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Kim Hutton persuades examiner Professor Richard Naftalin to reveal some unexpected tips on how to pass

At medical school we seem to spend very little, if any time, practising for exams or being taught technique, and yet exams feature so much in our professional lives. It is assumed that we know what we are doing. Of course, just to reach medical school requires a certain amount of exam technique, reading the question, allowing enough time for each answer and so on. That much is common sense. However I have always had the sneaking suspicion that there is something more to exams, secrets to which I am not privy.

To discover these elusive exam skills, who better to ask than an examiner. Professor Richard sets and marks the exams for the new integrated course at Kings, as well as the physiology exams and vivas under the old curriculum. He manages to fit me in between examiners' meetings to discuss the route to exam success. One misconception after another goes out of the window. Forget writing in an exam until your wrist aches, or straining to remember that clever detail you once read somewhere which will surely make the difference between passing and failing. Instead read on . . .

Setting exams
We start with the setting of the exam questions. The system is complex in order to ensure each paper is balanced and fair, and that as few people as possible know which questions make up the final paper. The aim of the examination board is to set questions on topics that the majority of students will have revised. It's a sort of game in which the examiners try to help students win, not lose, by guessing what topics students are going to gamble on coming up. The trouble is not many students understand the rules particularly those who spend their time learning minor topics instead of concentrating on the main ones. The way to play the game is to have a sound knowledge of the basics across the board, and not to worry about details. This is news to me. I always presumed that it was those clever details that got you the marks, but there goes the first of my many misconceptions about exams. A lot of time spent on small print ruins an otherwise good answer - it probably won't actually lose you marks but it's very annoying for the examiner who has to keep questioning whether something is really relevant and that's very taxing. You need to have the discipline and confidence to put down only the main points.

He picks a script up from a pile of essays, hands it to me and the exam paper. The question concerns a 58 year old woman with polydypsia, polyuria, fatigue, and weight gain - what does she have and what is the pathology. I turn to the candidate's answer. It begins: "this woman has diabetes mellitus . . ." There are no doubts, and no qualifying comments such as: "it would appear that", or "the symptoms suggest that . . ." It then goes on to discuss the pathogenesis of insulin dependent diabetes mellitus and non insulin dependent diabetes in short, crisp sentences. There's not much detail but it's very clear - like the ideal text book which gives you all the main points without the clutter. I consider slipping it into my bag for my own revision purposes but decide I can't get away with it.

Another thing which sets it apart from any answer I've ever written is that there isn't a crossing out in sight. Prof Naftalin says he often has a fair idea of how good an answer is going to be with a first cursory glance. "The real difference between an average and an above average paper is in the presentation." It is worth spending a few minutes thinking about the layout of your answer because what examiners are looking for is clarity of mind that they can literally see on paper - headings, bullet points, and diagrams following on in a logical order. Apart from showing you understand the topic well, it makes your answer easier to mark.

It is that organisation which makes an answer flow, not reams of prose. A 45 minute essay need be no more than three sides long, including diagrams. The 30 minute essay I have in my hand barely stretches to two sides, and it is written in quite big handwriting. Definitely a case of quality not quantity. As presentation is so important and I for one have never given it much priority, I wonder if someone could fail because they have bad technique. "It's unusual for a good candidate to fail through poor technique alone. It's more a case of people getting through when they shouldn't," he laughs.

What to avoid
He picks up another script and directs me to the first question on the exam paper which concerns a patient with the signs, symptoms, and investigation results of a peptic ulcer. He starts to read the essay aloud and stops, swearing: "I can't understand what they're going on about, can you?" The script has lots of crossings out. I don't know what the answer means but then I managed to get through two years of preclinical medicine and miss out the gut entirely, something I'm not about to own up to. There's a big fat zero in red at the top of the page which seems rather harsh. "Even errors of fact, providing there aren't too many and they're not real howlers won't lose you marks," he says. "It's easy to miss out words like "not" in the heat of the moment - but I do draw the line at people making up their own branch of physiology." So null points. All is not lost, however, when you are faced with your own exam question from hell. The secret is to remember you can get away with minimal knowledge if you can produce a diagram and text to go with it.

Cheating
There is another way to approach exams and that is to cheat. It is not a method Prof Naftalin advocates. Morals aside, he does not think it does you any favours. So much energy goes into the planning and you worry about what you're doing that you are too distracted to write a decent answer. Easier to do the work and pass fairly. He adds quickly that he is not talking from personal experience. "When I was at medical school a colleague smuggled Gray's Anatomy into an exam. He had it on his knee under the desk. He did quite well considering he wasted so much time flicking through trying to find the right bit," he says. "He's now a highly respected consultant haematologist."

Cheating is rare, he says, and those who do it are conversely often very good at their subject but suffer from extreme anxiety or worry about not doing their best, rather than failing. The consequences, if caught, are usually dire and Prof Naftalin is adamant that it is not a price worth paying.

Marking the exam
The exam is over, the candidates have done their part, for them it's a matter of waiting anxiously, but the story is far from over for their scripts. Initially a 45 minute essay takes Prof Naftalin about five to six minutes to mark, and then less time as he acclimatises himself to the standard of the answers. When he has been through the papers once, he goes through them again to make sure his marking is consistent. There is no problem identifying the clear passes and absolute fails. "Medicine isn't a classified degree. It's not about honours, it's about passing, and so it is the borderline answers which merit a third, more meticulous assessment."

He hands me another answer to the diabetes mellitus question. The candidate has picked up on the symptoms of lethargy and weight gain and states that the patient has hypothyroidism. It's very clearly written and well presented. It gets quite a few marks considering it's not on diabetes - not a pass in itself but enough to add to the overall result. "Unorthodox answers like that can be quite difficult. You can draw up a list of alternative answers for markers when you set the question. It's easier however to sit round a table together marking papers and you just shout out if you come across a problem and the expert on that topic can decide."

I visualise examiners sitting around a table with a pot of coffee, a plate of pastries, and a pile of exam scripts in the middle. It works well apparently. There is a certain synergy, and any problem with candidates' reading of a question can be sorted out quickly with all the relevant examiners present. Genuinely badly worded questions are a rarity. Either the candidate does not know enough to understand the question or misreads "antidiuretic hormone" for "angiotensin." In this case the examiner cannot award any marks because the candidate has not answered the question. In my year many of us misread "purkinje cells" as "purkinje fibres" in a short answer question. Because so many of us had made the same mistake in the end both readings were allowed.

Rumours abound about marking systems and many students I know believe that there are less places in clinical studies than there are preclinical students. A culling of weaker students in which the bottom ten percent are failed to get the numbers down. This hypothesis provokes a strong denial. "Quite the reverse," says Prof Naftalin. "We get into trouble with the hospital if we don't supply enough students. The whole year can pass first time - they just don't."

Vivas
As far as Prof Naftalin is concerned the purpose of giving a viva to someone who has already failed is to uncover the reasons why, both for the examiners and the examinee. It is not a situation he relishes and he tells the candidate at the beginning of the viva that they have failed outright. He is aware that staff in other departments put candidates through a full viva without informing them that they have failed and have no chance of redeeming themselves until the end, but merely comments that some members of staff feel their role is to keep the weaker students out of clinical, not to help them learn from their mistakes.

Prof Naftalin says he asks very basic questions. He either goes over questions answered badly in the exam, or ones that were missed out. So if you are faced with a pass/fail viva go over the paper with a friend beforehand - preferably someone who's done better than you. Pass/fail candidates are within the 45% to 49% zone and can still pass. They can get 3% from the viva and, in King's at least, also be compensated by a good mark in another subject. In theory he can take marks off for a bad performance but in practice he does not, and so a student with a pass/fail viva has everything to gain and nothing to lose. Prof Naftalin is keen for pass/fail viva candidates to pass. "If you're asked a question you can't answer then say so, don't try to bluff. If you're asked about something you do know about don't just answer 'yes' or 'no'. Play to your own strengths by keeping the conversation going on that topic. Draw diagrams."

It's a nerve-wracking situation and not one in which it is easy to perform. If a candidate goes to pieces he gets them a glass of water and tries a different question, in the hope of finding some redeeming piece of knowledge. If he gets really desperate he asks candidates to tell him about something they do know about. At the other end of the scale are the distinction vivas, which are not not any easier for the examiners than the pass/fail vivas. "It's not necessarily the nicest students that do best", he says. "It's meant to be an opportunity for them to shine, to show off a bit. But some students are really very arrogant." In this kind of viva examiners are looking for enthusiasm, confidence and all round ability that goes beyond a regurgitation of the lecture notes.

Exams suddenly seem so straightforward, just a question of knowing a little about a lot very well and having the confidence to give it your best shot without panicking and resorting to disorganised written diarrhoea in an attempt to hide your ignorance. It is all so simple and yet so alien. I don't know if I can change the habits of a lifetime when it is so comforting to spend endless hours making useless notes from fat books. On the other hand I want to be one of those people who breeze through exams, don't you?