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.emergencymed.org.uk/CEM/curriculum"
• Assesses:

  Behaviours
  Knowledge
  Analysis
  Psycho motor skills
  Decision making
  Communication
  Affect

Application:

• >15 weeks before exam
• Forms from Intercollegiate Speciality Board � phone them
• Signature required from Regional Chair of Higher Specialist Training Committee
• 4th year RITA - forms
• CTR x 3 copies � do it early - like 1st / 2nd year of training
• Log Book - ?even needed
• CV
• Good marker for starting 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 - same place - No clinical exam has been done with entirely new questions
  
• MFAEM
• Textbooks
• Study groups
• 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

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:

• Essential
• 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 / Emeregncy Medicine
• Clinical medicine handbook � Kumar & Clark
• ABC of Eyes / Skin
• 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

Also:

• Sackett, D. - Evidence based Medicine: how to practice and teach EBM (London: Churchill Livingstone)
  

Have a system: IMPISO / OMRAD / VIAD - see research page
Do 2 hard papers/week & discuss in groups with others

Management:

Go on a course
Documents � see Management page on this site - be familiar with relevant FAEM and DoH stuff.
Have structured responses to common scenarios, and PRACTICE vivas at every opportunity.

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 eyes shut
• Mock management scenarios

• Candidates will therefore either pass or fail, with no �grades� of pass or fail.

Components of the Examination: 

Section A

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:

"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 :

1. Theraputic RCT
2. 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.

Standard:

CTR at the level of an article which could be published in the EMJ

Appraisal at the level of review of an article for the EMJ

• 15 minutes � immediately following the review of published work
• CTR should be fine
• 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

Practice doing management exercises in your department. A failing at the moment is people who have book knowledge but no practical experience
 

Standard:

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
• 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 6 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 sometimes obtuse / unexpected
• Lots of repetition / crossover from MFAEM
• Lots of lists: Lists of stuff are easier to write questions for - MRCP - develop ways of remembering them
  
• Start at the back � question 1 will be a nightmare. This is not a deliberate ploy but seems to be a common thread in past exams
  
• Watch the clock - time allowed has been increased but can still catch people out
  
• Inevitable post-mortem afterwards = worry, dropped marks & panic

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
• 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

Sample Questions:

 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 12:9 844-849

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

1. Read the guidelines

   Regulations
   Components
   Structure
   Instruction to examiners
   Mark sheets
   Past questions

2. Critical appraisal

   Diagnostics & therapeutic intervention
   Read EBM literature � have a system
   Know basic statistics
   Practice - Trainee group - Past papers

3. 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!

4. 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!

5. 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

6. 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

7. Practice makes perfect
   

   Individual practice
   - Clinical
   - Management
   - Academic
   Group practice - with Peers / Trainer

8. Trainee�s role
   

Active learning
Deliberate practice on the job
Be disc