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FCEM Guidance




 

 

FCEM


The information below is written by previous trainees who have passed FCEM and is designed to supplement the content of the main College site (https://secure.collemergencymed.ac.uk/Training-Exams/Exams/FCEM/default.asp) so please ensure you read this for up-to-date regulations and advice.  (Updated 09 July 2011)

CONTENT

  • "Proficiency will be expected in the clinical management of all conditions that can reasonably be expetcted 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 https://secure.collemergencymed.ac.uk/Training-Exams/Curriculum/Curriculum%20from%20August%202010/default.asp 

APPLYING FOR THE EXAM

WHEN AND HOW TO START

  • Plan ahead: you need to start revision before you submit your application
  • Read all of the FCEM information on the College website, including the "FCEM Regulations" (see 'documents' section above)
  • Read the curriculum and plan your revision around this
  • Get hold of past papers: there are some available on the College website, or from senior colleagues
  • Some textbooks are recommended below
  • Practise, in groups as well as alone
  • Ask your seniors for practice sessions and get them to observe and feed back to you during your shifts
  • If possible, arrange mock exams throughout higher specialist training so that you have had plenty of exposure when the time comes.  Some deaneries routinely arrange this as part of their teaching programme
  • A number of FCEM revision courses are run at different venues - see the 'Courses' section of the main College and EMTA sites

WORK AND LEAVE

  • Prioritise and try and balance bookwork with shopfloor experience
  • Use secondments where available, particularly for practical procedures
  • Use annual leave and study leave as much as possible

COURSES

BOOKS AND OTHER RESOURCES

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.  See the Courses section of this website for more formal teaching (including web-based training) on critical appraisal.  There is some additional advice on the main College site (https://secure.collemergencymed.ac.uk/Training-Exams/Exams/FCEM/default.asp)

  • Crombie – Pocket guide to Critical Appraisal (London: BMJ Publishing Group)
  • McGovern – Evidence Based Medicine in General Practice (Oxford: (BSP)
  • Greenhalgh - How to read a paper (London: BMJ Publishing Group)
  • Sackett, D. - Evidence based Medicine: how to practice and teach EBM (London: Churchill Livingstone)

Management:

Make sure that your trainers give you as much practical experience as possible during your training.  There are several courses run by the BMA and others (see the Courses section).  Download as much relevant and up-to-date material as possible from NICE, the College, DoH, etc and browse the medicolegal websites such as MDU. 

Make sure you have a structured response to all of the common scenarios and practise at every opportunity.  Recent, topical issues are likely to be raised so keep abreast of these.

See this article in BMJ careers regarding management portfolios for EM trainees http://careers.bmj.com/careers/advice/view-article.html?id=20003682&q=w_bmj

Some useful textbooks are:

  • Legal problems in Emergency Medicine - Montague (OUP)
  • Medicolegal Pocketbook - Machin (Churchill)
  • The medical manager - a practical guide for clinicians - Young, A (BMJ)

COMPONENTS OF THE FCEM EXAM

The exam is divided into three sections: the format is detailed fully in the 'Regulations' - see documents section above.

SECTION A - Academic

This consists of a 90-minute SAQ critical appraisal paper and a 15-minute viva on the CTR (critical topic review) that the candidate has prepared and submitted in advance.

The SAQ paper will usually involve an article on either a clinical RCT or a diagnostic tool versus a gold standard.  Make sure that you are familiar with basic statistical terms, definitions and tests.  You need to have a structured approach to critical appraisal and to be able to discuss how the findings could be translated to your work as an ED consultant.

Previous papers that have been used include:

  • Maisel AS et al. Rapid measurement of B-type natriuretic peptide in the emergency diagnosis of heart failure. NEJM 2002;347:161-7
  • Flanagan DEH et al. Computer-assisted venous occlusion plethysmography in the diagnosis of acute deep venous thrombosis. Q J Med 2000;93:277-282
  • 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; 2618-25Delta 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 following structured approach can be useful:

Introduction

  • Is there a clear overall message?
  • Were the purposes/aims made clear?
  • Does the message really matter in the context of clinical practice?

Methodology

  • Describe the methodology
  • Comment on subject selection/ethical approval
  • If appropriate, is the hypothesis clear?
  • What statistical methods were used, were they appropriate, was randomisation applied, was a power calculation made?
  • Have all confounding variables been identified?
  • Are there potential errors (discuss if so)?
  • Is it possible to repeat the study based on the description given?  Could it be improved?  If so, how?

Presentation

  • Does the text plus accompanying figures, charts, 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 and are they appropriate?  Could any other conclusions be drawn from the data?
  • Does the article generate further studies, or an alteration in practice?
  • Are the references reasonably up to date and relevant?  Can this be checked?

Summary

  • Briefly describe the main conclusion and whether or not this is valid.

The CTR viva must be prepared for thoroughly.  Aim to produce a piece of work that would be suitable for EMJ publication.  Make sure you know the topic inside-out and back-to-front and do a last-minute literature search the day before your viva to see if any new literature has emerged.  The examiners will have researched your topic thoroughly and will know what you have and haven't considered.  Again, make sure you have an opinion about how the findings should translate to clinical practice. 

There is more information on the CTR at https://secure.collemergencymed.ac.uk/Training-Exams/EMTA/Academic%20Guidelines/CTR%20Guidance/default.asp.

SECTION B - Management

This consists of a five-minute preparation slot and two fifteen-minute vivas.  The standard expected is of a new consultant working independently when colleagues are not available for 24-48 hours (e.g. a weekend on call). 

There is a degree of common sense and logic involved but it is important to familiarise yourself with buzz words and spend time reading relevant documents.  The Regulations detail the areas assessed but these include analytical skills, ability to prioritise, time management skills, medico-legal awareness, communication skills, handling the media, lateral thinking, medical ethics, team-building, clinical governance, medical education and human resources issues. 

In the management viva, never be dismissive of a problem or joke about colleagues or patients.  Practise management exercises at work whereever possible.  See this article in the BMJ about the CEM management portfolio http://careers.bmj.com/careers/advice/view-article.html?id=20003682&q=w_bmj

Your in-tray may include the following items (there will also be a diary to refer to): medical director meeting, clinical director job, letter from anaesthetic department regarding sedation, information on terrorist attacks, information on OP poisoning, letter requesting data, letter from orthopaedic clinic, flyer advertising course/conference, etc.  There is usually (but not always) one item that clearly needs immediate attention, e.g. a patient who has been sent home and subsequently died, blood transfusion reaction, complaint from nursing staff about a junior doctor etc. 

Delegate tasks where possible and assume that nothing is trivial enough to go in the bin.

SECTION C - Clinical

This consists of a two and a half hour SAQ paper (20 questions) and an OSCE (16 stations, each eight minutes).  N.B. Both of these must be passed at the same sitting. 

The SAQ paper is hard.  As with MCEM, it is pressured for time and it is best to answer what you can immediately and then go back and fill in the gaps.  There is some repetition/crossover with MCEM so you can use these past papers for practice.  Remember that the first answers count so there is no point listing more things than requested.  Answers are generally best given as lists/bullet points rather than prose.  Make sure you read the question carefully and give details (e.g. name of drug plus dose plus route of administration). 

Previous SAQ topics include the following: supracondylar fracture, elbow ossification centres, radial wrist laceration, ED paediatric equipment, uncooperative child, tension pneumothorax, status epilepticus, measles encephalitis, stroke thrombolysis, LBBB and chest pain, red eye, notifiable diseases, eclampsia, poisoning, NSTEMI, croup, uveiitis, trauma, hypercalcaemia with acute renal failure (myeloma), PID, DKA and sepsis, malaria, blisters/rashes, burns and acute hepatitis. 

The details of the OSCE are laid out in the Regulations and, as with MCEM, the OSCE generally replicates a 'day at the office'.  There are always a mixture of ALS/ATLS/APLS scenarios, practical procedures, communication skills, teaching, etc.

Previous OSCE topics include the following:

  • Practical (psychomotor) - cricothyroidotomy, suturing a child and negotiating with the mother, insert/secure a chest drain, discuss the land marks for a greater auricular nerve block for an earring removal
  • Communication - STD in a male with dysuria, a history from a four-year-old with a limp, an argumentative SpR in resus over an RSI, psychiatric history, risk assessment and section in a psychotic patient with DSH, a patient who is unhappy with SHO management, breaking bad news, critique a video with an SHO performing poorly, consent and assessment of Gillick competence, talking to young people about asthma management or alcohol
  • Teaching - e.g. backslab POP or otoscopy, fundoscopy, etc.
  • Clinical - cranial nerve exam, fingertip avulsion, acute LVF in young person (myocarditis), a blistering rash in the elderly, PID, PV exam +/- removal of FB, Guillain-Barre, red eye, shingles, paediatric DKA (fluid management etc), pelvic fracture, febrile child, haematuria in young man, trauma series X-rays, pulled elbow, wedge-shaped opacity on a CXR, collapsed adult, paediatric resuscitation, CVS examination with murmur, LIF pain in female, wrist laceration with neurovascular injury,

Remember that the SAQ and OSCE exams have to cover as much of the curriculum as possible, so if there is a major section that is not covered in the SAQ paper it is more likely than not to appear in the OSCE.

AND FINALLY....

Top tips from Peter 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
Practise - 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
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