HitchHiker’s Guide to the ACEM Fellowship Preparation (2024)

As Ferris Bueler told us…Life moves pretty fast….if you don’t stop and look around once in a while you might miss it….

You are four weeks out from the written exam….and you are probably living, breathing, eating and drinking the ACEM curriculum. You not only have lists stuck to the wall of your toilet, you also have them on your dashboard, on the ceiling above your bed and backlit on your iPad behind the babies cot as you pat her to sleep.

But four weeks out is a good time to stop and take stock and remember exactly why you are doing this exam. It may help with the bleak helplessness and overwhelming need to visit elderly relatives you haven’t seen in years that may overcome you in coming days.

Here are a few of my musings on the new FACEM written exam

The new written exam is about fact regurgitation. As much as we have got away from the gaming that was required in the old exam to structure an “assessment question” in the right format and a discussion question in pros and cons the new exam seems to have lost a little in just going back to the first year anatomy regurgitation of facts. A bit like Ford Prefect you may feel that you are being asked to repeat the bleeding obvious over and over again…

HOWever – unlike first year anatomy where really one of Terry Pratchet’s imps could have passed if you took them to enough dissection class, the new exam does require some higher level thinking in that you have to prioritise the facts that you are regurgitating….… and this is a very good thing. So as a result there are a number of great things about the study you are doing write now.

1. Being able to Priotise the Facts is very useful for a FACEM : Trust me, in almost 10yrs of FACEMing I haven’t ever really needed to know every single cause of everything (that is what we have general physicians for…) but I certainly need to know the top five and the new exam definitely encourages taking the textbook answer and applying the clinical reasoning to take you to the next level.

AND the good news is that while at this moment you are hating every moment of the enforced love affair you have with your text book dinner party guests :

• Cameron (the allrounder who can talk on every topic but adds little )
• Dunn (who you always pair up with in trivial persuit but who struggles with small talk),
• Tintanelli (your loud American cousin that you invite over for the rare conversation piece you can’t get anywhere else),
• Harrison (who always raises the tone of the party with their well described stories but who never will be of use when the toilet’s overflowing and you need a solution now)
• and the specialist cousins (who flit in and out and add a little in between their other engagements).

….and you are probably currently thinking that you couldn’t in any of the hitchhikers travels possibly need to know this much detail about foreign body removal and weird and wonderful acid base issues …….So though you are now wishing you never invited any of these to your exam dinner party and you are definitely wondering if this is somebody elses party …and you are wondering if they are enjoying it…..

2.The text books haven’t changed since I did the exam and that was almost 10 years ago. Yes they may have a few new additions but seriously they aint that much different…a bit of new sexy kit… the troponin assays keep changing their time frames…but not much has changed.

• And as a result….The knowledge and the notes you are making now you can reuse with minor updates for years and years (believe me I have been rehashing the same set of slaved over fellowship notes to make MCQs, EMQs, SAQs, OSCEs, Powerpoints, Sims for years). The human body doesn’t change that much and while your twitter feed seems full of the latest news you will soon find that those trusty notes with a 3% update will serve you very well for many years.

3. This has been a good investment in your future. So while you feel you have lost the last 6.9.12.18 months of your life and you will never regain that time you actually will…. think of it like superannuation …you have had it in the aggressive investment phase for a little time and that may reap you rewards for a few years. Unless you are within 5 years of retirement and your should have it in safe investment meaning you really should have been resting your laurels chatting with the patients and using all your PDL not cramming for the books….just saying….then it has been a great investment in your future. Trust me on this one….

4. You need to be all over the written exam curriculum knowledgein order to pass the OSCE exam. Unlike the old clinical exam where you seemed to go from being an emergency physician in the written to suddenly pretending you spend an hour with a patient and learn the name of their dog and perform a respiratory exam checking for a flap EVERY TIME 😉 …..NOT ….The new OSCE exam for all it’s foibles is testing your ability to apply the painstaikingly ingrained knowledge to clinical situation. You can’t be sitting there trying to drudge up the contraindications to thrombolysis if the aim of the OSCE is to see how you clearly communicate risks and benefits to a patient and a family member who are resistant to treatment. You need to spend 0% of yourtime remembering those facts and all your effort communicating. Likewise your difficult airway algorithms need to role off your tongue. It will be expected that talking those through will be money for jam…you need to spend your time negotiating difficult relationships in convincing reluctant staff members that the stridorous infant really does need preparation for the airway intervention even though anaesthetics is 1 hour away and the patient currently is saturation at 93%. If you are still trying to remember what SOAPME stands for then your attention won’t be on the prize and your performance will suffer.

6.YOU WILL NOT PASS THE OSCE if you shouldn’t have passed the written….so if you happen to fluke it and score all your fave questions in the exam trifector….unlikely true but remotely possible ….you do NOT want blaringly great wholes in your knowledge when fronting up for the OSCE exam. Believe me it is like primal sense in there. The number of times I have turned up to teach something even these days,the one thing they ask is the one thing I was a little uncertain of…and examiners are better than your average hunter…they are tigers…they smell your fear and will pick the one thing you are crap at and your world will fall down. Even if it is just a passing knowledge – if there is something that always bugs you that you don’t know (AF for me) then revise it again so that when it comes up somewhere you can at lease start the conversation about it – in the written or the OSCE.

7. Final Pearls : And lastly in this last weeks before your written exam remember a few key things:

• You are at this point at being eligible to sit the exam because you have slogged out a helluva lot of shifts and unless you have magically combined homer simpson with Don Juan you have not been able to avoid seeing and helping manage a helluva lot of patients in this time. Where-ever you have trained that means you have gained by osmosis the practices that have kept numerous patients alive. By working through that school of hard knocks you have earnt the right to sit. You need to now use that knowledge you have inside and let it grow ….and show…(FROZEN refrain in background)
• To have committed to sit this exam you have spent time with those dinner guests – you will still to the moment you walk in have things that you wish you had time to revise or things you don’t think you know….it doesn’t matter….if you can step back and think big picture you can probably work your way from first principles through any condition and WRITE SOMETHING (trust me I have been bluffing it for years). Don’t get a block – write something down…just try and make sure the really important things are mentioned – but if they aren’t at least write something….it is really hard to give marks to an empty page – been there done that….
• Some of you WILL FAIL This exam. This is the cold hard fact and for many of us this is the first time in our lives that we have EVER failed anything…. For me I was lucky – I failed year 10 Gymnastics…damn forward rolls…. but that just made me more determined and doing PE in senior to prove my Gym teacher wrong probably changed my life….. and that is how you have to be. Don’t get me wrong you will and have the right to grieve for a few weeks if you fail but some of the best doctors I know have failed their fellowship exam and for many of them that was one of the best things that ever happened to them – they now know their theory better than the rest of us and they have gained empathy and nurturing for registrars that they never probably would have had. If you stop thinking that your life will end if you don’t pass this exam then you will probably actually perform better….worked for me! (I can now challenge any 7 yo to a forward roll competition….)
• The exam is not trying to trick you. The college and the examiners have to set the exam…and they get a whole bunch of FACEMs to standard set the exam… I got the invite the other day to help standard set the fellowship exam and I declined but if I had you guys would have probably known a whole heap more knowledge than I do – but I am a whole lot more street smart than you having survived being a junior consultant with the s$#@ hitting the fan and the buck stops with me and also having the title. So much confidence and backing of yourself comes with the title. Somebody awarded me that title back on a winters day in Melbourne (may have been a typo but there you go) and ever since I have just gone for it. Imagine yourself how you want to be – you are the consultant …now act like it in your answers.
• YOU DO NEED this again. As much as you fight it, want to burn your notes in a sacramental bonfire after the written you WILL need this again. You will need it for sure in the OSCE. Whilst I hope you are spending your OSCE prep time practising communication and simulated encounters rather than cramming lists there are probably a few lists that if you didn’t get them in your brain prior to the written you should probably do that then….or NOW – you have 4/52 so why not start preparing for the next leg – you are well prepared for the written so start preparing for the OSCE now….Look at resus lists – ARC, difficult airway, intubation algorithms, decision trees and look at administration pathways – dealing with complaints, deal with communication issues – you may not need it in the written but you definitely will in the OSCE and you are all over the study for the written anyway!!

So I hope some of this has struck a tone or at least amused you for a study break….and unlike Aurthur you have listened to me even though I am not your mother : I am way too young;).

You know,” said Arthur”, it’s at times like this, when I’m trapped in a Vogon airlock with a man from Betelgeuse, and about to die of asphyxiation in deep space that I really wish I’d listened to what my mother told me when I was young.”

“Why, what did she tell you?”

“I don’t know, I didn’t listen.