PASSING ERPM, THE

MYTHS,

CONTROVERSIES &

FACTS

Preface

The ERPM or Act16 is an examination aimed at screening and absorbing foreign

qualified medical graduates into the health system of Sri Lanka. As with many other

examinations this exam is shrouded in mystery, controversy and scandal. The aim of this

small compilation is to provide an idea on how the exam system works and emerge

victorious to an unsuspecting candidate. Side by side information has been added on

various methods used by the author in tackling this exam. It's appropriate to mention that

these methods worked well for the author in passing ERPM in one attempt and the author

sincerely hope that his effort would help students in repeating the feat. Wish you all the

very best with ERPM.

What is ERPM?

ERPM or Examination for Registration to Practice Medicine is an exam to absorb foreign

qualified medical graduates into the health system of Sri Lanka. It's conducted by the Sri

Lanka Medical Council. There has been a tussle as to who conducts the exam between

SLMC & the University Grants Commission but however the rights have been awarded

to SLMC as of Aug 2011.

Exam has 2 parts Part A is Theory and Part B tests the practical aspect. Exams are

conducted 3 times a year and are duly notified by SLMC at least one month in advance.

Part A

Part A

This paper tests theory knowledge in Clinical (Medicine, Surgery, Paediatrics,

Gynaecology & Obstetrics) and Paraclinicals (Forensic Medicine, Pathology &

Community Medicine)

The clinical paper is the same as the common MCQ paper that the local undergraduates

face. It’s a very high standard exam with difficult but passable questions.

As of now exams are being held thrice a year.

April/May - Coincide with Colombo repeat paper

August/September - Coincide with J'pura regular paper

December/January - Coincide with Colombo regular paper

N.B - There has been quite serious talk in town in reducing the number of sittings to two

per year. The change is expected to occur from 2013 onwards.

Composition of the exam

Each Clinical paper has 40 questions with 5 stems each of true/false type. For each

correct answer candidate is given 1 mark. For each wrong answer one mark will be

deducted. Negative marks will not be carried on so maximum a candidate could score

from one question is 5 and the minimum 0.

Paraclinical paper follows the same pattern except each subject has 10 questions of

true/false type with 5 stems each. So each clinical paper is marked out of 200 and the

entire paraclinical paper out of 150.

Time allotted is 2 hours per paper for clinicals and 1 &1/2 hours for the paraclinical

paper. All papers are held at a stretch with one paper per day except the last day where

you will have a clinical plus paraclinical paper on the same day with a 2 hour break in

between.

Passing Part A

The pass mark has been brought down recently form 50% to 44.5% and also you can pass

on aggregate if you attempt all papers at once. So it is advisable to have a go at all papers

at once. But one can still pass subject by subject. Pass mark for paraclinicals is 50% still

(this mark was not reduced). So the ultimate goal is to score 431 out of 950. Remember

the first attempt is your best so don't waste it.

Preparing for Part A

Medicine is medicine and will not differ be it Sri Lanka, Nepal or Russia. The core

knowledge that's being tested is already on books and what one has read during his or her

medical student days definitely matter. Main things are getting used to the format and

studying for the MCQs. I have mentioned below what I did during my preparation about

1 ½ months before the exam.

1. Get hold of MCQ's

Question banks are available with local undergraduates or one can even get hold of some

from senior students’ MCQ collection. Then start answering them.

2. Studying

It's difficult to go through those bulky textbooks when time is most difficult to manage.

So it’s advisable to refer shortnotes one has made during their undergraduate days.

Nevertheless you can always easily refer following books for following subjects.

Medicine - Oxford Handbook (if you master this book no need to worry about medicine)

Surgery - SRB Textbook of Surgery (has all MCQ points but no concept)

Short practice of Surgery Elsiver (Simple book with good concept)

Gyn Obst - Randeniya sir's book

Paediatrics - Illustrated

Imp: Some theory aspects are modified according to local scenario so it's extremely

important to read the local guidelines set by Health Ministry for all clinical subjects.

Guidelines can be bought from the Colombo Medical College photocopy shop.

3. Classes

For those who wish improve knowledge & confidence can do so by attending classes

conducted by senior registrars. Classes are conducted all over Colombo. Going for

classes by all means is not a must but will provide a good outlook about the exam. The

writer attended the following classes.

Medicine, Surgery and Paediatrics - Nobel academy at Sagara road, Bambalapitiya

0112505816

Gynecology and obstetrics - Dr. Jayan Jayasinghe's class at IAS Wellawatte

+94714835527

There are few other renowned lectures who teach at other places and its upto the student

to find out who are ideal for him/her.

Medicine

Dr Lalindra - Excellent teacher but can be naggy at times. Conducts classes at IAS

Bambalapitiya

Dr Charles - Slow and steady but gives excellent concept. Good for those who do not

have much idea about medicine. Conducts classes at Nobel Academy Bambalapitiya

Surgery

Dr. Shrishankar - A practicing and reliable surgeon (senior orthopaedics registrar).

Conducts classes at Nobel Academy

Gynecology & Obstetrics

Dr. Jayan Jayasinghe - Very concise gives only MCQ points. His MCQ collection is

sufficient to cover the syllabus. But he expects the students to know basics before coming

to class so not suitable for those starting Gyn Obst from the scratch.

Dr. ... - Conducts classes in the morning at Nobel. A practicing Gynaecoloist. Good for

those with limited knowledge in Gyn Obst. Slow and steady and covers all aspects.

Paediatrics

Dr. Bala Gobi - Conducts classes at Nobel. Has a very simple and concise way of

teaching. Finishes syllabus on time and does plenty of self made practice papers. Good

for those starting from scratch.

Dr. Daham De Silva - Ex-model turned consultant paediatrician. Good teacher and knows

where students screw up! (He lectures at Colombo Medical College) He might not lecture

for foreign students anymore as he's being inducted in to the ERPM examination board.

He expects the student to know basic paediatrics before coming to the class.

+94777748315

Para clinical

Forensic Medicine and Community Medicine classes are a must for FMGs as the set up

here is quite different. The writer did not attend pathology classes and it's in his opinion

that pathology classes are not necessary as they test basic and clinical pathology. If you

were sound in pathology during basic science days then no need to worry.

Forensic Medicine

Dr. Shanthanan - Teaches at Nobel Academy. He finishes the syllabus quickly without

bullshitting around. Practices and discusses MCQs daily. He's the teacher of choice if you

have limited time to prepare.

Dr. Prashan - Conducts classes at IAS. A foreign grad himself, he knows where we lack.

He doesn't distribute printed notes so it can be a real pain in the rump especially when

copying down what he lectures for 4 straight hours. He discusses theory in great detail

but drags classes almost right upto the exam date and can be very frustrating. Dr.

Prashan’s class is suitable for candidates having ample time to prepare and also for those

who have not studied Forensic Medicine as a subject during undergraduate days.

0718002632/0773099318

Community medicine classes are conducted by a Community medicine specialist at

Nobel academy and his notes are more than required for the exam.

4. Self assessment

Once the candidate has acquired satisfactory knowledge, he/she can time and do papers.

Remember though for locals this exam is a ranking exam, for us it’s just a matter of

passing or not. Hence this writer only ventured just above the passing level without

aiming for the moon and falling back flat on the floor!

This writer always attempted to obtain 120 correct responses. For the said purpose he

would make it a point to get atleast 3 responses correct from each question running upto a

total of 120 out of 200. This writer would never go beyond it unless he falls short of the

target or questions are easy enabling him to mark beyond the benchmark of 120. In other

words this exam requires some calculation as well. In summing up all above jargon;

make sure you mark 120 answers with absolute certainty and beyond doubt for each

clinical paper.

N.B: The pass mark now is 89 out of 200 but still it is better to score above 50% in my

opinion!

5. Answering MCQs

Though not strictly followed the general makeup of a question is as follows. All

questions have 5 responses of which 2 are very straight forward, one /two that require

some thinking and the remainder requiring advanced knowledge.

As an example take the following question which this writer attempted in his ERPM Part

A surgery paper in August 2011.

Q 1. In a solitary thyroid nodule which of the following indicate malignancy

A. Nodule occurring in a child

B. Multiple nodules palpated in the back of the gland

C. H/O uptake of radioactive iodine on scan

D. History of irradiation to the neck

E. Patient presenting with Marfanoid features

Out of the above options option A, C and D are clear and straight forward.

Option B is tricky and needs thinking

Option E Need advanced knowledge.

Answers to the above:

A – True. Young children and elderly have high chance of having a malignant thyroid

nodule

B – False. Multiple nodules being palpated indicate presence of a multi nodular goiter

rather than a malignant nodule which is usually single

C – False. Usually malignant nodules are cold nodules in majority

D – True. Irradiation to the neck raises the chances of Papillary carcinoma

E – True. Marfanoid features with mucosal neuromas are associated with Medullary

carcinoma of thyroid

Likely there are some questions where you know all 5 options correctly and some where

you don't know any. If you don't know the correct answer for any then mark all the

options based on guesses as there's nothing to lose. If you know only one or two with

absolute certainty then mark only them. Remember objective is to get at least 3 correct

responses per question. Do not mark responses you're not 100% sure of!

Don't be too greedy!

Many mark all the responses irrespective of whether they know it correctly or not (or

sometimes around 160 out of 200). As mentioned above it’s just a matter of passing for

foreign graduates not scoring high up! (Its advantageous if you do manage to score high

up but always strike a balance). As a principle the writer never ventured beyond 120

responses that he was absolutely confident of getting right. Hence this writer managed to

score more than 110 in all clinical subjects without taking undue risks. Nevertheless it’s

upto the candidate to decide upon.

The paraclinical subjects are approached in a slightly different manner. As

aforementioned you have to score 75 out of 150 (It’s still 50% for the paraclinical

subjects). Community medicine questions are straight forward and are right from the

theory books. Forensic questions are twisted but majority are answerable if you have

common sense. Pathology correlates with clinical knowledge and little basic pathology

knowledge. Candidate needs to be strong in at least one subject. One does not need to

pass the subjects individually as compensation is possible. This writer’s personal

experience in the August 2011 paraclinical paper sums up the situation. This writer did

not have a good knowledge in community medicine and in the exam managed to answer

only 18 out of 50 but did manage to answer 40 in forensic and 38 in pathology.

Ultimately when results were published this writer had scored 92 out of 150 despite

failing in community section.

6. Day before the exam

Can be extremely hectic and stressful as there's always that unturned page left. For

medicine just go through cardiology, renal, hematology & immunology sections of

oxford handbook (writer feels that these are the sections where most questions are asked).

For surgery, gynae obst and paediatrics notes will suffice. Don't cram all night. A good

night sleep is essential.

Make sure you follow the instructions given by the SLMC.

7. Day of the Exam

Be on time and follow instructions clearly. Candidates are allowed to leave the

examination hall at their own free will until the last 30 minutes after which you will not

be allowed to leave till the exam finishes. (It’s alright if you can leave early because if

you stay till the full time is up you might end up staying for another 30 minutes as you’re

not allowed to leave until invigilators collect, cross check and approve all the answer

sheets of all the remaining candidates and there’re lots of candidates!)

Count the number of answers you have entered after attempting all questions. Make sure

that you’ve marked more than the stipulated benchmark. If the candidate falls behind the

benchmark then he/she can go for answers based on logic or educated guesses. Unless

that situation arises AVOID GUESSES!

The time given is more than enough! This writer took 45 minutes to answer the first

round and then revised the answers for a second and then a third before entering them on

the answer sheet well within 1 ½ hours.

DO NOT MARK THE ANSWER SHEET IMMEDIATELY! The unlikely event of

changing an answer you’ve already marked on the answer sheet could be disastrous as the

candidates are advised to mark ONLY with pen. Tipexing is allowed but can smudge the

edges which can result in the computer not marking the entire question altogether. So

enter your answers on the answer sheet after careful scrutiny.

On the final day of the exam there’s a 2 hour gap between the last clinical paper and the

paraclinical paper. This time can be put to great use by studying community medicine.

This writer personally knows few candidates who passed community medicine through

the flash memory of those 2 hours.

Part B

Part B

Upon successful completion of part A he/she will be allowed to sit the practical section.

Part B consists of clinical section viva, community medicine viva, forensic medicine viva

and emergency viva.

Preparing for the exam is tough as one need to study theory as well as examination

technique but overall it’s easier to pass than part A.

1. Structure of the exam

Clinical stations

There are 6 clinical stations.

Station 1 – Medicine Long case

Station 2 – Medicine Short case & Paediatrics Short case

Station 3 – Paediatrics Long case

Station 4 –Surgery Short case & Gynaecology Short case

Station 5 –Surgery Long case

Station 6 –Obstetrics Long case

There'll be short cases as well as long cases per subject.

What's a long case?

Long case tests the candidate's ability to take a relevant clinical history and discuss on

further management. Candidate is given 15 mns and history has to be asked infront of

examiners. There’re usually 2 present.

There's one long case per main subject.

Note: In some situations they ask to take a relevant history as well as clinical examination

within 15mns esp in obstetrics long case.

What's a short case?

Short cases are very brief usually about 5-7 minutes. Candidate is asked to perform a

relevant system examination infront of the examiners (usually 2). In most of the times the

examiners will instruct on what system to examine and some may describe a clinical

scenario and ask the candidate to examine the relevant system.

Ex - This person was admitted with swelling of whole body and legs. Examine the

relevant system - this will encompass cardiovascular system, abdominal examination and

genitourinary system which is optional.

Usually the examiner will prevent the candidate from examining the wrong system but

it's better to avoid starting off from the wrong foot so be cautious.

In Surgery usually there're 2 short case stations (sometimes 3). The time limit will be the

same for all short cases hence the candidate should limit time to less than 3 mns per case

in Surgery short cases. All other subjects have only short case 1 station.

Medicine and Paediatrics short cases are done together. There will be two examiners one

physician and one paediatrician. Both will mark independently based on performance at

both stations (medicine + surgery) not only on their relevant specialty. The candidate will

not be given same systems to examine in both stations. (i.e. If you get cardiovascular

system in Medicine you will get some other system in paediatrics)

Note: In some short cases candidate is asked to take a brief history before examination.

This happens especially in Gynaecology short case. Ex - Getting DUB as the Gyn short

case. There will be no clinical findings except anaemia.

How will you be marked in the clinical stations – Long cases?

The candidates’ performance is assessed by two examiners. Each examiner is given a

piece of paper with the marking guidelines. There’re check boxes pertaining to specific

area in the history that examiner want you to ask!

There are check boxes to the following rough subheadings of the history.

1. Introduction

2. Elaboration of presenting complaint

3. Hx of presenting illness

4. Past Hx

5. Family Hx

6. Drug & Allergy Hx

7. Social Hx

8. Menstrual Hx in females

9. Systemic review (lot of people miss this one but there's a separate check box for

it)

10. Interaction with the patient

11. Demeanor

If the candidate asks relevant information under each subheading then the examiner will

tick each check box indicating that the candidate has asked questions satisfactorily.

So the objective is to obtain ticks for all checkboxes and if the candidate does manage in

doing so then he/she is sure to pass.

Note: In paediatrics you get ANC Hx, Birth Hx, Development Hx and Immunization Hx

in addition to above!

Next comes the discussion part. Discussion is nothing but regurgitating theory so YES

THEORY IS VERY IMPORTANT IN VIVAS!

Once the allotted time is over the (a bell will be rung) the examiners will secretly

(sometimes you might even be able to see) scribble the mark in a separate box at the

bottom of the same paper.

Remember if the candidate manages a perfect history then passing is a certainty!

However if the history does end up bad then the candidate needs to have a sound theory

knowledge to compensate and maintain a good discussion. If both parts go well then the

candidate can have a sound sleep at night thinking of a mark in the 60s.

Note: The key to passing is making the examiners believe that you're special than other

candidates or deserve to be passed than the rest. Try to ask or say something unique but

relevant which makes you stand out! The writer had the fortune of striking gold in

paediatrics long case. My case was a 9 year old child with PUO for 14 days and I asked

the respondent about notification which the examiners duly noted and appreciated which

made my passing in paedatrics long case a reality even before the discussion started.

How to prepare for the Part B?

A. Get exposed to the clinical setting of the local hospitals

Exposure to the hospital setting is of utmost important in part B preparation. The

candidate has to be familiar with prototype cases from the 4 main specialties. There’re 2

ways of getting it done; the official way and the unofficial way!

The official way is through the Sri Lanka Medical Council and the candidate has to

request for a non-teaching base hospital in close proximity to his/her area. Majority of

students go to these hospitals in the gap between the parts A and B. Following

registration with the SLMC, the candidate is advised to attend clinical rounds at the

designated hospital. Further information regarding this could be obtained from SLMC at

time of registration for ERPM. However, the candidates must note that attending these

rounds arranged by the SLMC is not a prerequisite or absolutely necessary to pass the

ERPM. This scheme particularly avail the outstation students as they get better stations

close to home but can be problematic for those who reside in Colombo. All applicants

residing in Colombo are given placements at Homagama/Panadura base hospital which

raises the issue of distance and travel time. Further, as quite a number of students apply,

ward rounds can be particularly crowded. Though common cases are treated there, most

of the complicated and rather good clinical cases are referred to tertiary centers.

Ultimately days become monotonous with the same cases repeating.

The remainder is the unofficial way, which this author used, of attending a ward under

care of a consultant known to the candidate with expressed permission of the said

consultant. The benefits include being able to see cases in a less crowded environment,

better cooperation with the non-medical staff and freedom of movement i.e the ability to

visit the ward in the evenings. This writer attended NHSL for Medicine, CSTH for

Surgery, DMH for Gyn Obst. It was extremely difficult to obtain permission from

reluctant and no-cooperative (or rather jealous) consultants to attend LRH for paediatrics

hence this writer did not receive an adequate exposure in paediatrics.

B. What to do in wards

In this writer’s opinion it’s not necessary to attend wards for months provided that you

have received some clinical exposure overseas. Writer is known to some candidates who

passed clinicals overseas just by demonstrating on dummies and not by interacting with

patients. Also there’re candidates who are taking histories for the first time at ERPM. If

that’s the case with a particular candidate then it’s advisable to remain in wards for a

longer time. Otherwise this writer feel 2 weeks of honest work in each respective

department suffice. However it’s upto the candidate himself to decide.

Following guidelines should be adhered to at wards in general

1. Become part of a small study group – 4 would be ideal and wear white coats

2. A point should be made to cover all common cases atleast twice

3. Be mindful of the time and make sure the particular case is completed within the

allotted time

4. Always present the case to another colleague maintaining eye contact at all times

in clear English and a loud voice (Candidate with good clear English and good

pronunciation definitely has an edge over the other candidates who are not well

endowed with English skills)

5. Have yourself critically analyzed by a fellow candidate each time you take history

or examine a patient (remember this is how you will be assed by the examiner so

be critical of the performance to the utmost. “the more you get ashamed the more

you learn”) and take all criticisms seriously (but do not think bad of your critic)

6. Make it a point that all members participate equally, avoid being selfish

7. Save time. Do not remain in the same ward for more than 3 hours

8. Be courteous to the staff (especially the nurses, interns and local medical

students)

9. Build a good rapport with the intern medical officer. They’re the one’s who know

what the good cases are!

10. It is not necessary to attend ward rounds. Majority of consultants do not bother to

teach FMGs at rounds so it could be a waste of time

Note:

Cardiac cases may not be there at the wards. If the candidate wants to examine cardiac

cases he/she can go to the cardiothoracic unit of the NHSL (ward 60 I think) and get

permission from Dr. Ruwan Ekanayake, a consultant cardiologist. He was extremely

helpful and granted us full permission to enter and leave at our free will.

Best respiratory cases will be found at Welisara chest hospital. Just one visit will cover

all respiratory system long and short cases.

Neuro cases are found at all levels except for advanced cases like motor neuron disease,

MS, myotonia dystrophica, peroneal muscle dystrophy etc which are found commonly at

the Neuro ward at NHSL. One visit to the neuro ward would cover all these.

All cases admitted in Gyn and Obstetrics wards are probable cases in the exam (there’re

no good or bad cases in Gyn obst. All cases are good). Focus particularly on Rh –ve.

Remember the likelihood of getting normal pregnancy for the exam is extremely rare. All

obst cases have multiple problems and nothing is absolutely normal.

Practice vagainal examination (PVs) as much as possible. It’s a bit difficult for a male

candidate to examine in wards so the best place to do PV is at the Gyn OPD where almost

all patients are subjected to PVs and none complain. If the candidate has difficulties in

finding an OPD, then he/she could attend the well woman clinics of the area with

permission of the MOH.

Master swelling, scrotal lumps, breast and thyroid examinations as they are common

surgical short cases. All short cases can be seen in the surgery OPD. So remember in

surgery for long cases go to wards for short cases go to OPD. Candidates can go to NHSL

OPD in the morning around 6 AM and take cases before the consultant comes at 8 AM.

Paediatrics is one specialty in which almost all consultants (and house officers, nurses

and registrars) are snobs. They abhor FMGs attending ward rounds and OPD at LRH.

When requested permission the hospital director sheepishly passes the ball to the

consultants who flatly refuse. Ironically the only place to see congenital heart disease,

thalassemia and cerebral palsy cases in Colombo is the LRH (they are the commonest

cases). Desperate situations require desperate measures and we went to LRH sans

permission once with an intern personally known to the writer and once with a preintern.

On weekends the writer would visit the cardio ward during visiting hours without white

coats, request permission from the parents who readily let the writer examine their

children (there’re no house officers or nurses on duty during visiting hours and even if

they do they tend to think that we are relatives. Do manage to conceal your stethoscope).

Writer was chased away twice once by a house officer and another time by a nurse. One

should be mindful of these especially while going to LRH and bear the insults meted

towards FMGs.

It is important to get input from a senior at the ward (SHO, registrar etc). The best

bargain for a foreign student would be to present cases directly to the registrar or the

house officer straightaway. This writer was fortunate enough to come across few good

souls who volunteered to teach at particular wards. So if available use your contacts and

get their help!

C. Study

The candidates need to study theory as well as examination techniques. The students here

follow Hutchison for clinical examination. They also follow some books written by few

great senior undergraduates regarding long and short cases. Such books are available at

the Colombo Medical College photocopy shop.

For Medicine Long/Short cases – Notes are available at the photocopy shop

For Surgery Long cases - Books are available at the photocopy shop

For Surgery Short cases – Dr. Sudira Herath’s book

For Paediatrics Long/Short cases - Notes are available at the photocopy shop (including

one compiled by Dr. Daham De Silva himself during his undergraduate days)

For Gyn Obst Long/Short cases – Notes & history format made by Prof Randeniya are

available at the photocopy shop

For Emergency Medicine – Buy the book “A Guide to the Management of Medical

Emergencies” from the Sri Lanka Medical Association bookshop at Wijerama Mawata.

For Emergency Gyn Obst – Read Ministry Guidelines

For Emergency Surgery – Read Ministry Guidelines

For Emergency Paediatrics – Read Ministry Guidelines

Long and short cases mentioned in these books are the ones normally given at any

undergraduate exam. The book is beneficial as it has the theory discussion mentioned as

well. These books are a must buy for those willing to study at home.

In addition classes are conducted by senior registrars. Some of them are mentioned below

Medicine

Dr. Lalindra – Teaches long and short cases in the class while demonstrating. Also gives

scenarios and practices history taking. Quickly finishes the list of cases. He also takes

classes on emergency medicine. Once all classes are over he takes the students to his

ward at NHSL (incognito) and let them practice cases.

Dr. Charles – Conducts classes at Nobel Academy. Slow but gives a good concept. His

classes are very interactive where he raises students and ask them to present cases. He

also conducts emergency classes but doesn’t take students to his ward.

Surgery Dr. Shrishankar – Conducts classes at Nobel academy. Discusses cases and shows

possible short cases on power point. Covers emergency surgery as well.

Gynaecology and Obstetrics Dr. Jayan Jayasinghe – Conducts classes at IAS Bambalapitiya. This writer felt that his

long cases somewhat lacked in theory aspect compared to Randeniya sir’s notes.

Discusses short cases in a very concise manner. Dr. Jayan completes emergency Gyn

Obst as well.

Paediatrics Dr. Bala Gobi – Took only one class for all short and long cases and didn’t do emergency

paediatrics.

Dr. Daham De Silva – Simply idled through the class asking the students to buy and read

the set of notes he had made during his undergraduate days. He took 3 classes to finish

the entire long/short cases and emergency paediatrics. He didn’t discuss short cases in

detail. However he did mention where students screw up in vivas.

N.B: This writer feels that it’s not necessary to go for paediatrics classes. One can study

at home provided that he/she has the long case book by Dr. Daham and the short case

book from the Colombo Medical College. Emergency paediatrics need to be read from

the Ministry guidelines except few topics such as paediatric surgical emergencies,

neonatal resuscitation etc..

For neonatal resuscitation reading the publication “Guide to Neonatal Resuscitation”

published by the Sri Lanka College of Paediatricians is a must.

Some classes are conducted by pre-intern doctors who await internship. As of what this

writer has heard, they give a student’s point of view of the exam. Writer cannot vouch for

its success as he had not attended such classes in person.

D. Time and practice

Need for this is already emphasized above.

There’re few senior registrars who bring ERPM students into wards of NHSL on

weekends and conduct classes for cash. It’s strictly illegal to do so but however quite a

number of students go for them (writer too attended few classes of such). They

demonstrate examination technique first hand on patients and let each and every person

try it on the patient. Then they discuss about the case. The advantage is that the senior

registrar finds out the best cases from the entire NHSL and lets the students practice so its

time saving. Also learning from an experienced clinician first hand is advantageous. The

disadvantages are ofcourse the fee charged and the repetition of cases after a while.

Writer feels that the same could be done by the candidate by himself if he has the

permission from a consultant at NHSL. After all it comes down to the amount of practice

received not the number of classes attended or amount of money spent. Writer has

included numbers of such registrars’ in this document. If interested then candidates are

advised to call and arrange a time for the class from the said doctor. The readers are

implored to maintain confidentiality as undue publicity would be detrimental to the

careers of these registrars.

Dr. Weerasudan – Medicine SR 0718323601

Dr. Kamalatheepan – Paediatrics SR 0777725824

E. Para-Clinicals

Preparation for the paraclinical viva is slightly different.

Forensic Medicine Candidates do not need to know theory in detail but should have a basic idea about

medico legal activities a HO might need to do. Candidates will be given pictures and

asked to describe them and answer questions related to it or a pathological specimen or a

bone to determine age sex or MLR & MLEF form to find out mistakes etc.

Viva classes are conducted by the same people who conducted classes for part A.

Dr. Shanthanan – Covers up the required amount quickly and practices pictures and

samples. This writer attended his class but however felt that the practice needed for

picture interpretation and bones is somewhat less.

Dr. Prashant – Though the writer did not attend he thinks that Dr. Prashan is the ideal

person for forensic vivas. Practices lots of pictures, bones and specimens right from the

JMO treasure trove. Points out at individuals who’re timid and reserved to stand up and

answer. Everyone receives a thorough revision of forensic topics and makes he candidate

feel confident. But as usual he conducts classes right upto exams which is quite

frustrating.

JMO classes – It is conducted by the College of JMO of Sri Lanka and is a must for the

FMGs. They discuss core topics with lots of pictures, specimens and bones. Incidentally

the same sets of examiners come for the ERPM viva so the candidate has the advantage

of familiarizing with examiners before the exam. JMO CLASSES ARE IMPORTANT!

Community Medicine Community viva is simply about beating around the bush with little theory from here and

there without allowing the examiners to ask questions. Main thing is to give the

examiners the impression that you’re interested in the subject and didn’t sleep in class

during lectures.

One can attend the class conducted at Nobel academy for CM. More than classes

candidates should visit an MOH several times to familiarize with the system. The

examiners will have a very bad impression on the candidate is he/she had not visited an

MOH and a failure is inevitable(Writer knows candidates failed by a mere 1 mark at the

exam).

At the MOH office the students should have a face-to-face interview with the MOH and

ask about the diseases prevalent in the area, her role in prevention, details about vaccines,

reporting process, what to do in an outbreak of dengue/diarrhea/typhoid etc, disease

notification, clinical activities of the MOH, duties of the MOH etc. candidates need to

visit MOH office atleast 3 times (one should be to observe the clinics). Firstly call the

MOH and arrange a date for the visit. While going to the MOH this writer feels that it’s

better to take small groups, preferably 4, as the discussion becomes more interactive.

Once the MOH visits are done arrange a visit to meet the area PHM through the MOH.

The PHM should be asked about her role in maternal/child health in the area.

This writer was fortunate enough to interview the kind hearted able MOH of the

Delkanda MOH Dr. Leeda Fernando. She made the hateful subject of CM a desirable

one. The writer had lengthy discussions with her on disease notification ad reporting

which helped in the vivas. Writer advises people to visit her MOH as she’s very

supportive of FMGs but to check her availability before going. Writer went and

personally thanked her for her help in passing the ERPM.

Through Dr. Leeda Fernando the writer met Ms Janaki the area PHM of Delkanda. Her

help was also immense.

Delkanda MOH – 0112852718

Ms Janaki PHM - 0718045036

Things to take to the exam

Equipment such as stethoscope, measuring tape, illuminoscope, watch with a second

hand, gloves, light source, knee hammer, neuro kit (with tooth picks, cotton wool) should

be taken. BP cuff is not necessary.

It’s important to take soft toys for the paediatric examination. A minimum of 2 is

required as the candidate is asked to gift the toy to the child. Do not offer children sweets.

Passing Part B

The clinical station can be passed on aggregate provided that the cumulative percentage

of all long and short cases is above 50% (49.5% is not entertained). All vivas have to be

passed individually with a percentage of 50% in each.

Writer’s personal experiences in clinical section

The writer faced vivas in January 2012 with results from either end of the spectrum. The

candidate need not worry about lackluster performances in one station as he/she can

compensate from subsequent stations.

Clinical station 4 - Surgery Short Cases

Writer received 2 surgical short cases.

I. A trophic ulcer due to long standing DM

Was asked to describe the ulcer; about types of ulcers, why the margin is sloping at one

area, how can you treat it.

This writer missed palpating pulses proximally and distally though he checked for

sensation which was duly noted by the examiners and questioned.

II. Tracheostomy

1st command was to observe the patient who was an elderly female. Next question was

“what's the problem she's having now” to which the writer replied “hoarseness of voice

with Tracheostomy in situ.”

Subsequent questions were the types & indications for Tracheostomy, when do you

change from cuffed to non-cuffed tubes,

The golden question was “how will you manage this patient in the ward” for which I

replied that I'll first give her a writing pad and a pen to write down complaints and a bell

to summon the HO whenever required, followed by regular suctioning and cleaning. I

was then asked about the frequency of suctioning and cleaning of the tube.

Guess this writer hit the jackpot with this short case when the examiner said that this is

what he expects from his HO.

Clinical Station 4 - Gyn Short case

This writer was asked to take a brief history & examine the abdomen of a 55yr old

woman giving a running commentary. They guided the writer whenever he felt confused

(or rather exhibited confusion). She had a uterus the size of a football.

This candidate was asked to percuss for the upper border, to comment about the size, to

differentiate from an ovarian mass and come up with differentials.

Ultimately the case was presented in line of endeometrial hyperplasia/Ca for which the

examiners said that it was a fibroid. They asked the writer about subsequent management

for this particular patient for which I replied TAH. Following that the writer was asked to

justify his reason for the Hysterectomy for which I replied that the women’s significantly

anaemic and is post menopausal which obviates the need of retaining the uterus.

Last question was, unless complicated, when the sutures should be removed in a post

hysterectomy patient and when should she be discharged; for which this writer could

manage only a feeble mutter and that too incorrect!

This write was let go after being grilled about the university in which he studied and

being satisfied at his overall performance!

Clinical Station 5 – Surgery Long case

Was given 7 minutes for history, 1 minute for summarizing the history and another 6

minutes (till the bell rang rather) for the discussion. The case this writer got was a 62 year

old female presenting with a 1 year history of PR bleeding with symptoms suggestive of

anaemia, asthenia & altered bowel habitus. History was completed in about 5 minutes.

Though requested to summarize the history, this writer opted to present a problem list!

(Candidate can present either a problem list or a summary but problem list is easy to

compile and express.)

The writer was asked to give a probable diagnosis for which he replied “possible

Colorectal malignancy of the sigmoid with synchronous lesions in the cecum” (the

history was suggestive of such a diagnosis). Writer was then asked to support his

diagnosis which was followed by the discussion which was a mere regurgitation of

theory. Each examiner asked questions for 3 minutes for a total of 6 minutes. The

questions this writer received were; how will you diagnose the condition? Investigations?

Do you know any biochemical markers for this? How to stage the disease? (they asked

me to describe the TNM and Dukes staging for which I replied that I’ve forgotten) Writer

was asked about surgical management depending on location! What’s pancolectomy?

And lastly how to prepare the patient for colonoscopy!

Clinical Station 6 – Obstetrics Long case

This is the station where this writer met his waterloo and hung up his head in shame! It

started and then finished in disaster with perhaps the worst ever performance by the

author at any given viva.

This candidate was given 15 minutes for history, obstetrics examination and the

discussion. 7 & ½ minutes were given for history as well as obstetric examination and for

summarization. The case given was a 24 year old P2C1 in her 2nd

pregnancy who was Rh-

ve. The worst possible scenario is getting a non-cooperative patient with the devil himself

as the examiner and this happened to the author on this very day.

Patient, perhaps out of fear of doctors, was not willing to come out with information this

writer needed and gave her LRMP (Last Regular Menstrual Period) wrong. She made no

mention (and I didn’t bother to ask) of a newer date given based on scans. Nevertheless

the writer managed to cover important headings in history but didn’t ask further details

on any possibility of Rh isoimmunization (a grave mistake). Time was limited and the

examiner came up to the writer to signal that his time is up. Worth mentioning here is that

there was no one at present observing my examination technique apart from the

chaperone who was giving me tips every now and then.

First the writer was asked to present the problem list the patient was having. This writer

serially mentioned all problems found till the examiner stopped him when he mentioned

about the pregnancy being post-dated (it was post-dated according to the patient’s

LRMP). Examiner became furious when the writer told him the LRMP wrong and told

the writer that she’d been given a newer date based on scans. He gave the new date and

asked the writer to calculate the period of gestation (POG) which the writer got horribly

wrong in the confusion. What followed was a series of insults and swears aimed at the

writer and foreign medical graduates in general. To the writer’s dismay the other

examiner was simply having a good laugh at the candidate’s predicament. Once the

examiner exhausted himself from the banter, the theory questions started coming. The

writer was asked to describe my management of this patient. When the writer told him

that he’ll avoid oxytocics and ARM he flatly told the writer to tell him only what I’d do

not what I’d avoid in a very arrogant manner. That let up to another round of abuses

which went on till the bell was rung. This writer had effectively screwed up his obstetrics

long case!

Later this wrietr realized that he had not been the only victim that day. Spare the fairer

sex endowed with the looks, all others had been blasted into oblivion by the very same

examiner.

N.B: Don’t be disheartened if you screw up a viva. There are many others who have done

worse!

Clinical Station 2 – Paediatrics Short case

There were 3 paediatrics short cases the day this writer gave his exam. Usually the

examiners will point out towards one. They had a Neonate, 5yr old child with respiratory

distress & a 3 year old child with a cardiac problem.

Writer was given the child with respiratory distress. The time allotted was 7 minutes for

examination as well as discussion. After permission and quick rapport building with the

mother this writer started examination from inspection; on which the child had obvious

respiratory distress with flaring, recessions and rapid breathing. Next went on with

auscultation skipping palpation and percussion as this writer feared that the baby might

cry. The only findings noted were reduced air entry and movement on the right basal area

without any added sounds. This writer could not comment about the vocal resonance

though the percussion was slightly dull. Child did not have any IV cannulas in situ or a

mark of a pleural aspiration. The writer had 3 choices; either pneumonia, collapse or a

pleural effusion. Child was quite active and afebrile. This writer switched on to pleural

effusion and presented in line of it but made sure that no contradictory statements were

made. In the end this writer mentioned that the “child’s having respiratory distress

probably due to a pleural effusion which I would like to confirm with an x-ray”! The

questions they asked were what are the types of effusions, age specific respiratory rates in

children, how to detect exudate and transudate.

Clinical Station 2 – Medicine Short case

There were several medicine short cases namely; lower limb examination, upper limb

examination (of the same patient), respiratory system examination.

This writer received lower limb examination as the short case. The writer started with

permission & a request for a chaperone as the patient was female. Followed the sequence

of lower limb examination which revealed unilateral left sided UMNL type paralysis with

hemi-sensory loss of all modalities! The examiners asked the writer to demonstrate the

plantar reflex and the jerks. Was asked where the lesion could probably be whether in the

spinal cord or above. The writer mentioned that the pattern of weakness is UMNL type so

might have involved upper motor neurons. However this writer further mentioned that he

would review history and perform a CT scan particularly focusing on the internal capsule

area. Was asked why the writer would focus on that area for which he replied that

internal capsule strokes typically affect the sensory neurons of contra lateral side as well

as the motor neurons producing a clinical picture compatible with that of the patient.

Discussion didn’t proceed further as the bell was rung.

Clinical Station 1 – Medicine Long case

The time allotted was 15 minutes with 7 and a ½ being for history and the rest for

discussion. 2 examiners were present at that time marking individually. The case this

writer received was a 72 year old female retired nurse complaining of low grade fever for

1 month, jaw pain and hemi facial headache. All in all it was a typical PUO case which

made the history just a matter of completing the headings. The patient was extremely

cooperative and threw everything at the writer. She was constantly mentioning about her

jaw pain as if hinting to the writer that there must be something sinister related to it.

However once history was completed the writer gave the open diagnosis of PUO with

jaw pain and u/l headache! The questions thrown at the writer were; ddx of PUO? What

investigations will you do in this patient? What will you suspect in this patient for which

the writer mentioned TB.

Next the discussion moved towards TB! The writer was asked about what type of TB

would he suspect in this patient for which the writer replied probably post-primary

pulmonary tuberculosis. Next was asked about the location of the disease in the lungs to

which the writer mentioned that depending on the level of immunity the location will

differ; namely better immunity will result in apical disease and poor immunity will result

in basal disease. Next theory questions came on TB and about the clinical features one

would expect in bronchiectasis and lung fibrosis! Just as the bell was about to be rung

they asked the writer if not TB then what other cause would result in such clinical picture

for which the writer replied inflammatory causes.

Writer was then asked to list the probable causes and his 1st choice was SLE and the

examiners asked if the age is compatible for which the writer replied no. The writer was

prompted to give examples for other inflammatory causes! Finally they asked the writer

whether any procedures had been done on the patient which the writer had missed in the

history. Then they mentioned that she has had a temporal artery biopsy and requested the

writer to think about what inflammatory cause would warrant it in a PUO patient. When

the writer was juggling up with answers with a blank look on the face the examiners

simply informed the writer not to be afraid and that the case is a bit advanced for an

undergraduate but however wanted to know whether the writer had heard of such

conditions to award extra marks. After many clues and lifelines the writer finally blurted

the Dx of polymyalgia rheumatica and was allowed to leave.

Clinical Station 3 – Paediatrics Long case

Again the same time limit was given and the case was a 10 year old child with fever and

diarrhea for 2 weeks. The respondent was the aunt and not the mother (had to ask

questions in social hx as to why the mother is not with the child at the moment) which

lots of previous candidates had missed. The aunt was very cooperative and at one point

listed out all the investigations done and mentioned that despite all those they still haven’t

reached a diagnosis. Viola the writer’s immediate focus shifted on to PUO. However this

writer ruled out dengue, leptospirosis and malignancy! The writer managed to impress

the examiners by asking about notification done at the ward (PUO for more than 7 days

should be notified) which they appreciated increasing the writer’s chance of passing the

exam.

Was asked what organisms cause fever and diarrhea? Can typhoid be a culprit (writer

didn’t ask about possible typhoid exposure in history)? Next theory questions started

coming in about typhoid and infectious mononucleosis; about detection and treatment.

Writer’s personal experience in viva section

The same examiners who came for the cases come for the vivas and 1st impression

definitely counts.

Emergency Vivas

Viva section last for 15 minutes with 7 ½ minutes given for each section. Usually the

examiners of both specialties (one from each specialty) would sit in the same place and

poor performance in the 1st station would create a negative impression in the subsequent

emergency viva.

Medicine – Scenario was given about an elderly male coming to the ETU with fever,

headache and patches all over body (meningitis picture)

Was asked what investigations I would do and the initial management

CSF picture of meningitis

Paediatrcis – Scenario was given about a 2 month old baby with respiratory distress.

Was asked about clinical examination of the child, what signs will you look specifically

in a child with respiratory distress?

Initial management of this child? Oxygen delivery methods in children!

Forensic medicine viva

There were 2 examiners; one snobby female and a genteel gentleman. The gentleman

taught us at ERPM JMO classes!

Was given pictures and asked to describe! This writer received 3 pictures; one of a self

inflicted stab wound to the chest of a female (was asked to describe the injuries on this

one), another with bilateral raccoon eyes (was asked to list the causes of it) and the other

of a decomposed body with a National ID by the side (was asked to discuss about

identification in this one). The picture description part didn’t go well. The other examiner

asked theory about the inquest procedure and asked what the writer would do if a patient

gets admitted into the ward with multiple stab wounds!

Community Medicine viva

Candidate is given 15 minutes.

Two examiners took this viva which became the most successful viva of the entire exam.

The 1st question this writer received was where he studied from and what the most

prevalent diseases there were to which the writer mooted TB! The examiners weren’t

interested about TB (I was quite prepared to answer questions on TB) so I diverted the

conversation into COPD! Then they asked about what causes COPD in the community to

which I replied cigarette smoking and exposure to domestic smoke. They were extremely

happy when I mentioned about cow dung burning as a source of firewood and its

relationship to COPD. Then they asked the writer what he would do in his capacity to

prevent COPD for which this writer replied that he would “target not those already with

COPD but those who are at risk namely the unsuspecting school children who’re prone to

develop the bad habit of smoking.” That was the passing point of the community viva.

Next was asked about the levels of prevention.

The other examiner asked about the EPI of SL. Asked whether the area that this writer

lives has JEV coverage. Next question was whether the writer had visited an MOH and

what were the activities conducted there! Lastly the examiner asked this wrier about

statistics of SL (MMR, Life expectancy) and statistics of Nepal (where I studied) and

what the reasons for lower life expectancy of females compared to males in Nepal.

Unknown facts about ERPM

In Sri Lanka everything goes by merit and even the foreign students do have a merit order

based on which they are given internship appointments. The cumulative percentages of

both parts are used in the grading of candidates. The highest order of merit is given to

candidates who pass both parts in one attempt (reason why it is important to attempt all

papers/vivas in one go. Then the list is arranged so as to include candidates who have

taken most number of attempts to pass in the bottom of the list.

Those who are unfortunate to be in the bottom of the list get run down and far away

stations during internship and post-intern period. So pass all exams in one go without

being chronic.

Candidates who pass part A in first attempt have an edge against others in the part B.

Statistically ERPM completion rate is higher among those who pass part A in one go. The

August 2011 Part A exam in which this writer sat saw 11 candidates passing part A in

first attempt out of which 6 completed the Part B examination in January 2012 in their

first attempt. Those who pass in the first attempt are allowed to sit for part B examination

on the very first day thereby leaving 2 spare days to prepare for the Emergency Viva

section after the completion of the clinical section which is less stressful for the

candidate.

There have been allegations regarding the transparency of the exam. On one occasion the

ERPM part B pass list issued by the SLMC had 85 names whereas the merit list issued

subsequently contained 87 names thus raising the issue from where the new names came

from. In some cases there have been some malpractices but overall those who deserve to

be passed pass where as the others get left behind. Writer has seen candidates who do not

know about cranial nerves and those who tap the quadriceps belly when asked to look for

knee jerk.

Future trends in ERPM

With the amount of attention this exam is receiving and the number of court cases

pending, drastic change is likely to occur in the ERPM examination. The following have

been proposed with regard to ERPM.

1. Standardization of the exam for all students foreign and local as they sit for a

common MCQ paper

This is being heavily debated in court and the final verdict has not been reached.

2. Decreasing the mark upto 40%

This is less likely to materialize. Already mark has been reduced upto 44.5% and

in this writer’s opinion that’ll put the standard of the MCQ exam in jeopardy.

Even those who are blind will be able to score 40%!

3. Abolish the ERPM and conduct a familiarization course under authority of SLMC

or any local university which is followed by an examination

The local medical fraternity will never agree to this policy. They might argue that

local medical schools do not have a mandate to conduct private lessons via the

university for foreign students.

4. Change the structure of ERPM. Namely omit true/false questions and have best of

five type questions

This point is also being heavily debated in court.

5. Recognize few overseas universities capable of a quality education and offer

registration to its students sans examination

The SLMC is also considering decreasing the number of exams conducted per year

upto 2 from 3 at present as the local undergraduates have exams only twice a year.

This policy is likely to materialize form 2013.

At present a significant number of students follow medicine abroad which roughly

amounts to 400 per batch. With the health ministry carder for medical officers

diminishing gradually, the medical council might reduce the internship opportunities

to foreign graduates citing priority to local undergraduates. If the current situation

prevails there will be a time where there’ll be too many medical graduates in the

country carrying placards forcing the authorities to grant them internship

appointments!

End Notes

What the writer has jotted down here is a rough outline of the monster we call ERPM.

The suggestions are entirely based on writer’s own judgment and do not reflect the

opinion of the SLMC or any one else.

The writer sincerely hopes that this compilation would answer all queries candidates

might have regarding ERPM. He does hope that his effort would be appreciated. He

also requests those who find this small compilation useful, to circulate it among

friends who are in need of advice.

Writer has come across many selfish individuals while preparing for ERPM who’d

misguide fellow students on purpose or withhold passing vital information regarding

classes, clinics etc. He sincerely requests those who read this to help fellow students

in passing ERPM without being selfish snobs. What goes around comes around.

The writer wishes all readers success in the Examination for Registration to Practice

Medicine/ Act16.

C.Y.A

R.C

2004 A/L