The examination for membership in the Royal College of Physicians (MRCP) is considered to be the British counterpart of the examination for the American Board of Internal Medicine. Its origins, however, are more venerable, being based on a royal charter granted by Henry VIII in 1518. It may also be safely assumed that its format has changed since the days of Vesalius and Morgagni, when medical students spent long years studying the philosophy of Aristotle, the wisdom of Hippocrates, and the precepts of Galen before being let loose on the public.
It also differed from its American counterpart in that decades ago no period of formal of training was required. Candidates could take the exam after completing one year’s internship; so that some bright young people would pass early on in their careers; while others, more experienced but perhaps less astute, failed year after year. It was accepted de rigueur that one did not admit to how many times one might have failed; and even one of the Queen’s physicians was said to done so several times. There was a certain mystique about the examination, many anecdotes and reminiscences, some undoubtedly apocryphal or impossible to confirm. I have heard it said that in the past registrars (senior residents) working at the great London teaching hospitals would not be allowed to take the examination until their chief said they were ready. Then, if they failed, their chief might pick up the phone and call his confrere in that elite brotherhood and question why they had failed his “boy.” Even earlier, it seems that candidates presented themselves in formal attire; and legend had it that a dandified candidate on examining a case of tuberculosis called it “consumption.” When one of the examiners suggested there might be a more modern term, he unashamedly referred to the eighteenth century, and said it was on the decline.
It also used to be said the MRCP was merely a license to train—the beginning, not the end. It tested not only knowledge, but also demeanor, common sense, and the presumed ability to someday in the future function as a consultant. Knowledge was important, but so was a certain degree of poise, confidence, of apparent self-reliance, even of elegance in approaching a patient, of making up one’s one mind and not just quoting the books. For many years there were three examinations, each given by one of the three colleges, London, Edinburgh, and Glasgow. The Edinburgh examination in earlier days was the more forgiving. But when in my green days I was asked how I would treat a certain patient, I must have blurted out something about textbooks because the examiner gruffly interrupted me and said he did care about the books but wanted to know how I would treat that patient.
Also in my green days, I had to examine a patient suspected of having some of the neurologic features of quaternary syphilis, general paresis of the insane, or dementia paralytica. The patient had fought on the Italian front during World War II in the Polish regiment of General Anders, then settled in Edinburgh and married a Scottish girl. His job was to paint the Forth Bridge, which as soon as he finished one end would start again at the other. Each year at Christmas his wife bought expensive gifts her relatives, and he had warned her that if she would do it again he would quit his job—which he did. I concluded that syphilis had not affected his brain—no dementia paralytica.
Often examiners would observe the candidates in action, sometimes asking them to show how they would elicit a certain physical sign. This could lead to much glee during the morning break in the side room to the ward where an examiner might describe with gusto how his candidate had picked up the patient’s leg by the big toe in order to elicit the ankle jerk; even more amusing, how a hapless candidate had tried to reach with both hands around an obese patient’s back in order to examine (ballot) the left kidney.
For the exam the hospital maintained a roster of patients with stable non-progressive diseases, since acutely-ill patients would obviously not be suitable, at least not for the long run. The usual suspects, willing and readily available, often had chronic neurologic disorders, Friedreichs’ ataxia, Charcot Marie Tooth disease, or syringomyelia. There was also a patient with large polycystic kidneys, presenting a fatal pitfall for the hapless candidates who misdiagnosed enlargement of the liver and spleen. And there was a genial patient with the unlikely combination of porphyria and Kartagener’s syndrome, who would whisper the correct diagnosis to candidates who had got on the right side of him.
The system at the time was that the examination was carried out in stages, beginning with written essays, long and short clinical cases, then, for some, an oral “viva” exam where candidates were shown electrocardiogram, x-rays, or pathology specimens. One examiner, famous for writing a book on occupational disease, was known to produce a piece of mineral rock out of his pocket and ask the candidate to identify it and expound about it. There was also the story on the street, perhaps apocryphal, about a much-feared examiner who had a glass eye. If he ever took it out of its socket this was a sign that he was much annoyed and that the game was up. Also, certain candidates would spread terror among their colleagues with stories they had failed because they did not know the metabolic pathways of some essential enzyme or bodily metal. Later one came to understand that more likely they had impressed the examiners with their lack of common sense, their poor clinical acumen, or even their deficient innate intelligence. Such would have been the case of the unfortunate young woman from New Zealand who confidently made a diagnosis of multiple sclerosis while failing to make the connection with the large scar on the back of the patient’s neck, tell tale of a previous operation for tumor or some other surgical condition.
Because passing the exam required accumulating a required number of points, like for the Electoral College, many candidates would early on fall by the wayside. They would receive a disappointing but polite letter stating that the censor and the examiners had considered their results so far, and to save them further inconvenience wished to spare them the trouble of proceeding further.
The overall the failure rate for the exam was at least 70%. The final session was held in a small room at the old Royal College of Physicians, now Canada House, in Trafalgar Square. Again, word had it that if you were asked easy questions you had already passed. But if they asked you about cadmium metabolism or obscure exotic intestinal nematodes, this was a sign that you still had many points to make up.
For my short clinical cases I was examined by the famous Sir Robert Platt. He showed me a patient who was shaking and drooling and seemed to have advanced Parkinson’s disease; but by some divine inspiration, as he blurted out something incomprehensible, I realized it was Huntington’s disease. Next he took me to an old lady who had a bump on her head and sat in a chair with legs tucked under a blanket. I said Paget’s disease. Off came the blanket to display her saber tibias, leading into a discussion about high output cardiac failure in that condition. Then he asked me to sit down and reverting to his interest in hereditary diseases asked me about the genetics of Huntington’s disease and then of a rare form of childhood rickets. I got the first right, but stumbled on the second, and pretending to think aloud I mumbled that surely it was not like pseudoxanthoma elasticum. “Who described that?” he asked. I said, “You, Sir,” and that was the end of it. I left walking on air, and on going down the stairs met the hapless girl who had diagnosed multiple sclerosis.
For the final exam I spent a few minutes in the little room at the College building. I seemed a pure formality. Out in the street I fell in with a Portuguese man who also passed. We floated across Trafalgar Square, to the Charing Cross side, and spent the next couple of hours in a basement, in a wine cellar, that I am saddened to report is no longer in existence . . .
George Dunea, MD, Editor-in-Chief (Summer 2013)