Fellowship exam advice
At the end of the day, the advice that you hear time and time again from supervisors of training and helpful consultants is actually true.
The exam is a clinical exam, so the more time you spend seeing patients in your unit, the better. Lots of successful candidates often comment that the cases that they got in their written, viva or clinical sections were similar to patients that they saw in the previous few weeks. There is no doubt that reading the textbooks and a few other sources is a major aspect of preparation, but don’t get sucked into believing that it is the only aspect that matters.
The exam itself is not the endpoint. It is not the pinnacle of your career. It is simply a gate you must walk through in order to start your career as an intensivist. So see it as a marker of your readiness to work as a specialist and it makes the exam much less confronting. This is your time to shine.
Prepare by engaging in activities that you know are representative of the exam –
Write answers to past papers (available from the College website http://www.cicm.org.au/examgenfell.php) under exam conditions. If possible, do this somewhere you won’t be disturbed, for example a conference room or a study room in your library. Try to complete you answers within 8 to 9 minutes, as this helps to build up a buffer for the longer questions and for reviewing your answers or going back to an unfinished question at the end. Some people find it useful to complete a set number of questions with a small group of colleagues and then swap the answer sheets and mark them straight away. This adds a bit of performance pressure and is a good way of identifying knowledge gaps and revising topics in a focussed way.
Get together with a group of colleagues and practice vivas on eachother. Again, stick to time constraints. Exam preparation courses are also good for this, particularly the 3 day Australian Short Course on Intensive Care Medicine held in Adelaide in the first part of the year and the Brisbane course held in September. The Sydney Intensive care Long Course (SILC) also runs a full viva session towards the end of the course, but ideally you should be practicing vivas before this and using it to refine your technique.
Practice clinical cases with a colleague or two and with your consultants. The aspects to really concentrate on are listening to the introductory stem so that you can quickly work out what is being asked of you, getting comfortable with the structured examination of an ICU patient so that you can free up brain tissue to interpret what you are finding rather than trying to remember which bit comes next and using the 30 or so seconds of hand washing time to work out what your opening line for your presentation is going to be and what the answers to the questions posed to you will be. Also, try to examine patients in other ICUs with other consultants – you will not be examined in your own unit, so it is worth getting used to being examined in a foreign department by scary consultants. Again, the Adelaide and Brisbane short courses and the Sydney Intensive Care Long Course are useful to attend.
The point of all of this is not just learning material for the exam. Its major benefit is desensitisation, so that on the day of the exam you are so used to the process that it becomes just another day, allowing you to concentrate on what you have to do rather than worrying about whether you can write an answer within 10 minutes or what examiners you might get. As an additional help, try to use exam language as much as possible, to keep your answers efficient and to the point.
Answer the question that you are asked. Don’t lead in to it. Get to the point and then expand. This is critical in all sections. In the written component, if you are asked for 3 things, give 3 things; even if you know 14. The examiners cannot give you extra marks and, as they probably have 50+ other papers to go through, they may become a bit irritable. So instead of earning extra marks, all you will achieve is less time available for other questions and an examiner who is less well disposed to forgiving minor errors. In the viva and clinical case components, you just don’t have enough time for for long winded introductions. Answer the question and if the examiners want more they will either let you keep talking or ask questions that take you further down that path. If they cut you off, you have probably said what they wanted to hear and they are moving you on to get more points and get you through the exam (They really do want you to pass).
In the written paper, answer the question and move on. Many candidates complain that they simply ran out of time and missed out on the last 3 or 4 questions. You will probably score more points by answering every question partially than answering some questions completely. As stated above, if the question asks for 3 things, just give 3 things. Time saved in quick answers can be given to others that require a little more work. Which order you tackle the questions in is a matter of what you are comfortable with, as long as you answer them all.
Have structures for answering the different types of questions (Diagnosis, management, equipment, procedure, critical appraisal, etc). You will often find you can write or talk more than you thought you could about a topic by filling in the headings of that structure.
When your time is up, your time is up – move on. Get used to stopping at 10 minutes regardless of where you are in your answer. In the written exam, unless you have created extra time during short answers, all you will do by going over 10 minutes is lessen your chance of attempting every question. In the vivas, when the bell rings at 10 minutes, the examiners cannot give you any more marks, so you are wasting effort and eating in to the next station by continuing to talk. It’s alright to stop mid sentence, thank the examiners and go to the next station.
Each question is independent of the previous one. This goes for all sections of the exam. So whether you think you crashed and burned or blazed a shining path through the last question, put it aside and deal with the next one as a completely fresh challenge. It can be very difficult to correctly estimate how poorly or well you answered, so move on; you will only really know when you get your letter at the end of the last day of the exams.
The clinical case causes particular anxiety amongst the majority of candidates, probably because it is perceived as the deal breaker and so deserves a few extra comments. It is especially easy to be lulled into a sense that the odds are stacked against you –
“How am I supposed to work out everything about this patient in only 10 minutes? In the real world I would get a handover and some initial test results and I would be able to review the observation charts.”
“How can I do a complete examination in 8 to 10 minutes? The full neurology examination alone can take 15 minutes.”
These are common misgivings heard prior to the exam, however, there are a few points to make. First, having been invited to the clinical exam, you know enough to pass. It is now more about technique, thoroughness, comfort and the ability to sound as if you can manage things at a junior consultant level. The examiners want you to pass and they will help you.
The examiners go into a clinical case with the same information as you and examine the patient for themselves, so that they can grade the difficulty and assess whether it is reasonable to expect a candidate to pick up on a particular finding. So depending on how difficult they think a particular detail is to find, you may not miss out on many marks for not getting it. For example a chest drain is hard to miss, so not spotting it will probably not look good. A cardiac murmur, on the other hand, might be quite subtle and, if not central to the case, may not count against you for missing it.
Listen to the introductory stem and questions given to you by the examiners. Everything you need to know to pass the case is given to you. Anything that you are not told, you are either expected to be able to find for yourself or it is not critical to the case; so don’t worry that they are hiding something from you. The questions that are posed to you are also a clue as to what the examination will be about. They are also specifically structured to accommodate for the fact that you only have 10 minutes with the patient. If you set out to answer those questions during your examination of the patient, you will usually find that you do have just enough time. So while the patient may be on ECMO and dialysis and 5 different inotropes and be missing his right leg, if the questions is to assess his neurological prognosis following an out of hospital cardiac arrest, it can be reasonably answered within the 10 minute quota.
If it helps you, repeat a summarised version of the introductory stem and the questions back to the examiners. This helps some people to clarify what they need to do and helps them to remember what questions they have been asked to answer. However, there are mixed views about this. Some examiners get a little irritated by having what they have just said repeated back to them. Don’t worry too much about this. It is acceptable practice and there is a second examiner who is often more flexible and should keep the irritable one in check. Some candidates feel that repeating the stem and questions just eats in to valuable examination time, so they quietly clarify the questions in their own heads while standing at the end of the bed, looking like they are taking it all in. Work out which approach works best for you.
When it comes to presenting the case that you have just examined, it is important to try an d summarise you findings and get on with answering the questions that were posed to you. How you do this may depend a little on whether you talked as you examined, examined quietly and plan to present at the end or used a hybrid of both styles. It matters little which option you choose, as long as you are comfortable with it and you don’t waste words. In summarising the patient, rather than simply listing your findings, it is arguably better to present a synthesised synopsis and then use your findings to justify your opinion. For instance –
“Mr Edwards is a 65yo gentleman who has been in the department for 5 days. My examination suggests a picture of ARDS, SIRS and multiorgan failure, secondary to his 65% body surface area burns. The evidence for this conclusion is …”
Then get on with answering whatever questions were asked of you. This approach is less likely to result in you heading off down a single track and getting lost in detail before you have had a chance to answer the other questions. Once you have headed off down the track, it can be hard to get back. If the examiners want more detail, they will push you for it. If they don”t, you have probably already scored enough points and they are trying to move you to a new area.
Whatever approach you decide to take, make sure you have practiced it well before the day of the exam. The more components of the exam that you can automate, the more brain space you free up to be able to think about what you are finding, what you are being asked and how you are going to answer and the more relaxed you will be.
Regardless of how you think your case went, put it aside when you walk away. You still have a second case to do and you want to be in a clear frame of mind. Also, no matter how you feel about it, you never really know how it went until you are given your letter at the end of the last day of the exams.