Why do Emergency Medicine

Why do Emergency Medicine?

Listen from the inspirational team of emergency healthcare providers in Edinburgh. 

For more, checkout EdinburghEM website 

Initially published by RCEM youtube channel - 21/01/2016

Posted by:

              

     Lakshay Chanana

     

     ST4 Trainee

     Royal Infirmary of Edinburgh

     Department of Emergency Medicine

     Edinburgh

     Scotland

     @EMDidactic

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

Don't be critical about "FRCEM Critical Appraisal"

The September 2017 diet FRCEM critical appraisal results were released last week and passing rates remained close to 60%. I took this exam in September diet along with some of my other colleagues. 

While preparing for this exam, we often used to ponder - Why are we doing this? But as our preparation went on, we realized that “Critical Appraisal” is one of the most essential aspects of modern day medicine. As exam-going candidates, like everyone else we had a lot of doubts and concerns about the pattern, how to start preparation and we found that there is a ton of stuff on MRCEM Part A, B and C prep but there was not much about FRCEM Final set of exams. 

I am going to address few BIG questions regarding FRCEM Critical Appraisal here:

Can we take this exam from India?

To my knowledge, I am not aware of anyone who appeared for this exam while working as an ED doctor in India. However, I think this should NOT be a problem and it is quite possible to crack this. The issue is lack of good mentorship, someone who can guide you through the process. At this point, I know only two practicing physicians in India who have been through the FRCEM series of exams. The exam itself is pretty much a revision of your third year medical school statistics and epidemiology (no rocket science!). You don’t need to be an expert in statistics but should be able to understand the very basics and know what the numbers mean to a clinician.

Cost will be another issue; the exam fee is approximately 25,000 INR, which is a hefty amount for an EM resident in India. If I include the cost of travel and stay, the exam will cost you at least 100,000 INR (including tickets and accommodation). Add another 100,000 INR if you want to attend a exam prep course.

Bottom-line – If you are lucky enough to have a mentor, then taking FRCEM Critical Appraisal is quite possible from any country (not only India) provided you are financially strong.

Do we need to attend a pre-exam preparatory course?

Well, my standard answer is - most of us do end up going to a prep course due to peer pressure. But if you are going to a course, make sure you read about the basics first. Trust me, it makes an immense amount of difference and the course itself works like a revision for you. Also, it is much easier to grasp the "statistics terminologies" if you have already read it once or twice. Otherwise, going to a prep course is a waste of time and money. My recommendation is "Read the basics and then go to the course to clarify things that you did not understand". 

If you end up attending a course without any sort of pre-course reading, then you will be bombarded with information overload. 

Bottom-line: If you are motivated enough, I assure you that you can easily pass this exam with the below mentioned resources and without attending any prep course. 

Exam Pattern

The exam lasts for 90 minutes and you get one paper (Diagnostic or Therapeutic, rarely Meta analysis) to critically appraise. You are expected to write your answers in the space provided (gauge the length of your answer as per the size of the box). The exam comprises of a total of 6-8 questions. There are some standard questions like "writing a summary of the paper" and "strengths and limitations" of the study. These are pretty standard and it is easy to fetch marks on them. 

Bottom-line - Enough practise and time management is the key. 

How we prepared?

We started preparation about a month prior to the exam. Despite understanding the concepts, most of us found it challenging to jot down things on paper. For instance, we knew what "p value" signifies but we could not define it. I recommend reading the "glossary section" everyday for 1-2 weeks. This will make the exact definitions stick to your mind. Glossary also includes all the equations to calculate Sensitivity, Specificity, PPV, NPV, PLR, NLR etc. Glossary is high yield. 

We read about 1-2 papers everyday starting 10 days prior to the exam, each one within a span of 90 minutes. 

On the day of exam?

As always, don’t try to do a lot on the day of exam. If you are very keen, then once again – go through the glossary, which should take <1 hour at this point. Just sit back and relax. You have done your bit in the last month and outcome depends entirely on that, not on the last minute preparation. Stay calm and remember, this is just another exam and not the end of your life! Sooner (hopefully) or later, you will get through this. 

Resources for exam preparation

Critical Appraisal for FCEM - This book is designed for FRCEM critical appraisal (as the name suggests) and focuses on key aspects that you need to understand to critically appraise a paper from an examination standpoint. It is designed for A&E doctors by A&E doctors. You also get a couple of practice papers at the end and glossary of all the important definitions, which are very likely to be asked in the exam. Highly Highly recommended. 

Rahul Patwari's Youtube videos – Even if you are not taking the exam, I insist spending some time with these videos. You will mature as a clinician during this process. In these videos, Rahul takes us through the very basics of evidence-based medicine and explains how to bring that evidence to the bedside. Every practicing physician, not only A&E doctors, must see these videos. The concepts are presented in a very simple and easy to understand way enough for a 10 year old to comprehend. Reading statistics comes with a mental barrier for most of us, as this stuff can be hard to grasp. I often felt like a dyslexic as I could not decipher what the text means, but these videos came with a solution.

Recommended Playlists on the youtube channel:

• Basics of Clinical Reasoning
• Probability and Odds
• Hypothesis Testing
• Sampling
• Distribution of Sample Means
• Sensitivity and Specificity
• Confidence Intervals
• Incidence and Prevalence 
• EBM - Introduction
• EBM - Evaluating articles on Diagnosis
• EBM - Evaluating articles on Treatment 

Sketchy EBM - Once again, a picture is worth a thousand words. Concepts that are difficult to understand are explained very well here. 

SGEM: One of the best blogs/podcast on Evidence Based Medicine. This will ensure that you get into that mindset and be comfortable with the terminologies that are used while interpreting evidence. REBELEM and COREEM are other options.

USMLE Step 1 Statistics – The concepts remain same across the world, whether it is UK, USA or India. If you have the time and patience, then check out these videos by Steven Daugherty. These videos give you a slightly more in depth review of Epidemiology and Statistics and are worth watching but not mandatory.

In hindsight, I feel that Rahul Patwari's and Sketchy EBM videos are a good place to begin rather than reading a textbook. Following this, go through the Critical Appraisal for FCEM.  If needed, review the videos again. One needs to read the textbook at least a couple of time because the content is quite volatile. I think 1-2 months are more than enough to prepare for the exam. Once you have gone through the videos and text, do several papers and simulate exam like conditions (write with a pencil, write legibly and within the box, finish under 90 minutes).

I hope this helps. Let me know if you have any further questions regarding the exam.

Further Reading:

http://stemlynsblog.org/the-critical-appraisal-fcem-exam/

http://stemlynsblog.org/taking-fcem-you-feeling-lucky/

http://emergencymedicineireland.com/critical-appraisal/

http://fcemprep.co.uk/tag/critical-appraisal/

Posted by:

              

     Lakshay Chanana

     

     Speciality Doctor

     Northwick Park Hospital

     Department of Emergency Medicine

     England

     @EMDidactic