Preparing for the fellowship examination

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Chapter 1 Preparing for the fellowship examination

If you study to remember, you will forget; but,

if you study to understand, you will remember.

Fellowship training requirements

Details of eligibility to sit the fellowship examination and other training requirements are listed in the Training and Examination Handbook (available via the ACEM Secretariat) with which all trainees should be familiar. Regulation 4.14 deals with the requirements of the fellowship examination. For the majority of trainees, eligibility to sit the fellowship examination is dependent on being in the final year of training and having satisfied the publication/presentation requirement.

The examination is ‘criterion referenced’ rather than ‘norm referenced’, which means that all candidates who meet the criteria will pass, and only those candidates will pass. It also means that 100% or 0% can pass a particular examination, depending on individual performance. The pass criteria are those expected of a competent emergency medicine special ist. In simple terms, this means that you will pass if you can satisfy the examiners that you can work safely and independently at the level of a consultant.

The format of the fellowship examination

I find the thing in this world is not so much

where we stand as in what direction we are

Oliver Wendell Holmes

The fellowship examination is currently held twice a year. The exam is divided into two components, written and clinical, and the written component is scheduled approximately two months prior to the clinical component. Only those candidates who pass following marking of the written component will be invited to participate in the clinical component. Candidates who are unsuccessful in the written component are notified by mail at the same time as other candidates receive their invitation to the clinical component.

At all times during the examination you are iden tified only as a number: names are not used. The initial digits indicate the number of the examination and subsequent digits are assigned in a manner so as not to identify candidates in any way. For example, the second examination in 2008 was the 42nd fellowship examination, so candidate numbers ranged from 4201 upwards. For the clinical components, you will be provided with a sticker to wear with your number on it. A marking scale out of 10 is used throughout the examination. A score of five constitutes a pass.

Written component

Written components are conducted in each region (with a maximum of two centres in each region). There are three parts to the written component, conducted in a single day:

• Part A: multiple-choice questions (MCQs). The format is 60 type ‘A’ questions (that is, only one choice out of five options) over 90 minutes (about one and a half minutes per question). There is no negative marking, so ensure that you answer every question. Marks are adjusted to account for the fact that candidates should answer 20% of questions correctly by random chance. Hence, answering fewer than 20% of questions correctly results in a score of zero: candidates need to answer 33 questions correctly (55%) to pass — other scores are graded accordingly (see Table 1.1).

• Part B: short-answer questions (SAQs). The format is eight questions over two hours (about 15 minutes per question). This section focuses on assessment, interpretation, prioritisation and management issues in terms of written communication at the consultant level. Some questions may contain subsections, in which case the percentage assigned to each will be specified. Each of the eight questions is marked out of 10. To pass this section overall candidates must obtain a pass (that is, score five or more) for at least five questions and have a total score of 40 or more (see Table 1.1).

• Part C: visual-aid questions (VAQs). The format is eight questions over one hour (about seven and a half minutes per question). Questions are arranged in the form of a back ground statement and a visual ‘prop’. A broad range of investigations and clinical material may be used. VAQs assess the candidate’s competence at recognising and interpreting data, as well as decision making. Up to three questions are drawn from the background statement and ‘prop’. There may be a second ‘prop’ depending on the particular question. Where there is more than one subsection, the percentage assigned to each question will be specified. Each of the eight questions is marked out of 10, with the same overall marking scale employed as for the SAQ section (see Table 1.1).

TABLE 1.1 The fellowship examination marking schedule

The MCQs are marked by computer, while the SAQs and VAQs are each marked by two examiners in turn. The examiners are blinded to each other’s scores until they discuss their marks and agree on the final mark to be submitted. As a result, there is a delay of approx imately four weeks until the final marks are allocated.

To pass the examination overall, candidates must pass at least two of the three written parts. Candidates who fail more than one written part will not be invited to participate in the clinical component.

Clinical component

The three parts of the clinical component are conducted over two days. This is typically held on a Saturday and Sunday in an outpatient/clinic facility, but may vary. Usually the long and short cases are spread over two sites, with candidates and examiners spending the whole day at one site, whereas the structured clinical examination (SCE) is held at a single venue. The current format of the examination has the long case on the first morning, the short cases in the afternoon and the SCE on the second day.

Long case

Each candidate sees a single long case. You have 35 minutes with the patient, five minutes for con soli dation and preparation, and then 20 minutes with a pair of examiners. An agreed mark out of 10 is assigned. If you are allocated to the first portion of the long case section, you will be quarantined until the remaining candidates have finished.

Short cases

Each candidate sees a total of four short cases — two cases with one pair of examiners and another two cases with a different pair of examiners — with the expectation that at least one of these cases will involve a child. Each of the four examiners will act as the lead for an individual case. Twenty minutes is assigned to each pair of cases, which is roughly to be split between the two cases. After the first 20 minutes on two cases, you will be escorted to a different location (often next door or across the corridor). When the bell is rung five minutes later, you have the second 20 minutes with the second pair of cases and examiners. The examiners award a score out of 10 for each individual short case, and these scores are then consolidated to derive an overall score out of 10. To achieve an overall pass, candidates must pass at least two of the four cases. Consistency is rewarded more than good performance on individual cases (see Table 1.1).

Structured clinical examination (SCE)

The final section of the fellowship examination consists of the SCE with six stations. The usual format is like musical chairs in six adjacent rooms (except in this game everyone gets a seat!). Outside each room is a brief ‘prompt’ such as a brief clinical scenario. For each station, you are allocated three minutes to get to the station and review the ‘prompt’, and seven minutes to spend with a pair of examiners, one of whom will act as lead while the other scribes. Candidates should expect that one station will focus on a difficult communication or administration scenario with an actor involved. Each of the six stations is marked out of 10: to achieve an overall pass, candidates must pass at least four stations and attain a total score of 30 or more. Once again, consistency is rewarded more than good performance at individual stations. Five or more stations must be passed to pass the section overall (see Table 1.1).

Additional clinical cases

Because the clinical component involves real patients, on rare occasions a situation may occur where for the wellbeing of the patient a short or long case has to be terminated prematurely. If this occurs, the Censor-in-Chief or Chair of the Fellowship Examination Committee (FEC) will determine whether the can di date must see an extra case. ‘Spare’ cases (and examiners) are prepared for this eventuality. Usually the supplementary case can be seen immediately, but may be at the end of the session depending on individ ual circumstances. Additional clinical cases are not awarded simply to give borderline candidates another ‘chance’.

Overall result

Details of the marking schedule are provided in Table 1.1. A final possible score of 60 is obtained from the score out of 10 from each of the six sections. To pass overall, you must:

• score a total of 30 or more with a pass in all six sections, or

• score a total of 31 or more with a pass in five sections, or

• score a total of 32 or more with a pass in at least two written and two clinical sections.

Notification of results

Once you have completed the final clinical compon ent, stay near the venue if you can, as the examiners meet shortly after candidates complete this component. Following this examiners’ meeting, the list of successful candidates is prepared for posting outside the venue and on the College website, and individual envelopes are prepared containing results. The envelopes are handed out at the designated time, usually approximately two hours after the clinical component has been completed. There is no distinction between the envelopes of ‘successful’ and ‘unsuccessful’ candidates: they all look identical, with only the candidate number on the outside. Those results not collected are mailed out to candidates.

The examination and the examiners’ meeting are highly confidential. No one other than the Censor-in-Chief is permitted to discuss any information on any candidate or any other aspect of the examination outside of the examiners’ meeting. Do not ask any examiner how you went. They are not permitted to discuss anything with you.

All candidates and their accompanying persons are then invited to drinks. Successful candidates are presented with a College pin and the winner of the Buchanan Prize is announced. The Buchanan Prize, named in honour of Peter Buchanan, one of the founding Fellows of the College, is awarded to the candidate with the highest score. Where two or more people have the same high score and other predetermined criteria are equal (including the number of sections passed and the number of examination attempts), the prize may be awarded to more than one person.

Who are the examiners?

There are very few monsters who warrant the fear

we have of them.

Examiners are clinicians who have successfully applied to become examiners. They are at least five years post-fellowship and have undergone an introductory process, including observing the primary and fellow ship examinations. Examiners volunteer their time to assist in this important task.

Many examiners tend to be high achievers in other areas as well. You will most likely recognise authors of textbooks or other ‘big names’ in publishing, research or College activities. Do not be intimidated by this. Con sole yourself with the knowledge that not all exam iners passed the fellowship examination on their first attempt! They are there because they want to assist you through the process. They really do want to see you pass — aft er all, it is far more satisfying from their perspective to be awarding pass marks. And remember, there is no requirement for anyone to fail: if everyone achieves the pass standard, then every one passes.

Examiner pairs are usually selected from diff erent regions. Each serves as a ‘check’ for the other to make sure that everything is done properly and that your comments and actions are accurately acknowledged. For the most part, one will lead a given section while the other scribes against predetermined criteria. Given the few examiners who are available at a sitting, it is not always possible to ensure that candidates are assessed by examiners who do not have conflict of interest issues with them. If one examiner is known to you, it is usually (but not always) the other who will lead that section.

Observers will also be present in some sections. They may be prospective examiners, site organisers, Directors of Emergency Medical Training (DEMTs) or other Fellows of the Australasian College for Emergency Medicine (FACEMs) who are bulldogs, gaining first-hand experience of the examination process. Non-FACEMs (e.g. advanced trainees) may be involved in the examination process, but they are not allowed to be present in the examination room.

You may occasionally find a scribing third examiner join the active pair. This is a ‘peer support’ examiner. Like the other observers, this person will not examine you and will not interact with you. Select ed from the senior court of examiners, this person is there to provide feedback to the examiners on their per formance as a quality assurance measure. Even the examiners get examined!

Who prepares the exam questions?

It is possible to store the mind with a million

facts and still be entirely uneducated.

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