Moving to Sweden as a doctor: Practical exam

This blog post is about my experiences in preparing for the practical part of the medical license exam in Sweden. I have provided relevant links and study tips for the practical exam in this post.

Everyone who passed the theory part of the exam is eligible to appear for the practical part. One is eligible to appear for the exam for a maximum of three times. The exam happens four to five times an year and the exam centres are Umeå and Göteborg (although they say Göteborg for all practical purposes, the exam actually happens in the Mölndals sjukhus, which is located in the Mölndal kommun). You get your turn to participate in the exam based on a priority ordering – those who cleared the theory earlier than you get a higher queuing time and they get prioritised in the waiting list for the practical exam. Thus, it is possible that you will need to wait for around 3-6 months for getting a chance to appear for the practical exam after clearing the theory part. Meanwhile, it is important to not lose patience and study systematically.

When I went through the practical exam questions, I figured out that I could learn easily if I have study partners. The practical exam is all about testing how you approach a patient, and this approach differs from country to country. You’ll need to learn the Swedish way of approaching patients. If you study on your own, chances are that you sometimes reinforce your own mistakes by misinterpreting the answer scheme or by not understanding some subtle aspects of the questions. Having study partners means that they can see the question from a fresh perspective and they can bring new ideas to the table. They can also correct your mistakes and teach you the topics that you are weak at. So, I strongly recommend that you prepare for the practical exam with study partners, at least half of your study time. From my experience, studying as a group online via Zoom also works well. The ideal group size according to me is three. If you are more than 5-6 people, it gets messier, so it is better to split yourselves into two groups of three people.

You can find all previously asked questions here (link requires UmU Moodle access). Ensure that you also go through the latest previous questions asked at Umeå University for their medical students which they update here (Moodle access required). I was late to find out about this and I regret that I did not go through it sooner. There were instances where these questions were repeated at the practical exam. Having contacts with those attending the KUL program at Umeå University is also helpful as they are likely to have access to a lot of reading material for the practical exam. The exit test for KUL program is the Day 1 (6 minute stations) of the practical exam, so the KUL students are essentially preparing for the same exam as you.

Most of the questions and concepts are repeatedly asked, so ensure that you study these repeating questions thoroughly. However, there will be new questions too, so it is important that you have a basic understanding about the commonly found disease conditions in Sweden. Read all the previous questions, and then make a clear plan about how you will approach each of the cases. Chart out a timeline for what topics you will study and when. Find study partners from the facebook or telegram group for foreign doctors in Sweden. There is also a Whatsapp group for Indian doctors in Sweden (contact me for details). It is also possible to go to Moodle>Kunskapsprov för läkare>Deltagare and search for those registered for the exam by using the keyword ‘Anmälda till praktisk prov’ and find those students who will appear for the exam with you. Find the profiles of these people and write direct messages to them.

It is good if you have access to KTC (every University has one, check at the University hospital near you), where you can practice clinical examination on dummies and perform procedures such as catheterising and diluting medication. You can buy suturing set, Peak Expiratory Flow Meter, BP monitor, knee hammer, tuning fork and other common devices online on Amazon.de or Wish.com. I also bought a Mini Anne from HLR-butiken to practice HLR. Buying all these stuff costs a lot of money, but my thought was that it was better to spend money and pass, rather than to save money and fail the exam.

You can email to the head of the departments at hospitals near you and ask if they can allow you to practice with ophthalmoscope, slit lamp and otoscope. This is easily said than done, as hospitals do not want to take the trouble of having a student hanging around. Most people I know accomplished this by working as a nursing assistant or as a researcher at some hospital, building contacts there, and using these contacts to go to the relevant department. With COVID-19 around, it has become harder to get an observership, so try to learn as much as you can from videos online. I sought help from my fellow doctors in India for learning radiology, ophthalmology and ENT. I even visited my medical school in India when I went there for vacation. I met my friends there, and discussed some concepts that I was doubtful about. I practiced HLR, BP monitoring, neurology and orthopedics examination using my colleagues at the research lab as ‘patients’.

There are some training programs for students appearing for the practical exam. Region Uppsala is conducting a training program for two days that covers the important topics for the exam. Lund University is also conducting a training program in Kristianstad for one week. Both these programs prioritise students who live in the same region (Uppsala or Skåne). I applied for both the programs, but got rejected, possibly because I live in a different region. Follow the news on the telegram group for foreign doctors in Sweden to get to know when it is time to apply for these courses. I also applied at the HLR centrum in Götenburg to participate in the A-HLR training, but I was rejected with the reason that they have no obligation to teach those employed outside of VG Region.

I appeared for the practical exam in November 2019 and failed for 2.5 marks (I got 127.5/200). It was a near miss, and I evaluate that the reasons for my failure were as follows:

1. I studied in a group, but we did not practice the questions by role play. We simply sat down and read the questions and answers. Without role play, it was hard to learn to make quick decisions and to hold an uninterrupted conversation with the patient. I also was poor at time management.
2. My Swedish wasn’t quite good. I was doing my SAS-G course when I appeared for the practical exam. I could understand what the patient said, but it was hard for me to find the right words to answer them back. The end result was that I spent more time finding the right words than addressing the patient’s concern.
3. I did not repeat and reinforce many questions and answers. There is not enough time to think and plan while you are at the exam, so you have to have a clear plan about what exactly you will do for each question.
4. I thought that I will get a clear fail if I give a wrong diagnosis, therefore I talked less and said only differential diagnoses. I always sounded unsure. You should not be afraid to say what exactly you suspect. If you are wrong, it doesn’t matter much unless you make a grave error. It is better to speak more than to speak less because the evaluator is looking for keywords in the conversation. You only get points if you say exactly those points and keywords specified in the answer sheet. Ensure that you speak loudly, because you don’t get marks if the evaluator does not hear you.
5. I appeared for the exam while I was working full-time and doing part time Swedish course. I worked at the lab until the previous day of the exam. This wasn’t a good idea as it is important to revise all the important topics during the last two weeks before the exam.
6. Those who appeared for the exam in 2017-18 will tell you that it is a breeze. At that time, some people prepared for less than a month and passed the exam. The exam has become tougher overtime and the situation in 2017 does not hold true now anymore. I would suggest at least three months of preparation, especially if you do not have experience in internal medicine or family medicine. It has become a fashion now to claim that one has finished learning Swedish and cleared both theory and practicals in the shortest possible time (six months or less). I would say that it is nearly impossible. Please don’t plan your career based on such exaggerated claims. I have known people who came to Sweden on visas lasting less than one year, and had to return to their home country after the expiration of the visa without even clearing the theory exam. A reasonable timeframe for the whole process (learning Swedish + clearing kunskapsprov) is two to three years.

After my first failure, my plan was to appear for the practical exam again in April 2020, but the exam got cancelled due to COVID-19. I had to wait until September 2020 to appear for the exam again. I had finished my PhD by then, but my Swedish classes were still ongoing. I also worked on the Författningskunskap course on Swedish law and ethics in the meantime. I studied for the exam with two other students and passed this time with 154/200 marks. The cut-off was 141 marks.

There is no one central place where you can get all materials needed for preparing for the exam. You need to search for them on the internet and ask fellow students to find them. Here are some reading material that turned out to be very useful for me:

1. 200 sidor : An amateurish study material prepared by students
2. OSCE by subject : OSCE questions divided up by subject
3. OSCE material from Sahlgrenska: Material used by students at Sahlgrenska. Many students say that the exam at Göteborg is tougher than the exam at Umeå. I got the same feeling when I compared the past questions from Umeå and Göteborg. Umeå has a long legacy of conducting OSCE type exams, while Göteborg usually conducts oral case discussions for medical students.

Here are the videos that I have used for learning new techniques:

1. Videos of a mock OSCE exam, Gynecological examination, respiratory system examination, diabetes foot examination, PEF use, rectoscopy and ABI examination are given on Läkareprogrammets filmer section of Moodle via UmUPlay.
2. Nervous system examination here.
3. Videos of orthopaedics examination from Lund University here.
4. Videos of psychiatry examination here.
5. Catheterisation video here.
6. ABCDE simulation video here.
7. Neurology and orthopaedics special tests on Physiopedia here (English).
8. Ophthalmology tropias and phorias explained in simple language here and here (English).
9. SBAR method for communication here.
10. Fracture management here.
11. HLR here.
12. Helmich manöver here.
13. ABG here (English).
14. Direct ophthalmology here.
15. Reaction Level Scale here.
16. Audiogram here.
17. Cardiac USG interpretation here (English).
18. Emergency tracheostomy here (English).
19. Examination of an unconscious patient here (English).
20. Dix Hallpike’s manöver here.
21. Epley’s manöver here.
22. Weber v/s Rinne test here (English).
23. Slit lamp examination here (English).
24. HINTS exam here (English).

Here are some websites and books I used for learning concepts:

1. OSCE Umeå : Question bank of previous questions of students at Umeå University
2. Internetmedicin for understanding difficult concepts in the answering scheme.
3. Läkamedelsboken and Hypocampus for verifying the approach to difficult cases
4. På Klink has detailed descriptions, so it is best to focus on the summary boxes in the book.
5. Procedurhandboken for knowing which types of procedures they expect you to know. Go to the tab innehållsförtechning in the link to the book given here and try to learn all the procedures listed there. No exam yet had procedures from outside of this book.
6. Akut Medicin book was useful in thinking systematically around the differential diagnoses.
7. Radiology Master Class for radiology.
8. Ophthalmoscopy pictures (enter any random number as patient number and student number)

Other general tips:

1. The exam consists of two days of hard work, so sleep and eat well. One of the fellow doctors who attended the exam with me fainted towards the end.
2. All ‘patients’ at the exam are actors. You will not meet a real patient. All actors act extremely well.
3. All cases you see at the exam are typical ones. The only atypical ones are the Allmänmedicin station for 14 minutes, where the patient has a range of symptoms and concerns.
4. Follow three Fs whenever possible. Communication with the patient is very important in Sweden. You could fail at professional utvekling station not because you don’t know the concepts, but because you did not communicate well enough.
5. Most people I know got lower points than expected, or even failed at HLR station. Take it seriously and train with friends many times. Many things can go wrong here, so be sure to know it inside out.
6. Alcohol history, antibiotic allergy, decreased quality of life and stress are important questions that can cost you points if you miss them.
7. The evaluator for the most part will be silent. You have to manage the situation on your own and explain your diagnosis to the patient in simple language as if you were a real doctor.

NB: I do not endorse any of the study material given in this post. It is possible that some of these sources contain wrong or outdated information. Please use your discretion to find out the latest and correct examination and management protocols.

Earlier posts in this series:

1. Moving to Sweden as a doctor: PhD admission
2. Moving to Sweden as a doctor: Learning Swedish
3. Moving to Sweden as a doctor: Medical license exam

Later posts in this series:

1. Moving to Sweden as a doctor: Practical training
2. Moving to Sweden as a doctor: Starting Specialist Training

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