FCEM Guidance

The following guide is now a little outdated, based largely on personal opinion and impressions collated from a few trainees who sat the examination around 2004-2007. Some information is derived from CEM regulations and guidelines - do make sure you read these! There's some information on content, components of the exam, and sample questions. A little advice is based on a talk given at the EMTA 2006 conference by the previous Dean, Pete Driscoll.

Based on hindsight, what has worked for some may not work for all, and some may well disagree with some of the details! One point on which all have agreed - the exam was the most stressful experience of their lives! Do not panic - this is normal.

For the future, there are a number of changes to the current format being considered. This guide will be updated soon.

Content:

"Proficiency will be expected in the clinical management of all conditions that can reasonably be expected to present to an Emergency Department." "The level of competence required for each component of the exam is based upon that expected of a newly appointed consultant in Emergency Medicine. This level is described in the curriculum." "Candidates are advised to use the College Curriculum in preparation for the examination which can be found on the website at www.collemergencymed.ac.uk/CEM/curriculum" Assesses: Behaviours Knowledge Analysis Psycho motor skills Decision making Communication Affect

Application:

>15 weeks before exam Forms online from college Signature required from Regional Chair of Higher Specialist Training Committee 4th year RITA - forms CTR x 3 copies – do it early Need to have already started revision!

When & how to Start:

Think ahead – 12 weeks minimum Download the “FCEM Regulations” – invaluable tool, used by examiners Get a curriculum & past questions/papers - available on college website & from colleagues Textbooks Study groups - usually good to work with others some of the time Practice +++ If possible arrange "mock" exam practice every year, so by the exam you've had four goes The College are providing all STC with 3-5 mock clinical questions so all trainees can get a consistent exposure to centrally derived questions each year The College now has a FCEM revision day course Kick off clinical stuff early, the rest can wait. Practice "on the job" so by the exam it's second nature.

Work/Leave:

Priorities???? Anyone who says you need lots of shopfloor experience leading up to the exam to pass probably needs you on the rota. However, many who fail OSCEs look like they haven't done procedures before, so practice techniques during every shift, and get trainers and peers to observe & critique you. Secondments Annual / Study leave - use it!!

Courses:

Not essential, but very useful Check out the competition Confidence builder Limited SAQ accuracy Good for OSCE and Management viva practice, reminder of exam stress See the Courses & Conferences section of this site

Textbooks:

Clinical: Textbook of adult emergency medicine – Cameron Oxford handbooks – Specialities / GP / Emergency Medicine Clinical medicine handbook – Kumar & Clark ABC of Eyes / Skin / anything else you can think of! Orthopaedics and fractures – McRae ECG made easy Others for reference, BNF, EMJs Self-assessment, ECG and picture books - more the merrier

Critical Appraisal: It is easy to learn to a competent level, but practice is essential Crombie – Pocket guide to Critical Appraisal (London: BMJ Publishing Group)- start with this McGovern – Evidence Based Medicine in General Practice (Oxford: (BSP)- clarifies stuff Greenhalgh - How to read a paper (London: BMJ Publishing Group) – definitive answer Sackett, D. - Evidence based Medicine: how to practice and teach EBM (London: Churchill Livingstone) Have a system: eg OMRAD - see critical appraisal page Do 2 hard papers/week & discuss in groups with others

Management: Best to harrass your trainers to give you practical experience during your training. Go on a course. Documents – download up to date material from NICE / CEM / NLH / DoH stuff. Medicolegal stuff often available from the MDU. Have structured responses to common scenarios, and PRACTICE vivas at every opportunity. Legal problems in emergency medicine – Montague (Oxford:OUP) Medicolegal pocketbook – Machin (Churchill) The medical manager: a practical guide for clinicians - Young, A. (London: BMJ) Wellard’s NHS handbook - The NHS confederation (Wadhurst: JMH publishing) Be aware of recent changes - topical stuff is more likely to come up

2 weeks to go... And you're probably bored senseless – at your limit You can always cover more stuff… Stress now becoming evident Increased OSCE practice / discussion Re-read CTR & papers Critical Appraisal with your eyes shut Mock management scenarios

There will be no compensation between any parts of any section, or between sections

Components of the Examination:
Exam spread out over 3-4 days
Section A
1) Critical appraisal		Recently published paper (without the abstract / summary / limitations of study sections) to appraise for one hour before a discussion of its content.  In the viva the examiners will start by asking the candidate to present an abstract/ overview of the paper. After approximately 2-3 minutes (uninterrupted) they will then go through the article in a systematic way, asking specific questions, and finish by enquiring about the candidate’s overall impression There is a systematic marking method, which you should bear in mind to ensure you maximise your marks:
Below standard Standard Above standard Mark Introduction No identification of message or aims  (0) Repeats aims of study (1) Summarises aims in own words and mentions relevance to A&E (2)   Method Simply recalls method, no attempt to evaluate appropriateness of study design (0) Names the type of study, comments on study design, appropriateness, identifies potential flaws e.g. case selection where present (2) Clear understanding of type of study and appropriateness, identifies errors where present and suggests ways to overcome (4)   Results & conclusions Identifies conclusions and is simply able to agree or disagree. No comments on references (0) Good critique of conclusions but no suggestions to improve or additional studies needed. Comments on references and identifies if out of date without prompting (2) Constructive & realistic suggestions for improvement and able to argue any author misinterpretation, able to discuss relevance to UK EM practice (4)   Summary of paper Long winded summary, repeats phrases (0) Good summary with some original interpretation (2) Summary brief. Has all relevant aspects of abstract (4)   Presentation and layout of the paper No comment on presentation (0) Comments on presentation but no suggestions for improvement if needed (1) Appropriate comments and good suggestions for improvement if necessary (2)   Overall Appears novice (0) Completes task (1) Clearly able to complete task with ease (2)         Total /18 "Identification of potential weaknesses in the work should be supported by suggestions as to how the paper might be improved.  Some broad general knowledge of statistics will be expected, but a detailed knowledge of specific tests is not required"
The papers are likely to be either : Theraputic RCT Diagnostic comparison to a gold standard The aim is: summarise a paper succinctly (abstract) have a structure for appraising papers - see below have an opinion on how this would apply to you and your practice as an A&E consultant know key definitions (ARR, NNT, Sensitivity, Specificity, PPV, NPV, LRs, CI, SpPin, SnNout, OR) general understanding of a few other things (i.e. stats)
2) CTR Viva   The written content of the CTR represents 40% of marks The viva is 60% of marks Candidate should bring his or her copy of the review with them into the examination.		15 minutes – immediately following the review of published work CTR should be fine. Standard should be at the level of an article which could be published in the EMJ, employing appraisal at the level of review of an article for the EMJ Know your stuff backwards. Check the day before for new research published on your chosen topic - examiners will look up references and read papers you have (or haven't!) referenced "Opportunity for the candidate to demonstrate their mastery of the topic, the literature, its relevance to clinical practice and the ability to write a pithy but comprehensible report. He or she is expected to be able to defend the review and the recommendations that come from it." "CTR should include evidence of deductive thought and not be restricted to a presentation of established opinion. Organisational aspects of patient care may be reviewed but questioning should chiefly impact on clinical practice.  Experimental work is not essential but will often have been undertaken ." For advice on choosing topics, researching & writing a CTR, see the page on this website - CTR Guidance
Section B
Management Viva   5 minutes’ preparation time to read through the in-tray papers, organise and prioritise them.  This is then discussed with the examiners for 15 minutes		Standard to the level of a first week consultant with colleagues not available for 24-48 hours (i.e. weekend shift). Management – common sense, logical structured answers and BUZZ words are the key. In-tray exercise. Takes up a disproportionate amount of revision time – documents, legal stuff, NHS structure/procedures The following areas of knowledge & skills are assessed (see regulations): Analytical skills Prioritisation Time management  Medico-legal awareness Communication skills  Handling the media Lateral thinking  Medical ethics Team building  Clinical governance Education  Human resource issues Never be dismissive of a problem, or joke about colleagues / patients Practice doing management exercises in your department. A failing at the moment is people who have book knowledge but no practical experience Light at the end of the tunnel at this point may be a fast approaching train - do not relax until it's over!
Section C
20 SAQs - 2 hours   Structured questions using clinical scenarios accompanied by data. Evaluate the clinical scenario, interpret the data and suggest appropriate diagnosis and management. This examination is taken approximately 4 weeks before the remainder of the examination.		Tough paper Pep-talk before you start Data may include: diagnostic imaging (X-ray and CT), ECGs, pathology results, clinical photographs and other clinical data relevant to patients in the Emergency setting. Expect to do badly on 3 – 4, well on 3 – 4, and ok on the rest Have the "crossword" mentality - quickly do what you can, then come back and fill in gaps First answers count - of 2 marks likely need to give four items for full marks. If you give 8 and the first 4 are not what is wanted - nil points Read the question carefully - for example there's no points for giving O2 if it says pt receiving O2 in the question Need to give detail - drugs with doses & routes of administration. Topics not an issue, but questions occasionally obtuse / unexpected Lots of repetition / crossover from MCEM Lots of lists: Lists of stuff are easier to write questions for - MRCP - develop ways of remembering them Watch the clock - time allowed has been increased but can still catch people out Inevitable post-mortem afterwards = worry, dropped marks & panic - Don't do it to yourself!
16 OSCEs   A 16 station objective structured clinical examination will use patients, and /or actors simulating patients, and manikins for scenario and practical procedure assessment 3 practical procedure stations 2 ALS / ATLS / APLS scenarios (the 16 minute stations) 4 clinical evaluation stations 2 "difficult case" station 3 communication stations – one from each of the following general categories: Breaking bad news Dealing with confrontation or conflict Teaching a junior doctor.		14 stations of 8 minutes each and 2 stations of 16 minutes each Total time, including two rest stations, is 162 minutes Need to pass a minimum of 12/16 stations to pass, cannot fail more than 2 stations in any section Content of each spelt out in the regulations 20-25% paediatrics Usually totally predictable, "day at the office" Lots of repetition Stress level the highest on this day Be nice no matter what happens Practice = perfect Over in a blur THERE ARE NO "KILLER" OSCEs - even if you eat the baby in the paediatric station, if you pass all the other stations you will still pass overall There is now an additional site on the CEM website showing OSCE mark sheets - examples chosen from include ones which have been notoriously badly done (CVS examination; Gynae exam & history) Standard: To be equal to the best clinician you have ever worked for/ with. Your clinical performance has to be very close to the best you will ever be!
Sample Questions:
Here we have collated a few topics that have arisen in questions from past examinations. No doubt recent candidates could name you many more....
OSCEs   There will be a station reflecting most specialities. i.e. Cardiology Respiratory Gastroenterology Renal/Urology Obs/Gynae Psychiatry Ophthalmology ENT Neurology Orthopaedics Rheumatology Toxicology Endocrine Dermatology Paediatrics Infectious diseases Major Trauma Resuscitation Paeds Resuscitation Organization of Healthcare Ethics     Those not represented in OSCEs will have been represented in the SAQs.		Psychomotor: Cricothyroidotomy Suture child / negotiate with mother Secure ICD Landmarks for ear nerve block and earring removal Communication: Male with dysuria – STD History from four year old limping child Argumentative SpR (RSI in resus) – negotiate solution Psychotic DSH – Psychiatric history/mental state exam & section Patient unhappy with SHO/management Breaking bad news Critique video showing poor sho performance with patient Consent and Gillick principle in under age seeking termination Talk to young person about alcohol intake or regarding asthma medication Teaching Teach about fundscopy or otoscopy to ECP Backslab POP for medical student Clinical: Cranial nerves exam – RAPD, blind left eye Fingertip avulsion injury with bone exposed. Acute LVF in young person due to Myocarditis Blistering rash in elderly PID PV and removal of condom, or PV examination alone Guillain Barre picture Red eye Shingles Fluid resus in a child with diabetes - resus, dehydration and maintenance Pelvic Fracture Young man with haematuria and dysuria Febrile Child Trauma series XRs Pulled elbow Wedge opacity on CXR Collapsed patient with ABG/U&E/FBC/ECG Paediatric resus CVS examination with murmur Left lower abdo pain in female Laceration wrist – examine and diagnose defecit
SAQs		Supracondylar fracture Ossification centres of the elbow with ages at which they appear Laceration radial aspect of wrist in child Equip your ED for paediatric patients Uncooperative child seen alone Tension pnueumothorax Status epilepticus Measles encephalitis Thrombolysis of CVA LBBB with central crushing chest pain Red eye Notifiable diseases Eclampsia Poisoning (name your poison!) NSTEMI Croup Uveitis Trauma/ATLS Hypercalcaemia and ARF (myeloma) PID Collapsed acidotic DM with pneumonia Malaria Blisters / rashes Acute hepatitis Burns
MANAGEMENT VIVA - Intray exercise: prioritize and be prepared to discuss anything! There will be a diary to refer to - use it. Delegate tasks where possible. Assume nothing is trivial enough to go in the bin.		Items you may find in the tray: Medical Director meeting Clinical Director job Letters from anaesthetic dept and SpR re: Sedation Information on terrorist attacks Info on treating OP poisoning Letter requesting data (Caldicott) Letter from orthopaedic clinic Flyer advertising a course / conference There is usually (but not always) a "killer" item - one that clearly needs immediate attention. This may include things like: SHO sent home chest pain – found dead; family, press, coroner, the Trust, police, prosecution, advice, responsibilities, risk, CNST, negligence, liability, meetings Blood transfusion reaction - incompatable group administered by middle grade Complaint letter from members of nursing staff alleging inapproprate sexual advances +/- assault by SHO Previously reliable SpR regularly late, smelling of alcohol, involved in a clinical incident, due on the nightshift.
CRITICAL APPRAISAL VIVA		The following are sample papers that have been used in past examinations: Maisel AS et al. Rapid measurement of B-type natriuretic peptide in the emergency diagnosis of heart failure. NEJM 2002;347:161-7. Download paper Flanagan DEH et al. Computer-assisted venous occlusion plethysmography in the diagnosis of acute deep venous thrombosis. Q J Med 2000;93:277-282 Download paper Mortality and prehospital thrombolysis for acute myocardial infarction. A meta-analysis. Morrison L J et al. JAMA 2000, 283,2686-2692. Heparin plus alteplase compared with heparin alone in patients with submassive pulmonary embolism. Konstantinides S et al. N Eng J Med 2002;347:1143-50. Dexamethasone in adults with bacterial meningitis. Gans J et al. N Eng J Med 2002;347:1549-56. Amiodarone as compared with lidocaine for shock-resistant ventricular fibrillation. Dorian et al NEJM March 2002, 346, 884-890. Use of Whole Blood Rapid Panel Test for Heart-Type Fatty Acid-Binding Protein in Patients with Acute Chest Pain: Comparison with Rapid Troponin T and Myoglobin Tests. Seino Y et al. The A J Med 2003; 115: Noninvasive Ventilation in Cardiogenic Pulmonary Oedema. A Multicenter Randomized Trial. Nava S et al. Am J Respir Crit Care Med 2003;168:1432-1437. Outpatient oral prednisone after Emergency treatment of chronic obstructive pulmonary disease. Aaron et al. NEJM 2003, 348; 2618-25. Delta Creatine Kinase-MB Outperforms Myoglobin at Two Hours During the Emergency Department Identification and Exclusion of Troponin Positive Non-ST-Segment Elevation Acute Coronary Syndromes.  Fesmire F et al ,. Ann Emerg Med 2004; 44:12-19 Prehospital Hypertonic Saline Resuscitation of Patients with Hypotension and Severe Traumatic Brain Injury. A Randomized Controlled Trial. Cooper DJ  et al 2004 American Medical Association.  JAMA 2004; 291 Diagnostic performance of venous lactate on arrival at the Emergency Department for myocardial infarction. Gatien M et al. Academic Emerg Med 2005;12:106-113. Cooper et al. A randomised clinical trial of activated charcoal for the routine management of oral drug overdose Q J Medicine 2005 98 655-660 Soundappen et al. Diagnostic accuracy of surgeon-performed focussed abdominal sonography (FAST) in blunt paediatric trauma. Injury 2005> 36: 970-975 A prospective comparison of supine chest radiography and bedside ultrasound for the diagnosis of traumatic pneumothorax.  Academic Emergency Medicine 2005 12:9 844-84
The regulations recommend the following structured approach to the appraisal of any paper: Introduction Is there a clear overall message?  Were the purposes and aims of the study made clear?  Does the message really matter, in the context of clinical practice? Methodology Describe the methodology in terms of its structure. For example; Is it a Randomised  Controlled Trial, a literature review, a personal series? Comment on subject selection and ethical approval. If appropriate, is the hypothesis clear? What statistical methods were used?  Were they appropriate?  Was randomisation used?  Was a power calculation made? Have all confounding variables been identified? Are there potential errors?  If so they should be discussed. Is it possible to re-run the study based on the description given? Could the study be improved?  If so, how? Presentation Does the text, accompanying figures, charts and diagrams or pictures clearly show the results? Are there any obvious gaps in the data presented?  Have aspects of the study been overlooked? Interpretation What conclusions were reached?  Are the conclusions compatible with the data presented?  Could other conclusions be drawn, based on the same data? Does the article generate further studies, or an alteration in practice? Are the references reasonably up to date and relevant?  How can this be checked? Summary Briefly describe the article’s “take home” message and whether this is valid or not
Top Tips - as Recommended by Pete Driscoll
Read the guidelines Regulations Components Structure Instruction to examiners Mark sheets Past questions Critical appraisal Diagnostics & therapeutic intervention Read EBM literature – have a system Know basic statistics Practice - Trainee group - Past papers Management scenario Check time table - See links Maintain vigilance - don't relax too much Knowledge & communication Affect - be sensible, be nice Experience - get some beforehand! CTR Plan & prepare Complete early on in training & update Personal interest Evidence of deductive thought Checked by experts / trainers Pithy - <3500 words - 40% = written content Practice viva - In april ’06 40 out of 43 passed (93%) Know your stuff! SAQ Past papers Practice interpretation Image ECG Blood results Clinical photo’s – skin Protocols - Learn every single protocol currently used in ED Standard – as good as the best clinician you have every worked with / for In April 06 – 42 from 52 passed the SAQ (81%). Pass mark set at 62% In your 4-5 years training you should see 2 – 3 thousand plain x-rays & 1-2 thousand ECGs OSCE Read instructions – important to identify the part of the history, examination or procedure you have to do Talk through the station - enables the examiner to know what you are thinking Ignore the examiner Timing – if have to give summary examiner will stop you approx 1-2 minutes from end No IT - yet Rest at the rest stations No sudden death Practice makes perfect Individual practice - Clinical - Management - Academic Group practice - with Peers / Trainer Trainee’s role Active learning Deliberate practice on the job Be disc