and freshly-sharpened pencils.
A single invigilator sat in his gown and hood on a raised platform to keep an eye open for flagrant cheating. He was helped by two or three uniformed porters who stood by the doors and looked impassionately down at the poor victims, like the policemen that flank the dock at the Old Bailey. The students scraped into their chairs, shot a hostile glance at the clock, and turned apprehensively to the buff question paper already laid out on each desk.
The first paper was on general medicine. The upper half of the sheet was taken up with instructions in bold print telling the candidate to write on one side of the paper only, answer all the questions, and to refrain from cribbing at peril of being thrown out. I brought my eyes painfully to the four questions beneath. At a glance I saw they were all short and pungent.
Give an account of the sign, symptoms, and treatment of heart failure
was the first. ‘Hell of a lot in that!’ I thought. I read the second and cursed.
Discuss the changes in the treatment of pneumonia since 1930
. I felt the examiners had played a dirty trick by asking the same disease two papers in succession. The next simply demanded
How would you investigate an outbreak of typhoid fever
? and the last was a request for an essay on worms which I felt I could bluff my way through.
Three hours were allowed for the paper. About halfway through the anonymous examinees began to differentiate themselves. Some of them strode up for an extra answer book, with an awkward expression of self-consciousness and superiority in their faces. Others rose to their feet, handed in their papers, and left. Whether these people were so brilliant they were able to complete the examination in an hour and a half or whether this was the time required for them to set down unhurriedly their entire knowledge of medicine was never apparent from the nonchalant air with which they left the room. The invigilator tapped his bell half an hour before time; the last question was rushed through, then the porters began tearing papers away from gentlemen dissatisfied with the period allowed for them to express themselves and hoping by an incomplete sentence to give the examiners the impression of frustrated brilliance.
I walked down the stairs feeling as if I had just finished an eight-round fight. I reached desperately for my packet of cigarettes. The other candidates jostled round, chattering like children just out of school. In the square outside the first person I recognized was Grimsdyke.
‘How did you get on?’ I asked.
‘So-so,’ he replied. ‘However, I am not worried. They never read the papers, anyway. I’m perfectly certain of that. Haven’t you heard how they mark the tripos at Cambridge, my dear old boy? The night before the results come out the old don totters back from hall and chucks the lot down his staircase. The ones that stick on the top flight are given firsts, most of them end up on the landing and get seconds, thirds go to the lower flight, and any reaching the ground floor are failed. This system has been working admirably for years without arousing any comment. I heard all about it from a senior wrangler.’
Benskin’s broad figure appeared among the crowd in the doorway. He was grinning widely and waved cheerily at us.
‘You look pretty pleased with yourself,’ I said.
‘I am, old boy. Today I tried out Benskin’s infallible system for passing exams, and it worked beautifully. What number are you?’
‘Three hundred and six.’
‘I’m a hundred and ten. All I had to do was walk into the room labelled “Two to Three Hundred,” wander round a bit while people got settled, and tell the invigilator chap they hadn’t given me a place. He apologized at first, then he looked at my card and turfed me out pretty sharply to find the right room. I was pretty humble, of course, and murmured a lot of stuff about my nerves – however, in my wandering round the desks I’d taken damn good care to read all the questions. Now, if you look up the regulations you’ll see candidates are admitted up to twenty minutes after the start of the examination, so I had plenty of time to dodge down to the lavatory and look it all up before presenting myself, breathless and distraught, at the correct room. Pretty smart, eh?’
‘I hope they can’t read your writing,’ I said bitterly.
The oral examination was held a week after the papers. I got a white card, like an invitation to a cocktail party, requesting my presence at the examination building by eleven-thirty. I got up late, shaved with a new blade, and carefully brushed my suit. Should I wear a hospital tie? It was a tricky point. Examiners were well known for harbouring an allergy towards certain hospitals, and although my neckwear might convince them I was not from St Mary’s, for instance, or Guy’s, my interrogators were quite as likely to be opposed to men from St Swithin’s.
I put on a quiet nondescript tie and a white stiff collar. The dressing-up was important, for the candidate was expected to look like a doctor even if he gave no indication of ever becoming one; one fellow who had once unhappily appeared in his usual outfit of sports coat and flannels was turned over to a porter by the outraged examiner with instructions to ‘Show this gentleman to the nearest golf-course.’
It is the physical contact with the examiners that makes oral examinations so unpopular with the students. The written answers have a certain remoteness about them, and mistakes and omissions, like those of life, can be made without the threat of immediate punishment. But the viva is judgment day. A false answer, an inadequate account of oneself, and the god’s brow threatens like an imminent thunderstorm. If the candidate loses his nerve in front of this terrible displeasure he is finished: confusion breeds confusion and he will come to the end of his interrogation struggling like a cow in a bog. This sort of mental attitude had already led to the disgrace of Harris, who had been reduced to a state just short of speechlessness by a terrible succession of
faux pas
. The examiner finally decided to try the poor fellow with something simple and handed him a breast-bone that had been partly worn away with the life-long pressure of an enlarged artery underneath. ‘Now, my boy,’ said the examiner. ‘What do you think caused that hollow?’ All he wanted for a reply was the single word ‘Pressure,’ but Harris looked at the specimen in blank silence. With a sigh, the kindly examiner removed his pince-nez and indicated the two indentations they left on each side of his nose. ‘Well,’ he continued helpfully, ‘what do you think caused that?’ Something clicked in Harris’ panicky brain. The depressed nasal bridge…a picture flashed up that he had seen so often in the opening pages of his surgery book. ‘Congenital syphilis, sir,’ he replied without hesitation.
I was shown to a tiny waiting-room furnished with hard chairs, a wooden table, and windows that wouldn’t open, like the condemned cell. There were six candidates from other hospitals waiting to go in with me, all of them in their best clothes. They illustrated the types fairly commonly seen in viva waiting-rooms. There was the Nonchalant, lolling back on the rear legs of his chair with his feet on the table, showing the bright yellow socks under his blue trouser-legs. He was reading the sporting page of the
Express
with undeceptive thoroughness. Next to him, a man of the Frankly Worried class sat on the edge of his chair tearing little bits off his invitation card and jumping irritatingly every time the door opened. There was the Crammer, fondling the pages of his battered text-book in a desperate farewell embrace, and his opposite, the Old Stager, who treated the whole thing with the familiarity of a photographer at a wedding. He had obviously failed the examination so often he looked upon the viva simply as another engagement to be fitted into his day. He stood looking out of the window and yawning, only cheering up when he saw the porter, with whom he was now on the same warm terms as an undergraduate and his college servant.
‘How are you getting on this time, sir?’ the porter asked him cheerily.
‘Not so dusty, William, not so dusty at all. The second question in the paper was the same one they asked four years ago. What are they like in there?’
‘Pretty mild, this morning, sir. I’m just taking them their coffee.’
‘Excellent! Put plenty of sugar in it. A low blood-sugar is conducive to bad temper.’
‘I will, sir. Best of luck.’
‘Thank you, William.’
The other occupant of the room was a woman. A trim little piece, I noticed, probably from the Royal Free. She sat pertly on her chair with her hands folded on her lap. Women students – the attractive ones, not those who are feminine only through inescapable anatomical arrangements – are under a disadvantage in oral examinations. The male examiners are so afraid of being prejudiced favourably by their sex they usually adopt towards them an undeserved sternness. But this girl had given care to her preparations for the examination. Her suit was neat but not smart; her hair tidy but not striking; she wore enough make-up to look attractive, and she was obviously practising, with some effort, a look of admiring submission to the male sex. I felt sure she would get through.