Dermatology

So I had derma yesterday. It’s been one week since radio, but I didn’t start studying before tuesday, so I really only studied three days. This is gonna be a long post.

I usually go through the topics orally with my girlfriend the day before the exam, and I did the same this time. However, I quickly noticed that I didn’t actually remember shit from any of the topics, not even the easy ones. It was thursday at like 22:00, so I didn’t have much time. I suddenly realized how fucked I was, which was a feeling I don’t usually feel before exams. The only thing I could do was to sit down and go through the whole curriculum again, which took me 3 hours. In other words, I didn’t get much sleep that night (only 4 hours).

At the day of the exam, we wait outside the library in derma department. I’m super tired from lack of sleep. A teacher comes and collects those who had to do the practical, while the rest of us waited. A secretary comes and tells us that the examiners today are Dr. Ágnes Kinyó and Prof. Rolland Gyulai. Ágnes comes a few minutes later and takes a few students in to the library to do the exam. I was still very stressed and I still wanted to go through my notes a few more times, so I didn’t go in as one of the first students.

The first student comes out not very long after, and says that she’s super nice. Great, I think, then I’ll probably pass at least. The next students say the same. Eventually, I go in and pick topics.

The A topic card I drew said “19. Basalioma, spinalioma”. “What the hell is this?”, I think. I was pretty sure that basalioma is another word for BCC, and I guess spinalioma could mean SCC, but I’m certain that that topic isn’t topic 19, so I’m super confused. Ágnes sees my reaction and explains that yes, these are BCC and SCC. Okay, fine, not a bad topic. My B topic was ” 7. Clinical outcome and symptomes of AIDS”. I say “shit, this sucks”, to which Ágnes replies “No, I think this is a good topic”. Okay, at least I know a few things here, I think to myself.

I sit down and prepare, and I write a good amount on the A topic, and a few things on the B topic. Definitely enough to get a 2 at least, also considering the people before me’s exams (we were preparing the same room as people were examined). It was true, Ágnes was VERY nice.

Eventually, the professor comes into the room. He says something to Ágnes in hungarian, she says something back and points to the remaining 3 or 4 students in the room. The professor says okay and then leaves. In my mind, the conversation went like “Are there many students left?” “No, only these few. I can probably examine them.” “Okay”. The professor is probably a busy man, he doesn’t want to waste time examining a few students.

Eventually, it’s my turn.

The exam

As I sit down next to Ágnes, she says “Just wait one minute, let me get the professor”. What? They’re changing examiner now? I start to get stressed, I know it’s always the department heads who take their subject way too seriously. But, I can’t really do anything else but try. He comes in and sits down. He doesn’t appear to be in a very good mood.

I start with the risk factors for BCC.

• Me: The biggest risk factors are excessive UVA exposure and skin types I and II. The lesion is usually a pearly papule or plaque with a rolled border and an ulcerative centre. The prognosis is very good as it virtually never metastasizes.
• Prof: Which types are there?
• M: Oh, there is a superficial type, and a nodular type… I don’t know any others
• P: There are at least 10 different types, and you know only 2?

He’s already sighing, holding the bridge of his nose and taking long pauses. I can sense that he’s getting frustrated already.

• P: Do you know which molecular pathway is mutated in BCC?
• I don’t know the answer, but I know BRAF and MEK are involved in melanoma, so they’re as good a guess as any.
• M: BRAF and MEK maybe?
• P: No… it’s the hedgehog pathway..

That does seem familiar to me, but I’d never had remembered that. He takes another long pause, annoyed. I can sense the atmosphere in the room is super tense, as the other students in the room are following my exam closely, in horror.

• P: Do you know the name of the disease which has congenital BCC as a feature?
• M: No, I remember that there was one but I don’t remember the name. Was it dysplastic something?

– Another long pause –

• P: No, it’s basal cell nevus syndrome.
• M: Okay.

I can tell that this is going to hell.

• P: Where do you find BCC most often?
• M: On the central face, and often on the upper lip.
• P: No, cancers of the lips are SCC, not BCC. Be more specific, where can you find BCC.
• M: (I’m guessing) Scalp?
• P: Can be, but not very typical
• M: Nose?
• P: Yes, the nose is typical
• M: The ear?
• P: Can be. What else?
• I pause as I can’t really think of anything else.
• P: It can occur anywhere on sun-exposed skin.

He sighs as if I didn’t know that. Of course it occurs on sun-exposed skin, wasn’t that obvious when I said that it’s related to UV exposure?

• P: Tell me about the treatments for BCC.
• (Finally, something I actually know something about)
• M: So the most important are cryotherapy, surgical excision and superficial radiation, but you also have options for topical treatment, like 5-FU
• P: No
• M: Calcineurin inhibitors?
• P: No
• M: Okay.. you also have phototherapy as an option.
• P: What type of phototherapy?
• (I don’t really know many types, but I think narrow-band UVB was used a lot)
• M: Narrow-band UVB?

He sighs loudly, obviously annoyed by my answer.

• P: Why would you treat a cancer caused by UV radiation?

That’s a valid point, of course, but are there any types of phototherapy that don’t use UV light? Not that I know of. Maybe the cancer is caused by UVB then, and using UVA is the answer.

• M: Is it PUVA?

He’s obviously annoyed, because in his mind I obviously didn’t understand what he just said. I realize that there is one last type of phototherapy I haven’t mentioned, so maybe that works without UV light and is the correct answer?

• M: Photodynamic therapy?
• P: Was that an answer or a question?
• (I realize by now that this is basically over, so I don’t really care anymore)
• M: It was a suggestion.

He laughs a little at my response.

• P: What’s the main treatment of BCC?

For some reason, and in retrospect I realize that it was stupid to think that way, but I think at the moment that he’s after a therapy that I haven’t mentioned yet; that I still haven’t mentioned the main treatment. Now, I had already listed most treatment options I had written down, so I was running out of options. There was one of the topical treatments I hadn’t mentioned yet, so I went with that one. I think it was imiquimod.

• P: Is it topical imiquimod?

His annoyance with me peaks. He shakes his head, sighs multiple times.

• P: How can you not know the primary treatment of BCC? This makes it obvious that you haven’t studied this at all, and that you haven’t attended any lectures or seminars. If I went up to a random person on the street and asked them what the primary treatment for BCC was, they would know the answer.

I don’t really know what to say to him. It’s obvious in retrospect that they’d rather remove the tumor than apply topical treatment. I think my wrong answer was partly due to me being very tired and not thinking clearly, and partly because I was certain that he was after something which I hadn’t mentioned yet.

• M: So it’s surgical excision, then.
• P: Yes, it’s surgical excision. I’m sorry, but this is not good enough. I could pass you even if you didn’t know the types of BCC or the molecular pathway, but since you don’t know the primary treatment of BCC I just can’t pass you. I’m sorry.
• M: Yeah, me too.

As I get up and walk to pick up my stuff I get eye contact with the other students in the room, who were stunned. I could tell that the other students were scared now. I don’t think anyone expected him to be so strict, especially after the previous examiner. Luckily, the girl after me passed, but she told me later that it was barely and that it was a very bad experience. I don’t know about the others, but I hoped they passed.

It’s kind of ironic how I would probably have passed if I was one of the first students to go in rather than to stay outside and study more.

Closing words

So that’s the story of how I failed derma. I haven’t failed an exam since the spring exam period of 2017, when I failed immuno after only studying 2 days for it (this was before I made notes). It was kind of a sobering experience, as I didn’t really expect to fail any exams anymore, especially after I was done with pathology and pharmacology.

It was surprising to have an exam in good old fashioned anatomy department-style©, where if you say the wrong thing once they’ll take it as if you don’t know the answer at all.

Anyone can fail at POTE; it happens to the best of us. I’m not immune to it either, despite being “greek doctor”.

The next possibility to have derma is next friday. I bought a ticket home to Norway for tuesday two days ago. I don’t want to lose that ticket and to have to stick around here for another week just for fuckin derma. I can take it next year as exam course without losing a year, so I’ll do that instead. I’m tired.

I’m not sad that I failed. I would be if I had to pass it this semester to not lose a year. I already started my vacay, although with a bit of a bad conscience.

Don’t be scared of derma because of my experience – I’m one of the very few I know who have failed it. For that matter, don’t be scared of ENT either – appearently nobody else (except one) had the same experience with the exam as I did. Maybe I just bring out the worst in department heads on exams?

I’ll write another post next weekend with some statistics and stuff. Good luck with your exams if you still have, and congratulations to those that are done already (although they probably won’t see this).