Tag Archives | Exam Preparation

Southern Health Practice ACEM Fellowship Written Exam, June 19th 2013

A quick note for people sitting the 2013.2 (August 2013) ACEM Fellowship Exam. There is a practice written exam, organised by Southern Health in Melbourne, on June 19th (at ACEM Headquarters in Melbourne), with a feedback session on July 3rd at Monash Medical Centre in Clayton. I must stress that this practice exam should ONLY […]

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CRP & Fellowship Exam Update from ACEM2012 in Hobart

I was lucky enough to get down to Hobart last week for the annual ACEM Annual Scientific Meeting.  Overall it was an excellent conference, with a great range of speakers and topics, and a fantastic social program culminating in a night at MONA.  Michelle Johnston (@Eleytherius) has written an excellent synopsis of the coference at Life In The Fast Lane, which you can read here.

Of relevance to EDExam readers however were two sessions that I attended. Firstly the session on the Curriculum Revision Project, and secondly was a presentation by Simon Craig, who presented the results of a survey of factors associated with Fellowship Exam success, which yielded some surprising results (which I’ll cover in a separate post).

Curriculum Revision Project Session

Presented by CRP project leads, and attended by ACEM President Sally McCarthy, this was a packed “standing-room only” session, reflecting the keen interest of conference attendees in this important subject, and the session actually ran about 40 minutes into the lunch break, due to some passionate discussion and debate in the question time.

Apart from the already published exam format changes, other important aspects of the CRP were presented, including:

  • ACEM has conducted analysis of the impact of the CRP on all affected groups, from medical students, through all ranks of junior doctors/Registrars, Consultants, DEMT’s and ED Directors so as to ensure that all views are taken into consideration.
  • Regarding implementation of changes: 18 months notice will be given with general information for major changes, and 9 months notice with specific/detailed information prior to implementation.
  • Workplace Based Assessments are a very controversial subject.  In the question time, serious concerns were raised about WBA’s, with possible negative implications including:
    • ED Consultants don’t have time to manage their current clinical workload, especially in the face of the 4-hour rule, so adding new supervision/feedback duties, with specific, high-stakes assessment requirements is not feasible for those working on the floor.
    • There is overwhelming pressure to provide pass marks for all WBA’s for all registrars, as the fallout from failing someone in a WBA is massive, and can include complaints, dispute resolution/mediation processes and even legal action. This “pressure to pass” is seen by many as a major downfall of WBA’s.
    • A counter argument was raised that each WBA should be of lower stakes, (possibly achieved by increasing the numbers of WBA’s… groan) so that failing one or two is not only acceptable, but expected, and that one or two fails won’t adversely affect one’s progress through training.
    • A recurrent theme was that many FACEMs aren’t interested in teaching or assessment. Many just want to come to work, do their clinical shifts and go home.  From what I understood, the College’s argument was that teaching and assesment are actually core skills of being a FACEM, and that it will actually be part of your future job requirements.  Personally I have grave concerns about forcing people to do things they lack interest or formal training in, and have no skills in (analagous to the 4.10 issue, and the clear fact that most people aren’t interested in doing research, as evidenced by the small numbers actually doing formal research for their 4.10 since the introduction of the alternative pathways).  ACEM is providing teacher/assessor training for FACEMs, but the utility of this will be hard to quantify, and while we all know that being taught by people with no teaching skills, (how nearly everyone of the current medical generation has been taught), is bad, we won’t know how good the new system will be until it’s trialled.

Despite the many criticisims of the CRP, (and there were many!), one thing that stood out was the enormous amount of work and thought that’s being put into this process, so while various aspects of it  may seem flawed in may people’s opinions, rest assured that no change will be made without serious analysis.

As mentioned in my previous post, those planning on sitting the Fellowship exam in the next year or two need to pay close attention to the CRP changes, bookmark the ACEM website and monitor CRP updates closely, liaise frequntly with your DEMT and any ACEM Examiners you know, and make sure that everyone in your study group is up to speed with the changes.  I’ll endeavour to keep you updated as well, as the new exam formats will require new study and preparation techniques.


Coming soon… Simon Craig’s Presentation at ACEM 2012 on a survey which looked at specific factors associated with Fellowship Exam success.

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ACEM Curriculum Revision Project – Time to revise your exam plans

CRP: Not just a useless blood test!
Many of you would now know that ACEM is redesigning the training program, which will change the way your progress through ED training is monitored and assessed.  Perhaps most notably will be changes to the Fellowship Exam structure.  In a statement released just over a week ago, (which you can access here) the College gave a clear update on the planned changes, which (apart from containing the seemingly mandatory photos of the very good looking Registrars and Consultants at Southern Health in the pdf’s!) has all of the documents you should read if you are starting your ED training, or are planning on sitting the Fellowship Exam in the next 2-3 years.

Some of the proposed changes over the next few years include:

  • Changes to the Primary Exam – aready implemented
  • Changes to the Fellowship Exam, including:
    • Improved MCQ’s: increased clinical relevance and possible replacement with other formats like EMQ’s
    • Removal of VAQ and SAQ sections and replacement with other “more feasible and clinically applied forms of assessment” (not defined)
    • Long and Short cases removed and replaced with improved/expanded SCE’s
    • SCE’s may include elements such as:
      • Simulation
      • Standardised patients
      • Assessment of non-technical skills
    • SCE’s may focus on asessment of:
      • Teaching skills
      • Health Advocacy skills
      • Critical Research Literature Appraisal & Application of EBM
  • Implementation of:
    • Online learning portfolio
    • the dreaded WBA’s – Workplace Based Assessments

Like any big change in any organisation, there will no doubt be hiccups, a few people who get upset and (hopefully) fewer still who are screwed over by the process.  Having said that I believe that on the whole these changes are for the better, and reflect the current extremely pro-active stance of the College.

Some of the benefits will be:

  • A clearer set of standards/objectives for your training – which will force your hospitals to provide you with the required training/skill acquisition. This may sound silly, but I and many of my Consultant colleagues got through without ever doing or being taught certain procedures or skills, which is a big deficiency of the current system.
  • A more standardised and therefore (theoretically) fairer exit exam
  • A focus on teaching FACEMs actual teaching skills.  One of my main gripes with medical specialty training is that we are taught by people with no teaching qualifications.  ACEM is trying to rectify this, which should hopefully make your Consultants better clinical teachers.

Some of the downsides are:

  • WBA’s: these will create even more forms to fill out, and if i could quote an eminent British Emergency Physician who spoke at the ACEM Conference in Syndey last year about WBA’s: “we just glanced at them, and as long as they weren’t filled out in crayon, or didn’t look like thier mum had filled them out, we just passed them”.  This refers to the extreme volume of paperwork created for Consultants by implementaiton of WBA’s, and the lack of scrutiny they may undergo, so hopefully ACEM will bear this in mind.
  • Those caught up in the transition phase may find it hard to have clear exam study goals a year or so in advance, which is the time required to prepare for the Fellowship Exam.

Of course I’ll try and keep you up to speed with the changes as they are implemented.  There will now be new exam preparation techniques, new study methods, and I predict some new exam preparation courses that you can attend, but I encourage you to sit down with your DEMT’s soon and talk about your exam plans, even if it’s 2-3 years away, keep a close eye on the CRP section of the ACEM website for updates, and be strategic about when you sit the exam.

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Preparing for the exam? Check out the Emergency Care Institute.

Founded by ACEM luminary Sally McCarthy, the New South Wales Emergency Care Institute (ECI) is a great resource for those of you preparing for the exam.

Click on the “Doctors” tab in the slider-menu, and have a look at their Clinical Tools.  There you’ll find a wealth of clinical guidelines (mostly from NSW Health) and even links to some useful apps.  

There’s a “Top 20 Sites” page (which EDExam features on!), showcasing the top Emergency Medicine online education resources, as well as a section on Clinical Education and Training with links to various courses.  There’s some quick reference guides to various bits of ED equipment as well.

There is still no “one stop shop” when it comes to Emergency Medicine webucation, but the ECI site has a lot of great, local information for those of you preparing for the ACEM Fellowship exam, and I recommend you check it out.

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Examination Kits for the Clinical Exam

I was lucky enough to get to help out at the recent 2012.2 Clinical Exam in Melbourne, and some of the candidates generously allowed me to have a look at their examination kits so I could share with you what goes into a great examination kit.

Here’s my article on Examination Kits for the Clinical Exam, feel free to leave a comment if you have any other tips or suggestions!


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Use visualisation to boost exam performance

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Textbook Review: Examination Emergency Medicine – Wilkes, Peirce, Foot & Ting

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Checklist Manifesto – Book Review: Works for surgeons, can it help Emergency Physicians?

I saw  The Checklist Manifesto: How to Get Things Right on a “what I’m reading” spot on Amit Maini’s EDTCC Blog recently, and thought it looked interesting, so bought myself the Kindle version, and read it a couple of days on my iphone.

The author (Atul Gawande), an American surgeon, delves into the story behind his recruitment into a project to develop surgical checklists.  He was directly involved in the development of a checklist, which was distributed internationally by WHO and was shown to drastically improve patient safety and reduce morbidity and mortality.

His research covered areas as diverse as business, skyscraper building, fast-food, disaster management, aviation and of course, medicine.  The book contains a fascinating plethora of anecdotes showing how checklists are used in all of these industries (and many more) to improve outcomes.

The underlying theme is about simplifying processes that we as modern professionals, in industries where the volume and complexity of information we are expected to know has outstripped our ability to retain and execute all of the tasks and procedures we’re expected to deal with.

How does this apply to Emergency Medicine?  Firstly, in exam preparation: I used checklists (2 years before I read this book) to keep track of topics I was studying for the Fellowship exam.  I didn’t just use the syllabus as the checklist (a sure fire path to insanity), instead I looked through the syllabus and picked out the expert level knowledge topics, and made one checklist of those, as they were the “must know” topics.  I also used them to plan my study for the week, putting short lists of topics I had to get through for each day up on post it notes.  Once I got better at writing checklists, I started writing some topic summaries as checklists.  The most obvious topics these could be used for are the resuscitation topics, as these require factual knowledge and procedural skills to be combined, and are often done incorrectly or out of sequence.  Checklists are different to most lists you learn for the exam, and from protocols (which are voluminous and tiresome to follow).  They are succinct, practical lists of things to check & do in defined situations, and by definition should improve your practice, not hinder you by being an obstruction to proceding with whatever task you’re applying it to.

I also think that given the complexity of what Emergency Medicine entails, there are numerous potential applications for checklists that could be formally used in our day to day work.  While experienced ED docs subconsciously use them, they would be great teaching aids, and would surely improve the performance of just about everything we do, from resuscitation, to procedures, to referrals, admissions and patient discharge. 

Here’s a couple of examples:

Pre Intubation Checklist:
Check BSL – don’t intubate hypoglycemia
Check K+ on VBG – no sux if K+ high – femoral stab if no IV access
Check Laryngoscope handle/light
Check backup handle/light
Check & size ETT/cuff
Check Bougie
Check & size LMA
Check Suction
Check BVM/O2 supply
Check ventilator
Check patient position – ear to sternal notch
Check Vital signs – normalise as able
Check drugs & doses
Check & allocate staff roles before commencing
Check difficult airway trolley – cric kit at bedside
Communicate failed intubation plan to team

You can see how having a nurse standing next to you reading these items out while holding a red pen and a clipboard would minimise the chance of a bad intubation attmept!

Pre Lumbar Puncture:
Check for raised ICP – Clinically
CT If indicated
Check Platelets +/- coags – reconsider need if Plts < 50
Check for petechial rash (contra-indication in some jurisdictions)
Check for local skin infection
Check for previous back surgery
Check ability to maintain patient position
Check nurse assistant available for whole procedure
Check that lab able to process samples (BEFORE procedure commences)
Explanation & Consent verbal/written

I just made these up off the top of my head, but you can see, in our job, with the constant interruption to our thought processes, where it’s quite easy to forget or be distracted from one or two items on a checklist, how these sorts of lists could help avoid complications, and even potential disasters.

While the information you need to know to write these lists is all in the books, combining this with practical experience and sequencing of tasks is what helps create checklists, and like all dynamic tools, they need to be frequently revised before the optimal checklist is created.  The practical application of this knowledge is also what turns it from a “list” (that you need to know for an exam) to a “checklist” that you can actually use in your day-to-day work.

I’d thoroughly recommend The Checklist Manifesto: How to Get Things Right to anyone studying for ACEM Primary or Fellowship Exams, and any experienced Emergency Physicians who want to improve their practice and teaching.

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Passive learning: Bathroom Osmosis, Moonwalking with Einstein & learn to love your own voice

Bathroom Osmosis & Moonwalking with Einstein
When I was studying for the Fellowship exam I was overwhelmed by the amount of information I had to cram into my little brain, and frequently would read a list or a summary, and promptly forget it. I found I needed repetition to get these facts cemented in my brain, but going over and over lists while sitting at a desk was excruciatingly boring, and time consuming.  So I began to think about all of the “dead time” I had during the day and how I could put this to better use.  I figured if I could read one list every time I had a shower (average once/day), brushed my teeth (twice/day), and went to the toilet (say, 3 times a day at home), that’s at least six lists per day I could read, with essentially no effort.  If you do this every day for 6 months before the exam, that’s over 1,000 exposures to your lists.  Add to this lists on the fridge (how many times a day do you open your fridge? At least 4 or 5 right?!) and you can double that exposure.

So I set about plastering my bathroom with lists.  Causes of a non-anion gap metabolic acidosis, management of Digoxin toxicity, ECG changes of hyperkalaemia… if it could fit on a post-it note or a 5 x 4″ index card, I stuck them all over the bathroom mirror, the shower and in front of the loo.  There was no system to it, just randomly pick a list, and read it a few times whilst brushing my teeth, having a wee, or standing in the shower. (Tip: put the lists on the outside of the shower glass facing inwards – so they don’t get wet). I made them all a bit different, used bright colours & highlighters for the ones I had trouble remembering which made them much easier to picture later on.

I found that when I was writing answers to practice questions, I didn’t just remember the lists, but I could picture them, in detail, in the exact spot on the wall where they were.  The familiar surroundings and constant repetition had seared them into my memory.  I think this is a similar practice to the “memory palaces” described by Joshua Foer in Moonwalking With Einstein. ( Moonwalking with Einstein: The Art and Science of Remembering Everything )
I could picture myself walking into the bathroom, looking up to the top right corner of the mirror and see the list for “causes of QTc prolongation”.

My wife, and our friends who came over and used the bathroom, initially thought I was crazy.  But eventually our friends came to love the lists too, as they’d come out saying “I love using the loo at your house, I always learn something when I’m in there!”

Learn to like the sound of your own voice:
I also did a lot of driving to tutes, teaching sessions, practice exams and clinical practice sessions during my exam prep year, not to mention all the usual driving to work, shops etc.  This was more “dead time” that I wasn’t learning anything in, so I started reading my lists out loud and recording it onto my computer, saving it as an .mp3, adding it to a playlist in iTunes, and uploading it to my phone, so I could listen to the lists whilst driving.  Even doing this once or twice a day meant I had hundreds of more exposures to the lists that I otherwise wouldn’t have had. There’s loads of free audio recording software for Mac & PC, just Google “free audio recorder”, or use the built in Voice Recorder on your iphone, it’s so easy, and will really drive those hard to remember lists into your brain.

So if you’re like me, and don’t have a photographic memory, get narcoleptic when trying to read lists whilst sitting at a desk, or just want some variety in your study routine, then start using the passive learning techniques I’ve described above, and I guarantee you’ll improve your recall and your exam marks!

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Are you interested in the ICU Fellowship? Check out Crit-iq

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Exam Preparation Tip: Are you ready to be an Expert?

Preparing for this exam is preparing yourself to be an Expert Physician.  Not only do you need to know the topics in the syllabus well, and have expert medical knowledge, you also need to know the Emergency Medical and Hospital System capabilities and limitations, inside out.  You need to know when to take charge, and when to defer to someone better qualified to manage the situation at hand.  The buck will stop with you, and you need to know what to do with it!  Remember, this is an exit exam.  Obtaining the FACEM qualification entitles you to be left in charge of the most chaotic, challenging, diverse and difficult of medical environments in the modern hospital system. Are you ready to “be the expert”?
The sign from President Harry S. Trumans desk. My dad had one of these on his desk at home… (ironic, given our surname…). If you’re sitting the exam you should get one of these, or print this out and stick it up above your desk to get you in the right frame of mind.

Still confused?
Never mind the difficult airway or running an arrest, they’re the easy parts of the job. Here’s a few (of the many) real life situations I’ve been faced with as a Consultant that took expert skill to manage (hopefully de-identified enough not to implicate anyone or any hospital).

Treating a medical colleague for prescription drug abuse.
Treating a pop-stars mother for a psychiatric condition
Dealing with the fact that my entire (full) department may have been exposed to measles.
Being physically & verbally intimidated by a Paediatrician who disagreed with my treatment of a child! (I know… of all specialties, who’d have thunk?)
Managing an inpatient unit Consultant physician (as a patient) who’d been sent home with a spinal fracture, who I had to recall to my ED.
Dealing with a full department with 9 ramped ambulances, 45 patients in the waiting room, and no beds in the hospital…

I could go on, but do you get the picture? If any of the above scenarios seem beyond you, then you need to question whether you’re ready to “be the expert”.  If the above scenarios excite you, and make you think “bring it on!” then maybe you’re ready…

Got any tips on “being the expert” for future FACEMs? Got any scenarios that tested your expert FACEM abilities?
Then make a comment (below) or send us an email.

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