Revalida Tips:



Revalida Tips:

Foreword:

First of all, I believe that the Revalida is an outdated tradition. Outdated because its all-or-nothing philosophy reminds me of the Catholic church before Vatican II: Medieval. I do not believe that a single examination, especially one judged by 3 doctors who will have different views and attitudes towards you and the test itself, is an accurate assessment of what you have learned and more importantly, your effort over the course of 4 years. I remember once, where a friend of mine got a case in the pediatrics case in the OPD, randomly picked by a consultant. The case was dermatologic and difficult, not even the residents or the consultants knew the diagnosis. My friend was not able to get his honors. No one can know everything. However, it is also a tradition, and I believe that traditions are there to institutionalize something, to protect a value. It is an advantage to review everything and test yourself for competency, and in this sense, Revalida is needed. When you pass it, it gives you so much sense of fulfillment and confidence. As such, you may love or hate Revalida, depending on how you prepare, and who you get as tribunal.

What I do not like most about Revalida is that some people who do not deserve to fail, fail, while those who deserve to fail 10 times over, pass. No matter what becomes of your Revalida, always remember that it is just a single test, on a single day and 4 years of hard work, is proof enough to yourself that you made good of what God has given you and what your parents have worked hard for. We are not born geniuses and we all have our weaknesses. As long as we lived and worked through Med school with truthful hard work, backed up by the love of our parents and friends: we don't need to prove anything to anyone, because you already have. Medicine is not easy and the fact that you have made it through 4 years is proof enough that you've done good.

Part 1:     Written Revalida:

    Let me just say that I told some of you before taking the written Revalida that there was a lot of OB-Gyne in our test and that you should study it. Apparently, it was the same in your case. Implication: OB-Gyne is a major force in the UST academic institution. Anyway, I didn't get to study for that, we didn't have a day off before or after that exam and to a sense, I never really crammed a day before it. Why? Because you can't! However, the only thing that I remember studying for that day was a few hours before the exam: OB oc oc notes, because that was my weakness when I was a clerk, and luckily it paid off somewhat. Implication: the written Revalida has given you a taste of the knowledge base you must know or more importantly, the knowledge base you are deficient in. Tip: concentrate on your weaknesses. The written Revalida is nothing like the oral, but it gives you it is an aptitude to tell you where you suck.

Part 2: Oral Revalida

Section1: Mechanics

    Oral Revalida is supposed to be a practical test to assess what you have learned over the last 4 years in medical school. You will be grouped into 3 clerks and with 3 corresponding consultants grouped as a tribunal. Clerks are grouped alphabetically, and consultants, usually still have the same grouping as last year, unless they failed someone, sometimes, they are disseminated. The picking of the tribunal is probably the scariest part because as you may know, Revalida is somewhat tribe dependent. I know of some people who cried and cried after having their pick, and some celebrated as if they had already passed. Well, after picking your tribunal, you have to make a courtesy call to each of them, usually the senior of the tribe first. He or she will have the final say when the actual Revalida will take place, and the venue. I suggest you do this as soon as possible, because their schedules are not very easy to follow. I also advise that during this courtesy call, stick to the definition: "have courtesy." I remember someone who, as the courtesy call was about to be finished blurted out: "Doc, do you have any tips for Revalida?" and the doctor said: "Tips? Tips? What Tips? When I was a clerk I didn't have any tips! And If you don't know anything come Revalida time, then you deserve to fail!" Yes, just be nice to them and try not to ask any favors. Oh, and when doing the courtesy call, bring the document that the tribe has to sign confirming the schedule. I remember some of my friends who forgot to bring it and the doctor said; "Well, where is it? –silence—well, get out of here and get it!" hehe, just be nice and responsible.

    The Revalida consists of 3 parts, namely the basics, the clinical and the emergencies. In the Basics part, you go into the room while the other 2 stay outside, usually the sequence is alphabetical. The tribunal will ask you anything under the sun on a list of topics that will be given to them: namely, all the systems of the body, and the basic subjects. For instance, they will ask you about the cardiovascular system or they can ask you by subject, like certain topics in pharmacology. When you pass, they will tell you. When you fail, they will tell you, and you have to leave. Some fail in the first step.

    The second step is the clinicals. When you're done with the basics, you go back to the dean's office to pick a case from the hands of Dra. Dakis (well, during our time it was her). She will spread out a bunch of envelopes for you and you will pick. They say, pick the ones on the extreme ends, since mga OPD cases daw yun. But I have yet to find conclusive and consistent evidence that this is as such. In any case, suwertihan talaga. Once you've taken your envelope and sealed your fate, you will go either to the ward or the OPD to have your examination. And you will be tested on the whole shebang, much like MLE step 2: patient-physician relationship history taking and PE. You have to be quick since they will give you only 10-15 mins for everything. Bring a scratch and pen. Be nice. Usually, one consultant per clerk will accompany to the OPD or the wards. Often, the consultant will observe you while doing your history and PE. Once you are done with this, you go back to the "room" and whoever gets back there first, is the one who will usually go in first (usually). Then the test: if you fail, they tell you. And if you pass, you go straight to the emergencies.

    In the emergencies, they have a bingo bottle where they have a bunch of numbers, and those numbers correspond to specific emergencies. You will pick three bingo numbers and from those, you will select one which you will discuss. After this step, you go out and then they call you in the room for the final judgment. Then you take a picture with them if you're happy (optional).

Section 2 Basics:

    Luckily, I never had to take this test because, awa ng Diyos, I passed the written Revalida (this was the ruling in our time, I don't know if this is still yours). But I have heard many stories from this part: this is the part that will make or break you. This is also the most difficult part because they can ask you anything, absolutely anything. Here are some stories: The tribunal asks the clerk: "I see you've brought many strollers for your pile of books. What's at the bottom of the pile? Robbins po Doc. Ah, ok tell me something about the pathology of breast cancer." Story 2: First question: "What are the anti-arrythmic drugs, their MOA and indications? " Story 3: "what muscle am I moving? What about this one, and this one? Nerve supply?" Story 4: "Tell me the anatomy of the GIT from mouth to anus and the respective blood supply." That's just a fraction of the things I heard, and well, that's me (usually huli sa tsismis), and there are probably more stories that are a lot worse. So, if you want to study for something, this is it. Once again it is a very daunting task but my advice: focus on your weaknesses. If you suck in Anatomy, then study anatomy. In my opinion, the most important basic subjects are the ff: Physiology, Anatomy, Pharamacology. Biochem is impossible, but usually, the consultants don't ask much of it, unless biochem ang tribe mo. A seemingly constant feature though is the biochemistry of digestion, and metabolic integration: study that.

Which brings me to another advice: regardless of what they have advised the consultants in the tribe, they will ask you about their specialties and this is where you should focus your studying also. If you have a surgeon in your tribe, they will ask you on anatomy. If you have a pulmonologist in your tribe, he will ask you about lung physiology. If you have an obstetrician in your tribe, she will ask you on the menstrual cycle and the stages of labor. If you have a pharmacologist in your tribe, she will ask you about antimicrobials. If you have a radiologist, he will center on anatomy. If you have a nuclear physician, he will center on physiology. In my experience, the most difficult specialties to have in your tribunal are the following: Surgeons (it's a one-two punch with anatomy and surgery: blood supply of this and that), Obstetricians (OB-Gyne and Ethics), and probably the most feared, Pharmacologists (anything under the sun, and most of them are very good too, I had two pharmacologists in my tribe: nerve racking).

As mentioned, the style of asking will depend on the tribe. Some follow the script, and they go through all the systems. Some just ask you to say something about physiology in general. Some will actually prepare their own questions at home! The secret in this part, is to just keep talking and talking about things that you know. A tip from Dr. Go "If there was no cardiologist in your tribe, and they ask you to talk about physiology, concentrate on cardiac physio and say a lot. Don't stop talking, but be sure you know what you're talking about." Great advice right there. Contrary to what most people think, if you get Dr. Go as tribunal, be thankful: he asks questions to lead you to the answer and he is fair. It is rare that people fail under him unless from his questioning, someone's true incompetence is unmasked. And before I forget, there is one thing you must never forget to study for the Revalida, even in basics: ETHICS! Someone, has failed every year, from an ethical issue. It is a consistent pathologic feature of Revalida.

Lastly, although it is basics…they will always ask you something clinical about it, especially anatomy. Basics to consultants may be boring, unless you connect it with clinical applications.

Recommended resources: handouts during the medschool will do. Personally, I never really studied my handouts because majority of them are lost and I'm a book guy. I'm also not oc oc enough to take notes. Basically, read something that you've read before so that it really becomes a review. Do not read something new. I read my books, so I just reread the highlights for study. Otherwise, these are pretty good resources: Anatomy: Snell, esp clinical notes, Physiology: BRS, the best. Patho BRS is very good. The must know book is…well, must know. Study that too.

Clinicals:

    This part is easier than the basics, in my opinion. You can actually study for this, because, patients will be chosen by each department and they will submit this to the dean's office, so you can study these cases nights before the actual Revalida. Some services like Pediatrics, ENT and possibly Surgery will tell you the cases for the clinicals: but remember, it changes every day. Some services, like medicine, will not tell you and you have to study all of the patients. Well, that's if ward ang nakuha mo. If OPD, you cannot study for this, unless OB ang nakuha mo because they usually only give first pre-natal check-up.

 In the actual test, you have to do history and PE quickly. Tips: remember to take the general data. It is a big mistake to forget to ask the patient's name! I remember when I had my Revalida, Dr. Baroque talked to the patient in private and asked if I asked the patient's name. In his words "Establishing rapport is halfway in curing the patient." And I believe that. In fact, it is probably the best lesson I had from Revalida. Anyway, after the general data, you will have to do history and PE very quickly and very smart. Some general tips on history taking: 1.) People often focus too much on the HPI and forget the past medical, personal social and if female…menstrual and obstetric history. 2.) Do some of your ROS while taking the HPI 3.) After HPI, complete your ROS by system 4.) Make sure you have a diagnosis at the end of HPI palang: PE is confirmatory of your hunch. If you do not have a diagnosis at the end of your history, take a gamble of taking more time with HPI since PE is just confirmatory.

Now to the physical exam: 1.) Always take the VS first! 2.) If your patient is pediatric, fat or pregnant, take the height and weight 3.) Do a focused PE. As mentioned earlier, I believe that the PE in this case where there is time constraint, is merely confirmatory of your impression by history. Some will advise you to do a complete PE. I agree that you must do a complete PE, but it will depend on your definition of complete. If your patient is 24 yrs old complaining about dysuria, is stable and your impression by history is cystitis, do you need to measure the JVP, assess splenic size, test all the reflexes in the body and test for dysmetria and nystagmus? I advise a focused PE. Do the tests that will confirm you impression in addition to a basic PE. I think that the word basic is more appropriate than complete. 4.) However, there is always the sometimes, outrageous concept of having to do DRE in every patient. It is part of the PE, but you always have to ask the patient first if he wants a DRE. If he declines, then good. If not, you will have to do it, unless the consultant tells you that it is not needed. 5.) When doing an abdominal exam, never forget to stand at the right side of the patient! Some consultants are particular about this, especially gastroenterologists . There is only one other instance when you will stand at the left of the patient and that is when you want to accurately examine the pelvis, like in Leopold's 4th maneuver. 6.) Practice your Neurologic Examination. It is time consuming and if you are not adept in it, it will kill you. Learn how to illicit the reflexes without fail (there are certain techniques). Bring a key for the babiski. Don't waste your time if on Oppenheim, Chaddock and Gordon if the babinski is positive (there are about 40 variations of the babinksi last I checked, and they're all saying the same thing). Have the patient walk, and if he walks straight, then there is probably no problem with coordination. If he's bedridden, then you have to do the cerebellar tests. Never forget to assess the patient's mental status and orientation.

Special situations: If you get a pediatric case, good luck. Pediatric history and PE are very time consuming and while you really have to have composure and smarts to get it done. Toxic. In taking the history, you will often have to interview the mother, but never forget to talk to the kid! History is toxic because of the peri-natal, immunization, nutritional, family etc: So do it fast. Physical exam is even worse: weigh the patient, with the clothes off, take the height, calculate the WFA, HFA, WFH, listen to the lungs and heart with the clothes off, and have the patient walk to quickly assess neurologic status. But that's not the main problem. The main problem is having the patient cooperate! If your patient is crying from the onset, good luck. The dictum in pediatrics holds true, do the most invasive examinations last. The problem here is that the whole flow of the PE is ruined and people tend to miss out important parts, like the abdominal exam. Practice pedia history and PE taking. Special situation no. 2: OB-Gyne. To the men, never forget to have a female accompany you while you do your examination. Never forget that. Weight the patient and take the height. Bring a good stethoscope to hear the fetal sounds. OB rotation should have prepared you more than enough for this. Special situation no.3: ENT, make sure you know how to use the different instruments.

After the visit to the ward or the OPD, you will be asked to report to the tribunal your findings, diagnosis and management. This is where you shine or tarnish. In reporting here are some tips: 1.) Even if you know the diagnosis of the patient because you've studied this case the night before, or you are the CIC of this patient, never ever have a very specific clinical impression. For example, never say that your clinical impression for a 40 yr old man coming in with a 2 year history of swelling or mass at the region of the parotid gland is a pleomorphic adenoma. That is a pathologic diagnosis. When reporting, do it with sense: as an approach! In Dr. Baroque's words: "Before you can appreciate the trees, you must first appreciate the forest." Go from general to specific. One could have said, "because of the patient's profile, the location of the mass, chronically progressive expansion of the mass, symptoms of dryness of the mouth and associated finding of facial weakness in the post-parotid distribution of the facial nerve, the patient most probably has a Neoplasm of the Parotid Gland. The most common histologic subtype is a plemorphic adenoma, and the patient fits this profile of a benign tumor. However, since I was able to palpate lymph nodes from sites draining the area with the mass, there is a possibility that it could be malignant." Remember, trees before the forest. 2.) Always have a differential diagnosis. It may also become very obvious that you just memorized this patient's case the night before the Revalida if you do not have a substantial amount of differentials, meaning that you have a one track mind. 3.) Have a good knowledge of clinical pathology and radiology. It helps to know what tests and imaging you want to request. 4.) Correlate the clinicals with the basics: consultants love this because they know you aren't just memorizing. I advise this aspect for those running for honors.

How to prepare for the clinicals? 1.) As I mentioned earlier, join the endorsement rounds of the residents in each of the services, including medicine. Although medicine will not tell you who is for Revalida the next day, the endorsement rounds may be useful for you to remember the patients. In any case, if you're really up to it study as many cases as possible in the hospital a few days before the Revalida (Dra. Punsalan knew every single patient in the hospital when she studied for the Revalida). 2.) Start studying now for high yield topics. Here are some in my opinion: Surgery-Cholelithia sis, Choledocholithiasis , Thyroid, Hernia, Hemorrhoids, Breast Cancer, Colon Cancer, BPH and Prostate cancer, Urolithiasis, Fractures. Medicine: MI, Pneumonia, TB, Asthma, Pleural Effusion, Renal Failure, UTI, PUD, Cirrhosis, Hepatitis, Thyroid, Diabetes, Dengue, Typhoid, Cellulitis and yes, SLE. Yes, they give Lupus in Revalida and it's actually not that bad because all you need to do is memorize the criteria, know how the ancillary labs and steroid treatment. What makes SLE patients in the ward difficult come Revalida time are the comorbidities: pleural effusion, infections, complications of steroid treatment etc. That's where it hurts. Systemic talaga. Special mention: they will not give cases at 203 because isolation ward yun, which is good because those cases are really difficult. Pediatrics: Typhoid fever, Dengue, Pneumonia, Asthma, Diarrhea, Post-infectious Glomerulonephritis, Pyelonephritis, and yes, Leukemia. They do give cases of ALL or AML once in a while. I don't know if they give Kawasaki though, I have a feeling they might. OB: Pre-eclampsia, GDM, CHVD. Gyne: ONG, Myoma Uteri. ENT: Thyroid (yes, tatlong beses na lumabas ang salitang thyroid, aralin ninyo), Chronic Otitis Media. Neurology: Ischemic and Hemorrhagic stroke, Hypokalemic periodic paralysis. 3.) Prepare a speech. If you get a case of Chronic Otitis Media, you should have a ready discussion so that if the tribe asks you to discuss, tuloy tuloy ka lang.

Section 3: Emergencies

    If there is anything that will save you from a mediocre performance: this is it. This is the only sure way that you can assure yourself some points because you can study this! You have a handbook of emergencies and you will later be given a list of emergencies (by the Dean's office) that will be included in the Revalida. They often add and subtract topics from the previous year's topics but not much will change. This year, ewan ko lang since supposedly you had a new book published, they might include everything. So I suggest that you get a copy of that book and study everything! And I mean, everything! Start with those included in last year's Revalida and then brose through the others. There have been some tribes who ask about emergencies that were not listed, but this is in the minority, if not a rarity. Study everything because you may have the fate of picking 3 numbers from the bingo bottle…which you know nothing of! I have had not one, not two, but many friends who did not know any of the emergencies that they had picked. Minalas lang talaga sila na nabunot nila yung hindi nila naaral at pinansin. Start now! And I would advise that you pass by the ER when you get the chance, look around for emergencies and observe (that's why I always loiter around the ER, it's a habit I still do until today). It is the best, if not the only sure way to remember the things you read in the book. I don't have very good memory and so I have to do it by what I call "learning by trauma." See it, get shocked, go home, study it and you wont forget. I lost my list of emergencies included but during our time, nearly all the pediatric and medical emergencies were included. I adivse begin with the easy ones and master it, because emergencies is a game of volume. The more emergencies you know, the higher the likelihood that you will pick something you know. Its nominal. And so when people ask me for advice on how to study for Revalida, start with emergencies now! It may be your saving grace.

Part 3:     The Tribunal

    Yes, the tribunal is a big part of what will happen to you on Revalida day. Which is why bunot-day is probably the most nerve-racking day of all. Tip: look for the intern who had that same tribunal as you and ask tips from them, even if they are in another hospital. I believe many of them are willing to help (it worked for my friend). The other tip is concentrate on studying the basics related to their specialties, as I have mentioned earlier. The last tip is this: No matter what they say, totoo ang phenomenon ng top 10 na nangbabagsak sa Revalida. Know who these people are and prepare if you get to pick them for your tribe. For security purposes, I cannot list down the top 10, but ask around: it's common knowledge.

    In any case, I believe that the tribunal is a big chunk, but it is only as big as your chunk. 1% is up to you, the other 1% to the tribe, the rest is up to God.

Part 4:     Honorables

    For those running for honors, your task is difficult. You are out there not only to pass, but to impress and I therefore advise you to practice talking like you want to impress. I know of someone who was aiming for big time honors and was not able to get his/her honors because he failed to impress by delivery. One of the sure ways to impress your tribe is by correlating basics to clinicals. It shows them that you are not just memorizing guidelines and you know what you are talking about. Second, be evidence based. Cite studies, criticize them and draw conclusions. Third, talk like a lecturer and bring a bottle of water. I remember coughing my throat off when I was doing my clinicals since the aircon was aimed straight at me. Still, you may fall into the trap of talking too much and wandering off to something you don't know. Never talk about anything you are not sure of. Remember, you are there to impress and pass. Just think, what if you picked a case of impacted cerumen? How are you going to get a meritisimus from that? I thought of that when I was a clerk, and so I prepared a ready speech in case I got such a case, complete with epidemiology, pathophysiology and latest clinical trials on how to get that crap out of your ear.

    There is some controversy on whether to tell the tribunal if you are running for honors or not. There have been a substantial amount of people over the years who have failed to get their honors because the tribunal didn't know that he or she was running and when the tribunal found out, they regretted it since they would have given the clerk a better grade. It is indeed a gamble because you are treading the line between honor and kakapalan ng mukha. I suppose it will depend on the vibes between you and your tribe. If you think they are approachable, then perhaps you may want to attempt to inform them. If not, don't take the chance, they might fail you from the outset. Usually, doctors will ask you if you are running during the courtesy call and by all means, say yes! Otherwise, it's still your call. I have no sound opinion on this issue. Perhaps, informing them if what you have discussed was adequate enough, in order to hint to them that you are aiming to please them so that you may get an E from them. I suggest that if ever you are going to do this, do not do it at the outset.

 

Part 5:  Peers

    I have said it time and again, you have to have good friends for Revalida time. Friendships will be tested and the true stuff of people will show. Maraming manlalamang at marami ang mag-aabsent. I have seen it at it's worse and I must tell you, friendship is a valuable thing, do not break the trust of your friends. Ayusin ninyo ang mga schedule ninyo so that hindi sabay sabay kayo mag-absent: kawawa ang mga naiwan na clerks and interns and residents and most of all, the patients. Some patients deteriorated because sobrang kulang ang mga clerks, some of whom had the nerve to be absent after passing Revalida in order to party. Dear God, for your sakes huwag kayong manlalamang sa isa't isa. Man does not live on bread alone. Help each other pass, do not compete and do not be selfish.

Part 6: Waking up to Revalida

    Tip: do not cram the night before the test. Get some sleep: a zombie brain, is a dead brain and a dead clerk. Brain cells fatigue (too much discharging and intracellular calcium exceeds regulatory levels causing cellular dysfunction) . I have also come across a study that says that excess cortisol is toxic to hippocampal cells…so don't stress yourself too much that your biologic clock goes haywire. Be fresh and have a good breakfast. Just right, not too much and not too little. Mahirap maging gutom at sinisikmura sa Revalida. In conjunction with that: tumae ka the night before or in the morning: masmahirap umebak sa kaba sa Revalida. And most importantly, relax. Nervousness will kill you. I know of people who on the morning of Revalida were vomiting on the way to school from anxiety. I assure you, if you are a nervous wreck, it will work against you. One of the things tribes hate is if you are too nervous to say anything or think and end up crying during the test. I personally know of two accounts where the clerk failed because iyak ng iyak or walang sinasabi sa kaba (ang masaklap pa, mabait ang tribe niya).

Part 7:    The most important thing

    P    R     A    Y.    There is a God and He will be there to help you if you ask and if you prove yourself to Him. Miracles happen and I have witnessed this on a personal level. There is a God. I cannot emphasize it more, hanapin mo ang panginoon sa buhay mo at ialay mo ang pagsisikap mo sa Revalida sa kanya. And whatever happens, count your blessings and thank Him.

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