The MCCQE Part II has Placed a Cap on the First Round of Exams

Below is a rant from a friend in PGY1 of a specialty that diverges from the pack early in residency.

The more I think about the MCC imposing capacity limits for the fall MCCQE Part II, thereby forcing many first years to defer the exam until spring of 2016, the more angry I get. Here's why:

CAPACITY CAPS ARE INAPPROPRIATE

1. The MCC has had ample time to prepare for the high demand

The MCC cites two causes of the high demand this fall:

- No more harmonized exam for family med after 2015
- More candidates in general

The de-harmonization was announced over a year ago. Further, the exam was only harmonized 4 years ago, so the MCC already has experience with a larger volume of applicants.

As for the number of applicants in general, Canadian trained residents make up the majority of MCCQE test takers. The number of Canadian residency positions is easily accessible and is also known over a year in advance.

Despite so much warning, the MCC has only increased fall exam capacity by 7% over last year's fall administration.

2. The MCC's arguments for requiring capacity caps are not supported

The MCC says capacity caps were required to:

- Ensure the integrity of exam scores
- Keep costs down for residents

The MCC has not explained either argument.

Why not hire more people to mark the exam using the extra money from more exam fees? Why not delay releasing the results for a month or so until the scores' integrity has been assured? Why not split the exam into multiple sessions over a few weekends?

As for exam cost, no breakdown has been provided of where our exam fees go, nor how they would be influenced by an increased examinee pool. My impression is that the very steep exam fee of around $2300 should more than cover the cost of one administration. Of course more applicants increase cost (linearly), but they also increase income (also linearly).

3. The MCC is not offering any alternative within a reasonable time frame

The MCCQE is a mandated exam, and it is the MCC's obligation to ensure there are sufficient spots for eligible examinees to take it. This has always been the fall of 2nd year, and by capping spots, they are forcing examinees to wait an additional 6 months beyond that. A couple of weeks I could understand, but not a whole exam cycle.

HOW IS THIS UNFAIR TO RESIDENTS?

1. Many residency programs have a general first year, in part to prepare for the MCCQE.

Therefore, residents who have to defer the exam an additional 6 months are put at a disadvantage. For example, I will have been doing nothing but (specialty) rotations for almost a year before the exam, making it challenging to perform well in a general medicine OSCE.

2. The application process was biased.

An email without any notice was sent out, favouring those with immediate access to the internet and a credit card. Many residents working long hours that day were blindsided as by the time they returned home and checked their email, the exam was already at capacity. The same goes for residents that happened to be on vacation, or residents that needed time to assemble the $2300.00 fee. It also favoured residents on the East coast over the West coast, as signing up at the end of the fday in Halifax is hours earlier than the end of the day in Vancouver.

3. Anxiety
Every resident knows it's stressful to have a major exam looming over them. We had all expected to be done the MCCQE by the end of the year. We now face half a year of more waiting for the test than any group of residents before us.

4. This is the MCC's problem, not Canada's residents'.
I want the MCC to know that they are acting inappropriately. I believe they have failed to address the high demand for their exam properly and are bullying first year residents into accepting their mistakes.

Use of IO for IV Rad Contrast

In ATLS we are taught that anything that can go through an IV can go through an IO. This was questioned when we were unable to obtain a large enough gauge IV to give a patient the contrast solution he needed. Would an IO be safer than a PICC line? Would one less ambulance trip make more sense? Would this cause unnecessary damage to the patient?

At our small hospital, we don't have access to much, but we can do IOs. When all you have is a hammer.....

I had a quick look at my PubMed On Tap app and found 3 case studies of others who have done this successfully. No side effects are noted.

These are case studies, certainly not case controlled research. Hopefully someone will pursue this.

IO access appears to be safe but I don't see any studies comparing safety to a PICC line, likely because IOs are only used in emergency situations.

So, would I use an IO for a patient needing radiocontrast? I would advocate for it if IV was unavailable, it could avoid an admission to City Hospital, I was able to convince the radiologist on call to let me do it. It's just as invasive as a PICC. Truly though, I'm not sure of a situation when this might be the right choice given my current practice. If a patient is unwell enough that they do not have IV access, chances are good they should go to the City anyway.

Pocket Blockers for Atrial Fibrillation

This week during rounds, a question was raised about whether or not "pocket blockers" as recommended by the CCS for symptomatic paroxysmal atrial fibrillation will actually work or if they take too long to work. Cardiology is NOT my strongest area of practice.

The patient was an elderly man who was having occasional, upsetting episodes of palpitations that were caused by paroxysmal atrial fibrillation that lasted for several hours, especially at night. During the day, his heart rate was often too low to consider a beta blocker. I don't want to be the cause of a fall in one of my elderly patients. I decided, on the advice of another doc, to give him a beta blocker (bisoprolol) at bedtime only. I still worry though that his heart rate may drop when he doesn't need it and cause a fall on the way to the washroom at night. Would it be worth considering a pocket blocker for this guy?

"The choice of rhythmcontrol relates to AF characteristics. For patients with a lowburden of infrequent paroxysmal AF, pill-in-pocket antiarrhythmictherapy might be reasonable. For more frequentparoxysmal AF, daily maintenance antiarrhythmic therapymight be tried, followed by consideration of catheter ablationif the response is not adequate."

It seems unlikely to me that the CCS would make this recommendation, and a pretty graphic to go with it, if it wasn't going to work.

Now, to determine which beta blocker to choose, because, damn, there are a lot of beta blockers.
Let's go alphabetically. I've taken my info from Up To Date because it's the easiest for me to search through the blockers. I'm just looking at the Canadian types and oral delivery because that's all I care about for the patient we were discussing.
acebutalol: onset 1-2 hours, 1/2 life 12-24 hours
atenolol: onset 2-4 hours, 1/2 life 12-24 hours
bisoprolol: onset 1-2 hours, 1/2 life 9-12 hours
carvedilol: onset 30 min - 1 hour, 1/2 life 7- 10 hours
labetalol: onset 20 min - 1 hour, peak effectiveness in 1-4 hours, 1/2 life 6-8 hours
metoprolol: onset 1-2 hours, 1/2 life 3-4 hours
nadolol: no onset info given, 1/2 life 20-24 hours
nevibolobol: peak onset 1.5 hours, 1/2 life 12 hours
penbutolol: peak onset 1.5 hours, 1/2 life 5 hours
pindolol: peak onset 1 hour, 1/2 life 3-4 hours (up to 15 hours in the elderly)
propranolol: onset 1-2 hours, 1/2 life 3-6 hours
sotalol: onset 1-2 hours (or sooner), 1/2 life 12 hours
timolol: onset 15-60 minutes, 1/2 life 2-2.7 hours

OK, so 3 of these are appealing based on onset less than an hour - carvedilol, timolol and labetalol. They also have half lives less than 12 hours with timolol definitely winning. Most of these though are active by 1 hour. For most patients that are symptomatic during the day, any of these might be great. But I worry about this elderly man with low blood pressure, low heart rate during the day, and multiple medications.

 I think finding a cardio selective drug might be most helpful and decrease the risk of side effects. Those are metoprolol, acebutalol, atenolol and bisoprolol.

Of these, metoprolol has the shortest half life. I have a winner, and since my patient has side effects on the bisoprolol, it's worth changing.