A guide to passing MRCP Part 2 written

The MRCP part 2 exam is a multiple choice, best-of-five written exam with 2, 3 hour papers. You’ll be familiar with the vague format of the exam if you’ve sat the part 1 exam, but part 2 has a much more clinical focus, compared to part 1’s focus on basic science

What it’s assessing

If you look at the curriculum for Part 2 (and you should, it’s here), it is as enormous as it is vague. It’s essentially every aspect of medicine, plus bits from other specialties including ophthalmology, psychiatry, surgery, obstetrics and more. There’s a real focus on clinical guidelines, assessing and investigating patients based on presentation, and covers both basic management as well as the small-text second and third-line management options (for instance, resuscitation in hypothermia)

How Difficulty is set

If you look at the pass rate for Part 2, it’s encouraging, with a pass rate of 61-73% compared to 47-52% for Part 1. That might reflect a number of factors, for instance, candidates being further into their medical training, and the exam being more focussed on what they are actually doing on the job rather than theoretical basic sciences & physiology.

Although the pass rate does vary a bit by sitting, in theory, the pass mark is set relatively objectively using a standardisation process, described in detail on the MRCP website. In brief, however, this adjusts for difficult questions to make them worth more, and easier questions to be worth less, and gives lower value to questions that are poor discriminators of a passing candidate- e.g. where almost nobody got right, or those that everyone got right.

Why I’m writing this guide

So now for total transparency- I took five attempts to pass this exam. Before you put this guide away and discount me as a total charlatan trying to give out exam advice when I’m clearly so bad at exams, I’d just say this- very few people have as much experience of the exam as me. Most of the advice you’ll get from people who passed this exam the first time (up to 78% of UK graduates) will be the same, but this clearly doesn’t work for everyone; perhaps that’s why you’re reading this guide.

Generally, the advice that I received from others was to “do more”. One consultant told me “PACES is a bit random, but if you just do enough work, you’re guaranteed to pass Part 2”. I don’t think that’s true, and I think there’s a lot of evidence that discounts this notion. Other trainees’ advice was “do the question bank through” “do it twice” and “do it three times”. Doctors are praised for their work ethic, so this advice is unsurprising, however, it absolutely did not work for me, and so I’m writing this as a way to work smarter, not harder.

Now I’m not thick, I’ve just come from finishing a PhD and have won a number of academic prizes, and prior to this exam I’d never failed an exam before, but my tried-and-true techniques of “Just Study HarderTM” did not help me here, and I was coming up against a brick wall when working towards this exam, with lots of limitations on my time trying to balance ongoing research work with a newborn! Therefore, I’m sharing the things that worked well and were time-effective, and those that didn’t.

Survivorship bias

Survivorship bias. In WW2, planes returning from combat were studied and bullet holes (red) were tracked to identify weak areas to reinforce. But the error with this approach is that it only studied the planes safe and stable enough to get back home, not the ones who were shot down! In fact, the lack of hits over the fuel tanks (wings) engines and cockpit were the weak areas. So too with exams; you often only get advice from those who have survived the exam. You need to identify where your gaps are because they won’t necessarily match with the individuals giving out the advice.

Review & comparison of different question banks

A question bank should form at least part of your revision, if only so you get used to the format of the questions. I’ve used all of them, so I can fairly confidently say the merits of each. Just to say none of these links are affiliate, and I was not paid to write any of these reviews.

PassMedicine

Good variety of questions across a number of specialties, good questions which reflected the exam fairly accurately, and very good quality explanations further improved by discussion boards. It also gives you an indication of where your score lies compared to others to show if you’re “on track” for revision. No app, so limited revision options on public transport, if that matters to you. I would recommend PassMedicine.

PasTest

A good number of questions across a variety of specialties. The questions themselves can be good, but some questions fell into the “keyword trap” where there’s a keyword in the question which immediately yields an answer (“Heinz Bodies” on a blood film = G6PD). In my experience, only a small minority of questions in the exam were of this type, and quite a few more had keywords pointing to one answer but did not fit otherwise- in other words, the keyword was a distractor. The podcasts are of okay quality but hidden within a slightly clunky app, which itself crashed and didn’t always work reliably for me. Overall I’d recommend PasTest but there are some potential improvements.

BMJ OnExamination

While there’s a good number of questions, they are very, very long questions that I felt didn’t accurately reflect the exam at all, and some felt like they’d been recycled from other sources. Most questions in the exam are around 1-2 paragraphs with ¡10 results to look at, while the BMJ questions were frequently 5 or more paragraphs and a large table of results. I wouldn’t recommend BMJ OnExamination.

RCP London Masterclass

For a resource produced by the very college overseeing the examination, you would expect good re- sources, however the question bank was frankly abysmal, with simplistic pop-quiz questions that did not reflect the exam at all. Many questions were repeated, and on some, the resources were not included (“look at this ECG” but no ECG was visible). Would not recommend this at all.

Spaced repetition & Flashcards

Doing question banks is all well and good, however, there are a few flaws with relying entirely on this approach:

  • You only learn as much of the subject as the questions cover
  • You can often only select by specialty, so you’ve got no control over when topics/presentations come up
  • Some exam questions rely on your understanding of the topic to reason through the answer, rather than pure factual recall. To overcome this, it’s important to have a deeper understanding of the subject, and reinforce that learning regularly.
How it works neurologically

My PhD was in neurophysiology, so I apologise in advance for a brief digression to explain the basic premise at a neurophysiological level. Your brain is plastic (adaptable), and adapts over time. Neurons that activate at a similar time & pattern form stronger connections (Hebbian learning), or to put it simply- “what fires together, wires together”. This neural plasticity is rarely established immediately, and more often is produced by repeatedly activating the same groups of neurons together.

That’s especially true of emotive or immersive memories- you spend your whole holiday drinking strawberry daquiris, so when you now have that cocktail, you think of Spain and can remember sitting by the pool, and the colour of the shorts you were wearing.

This is called spaced repetition. You repeatedly test and recall the same facts, testing more commonly the topics that you find difficult, and less commonly the topics you find easy, and adapting the interval based on your performance. You try and link these (boring, by-the-book) facts to an emotional or immersive connection in some way to reinforce that link.

The most common way of performing spaced-repetition is flashcards. You can create a pile of flashcards, and start sorting them into piles- Easy/Learning/New/Difficult. Review the easy cards once a week, the cards you’re still learning every few days, the new & difficult ones every day, and try to create new notes, mnemonics or charts to learn the difficult ones.

Using Anki

Enter Anki. You may already have used this during medical school, in which case you’re probably already aware of it’s power. It’s a program & app for automating your flashcard studying. You create flashcards, and then review them. After each one, you rate it based on how difficult you found it, and then Anki will show you the card again after a specified interval.

So the cards you first add will appear every 1-10 minutes, reducing to every few days after you’ve got it right a few times, continuing to reduce to monthly or less the easier you find it. If you then forget the card and have to re-learn it, you reduce the interval again until you recall it. You therefore see the more difficult topics more often, and the easier topics less often. You can combine this with your other methods of studying- for instance you could create a flashcard every time you get a question wrong, or every time you see an interesting case that confuses you.

My general workflow for Anki was to create a flashcard for anything I got wrong on a question bank, but broaden the card to the wider topic at hand; so if I didn’t get the diagnosis of SLE, I’d create a flashcard on the “SOAPBRAIN MD” mnemonic for the features of SLE. I then reviewed Anki daily, which took ¡20 minutes on most days. This meant that even on days where I was too exhausted or busy to do anything else, I could at least be confident my knowledge wasn’t actively regressing. If I came across a good mnemonic or learning technique, I’d take a picture and add it to the flashcard deck later that day.

As part of my studying I’ve built an Anki deck of 675 flashcards for MRCP part 2, including mnemonics & guidelines, which you can find on my website https://maitland.dev/flashcards along with instructions for how to import it. Feel free to use it, but remember the power of Anki is in it’s personalisation to you, so make sure to add your own cards and modify mine to suit your own needs.

Other resources

Flashcards worked very well for me, but aren’t everyone’s cup of tea. They require discipline and you need to engage with them pretty much every day to make the information stick. Some other resources that I found useful (some of these may be affiliate links):

  • 1000+ MRCP facts by Dr Ali- Quick, high-yield learning points written by an endocrine SpR for all parts of the MRCP exam. There’s also a related Instagram page where you can preview many parts of the book and use it as a way to study.
  • Medicine for MRCP by Bessant & Ford- This is a really comprehensive text which covers most parts of the MRCP curriculum, in the appropriate depth for the exam. It’s really nicely laid out, and goes through condition by condition, as well as where conditions overlap multiple specialties.
  • Clinical Medicine for the MRCP PACES by Mehta, Iqbal & Bowman- Obviously this text is geared towards PACES, however it has good applicability to Part 2 as well, and gives a good holistic overview for many conditions. This gives you a case-based approach for learning the conditions and how you would approach and investigate them.
  • 150 ECG cases by Hampton, Adlam & Hampton- You are guaranteed to get at least a couple of ECG questions in the exam, and it’s difficult to get sufficient practice on ECGs. This is a brilliant text for walking you through ECG interpretation in a case-based approach.
  • Osmosis YouTube channel- this is very USA-focussed, but the general principles are good for an overview of a disease or presentation
  • Pre-PACES podcast– again, very geared to PACES, but has good overview of diseases and pre- sentations by consultants delivered at the appropriate level

General Advice

Finally I’d just like to round off this guide with a few general tips for how to approach the exam. Read the question carefully- the most common question type is “What is the most likely…”. Some questions may point to “what is the gold-standard” or “which test is most likely to provide a diagnosis” vs “what is the best next investigation”. These are absolutely different questions; the next best investigation for a fall is likely to be an ECG, but the test most likely to provide a diagnosis might be an MRI. Don’t be led too early by keywords within the question stem. I’ve alluded to this before, but there are some keywords which point to a diagnosis very strongly. They are as unreliable as they are common, and a frequent trick by the question writers is to use this to distract you. Try to read the entire question stem before coming to a provisional diagnosis.

Work backwards- Most questions have a brief stem with a few pertinent points, but some are extensive and have many data points as a way of camouflaging the pertinent information and wasting your time. Start with the actual question and answers and apply these to the stem to find the information, for instance asking “What is the most likely poison”, but only one causes a raised anion gap, you can search the stem for the anion gap to select or exclude it.

Life Advice

Sitting MRCP is a careful balancing act which feels impossible. You have on calls, nightshifts, portfolio, and now studying on top. Find the ways to fit in studying regularly as a way of reinforcing that knowledge and building those neural networks, rather than sporadic or isolated marathon sessions. That might be committing to doing some studying before you go in to work, or ensuring that you do it as soon as you get back home.

Know your limits- I’ve said a few times that sitting MRCP is not about “working harder”. There’s no point sitting staring at a textbook or mindlessly doing questions while you’re too exhausted to read. You won’t retain the information and you’ll be falsely reassured by your progress and time spent on this.

Written by Dr Stuart Maitland (ACF in Neurophysiology, PhD)
PS – Good luck with your exams, and if you find this guide useful, or think it can be improved, please
do drop me a message ([email protected])

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