Exams – what to do, what not to do – and when to do?!

Having recently passed the FRCEM (Primary) – I have yet to decide what my next step is going to be. I start my second year of training in 4 weeks. I had initially planned on a practical approach to training requirements, such as trying to get atleast 1 exam (check!) and 1 course (ALS/ATLS/APLS) per year of training, and though I have not yet done another course (I did my ALS in 2015!) this year and ideally would like to do another course this year – I am getting more and more inclined towards taking the next part of the FRCEM, known as the intermediate part. I am wondering whether that would be a good idea. Everyone I encounter seems to think that is a good way to go. One of my consultants even feels the intermediate might be an easier exam to take than the primary, since it is clinical oriented and has to do with what you deal with on a day to day basis rather than the facts and figures of physiologyanatomymicrobiology and the other basic sciences. So it tends to be easier for someone who is working in an environment that gives them good amount of clinical exposure to day to day EM cases. Thoughts, anyone?

The whole examination schedule is a bit of a confusion at the moment – well, let’s face it, examinations are very confusing anyways, atleast for someone like me. So let me break it down for you, if you were as confused as i was – if you weren’t, good on you and you can move on!

WHAT IT USED TO BE
It used to be a membership exam, which entailed 3 parts and got you a ‘Membership by examination’ of the Royal College of Emergency Medicine, UK (which used to be just the College of Emergency Medicine until about 2014 when it was given the status of a Royal college, in essence converting the MCEM into the MRCEM) – the first part was the written, true or false patterned exam. It dealt with all the basic sciences (physiologyanatomymicrobiology), and the format was 50 questions with 4 parts each (so in essence 200 questions) each with a true/false answer. This was followed by a 2nd part, the MCEM B which was a clinical knowledge exam, also written. And then came the MCEM C, the practical or “multiple stations of interaction, examination, history taking, counselling etc” exam. Pass all three and you gained the membership of the RCEM. This was the prerequisite for someone training, or interested in training, in emergency medicine needed to pass before being considered for a higher training post (the ST4 onwards stint in a ST1-6 training program). After entering ST4, and before the end of ST6 you were required to sit for the FRCEM (used to by the FCEM) exams which were the Fellowship of the RCEM exams – pass the 5 parts of that (yes FIVE! hideous, I know!) and you can move on to a consultant post – a specialist in the field of emergency medicine.

WHAT IT IS NOW:
They are now in somewhat of a transition period. They are starting to phase out the MCEM/MRCEM exams as a requirement for trainees in the UK at least – after 2018 I believe it won’t be a requirement at all. They have now coalesced the MRCEM and the FRCEM exams into one single entity, called the FRCEM exams, which entails three parts. The first part is the basic sciences bit, the equivalent of the MRCEM A, and is called the FRCEM (primary) – *please click here to get to the post about my experience with this exam*   followed by the FRCEM (intermediate), which as I understand consists currently of 1 part, the written clinical oriented short answer questions exam but as of a few months later (autumn 2017) there will be a ‘part 2 of the part 2’ a second component of the Intermediate exam. This bit, called the Situational Judgement Paper or the SJP for short (and for convenience!) is more of a management type exam that is once again a written exam like the SAQ. But I have no idea what else it entails; more on that in a later post! But as it stands right now, the FRCEM intermediate is just the clinical written exam.

I am yet to figure out what is the counterpart of the MRCEM C, the practical bit of the previous set of exams, in this new-fangled exam scenario. I have been told however that you can take the part C exam of the MRCEM and if you are able to do that before August 2018, then you have 2 pluses: you are exempt the SJP (which means its the counterpart of the MRCEM C?) and you get an official membership degree, the MRCEM, in addition to the FRCEM degree when you complete it.

The third and final part of the FRCEM exams is the FRCEM (final) which is basically what the original FCEM exam used to be – with a slightly different format/ and 1 or 2 parts either exchanged to something else or dropped completely from the list.

As I understand, you need the FRCEM  primary and intermediate before you can be considered eligible to progress from ST3 to ST4 as an EM trainee. The rest you can complete thereafter. You have 6 attempts at each part, previous attempts at their counterparts do not count – so if you have attempted and failed the MCEM A, those failed attempts won’t count when you attempt the FRCEM primary, it will be a clean slate that you start off with. If you fail a 6th time, and can explain away the reason for failing as a genuine distraction/trigger for failing – the college does consider and may allow you to take the exam a 7th time but that is to their discretion and is dealt with on a case by case basis. You are also allowed an extension of 6 months of your rotation, from ST3 – to allow you to pass the exam and move to the 4th year of training.

Non-trainees or doctors not working in the UK can still choose to obtain the MRCEM by examination, and take parts A, B and C of the MRCEM; it carries weightage in India, Pakistan, Sri lanka (not sure) and UAE/Dubai/Middle East. If you are in a UK based training program in emergency medicine you automatically become a member of the RCEM by association – so the MRCEM is now technically obsolete. It is still a good exam to have on board, a great feather in the cap.

I am just beginning my journey in the EM training field so my experience with the rest of these exams is minimal. I will update this post as and when I prepare/take the other exams, and/or find out more knowledge/updates about the various parts/schedules/content. Or it may be in a later post, the link of which I would put up here. Till then, I sincerely hope I have not confused you further!

FRCEM (Primary) – Done and dusted!

So I am happy to report that the results of the recent FRCEM (primary) exam were announced this evening – and I am proud (read ecstatic!) to share that I passed it! *takes a bow* (if you are interested in questions from the exam, read about that in a separate post here)

This is why I have been slightly out of the blogging scene for the past few weeks – prepping for the exam, juggling the ARCP for my first year of training and what has been very likely the hardest and longest and hottest summer stretch I have ever endured (and I am from Pakistan!) But I am back with the proverbial bang!

And I bring with it the novelty of experience.

It’s not a difficult exam per se – but it is an exam that requires commitment, and time and energy. Be ready to make that commitment. It’s a new exam, only started in Autumn 2016 I believe.

Back in the good old days when I was a (very) junior doctor back home in Pakistan, I had the luxury of having ‘many’ weeks off in lieu of exam prep – the job itself was intense but i had no other commitments; i.e training, portfolio, assessments, ARCP, etc. For this exam, I was working in your regular, run-of-the-mill A&E department in the UK, as a 1st year trainee. I decided to take the exam, decision was taken in January, I booked an online question database then, and I booked the exam in mid February, but I didn’t really get a good momentum going initially, and was still in 2 minds. Why? Because of the ARCP which is an assessment of all your competencies for a required year of training that you have managed to accumulate over the period of the past year, and a panel of judges basically sits and decides whether your performance (based on these signed competencies) is good enough to warrant your progression to the next stage/year of training. So this year was to be my first ever ARCP and coincidentally the exam fell on the exact same date as the ARCP, so in addition to the preparation of the exam, I had to focus on my assessments/requirements for ARCP – all to be juggled along side a full time job in the A&E as one of the juniors. It is doable folks.

So in bits and bobs I started my prep. I had that textbook of emergency medicine, but I must admit I never got beyond the first 5-7 pages of it! Doing the questions from the question bank is what helped me pass along with (as I said) youtube videos. I took a 4 month subscription for the FRCEM exam prep website – previously known as MCEM exam prep website. (‘tom-aye-to, tom-aah-to’). They have a good database of questions fortunately of the SBAQ type as well as the older true/false format. I have ready in many places that you could use any of the other websites/question banks as well.

On my days off, I aimed to do 50-100 question (see, I made you laugh there!) Who am I kidding, I barely got 30 done on a good day – these questions came with explanations, why this option is right, and why the others are wrong, along with a short description of the topic that the question deals with. I inevitably began making a habit of taking pictures of the explanations in my cellphone, and I went back to them again and again, for example before going to bed, or while waiting for my wife/son to wake up in the morning on my rare days off. I found this habit helpful, as you may not retain some of the information that you read, but if you go back and go through it again, or atleast if not all of it, then maybe just the major salient points, it is bound to stick to you.

On my days where I was working, I tried doing a few questions while at work, on my phone, between patient. That was a bad idea. Not only did I not have enough time to do even a single question justice – I also did not retain too much due to the lack of concentration in a busy A&E department. Ditched that idea fast. I did however vow not to waste any of the days I was working though, so after a busy shift, I used to come back, rest, recuperate or sleep (mostly slept) thanks to my wife who really upped her support game and banished me to a separate room in the house at all hours of day or night, waking or asleep – no diaper duty, no bath time no sleep time with the baby – just the books, fooding and my laptop. Where was I? Yes – days I was working, depending on what shift I had done, I still tried to get a good solid 3 plus hours of ‘mcqsing’ as I called it. On days that I was on morning shifts, I came home by 5 pm, straight to bed, slept for an hour and a half or 2 – woke up – tea/food/family time for an hour or 2 and then hitting the books (or laptop in this case) from 10 pm onwards up until 2-3 am – then 5+ hours of sleep and a repeat of this. Or on the afternoon shifts (2pm/4pm to 10 pm or midnight) similarly I used to come back home, freshen up, spend a minuscule amount of time with the family before they dropped off to sleep and then ‘mcqsed’ till the wee hours of morning, going to bed at 5 am or thereabouts, to wake up just in time for lunch and off to work. Night shifts were a bit more difficult, and I sort of gave up on trying to cram anything in my head during the 4-5 night stretch we have – the hangover like state I was in during the night shift stint was not really amenable for any further insult to the brain by forcing it to swallow any other bits of information/mcqs.

I also youtubed a lot of videos – specially anatomy ones, and one or two for physiology and microbiology. There are a lot of good ones out there. I focussed on upper and lower limb anatomy the most, along with the plexuses. You can just search for them under ‘anatomy, mcem or mrcem’.

My strategy towards the middle/end of my prep was to focus mostly on the maximum yield subjects – broadly anatomy and physiology which carried the most weightage in the actual exam, with 60 questions from each subject (out of a total of 180 questions!) Followed by significant input from microbiology/pharmacology/pathology. I used to do 3 sets of 20 questions in a row – the first set being anatomy, second physiology and the 3rd annoys the others, but I kept the first two sets the same, due to its weightage. Anatomy threw me, as it was basically learning a new something I had learnt almost 13-14 years back in the early medical school years! I think it was safe to say I had forgotten most of it, despite having a refresher course during my stint at the USMLE exams. But I digress. I found the following topics high yield, and got an inkling from my various forays into the question banks that these were important enough to be tested and warranted more attention (or repetitive attention) from my end.

ANATOMY

– Upper limb (muscles -attachments and function, nerves, bones, blood vessels) -Lower limb (Same as above) – brachial plexus – abdominal wall layers – blood supply of the heart – borders of the heart – contents of spermatic cord/inguinal canal – Sacral plexus – Optic nerve lesions – cranial nerve basics – triangles of the neck – foramina of the skull and their contents – diaphragmatic openings – Facial nerve – spinal cord lesions based on presentation – stuff going on at T4 level – brain blood supply

PHYSIOLOGY

Lung volumes – cardiac cycle – hormones (renin, angiotensin, mineralocorticoid, cortisol, adrenal medulla, pancreas, PTH, calcitonin, Vit D and its metabolytes) – renal physiology – 

MISCELANEOUS 

Vaccination program – Drugs that induce/inhibit cytochrome p450 – broad microbiology – allergic/hypersensitivity reaction types – types/examples of vaccines – immunoglobulin types – 

I also attended a course arranged very kindly by our deanery for candidates interested in the FRCEM primary. It was purported to be a tough exam, as the previous attempt had had a passing percentage of 43 percent. Yes, only 43 % of the candidates who appeared for the previous attempt passed. We gulped down our fears, and while the course gave us a broad idea of what wee needed to be doing (which was a lot!) it served no greater purpose than to tell us that we were not alone in being scared and that everyone seemed to be equally stumped by their performance in the questions – slightly reassured by the fact that during practise mcq sessions, when the consultants tried to solve the questions they were mostly unable to. Slightly reassuring, and mostly horrifying, as how were we supposed to pass the exam?! Yikes. What threw most people was that the exam format had been changed – from the previous true or false format, to the  Single Best Answer Question or SBAQ format. All options in a given question may be correct in different ways, but select the answer which is most appropriate according to the stem. Which basically translates to “guess what the examiner was thinking when he/she made this question” – so no pressure!

By the last few weeks, I was about to pull my hair out – the amount of mcps I was doing wasn’t too much, and I didn’t seem to be ding all that well if you calculated the number of questions I was getting right – overall a 52-55 percent of correct answers. Abysmal. I did not let that disappoint me, however, knowing full well that practicing questions was the way to go in such an exam format.

I used up all of my 2 weeks of annual leave and 3 out of 5 days of study leave for this exam, which brought me to just about 20 days of uninterrupted preparation (coupled with MANY visits to the department for ARCP related issues). That I feel was the single best thing in way of preparation – the time off was focussed, and I wasn’t tired from running around – preparation is mentally exhausting as it is, coupled with the physical exhaustion of day-to-day ED life – it takes a toll. All I did was sleep, eat and study. Lather, rinse, repeat.

But I will reiterate here what I have said before as well – you can never do enough questions as practise – just keep doing as much as you can, every waking minute make sure you are doing questions. Whether its 5 or 50 questions, make sure you stay consistent and do not get laid-back and forget to do questions – keep doing them, whether right or wrong, as long as you are also focusing on the explanations of those questions, its a learning experience.

Advice about the exam itself: Time management – 180 questions, 3 hours. The way I did it was divided it into 3 parts, so I needed to have completed 60 questions in 1 hour, and preferably even faster than that, since I needed to allow some time at the end to go back and tackle the more difficult or confusing questions. Keep track of time as well – if you seem to initially be on track, keep checking the clock every 10-15 minutes and make sure you are on track. If you feel you need to think more than 20 seconds for an answer and are still unable to do so, then mark the question and move on, return to it later. Do not waste minutes on a single question, causing a delay and jeapardising multiple other questions. Read the stem carefully – often we do not read the ‘except’ ‘all’ which’ ‘most appropriate’ next step’ gold standard’ ‘not included’ bits of the stem and inadvertently end up selecting the wrong option. In case of long stems, read the last bit/question and the skim over the rest of the stem, to gauge what they are looking for. If you don’t know the answer, go through the options by the process of elimination. Eliminate the blatantly wrong options. Think about the rest, if possible eliminate another 1 or 2 till you are left with one. If you read the stem and know the answer, look for that in the options, if you see it, select that. Always attempt all questions, no use leaving a question blank and lose an opportunity of a lucky guess. Feel free to draw, make flowcharts, write things down in the margins of the question paper if it helps you remember, calculate, reach a conclusion (I remember I drew the whole optic nerve/tract/radiation diagram to help me diagnose where a lesion was based on the hemianopia referred to in the question paper!) The questions may be easier than your practise question bank – don’t worry!

And I had the support of good friends. I don’t know, there is something about prepping for an exam (or anything in life for that matter!) and knowing that there is someone else going through the exact same thing as I am – it creates an interestingly unique bond. I had 2 such colleagues and friends, and I am pleased (and incredibly proud) that they have passed as well. We used to work together in the same ED department back home in Pakistan, and are now in different parts of the UK pursuing careers in emergency medicine. Onwards and upwards!

An interesting lump, courtesy of Warfarin – a dilemma in clinical management

59 Year old female came in to ED due to a painful lump that she had noticed overnight in the right side of her abdomen, associated with pain in the right half of her abdomen, back and upper part of her hip. This was the vague and slightly confusing history on the card as I went to review her. She was a very pleasant lady, who walked into the cubicle without assistance, no support required – and clearly no hip pain?

She reported she had had a cough x 6 weeks – not continuous, but had had a chest infection initially, and was still recovering from that about 3 weeks back when she began to have productive cough and fevers again – and had to complete a second lot of antibiotics, the last of which finished yesterday. She still had bouts of cough though, even though it had improved considerably – one of which had happened last night just as she was going to bed. She couldn’t sleep all night due to the continuous coughing, but this wasn’t the reason why she was here that morning. She woke up in the morning feeling quite sore in her upper abdomen, and put that down to her constant coughing. She tried to ignore it, and took some paracetamol, but as she tried to dress herself, she felt that she required help with undressing and dressing, which was a concern. To top it off, she also noticed in the shower that morning that she had a palpable tender lump under her ribs, in the upper part of her abdomen on the right side. This concerned her enough to come to the hospital. Oh, and she was on warfarin – that lovely blood thinning medication that’s given for clots in the lungs or in the legs, or if you have a heart rhythm disturbance that makes you prone to throw clots to your brain – for recurrent PEs (clots on the lung) and her last INR was 2.6 (a test to see if the warfarin is doing what it is supposed to be doing, and whether it was doing more or less than it was supposed to be doing – recommended range for her condition was between 2.5-3.5)

When I examined her there appeared to be no bruising to the area in question, and her abdomen was soft, though there was definitely a palpable tender firm swelling in the right upper quadrant, sort of jutting out of the lateral aspect of her liver – my thoughts immediately went to a spontaneous hepatoma/bleed into her liver because of her being on the warfarin – I quickly ticked off in my mind a checklist of things that would signify severe ongoing bleeding internally, like pulse and blood pressure (both within normal ranges for her) and she appeared nice and ‘hemoglobin-y’ – adequately perfused! I decided to request a quick ECG (which was normal sinus rhythm) and did some baseline bloods on her including a clotting screen (to check her haemoglobin and INR today – both were normal, though a slightly raised white cell count and CRP) as well as a chest x-ray (I felt there were two reasons for this: 1) cough for 6 weeks gradually worsening, warranted radiographic evidence and 2) in someone presenting with tenderness of right upper quadrant, it is very relevant to be thinking about problems with the lower part of the lung above, rather than just focussing on the abdominal complaint – she may well have a pneumonia sitting in her right lung base, causing pain in her right upper quadrant! In this case, however there was nothing nasty on the chest x-ray on the right, though you could argue the left lung base looked slightly more hazy than I would have liked; at any rate, she needed treatment for an LRTI)

I spoke to my consultant, who quickly magicked an ultrasound machine within the ED and did what is called a ‘FAST’ scan, an ultrasound to quickly rule out free fluid within the abdominal cavity, usually done for patients of abdominal trauma to look for bleeding, etc. The scan was negative for free fluid within the abdominal cavity (we both breathed sighs of relief!), however we did find what seemed to be a collection of blood within the abdominal wall in the area of pain – she seemed to have bled into her abdominal wall, probably due to the coughing, which caused a tear within the muscle wall, and due to her being on the warfarin, caused her to bleed internally but contained within the wall of the abdomen – causing her presentation of a tender painful lump in her abdomen. Mystery solved. Now to the management of said mystery.

The dilemma we faced was this: We couldn’t stop her Warfarin due to the indication for which she was taking it in the first place – it could prove fatal if she had a clot on the lungs again. We couldn’t just leave her bleeding on the warfarin and do nothing. We needed to treat her cough as well, because even if it wasn’t life-threatening at this point, if she went on coughing, who knew how much worse this bleeding might get? And we had limited treatment options for her cough-slash-chest-infection, because many drugs including some antibiotics interfere with the action of warfarin, and the patient was allergic to penicillin (of course, we wouldn’t want this to be too easy!)

So we requested a formal ultrasound from the radiology department – much more detailed than our very ‘FAST’ scan. They agreed with our preliminary findings, with the very valuable additional information that there seemed to be no evidence of ongoing bleeding – the hematoma was contained and was not likely to worsen. Her INR was within the limits appropriate for her, maybe slightly on the higher side, so we decided to advise her to skip the next dose of her warfarin, and to liaise with the anticoagulant monitoring service to monitor her INR in the next few days to make sure it was still within the prescribed limits for her. We sent a sample of her sputum for culture and sensitivity, and based on the haziness in the left lung base and the raised inflammatory markers (CRP and white cells) we decided to start her on some antibiotics – she was allergic to penicillin, and so the next best option was clarithromycin which unfortunately interacted with warfarin so we couldn’t go down that route; we decided on doxycycline being the best line of treatment for her. We explained to her any of the red flag signs, if she experienced any concerning symptoms, to come straight back for review. We advised some analgesia, and some cough medication as well, and the patient was very happy to go home. Fingers crossed, she has neither returned nor have I heard of any problems coming to light following her ED visit.

This served as a learning experience for me – coming to a diagnosis in this case when the presentation was completely different from what was actually going on, and then connecting all the dots in the history (warfarin, chronic cough) and the physical examination (presence of a tender palpable lump in the absence of trauma) and ultimately finding out the mystery of the sudden lump, and then reaching a management plan that should have been so easy and straightforward, but really wasn’t due to the patient’s unique situation.

To X-ray or not to X-ray – that is the question, but what is the answer?

Guidelines and protocols are in place for a reason. Based on years and years of experience and collated data and individual opinions of specialists etc, these guidelines are set up to aid the budding EM physician. They are not absolute though, as I learnt the hard way (a most unenjoyable way to learn!)

56 year old female, otherwise fit and well, comes in to ED one fine morning around 7am. I was part of the night team, counting the minutes down to when the day team will arrive and I will be able to go home. I was asked by the registrar to see this patient who had turned up to be assessed in the first assessment bay; she was at that time the only patient waiting to be seen (a rare occurrence in ED). I went into the makeshift cubicle (which basically meant drew the curtains around myself and the patient’s bed) introduced myself and asked her what brought her to ED that morning. She reported she had an ongoing pain in her left ankle, that she had been to her GP for. Twice. When I asked her when it first began, I was quite disappointed to find out this had been going on for a few weeks (3 I think she said!) She had been to her GP who had told her on two separate occasions that this seemed like soft tissue injury, and she was advised pain killers. She came in today because she felt she was not improving. She was into hiking and jogging and was a very fit 60 year old. The concern for her was she was unable to pursue her rigorous exercise routines due to this pain. She denied any direct trauma to the affected limb, and reported no swelling or bruising. No previous history of any joint problems (no prior medical history, actually!) and she examined very well: no bony tenderness to medial or lateral malleolus (the inner and outer parts of the ankle); she was able to put weight on it, as evidenced by the fact that she had walked into the department of her own accord without any support (and without a limp!); she had full range of motion except some difficulty in everting her foot, which reproduced the pain. There were no wounds or bruises or swellings, and full power and normal reflexes ended my examination, along with palpable pulses, good capillary refill distally and no neurological deficit. I advised her to continue taking pain relief and to seek a physiotherapist because she may have injured her muscles or a tendon/ligament and may require some specific exercises. She then suggested I x-ray it, and I explained to her why I thought it didn’t warrant an x-ray. She seemed a little less convinced but did not argue, and I sent her home. I documented everything, and thought that was the end of that.

I was called by one of my consultants a few days or weeks later, informing me that I had had a letter of complaint against me. It transpired that eventually when the pain had not gotten better over the next 10 days, despite having been seen by physiotherapy as well, the patient went private and got an x-ray done, which revealed (or so I am told) a stress fracture of the distal end of the fibula! A stress fracture! Of the fibula! The fibula is one of two long bones forming the lower part of your leg. I had never actually in my not-so-many-years of experience heard of a stress fracture involving the fibula.

My consultant was very supportive about it. She had gone through my documentation, and was quite satisfied with the plan I had made for the patient based on my assessment at that time. She agreed that based on that assessment there was no indication for the x-ray. But she taught me a few things about stress fractures that I did not know; that they are more common in the metatarsals than in the fibular end, but that in view of her age, I should have considered the possibility that she might have been osteoporotic and would be prone to fractures without any significant trauma, a detail that I had failed to factor in in my assessment of her. The experience taught me so much about how I need to remain humble in this profession that I decided to do a reflective note on it at the time and added it to my portfolio.

What have I learnt? I have a lower threshold for stress fractures in older patients, despite having no findings on examination/history suggestive of bony injury. I intend to read up on stress fractures and increase my knowledge base on the topic (and maybe blog about it in a later post!). I still intend to continue fully taking a history and doing a proper detailed examination of a patient, and then using my clinical judgement in order to decide on a plan of management for a patient.

You never know when your well-intentioned actions may be the wrong way to go, regardless of whether or not they work for the other hundreds of similar cases. So never get cocky, never get complacent, always be humble, and always, always DOCUMENT!