FRCEM Final SAQ - The Holy Grail

I took the FRCEM Final SAQ exam lately and in this post, I am going to share the way I prepared for this exam. EM Trainees take this exam anytime between ST4-6 years of training (EM training lasts for 6 years in the UK). This way of preparation worked well for me and this is just one of the ways to prep for the exam. If you have any further thoughts, please feel free to comment below. 

Exam pattern: 60 questions with 1-3 stems in each question. Each question carries 3 marks and you score out of a total of 180. To pass the exam, you need to get about 120-130 questions correct. This exam basically tests your EM knowledge and management skills. It is a good idea to familiarize yourself with the basic structure of NHS. However, it is not must to have UK work experience prior to taking this exam. 

Study time: I spent around 2 weeks to actively prepare for the exam. Since I work in a busy A&E, I was in constant touch with Emergency Medicine. I believe 1 month is a decent amount of time to prep for this exam. 

Study Material: 

• Oxford Handbook of EM
• Oxford Handbook of Acute Medicine
• Oxford Handbook of Clinical Specialities
• Victoria Stacey 
• RCEM guidance from RCEM website 

Tintinalli's Textbook or Rosen's is not typically followed in the UK as core EM Textbooks and are not must for this exam. But you will certainly have an extra edge over other candidates if you have read an EM textbook cover to cover. 

RCEM Curriculum, Images (Clinical Images, ECGs, X Rays)

Scroll through the college curriculum as you read OHEM and as you do the practice questions. Ensure you cover each bit of the curriculum, for instance, stuff that we don't see routinely (STDs, vaginal discharge, rheumatological diseases, sarcoid, spinal cord syndromes etc) should also be covered. Questions related to Lupus Psychosis, Ovarian Hyperstimulation Syndrome are some of the favourite topics. 

Questions with image interpretation are easy to score. Glance through X Rays of various differentials of limping child, C-Spine injuries, images of skin rashes in children and fundus findings for ophthalmological pathologies. Search "Google images" and look what pops up whenever you come across a question with a likely image interpretation scenario. 

Important ECG topics include 

• Posterior wall STEMI
• Types of Ventricular Tachycardia 
• ARVD
• Brugada
• Subtle ischemia (Wellens, de winters T waves, Early reciprocal changes in aVL)
• Torsades
• Trifascicular block
• AV Blocks
• Sgarbossa Criteria 
• ECG findings of PE
• Long/Short QTc syndromes 

How is FRCEM Final SAQ different from MRCEM SAQ?

While preparing for the exam, I always thought that this exam appears very similar to MRCEM SAQ. FRCEM Final SAQ focusses more on management aspects (RCEM Guidelines) in addition to core EM textbook knowledge. Please make sure that you go through the RCEM website and have a glance through the guidelines (absconding patient, frequent attenders, dealing with police, domestic violence, sexual assault, valid consent, confidentiality, handling complaints, adverse events, MH issues covering all the sections, common law and assessing capacity, dealing with intoxicated colleagues, major incident management, quality indicators, RCEM standards of care etc.)

Study Buddy: Choose to have 1 or 2 study buddies to prepare. I suggest to read the text on your own but do questions followed by discussions together. As you read OHEM, you will realize that it possible to frame a question from each sentence of this handbook. It is a good idea to think how a question can be framed on a particular topic as you read OHEM and then test your partner with that. 

Exam preparation courses: Surprisingly, there are only a few resources and question banks to prepare for the exam. Take your pick between a formal prep course or an online question bank. Going to a course (which is more expensive than the exam) without brushing up OHEM is a sheer waste of time. 

Exam taking strategy: With electronic health records in place, most of us are not used to swiftly scribble on a sheet of paper. In fact, one of my mentors once told me, if you attempt all the questions then you are highly likely to pass. Therefore, practice a few timed mock tests prior to the exam. Tips for the day of exam:

• You are given 3 hours to answers 60 questions. If you are not sure about an answer, keep moving forward and get back in the end. 
• Do NOT spend more than 2:00 - 2:30 minutes on one question 
• Image questions: Don't jump to conclusions and Don't jump to the stem after seeing the image. Even if you are 100% sure about the image interpretation, you MUST read the question completely before you write down the answer. 

Decision-making tools

You don't need to remember all of them but have an idea about few components of each decision tool. For instance, remember 4 things that makeup PERC criteria or 4 things that make up TIMI score or HEART score. Use mdcalc to check up to date scores. 

We have also covered 2 posts in the past about MRCEM SAQ. A lot of what has been mentioned in these posts holds relevant for Final FRCEM SAQ as well. I highly recommend you to go through them:

MRCEM part B by Lakshay Chanana
MRCEM Part B by Apoorva Chandra

Posted by:

              

     Lakshay Chanana

     

     Speciality Doctor

     Northwick Park Hospital

     Department of Emergency Medicine

     England

     @EMDidactic

FRCEM SAQ INTERMEDIATE – 1 WEEK to GO – THE DO’s and DON’Ts

Yes, the exam is back. And it shall be over sooner than you can imagine. Well one thing is common for most of students – the Uncertainty. No matter how well they have read.  Also if someone would question them about their preparation at this juncture they will hate you for simply asking.

In January, 2017 I had written a post on my experience with FRCEM SAQ intermediate exam. Of late, I have been getting multiple mails and phone calls from exam going candidates asking how to prepare, what to read and so all. Yes, I may have cleared this exam almost a year ago but totally empathize with all the following statements – “My mind has gone numb” “I keep forgetting everything” “How will I revise” and so on…

One week to go. Maybe you’re the guy who has read and revised the entire course OR maybe you’re the one who is starting today. Either way all any candidate wants is to pass this exam. This is the crash zone. Either you make it or break it. Any panic, anxiety or worries are detrimental. The main reason of this is thinking about the exam result and what catastrophe would beckon if you were to fail! All these thoughts will make you anxious and if with that thought process you try to study you will feel frustrated because ‘nothing is going inside your head!’ and your mind wants to take a break to relax. This loop of worry, anxiety and breaks continue and the day gets over. Similarly more days go by and when it is just 24hours before the exam, you realize YOU COULD HAVE prepared a lot better IF ONLY YOU HAD A WEEK!

So, now, you do have AN ENTIRE WEEK! That’s a whole lot of time if you plan correctly and simply focus on the task to complete in the NEXT ONE HOUR!

Let’s change our mindset from what will happen to what is to be done. Let’s begin. Here is an Eight pointer for you:

1.     Make a promise to yourself now – That you will not think of the result of the exam. Passing or failing is not in your control. Your result entirely depends on WHAT YOU DO NOW RATHER WHAT YOU WISH should happen.

2.     PLAN. IF PLAN fails – REPLAN. Exam preparation in last week is like a busy shift in the ED, your plans of treatment and disposition may work sometimes and most of the times they won’t. You don’t leave your shift because it got crazy. You complete the shift, tackle everything, come what may.  Therefore if you slack in your plan, don’t worry, replan your day from that moment and start doing. Remember every second you waste in worrying makes your brain tired and less receptive to newer information.

3.     Adjust your shifts. Take leaves if possible. Can’t elaborate on that further.

4.     Take a brand new notepad/folder - Name it - ‘LAST MOMENT FOLDER’. You may add your old notes but I insist you write all new . (For that matter I even brought a new OHEM as my old one was all colored and gave me a false impression that I have read everything). The new notes/ folder will be based on your current status where you know what your strengths and weakness are. So make a folder and keep adding nuggets of information to it. Let it be a live tracker of your week and store all important stuff out of whatever you read. It doesn’t have to be bulky or comprehensive. The aim is to identify the key points that that you would want to revise on last day if you had only 2-3 hours left. Keep it 24x7 with you.  So here are few suggestions for the ‘Last moment folder’ - (Filter the items according to your requirements)

a.     Management of every acute or emergency condition (in no more than 3-4points - This helps in answering in exam also) - Write the interventions. Write the Drugs with name - dose - route. (Believe me! This is where most people falter)

b.     Formula/ Calculations like Anion Gap, Sodium correction, Calcium correction, A-a gradient etc with their normal values

c.     ECG changes in various conditions

d.     Classification and scores

e.     Definitions

f.      Pediatric doses and NICE guidelines on pediatric traffic light system

g.     Conditions/ signs with specific names

5.  Use GOOGLE images search- Since most of the questions in the exam are image based, it is suggested that with every condition you read, keep searching it’s images. The first page of Google image search will give you the most representational pictures and it is highly possible that you get one of those images in the exam. Also it helps developing a visual memory that stays longer.            

6. Now the question comes – HOW TO PLAN? Well there is no ideal way. Every person have their own methods. Considering the exam day as day 7. Let us divide the 6 days in hand into 3 segments - a) 72hrs - Days 1-3  b) 48 hrs - Days 4,5 c) 24 hrs - Day 6. Define your goals for each aforesaid segments. Next,  I’d suggest divide these segments into 6 hour intervals. Have a specific target for each 6 hours. Plan your breaks and naps accordingly. This will keep you focused. So if the exam date is 28^th September - The week starts 22^nd September. 

A) Days 1-3 (22,23,24^th September) - Plan to simply read through entire syllabus according to the topics in the curriculum and identify key points needed for revision. Since it’s the last week I would not go for bigger reference textbooks, rather read from books and sources which I am familiar with and are exam oriented viz. Oxford Handbook of Emergency Medicine and Acute Medicine, Few NICE guidelines, SCORES. Keep 6 hourly targets for example  - Surgical and Environmental emergencies in 6hours. While reading keep marking ‘Q’ whatever you feel is a possible question. (Well sometimes there were more than 20 Qs marked on the page!). None the less, it will help you in later stage.  Also keep writing the points which needed to be revised and add them to your ‘last moment folder’.       

B) Days 4-5 (25,26^th September)- The REVISION - These 48 hours revise the highlighted texts or the ‘Qs’ you have marked in your books. Keep adding and updating your ‘Last moment folder’.  If you have some topics pending (probable) and time left (improbable) then try covering them as well.

C) Day 6 (27^th September)- This is the last day before exam. Plan your day in 2^nd hourly intervals. DO NOT read anything new. Just read you ‘Last minute folder/ notes’ and the topics. You have to ‘by heart’ all important stuff.

D) Day 7 (28^th September)- Day of exam. Preferably do not keep anything to read today. If you still have to, then no more than 1-2 hours with only pre-planned topics from your revision folder. Don’t read new stuff neither do haphazard studying, this will drain you off energy.

 Nobody gets a good sleep before an important exam. So don’t worry about it much. Have a decent breakfast. Keep nuts or chocolates with you when going for exam (although you’ll be provided refreshments). Stay hydrated but pee before the exam. For further details of the way exam is conducted and how to manage your time, kindly refer to my previous post in January.

7. Online questions - Use them to test yourself - Assess your time management. Use these questions to streamline your answers.

8. Breaks and naps - Take effective breaks of no more than 2hours per 6hour. Do not be away from reading for more than 12hours. The break should recharge you and not leave you with guilt. 

Dear Friends, in the last week, the objective is to cover entire syllabus and revise it effectively. There may be different way to prepare for this exam. I just shared with you what I would do if it were 7days to the exam. I wish you the best. Stay Calm, Stay focused.

Let me know if this post helped. Cheers! :)

Written by:

Dr. Akshay Bhargav MBBS, DEM, MRCEM

Akshay is an emergency medicine enthusiast. Originally from Kanpur, he did his graduation from Kasturba Medical College, Manipal and his post graduation residency in Emergency Medicine from Apollo Hospitals, Hyderabad. He Loves teaching via simulation methods. His dream is to spread emergency medicine awareness among masses and improving standards of ED care in the country. As a student has always hated examinations but thankfully chose never to give up.

FRCEM intermediate SAQ: It’s about momentum. How you build it. How you plan it.

I recently cleared my FRCEM intermediate SAQ exam. Many of my colleagues and juniors have been asking to share my experiences about it as the exam format is new. Also the pass percentage was very low this time (~15%)

I’d like to begin with what can go wrong. I will confess. This was not my first attempt. I had a torrid time giving my part B exams in June last year. I read a lot. I Read OHEM (Oxford Handbook of Emergency Medicine), Practiced online questions. Was I stressed about the exam? Perhaps a little too much. I was doing a lot of combined studies with friends and when I was alone the tension/ stress got the better of me. Sitting for even 10minutes with the book seemed like a great deal. And to set it off I used to browse FB/ chat/ watch YouTube just to cool things off. This caused a lot of wastage of time. The targets set for the day were not being achieved and getting procrastinated. Although I was already scoring around 100/160 in all practice tests but that was borderline. I was like ‘Read OHEM complete, revise it again’ also I had some cloudy concepts regarding dermatology/ choice of antibiotics/various fractures and injury management and many more. To eliminate that uncertainty I had to probably read and make my own notes. But how? 

The syllabus is enormous and time always seemed limited. So the exam date came closer and closer and I continued with my haphazard way of studying. I was hoping that somehow I will pass the exam. But on the night before the exam I had a sinking feeling that things were not alright. The doubts still existed. The uncertainties were still there. I could barely sleep that night. I was just hoping that somehow I will pass. But such prayers are rarely answered. Next day the exam was a disaster. The questions seemed familiar but the answers were not on my fingertips. I had to try hard to remember each and every answer. Since the accurate answers were not striking fast and smooth I was writing longer sentences to rephrase my answers. This took me longer time and the momentum never built up. You need that flow to answer some questions which are not straight forward and need some logical reasoning.

After the exam I was a little broken. Not knowing exactly where to start again. But I knew the problem was not only the knowledge per se but also how I need to plan and prepare for it. As the saying goes Proper Planning Prevents Poor Performance I realized I have to learn to study alone. I had to learn to sit still and. Have some self control so as to achieve my daily targets. Learn to stay calm and not panic. And for that I did try meditation. No rocket science, but a simple way of learning how to stay in the moment.

So now let’s come to the point. How to prepare for the new format of FRCEM SAQ intermediate exam. We will go through it retrospectively. Describing the exam process and proceeding backwards to the time now.

THE EXAM

This exam is not just a theory paper. The paper is designed to test your clinical acumen. Most of the questions are clinical case based scenarios supplemented with images. The exam has 60 questions of 3 marks each divided into 3 (1 mark each) or 2 SAQs (2+1marks). Time duration is 3hours. So that makes 180mins for 180 marks. You should be at the exam centre atleast 30mins before the starting time or at the reporting time as suggested. You will be required to verify your identity and then wait till you are called in and seated according to your candidate numbers. You will be provided with pencils/erasers/sharpeners and refreshments like chocolates/fruit juice/ water. You will be required to enter your details in the sheet provided. The timer/clock will be displayed where you can easily see it.

TIMING the exam

60 questions in 3hours. 180 marks and 180mins. You should aim to complete 10 questions in every 25mins. Hence try to finish all 60 in 150mins. Do not pause or wait too long at a question of which you are not very sure of or are doubtful. Keep moving. Keep time to come back for a second round. Mark with pencil the question you have left and have to review. There were candidates who failed marginally this time because they could not read all the questions! Do not make that mistake. You fail the exam even if you fall short by 1 mark or 10 marks. If you feel stressed out during the exam take a deep breath and exhale through mouth, take a sip of water and start again. Answers may strike you a little later when you have developed a flow. Keep moving. Time is of essence. I had only 15mins left for the second round but I think I managed to answer atleast 8-10 stems (8-10 marks then)

1 day before the exam and the morning: This day is very important. Every hour should be planned for. You have to reach the peak level of your preparation and stay calm no matter what. Things to take care of:

TRAVEL and STAY: If you’re travelling to a different city reach atleast by evening. Try to find a place of stay within 5kms of the exam venue as it may save you good time in the morning and helps in getting a peaceful sleep.

READING: You have to reach your peak level of preparations on this day. You cannot be carrying all of the study material or planning to revise everything on last day. So filter out. Prepare your notes of all the important material that may be volatile like drug doses/ scores/ treatment protocol/fracture names/investigation findings or whatever you think is vital. You should plan it properly. And DO NOT read anything past midnight. Just shut it off. Anything you read after that will do more harm than good. Do something to take your mind off the exam. Chill. Unwind.

SLEEP and the MORNING: People say to take a good night’s sleep before the Exam. Of course it is important but I find that advice very futile. I myself have never been able to get a sound sleep before a major exam and this was also no exception. But I think more important thing is to not fret over if you’re not able to sleep. We as emergency physicians can save lives even if we have been awake for 24hours straight. Stressing over lack of sleep does you more harm than lack of sleep itself. And when it’s the morning take a power shower that washes off all tiredness and anxiety and sets you all ready for the exam. Take a good breakfast. Get into the cab or whatever transport you’ve arranged and GET SET GO.

The WEEK before the exam: 6 days excluding the penultimate day

PLAN. EXECUTE. REPLAN. DO. KEEP DOING. This is how I will describe the last week.

PLAN your leaves/ duties well in advance. Arrange duty replacements or take leaves. I suggest breakup the last week or last 6 days as first 4 days and last 2 days of the week. You should have gone through your books atleast twice before entering this week. Try to finish subject wise in the first 4 days of the week. Break the syllabus into 4days and cover all that can be. (Syllabus available from

https://www.rcem.ac.uk/docs/Exams/2.2%20FRCEM%20Intermediate%20Certificate%20Information%2 0Pack.pdf)

Last two days try to read the high yielding and must know topics. Build the momentum and prepare the material you will revise the last day. For example I had notes written for antibiotics/ antidotes with doses/ treatment regimens and guidelines/ scoring systems/ ECG abnormalities/eponymous fractures etc.

Take practice tests: Simulate yourself atleast once according to the exam scenario – 3hrs & 60 questions. May be sit in a group or do it alone. You can use online question banks for this purpose. This exercise is most important to time yourself. Use pencil while writing answers as you will do in the exam.

Lastly all you need to do from the time now till you enter the last week:

Go through the curriculum and identify the areas that you find difficult to understand or remember. Read them through standard text books of your preference or some reliable internet sources. Clear your concepts and preferably make small notes about them. Organize and Simplify.

Oxford handbook of Emergency Medicine: Each and everything. Read atleast 3-4 times cover to cover. Mark sentences which could be possible questions.

Oxford handbook of Acute medicine (especially Dermat/ Rheumat/ Onco/ Practical Procedures/ Infectious diseases/ventilator modes)

I also suggest to google search images of the clinical conditions which involve a rash and take screenshots of them. Try to correlate the image with the definition of rash/ diseases. Similarly go through images of ECGs and radiographs. Go through as many images as possible.

Updated NICE/ SIGN guidelines for topics enlisted in curriculum. Also read Medicolegal and social aspects example Rape/ Violence/Abuse/ Consent/discharge advices. Go through Critical care basics like: Ventilator management/ modes/ permissive hypercapnea/ weaning strategy etc.

Online resources: There are few websites like ‘mcemprep.ac.uk’ and others which provide sample questions for you to practice. It is reasonable to subscribe them atleast 3 months prior to exam. Make a target of doing 10-20 questions/ day. Simultaneously try to finish off those topics from the books you refer.

Also I came across a facebook page named ‘MRCEM examination resources’ which gives out valuable information time to time. You may choose to follow it.

FINALLY the question... when to start preparing - Although there is no alternative to daily reading but you should ideally start preparing 6 months prior to exam date. Late starters may choose to begin with 3 months in hand but that’s a little risky. I also think people should have atleast 2.5yrs of experience in Emergency Medicine when they plan to attempt the exam. But remember it is never too late to begin. Plan properly whatever time you have. If you have months then plan your days. If you have days left then plan your hours. If you have hours then just take a chill pillBelieving in self and staying positive never hurt anyone.

That’s all about my opinion. I hope that helps! Cheers and All the best Guys.

 

Scores Final by Akshay Bhargav on Scribd

Author:

                                              Dr. Akshay Bhargav MBBS, DEM, MRCEM

Akshay is an emergency medicine enthusiast. Originally from Kanpur, he did his graduation from Kasturba Medical College, Manipal and his post graduation residency in Emergency Medicine from Apollo Hospitals, Hyderabad. He Loves teaching via simulation methods. His dream is to spread emergency medicine awareness among masses and improving standards of ED care in the country. As a student has always hated examinations but thankfully chose never to give up.

MRCEM part C: 9 unsolicited advices!

1.    Practice is the mantra!

For part C, the formula is simpler than B. The more you practice stations, more the chances of passing the exam with ease.

2.    Find someone or be found by someone (who has cleared part C) who can monitor your practice sessions and give corrective feedbacks each time.

Plan the practice sessions well in advance so that you don’t mix it up with part B preparation and mess up both.

3.    Be the Bond, James Bond!

Develop a unique opening line for introduction in every station. NEVER fumble in introduction or conclusion! Also, clean hands save lives!

4.    Form a group for the practice

Decide what a group is, what a crowd is and what a mob is! Be careful!

Stress on things that you don’t do often – Psychiatric assessments, systematic joint examinations, etc.

Some unforgettable fun moments during the practice sessions are guaranteed!

5.    YouTube is your best friend – Like always!

This is extremely useful. This channel called ‘geekymedics’ on YouTube is a goldmine.  These videos are very well structured and almost cover everything that you need to perform in an OSCE. 

The following links might be very useful for different sections of part C

1.Geeky medics (All examination and procedural skills): https://www.youtube.com/user/geekymedics123

2.Difficult communication (Angry Patient): https://www.youtube.com/watch?v=POiRQrrQJQU&list=PL4k-QOugg2L7MZ4g5ov8xDSMhG5Z3Mpjw

3.Ottawa knee rule – Application demo with explanation: https://www.youtube.com/watch?v=sPMmIptAs-w

4.Ottawa ankle rule – Application demo and explanation https://www.youtube.com/watch?v=Dqq09sR0vuc

5.Clearing C spine: https://www.youtube.com/watch?v=k0cqlYvpv1o

6.Latest ACLS update has a very good video about breaking bad news

7.Psychiatric history taking by University of Nottingham: https://www.youtube.com/watch?v=4YhpWZCdiZc (these videos are longer than 7 mins. So you need to create a tailored down version of yourself once you see these videos)

6.    What books?

Though the main focus should be on practice some books help you to get an idea about the checklist. Though these are not standard checklists and may vary from the actual checklists in the exam, having an overall idea is not bad, isn’t it?

‘125/110 OSCEs’ and ‘Mastering emergency medicine’ can be very helpful in this regard.

7.    Reaching a specific diagnosis might not be always very important but being logical, empathetic and structured in your approach is. So if you are Donald Trump, you will never pass the exam (Oops!). Always explain the plan to the patient and ask if they have any further questions or concerns!  Another very important aspect is always maintaining a non-confrontational attitude towards the patient! Patient has 5 global marks with him. Be nice and he’ll be nice to you!

8.    Read the pie chart: Before you enter every station, know where the focus is! There’s no point taking history for 6 minutes when the history is only 25% of the pie chart and the rest is examination!

                    

9.    Difficult stations!

Difficult stations are usually difficult for everyone. You need to pass just 14 out of 18 stations. So, do the basics very well, do not lose confidence and think what you would do in the ED if you encounter a patient like that, conclude well, thank the patient!

The most crucial aspect in passing MRCEM is time!

-       Manage time during your preparation – Prepare a study schedule for the entire month covering all the topics – For B and C.

-       Time your sessions while practicing for part C. Each station lasting up to 6-7 mins(use a stopwatch)

-       Maintain strict timing in all the mock sessions of part B.

-       Reduce the time you take for answering each question!

-       Always be aware of the time you spend on each question in the exam

-       Writing using a pencil consumes more time compared to pen – So practice writing with a pencil! Also, pencils can break!

-       Be very cautious of time in stations which expects you to do multiple things at once – Ex: Teaching, examining, taking history and explaining the plan to patient.

             TIME IS LIFE!  YOUR TIME STARTS NOW!

       

  

Author

Dr. Apoorva Chandra, MRCEM

Twitter: @apoorvamagic  

Resident, Emergency Medicine         

Apollo Health City, Hyderabad                                                         

apoorvamagic@gmail.com