To be honest, the questions were rather difficult this time, and many candidates were taken surprised when they received questions of almost a sub-specialty level.
In the past, trainees from major hospitals had an advantage because they usually had much better exposure to a wide range of diseases. (I still remember one MRCP part II candidate from a peripheral hospital admitted that he had never encountered a real case of acromegaly during his three years of basic physician training.) Unfortunately, the argument seems reversed in recent years; large regional referral centers have so many sub-specialists that the main duty of a general physician is to determine what specialists to consult, and a physician (or trainee) would need to be able to do everything if he works in a small hospital and has nobody to consult.
As Geoffrey Vickers said (in The Art of Judgment):
Even the dogs may eat of the crumbs which fall from the rich man’s table; and in these days, when the rich in knowledge eat such specialized food at such separate tables, only the dogs have a chance of a balanced diet.
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