Part II Overview

Getting Started

Welcome

Welcome to the Christchurch Hospital Fellowship Examination preparation program! The Fellowship Exam is a consultant level exam. Although the written can now be attempted as early as the first half of advanced training, you need to be functioning at or close to the level of a consultant in your daily clinical work on the floor. If you are not there yet, it is too early to sit the exam.

The Fellowship Exam can be likened to a marathon - this is not an exam that can be passed with last minute cram. This is an endurance event, not a sprint. Slow and steady wins the race. Just like a marathon, you need to pace yourself so that you finish with your health, brain and relationships intact. Athletes often have a training cycle that starts with a recovery period to freshen up before the hard work begins. Don't "gently study" before your starting date - give yourself a complete rest, go on a decent holiday before you start your year of study.

The exam has been described as a "1000 hour" exam. this is as bare minimum. obviously you started preparing for this exam from the day you passed the primary exam, but the hard work really starts a year out from the written. that means that from the start of concentrated study until the clinical, you will need to dedicate 1.5 years of time to achieving this hurdle in your training. a rough guide would be to aim for 2-3 hours per day of study on a work day, with 6+ hours of study on a non-work day. many people factor in a day off per week. over a year, that will roughly come to 1000 hours of study.

It is true that quality is more important than quantity when you are studying. Good quality study is very important. You need to make sure that you are getting bang for your buck when you are in study mode, however you also need to spend a lot of time at your desk.

It is hard work, but this exam is passable, and once the wrinkles are ironed out of the new exam system, it will hopefully be a very fair test to determine if you are ready to be an Emergency Medicine Consultant. The effort is worth it - this will hopefully be the final exam of your life – there will be no other time in your career when you have so much knowledge. Pass the exam, climb to the top of Mt FACEM - the view is fantabulous!

Have Your Life Sorted

The aim is to do this exam once, so it is really important to do it right the first time. Your road to the exam needs to be clear. You need to dedicate a year to this project, so moving house, getting married, having babies or going on extended holidays need to be planned around this time. Obstacles will always appear that are out of your control, so make sure you plan for all those things that can be controlled.

Organise your training time to best fit your study - in the 6 months leading up to the written exam you are likely to want a good amount of study leave - make sure you are in a job at that stage that will give you leave, and apply for it very early. If you want to be involved with the study program in Christchurch, you don't necessarily need to be working in ED, but you really need to be in Christchurch for the 6 months before the exam. 6 to 3 months out from my exam I did an OOPD run - this was fantastic as the work is not as tiring as ED, leave is plentiful and easy to get (if you apply early), and there are no night shifts. Just ensure that the run you are doing is happy to give you leave - some non-ED runs (such as anaesthetics) do not prioritise study leave if you are not one of their trainees. Leading up to the OSCE you NEED to be working in ED. Nowhere else. The OSCE aims to replicate what we do on the floor every day. Therefore, the best revision is to be on the floor every day.

Looking After Yourself

You need to work hard for this exam, but you also need to take time off from study. You still need to live life, walk the dog, go for a run, take the kids to the park, go out to dinner, whatever. Unwinding is a really important part of coping with the stress and hard work of exam preparation. Advice given to me which I tried to follow was to take one whole day off a week. No study. Enjoy yourself. You may decide to split this up over a couple of days and allow yourself a break. It gives you an incentive to work hard knowing that your planned day off is on the horizon. Remember to keep moving - you will spend many hours sitting on your butt at your desk - regular exercise keeps the body and brain working efficiently.

Looking After Your Family

Don't forget about your family. This exam is taxing not only on yourself (mentally and physically), but on loved ones around you. Sit down your family/partner before you start this process and let them know just what it will involve, that at times you may be tired and cranky, and just how important revision time is for you, so that you can pass the first time and get on with life. My husband referred to himself as an "exam widow" - some tactics I used to keep the other half happy was to organise "date night" once a week, as well as introducing my husband to another "exam widow" with a mutual interest in mountain biking, husband of one of my study buddies, so that the boys could get out of our hair during the weekend and entertain themselves, while we studied.

Finally, don’t lose your perspective, if it starts falling apart at home - remember that no exam is worth your marriage or family.

What To Do Now

In the month before you start studying get your books together – see recommended texts. Set up your study - buy new furniture if needed to make it comfortable - it will be your home for a good proportion of the next 12 month. Start looking at #FOAMed (Free Open Access Medical Education) websites that might be helpful during your study, because a lot of time can be wasted finding these resources once you are already deep in your study program. Sort out a study group. Ideally this should be 3-4 people. Your study group is really what gets you through this ordeal – when you feel low or unmotivated, generally there is another who is doing OK and they drag you through. You are then there to drag them through when they are low. Have a study program - there will be a dedicated 6 month program run in Christchurch ED before each exam sitting, but you should aim to have covered the entire curriculum at least once, and have all the "base-line" knowledge before you turn up to these sessions, which will be based around exam technique and prioritisation, rather than learning facts. Having a revision schedule and ticking off each topic when you have covered it can provide positive reinforcement and a sense of achievement (or motivation if you need to work quicker!)

Eligibility Requirements

Candidates for the FEx (Written) must meet the following criteria:

  • They must be a registered and financial trainee of the College
  • They must hold current registration to practice medicine in Australia or in New Zealand
  • They must have successfully completed the 'Early-Phase' WBA requirements, which includes completion of at least 12 months (of 30 month minimum) of accredited ED time in Advanced Training

Candidates for the FEx (Clinical) must meet all of the following criteria:

  • They must be a registered and financial trainee of the College
  • They must have completed at least 36 months of 48 months of accredited Advanced Training time prior to the relevant examination application closing date (not including any required ED remediation time)
  • They must have satisfied the trainee research requirement
  • They must have successfully completed the FEx (Written)

Exam Dates

Exam Format

The new format of the exam is divided into 2 discrete assessments, a FEx Written and FEx OSCE.

FEx Written

The written examination is made up of 2 x 180 minutes papers with a break in between.

Select Choice Questions (SCQs)

  • Multiple Choice Questions (MCQs)
    • Each MCQ comprises a stem and four alternative responses
  • Extending Matching Questions (EMQs)
    • Each set of EMQs Questions are written around a theme/Dx/Rx/Ix.
    • Select an option from a list of up to 20 options. You may select the right option more than once (i.e. for different questions, you may select some of the same answers).
    • Tip: Read the vignette/stem & try to come up with the answer first, then look at the list of options. This will stop you getting distracted by the options.

Short Answer Questions (SAQs)

The revised format SAQs require answers that are highly structured and specific, with responses that will require single words or short phrases, rather than mini-essays. These allow you to show your consultant-level integration of knowledge and ability to prioritise.

How to study for the Written

SCQs

Do lots and lots of practice MCQs. And then do some more. If you have MCQ papers that don't have answers, get your study group to do the paper and then compare answers. Then go and search the textbooks for the 'correct' answer - questions in old papers turn up again and again. See shakEM.co.nz for a mix of MCQ papers, plus invest in the two MCQs books listed in Recommended Texts. I found that the questions in the Tintinalli MCQ book were slightly easier than average, while the questions in the Yolande Weiner book were slightly harder than average.

A certain FACEM once told me that you should be aiming to get about 60% in your practice papers leading up to the exam. Don't be disheartened that you are not getting more - our study group averaged about 60% in the lead up, then beat the rest of Australasia in the real thing! Trust that everything will come together by the big day.

SAQs

You need to practice doing exam questions. You’ve got to practice. Real questions. From the start. The SAQ exam is very time-pressured - you need to be able to organise your thoughts and write them down in a short space of time. You could start doing them with open book technique, then closed book, then to time. Doing SAQ’s to time is very important – you need to train your hand muscles to endure writing for 3 hours solid. Start by doing just one to time, then two in a row, then three… and build up. Use a stopwatch and be firm on yourself. Tell anyone in the house not to disturb you for that time and just keep writing. You find that if you go just one minute over on one question, it throws you off for the rest of the exam. Time management cannot be under-estimated in importance.

The new format is not completely intuitive, and getting used to providing coherent, prioritised and correct answers, under pressure, will take some practice. Do lots of the old-style SAQs and VAQs to learn content, but do the new SAQs to practice your consultant-level prioritisation. Practicing the new-style SAQs can help to control anxiety you may feel during the exam, induced by the large number of blank answer spaces you will face. Don't panic! Develop your exam time-management skills during revision so that you can finish the exam with time to go back to questions that need a second look.

Compared to the old VAQ/SAQ system, relatively few words/short phrases are required. The amount of space provided is the clue to the amount to write – so DON”T WRITE OUTSIDE OF THE LINES. Examiners were specifically instructed to ignore anything written outside the provided boxes in the 2015.1 exam. Try and be succinct – less may be more, don’t say in a sentence what you can say in 1-2 words If you accidentally write 4 things in a question that asks for 3, or you want to re-prioritise your answers, you can go back & write: 2nd, 1st, 3rd - next to each line if you want to re-prioritise. Prioritising answers in the SAQ is a big issue, and probably the hardest part of the exam. Grill your study group partners about why they chose to prioritise answers certain ways.

Cut the Crap - the generic "Triage to resus, cat 2, IV/O2/monitoring" will no longer get you marks, and will take up some of your precious answer space. A house surgeon can provide that answer. This exam is testing to see whether you can think like a consultant.

High Yield Topics for the Written - where to start

ECGs - you need to be an expert ECG reader - this allows you to go into auto-pilot on these questions and make up valuable time, in a very time-pressured SAQ exam

ABGs - as with ECGs, interpreting ABGs needs to be something you can do in your sleep. Practice all the old-style questions on ABG interpretation that you can find

X-Rays - especially Chest and Orthopaedic X-rays

CT Scans - especially CT Head, CT Abdomen and CT Chest

Resuscitation - as Emergency Physicians we need to be “expert in this area”, a significant part of the written exam will be on adult and paediatric resuscitation

Airway - advanced airway questions occur commonly (think of how many ways you can alter a 'standard' RSI depending on different patient factors - eg trauma, pregnancy, head injury, tox)

Toxicology - have a proforma that you can use for all Tox Presentations

Administration - classic questions appear in the FEx on various admin topics

FEx Clinical

The OSCE is made up of 18 clinical examination stations, which may include standardised patients, observation stations, clinical scenarios, communication scenarios and simulations of management of critically ill patients. Most stations will be 10 minutes duration, which includes 3 minutes of reading time before you enter the room. There are also double length OSCEs which have previously been simulated resuscitation stations. The first sitting of the OSCE in 2015 was run over 4 days, with each candidate doing 8 x 10min stations and 1x 20min station on each of two consecutive days.

How to study for the OSCE

You really, really need to be studying for the OSCE with others. This cannot be done by yourself, no matter how helpful your partner/dog/cat/pillow are for practicing on. You need the feedback of others who are in the same mindset - this part of preparation will not work for Lone Warriors who feel that they study best by themselves. Leave your ego at the door and join in your study group!

You should be working in ED during the lead-up to the OSCE - treat every patient you see like you are in an OSCE. Do lots of Mini-Cex assessments to get feedback from different seniors. Watch each other seeing patients. Teach juniors to do procedures, like you are doing a teaching station in an OSCE. Unlike the previous exam setting where you needed to go and trawl the wards for patients with sarcoid or other random diagnoses, all your preparation can be done in ED.

Read the curriculum & know the domains.



The "medical expertise" domain is the main one for factual medical knowledge, but you need to know all of the domains, and how to approach and answer questions with regard to the domain/s being tested. The OSCEs will test all of the domains in the framework. Each station stem will have the domains being tested on the question sheet/stem, that you can read outside the room, and use to start preparing your approach.

Resources

Recommended Texts

Core Texts

Tintinalli Emergency Medicine: A comprehensive study guide.
Cameron Textbook of Adult Emergency Medicine.
Cameron Textbook of Paediatric Emergency Medicine.
Dunn The Emergency Medicine Manual.
Murray Toxicology Handbook.

ECGs

Mattu & Brady ECGs for the Emergency Physician 1.

MCQs

Alwis & Weiner Emergency Medicine MCQs.
Tintinalli Emergency Medicine: Examination and Board Review.

You will need to refer to one of the main emergency medicine texts (Tintinalli or Rosen) no matter how unfriendly they appear. I strongly recommend using Tintinalli, as it appears to have a large number of MCQs drawn directly from it.

To complement one of the main US tomes, the Australian books ‘Textbook of Adult Emergency Medicine’ and ‘Textbook of Paediatric Emergency Medicine’ are essential. Numerous authors who are closely involved in the exam process have contributed to these books. They also provide a more useful Australasian clinical context. Robert Dunn’s ‘The Emergency Medicine Manual’ is very useful. Although in point form, its coverage is broad, Australian based and directed at potential exam topics.

'Toxicology Handbook' by Murray et al. is also essential and covers all you need to know for toxicology, as well as a good section on snake bites.

ECGs for the Emergency Physician 1 & 2 by Amal Mattu are fabulous books to quiz you on all aspects of ECG interpretation, with good descriptions of each abnormality.

#FOAMed and other resources

Life in the Fast Lane The Bible. The source of everything, old exam questions.
www.lifeinthefastlane.com
ACEM College Website, includes ACEM example questions.
www.acem.org.au
ED Exam Fellowship exam resources from Andy Buck.
www.edexam.com.au
ACEM FEx SAQs/OSCEs Crowd-sourced #FOAMed database of OSCEs/SAQs, Adelaide.
acemfex.adelaideemergencyphysicians.com
EmergPa Princess Alexandra, login required but free to join.
www.emergpa.net
EmergencyPedia Western Sydney.
www.emergencypedia.com
ACEM Fellowship Growing collection of 'new' SCQs, SAQs and OSCEs.
www.acemfellowship.com
Improving Care in ED Auckland.
www.improvingedcare.org
EmergencyPedia Western Sydney.
www.emergencypedia.com
GCS16 Monash.
www.gcs16.com
The Sharp End Includes toxicology online lecture series.
www.thesharpend.org
Don't Forget the Bubbles Paediatrics.
www.dontforgetthebubbles.com
HippoEM Online lectures + MCQs on the entire EM curriculum ($$).
www.hippoem.com

Courses

I highly recommend attending a number of courses to consolidate your knowledge in the 12-18 months before the exam. If you haven't done these courses before, now is the time to sign up for them. In New Zealand they are all paid for by your registrar training funding.

Particularly helpful courses for your exam study include:


Emergency Trauma Management (ETM) Designed by Emergency Physicians, for Emergency Physicians. An alternative to ATLS/EMST that covers all of trauma, plus other topics such as trauma radiology, human factors, teamwork and leadership.
www.etmcourse.com
Advanced Paediatric Life Support (APLS) Covers all of paediatric resuscitation, and good practice for the simulation stations in the OSCE.
www.apls.org.nz
Advanced Cardiac Life Support (ACLS) - CORE Level 7 Refreshers available regularly at Christchurch Hospital Contact Resuscitation training coordinators
Practical Obstetric Multi-Professional Training, (PROMPT) 4 courses per year held at Christchurch Womens Hospital. Places available on each course for ED . Covers all major O&G emergencies in a one day course.
www.promptmaternity.org

Christchurch Hospital Fellowship Program

Any trainee preparing for the written examination is welcome to attend the program. Please talk to your DEMT or Laura Joyce to declare your intention to participate.

You need to arrive prepared. Most of the benefit from the session will be derived from discussion around concepts and answers to questions. You should have a bank of 'core' knowledge for each session before you attend, to get the most out of the group revision. If you have specific requests for the sessions, please direct them to Laura Joyce.

If you follow the recommended one year (minimum) to study for the Fellowship Exam, the first 6 months should be dedicated personal study to organise your texts, thoughts and notes, and you will have covered the entire curriculum before you attend the intensive group sessions which will be based around answering old questions.


Revision Timetable for 2016.2 FEx

Group sessions are held 1100-1300 Fridays in the Conference Room.

Those sitting next exam who are rostered on can attend until 1200.

Those sitting 2017.1 are welcome to attend 2016.2 group but cannot be guaranteed time off the floor.

Christchurch Hospital FEx 2016.2 Revision Timetable


Final Words

From the guru herself, Dr Jan Bone:

Don't Forget!

This is your exam: you need to drive it.

This is the culmination of all your medical training.

This is your career.

You get to choose whether you want to just scrape over the line and be an average Emergency Physician, or whether you want to be a friggin' awesome Emergency Physician.