Peer advice for doctors preparing for the FFICM Practical Exams

Introduction

The fellowship examination is a significant milestone in your training journey, akin to any other practical exam that can be linguistically demanding. This can be particularly challenging for international intensivists in training (IiTs) who may not be familiar with the exam format, or whose first language isn’t English. It is well-recognised that IMGs often face differential attainment in postgraduate exams, resulting in a lower pass rate compared to their UK graduate counterparts.

This is peer support advice from an IMG who passed the exam on the first attempt with full marks, aimed at assisting all my colleagues prepare for their exams. 

Timing is Key

Time management plays a crucial role in your success. The exams are designed for candidates at the end of stage 2, after completing all specialised placements. Sitting the exam too early may mean you are not yet familiar with important aspects of the format.

For ICM doctors on the portfolio pathway, it’s best to take the exam after completing your Medicine block. A strong understanding of medical knowledge, which you usually gain from working for a year in medicine within the NHS, is vital.

Fellowship exams require focus and mental energy. It’s best to avoid scheduling your exam during other significant life events (e.g., moving house, getting married, etc.). Try to choose a time when you can concentrate fully and feel emotionally settled.

Many colleagues have found that short, intense preparation yields better results than extended, slower-paced studying. Approximately eight weeks of focused preparation seems optimal.

Tip: Make sure you are familiar with the UK exam culture. For example, being calm, professional, and structured in your answers is important. If you are unsure, ask colleagues or mentors what is expected in UK exams.

Also, take care of your mental health during preparation. Use simple tools like breathing exercises, short walks, or mindfulness apps to stay calm and focused.

Essentials:

A Companion on the Journey

Choose a study partner who is equally committed to taking the exam alongside you. Personally, I found that practising with a colleague whose native language is English was tremendously helpful. It allows you to learn natural phrases and develop a more structured way of thinking, even if you’re unsure about the correct answer.

Consider partnering with someone from a different background. This can be advantageous as you can mix and match strengths and weaknesses. For instance, if your background is primarily medical, collaborating with an anaesthetic intensivist could be mutually beneficial. You’ll learn their approach for certain questions, and they can benefit from your expertise in areas like hepatology and endocrinology.

Consistency

Revising on a nearly daily basis in the weeks preceding the exam will allow you to build your skills gradually. This is better than studying in large blocks with long gaps in between. Try to keep a regular routine. Even short daily sessions can make a big difference over time. 

There are days when we are doing a run of nights or long days. My personal advice is to keep your momentum going during these times. Even just one hour of light revision before your night shift, or early in the morning before a long day, can help maintain your confidence and keep your mind engaged. On these days, I usually choose short and light areas to revise, like a paediatric topic, maternal critical care, or non-clinical content. These are easier to review in a short time and still help you feel productive.

Tip: Use flashcards or summary sheets for these lighter topics. They’re quick to review and easy to carry with you.

Topics Matrix

Approach the syllabus systematically by creating a matrix to cover most of the exam material. Choose a book that you and your study partner like and start covering the topics together. Below is one example of how you could organise the topics:

Note: This is my personal topics matrix I developed when preparing for the exam. It helped me to cover the syllabus in a structured way. However, you may be asked questions on topics not included here, so please feel free to develop your own matrix and cross-check it with the FFICM official exam syllabus.

• Airway Management
  • Respiratory physiology
  • Oxygen delivery systems
  • Flow volume loop interpretation
  • Mechanical ventilation
  • Proning
  • ECMO
  • Respiratory weaning
  • ARDS
  • Oxygen toxicity
  • Difficult airway algorithm
  • Stridor
  • Anaphylaxis
  • Inhalation injury
  • Aspiration pneumonia
  • Ludwig’s angina
  • Haemoptysis and pulmonary haemorrhage
  • Tracheostomy anatomy
  • Tracheostomy complications
  • Tracheostomy emergencies and NTSP
  • Laryngeal complications
  • Bronchoscopy: anatomy, types, indications, and techniques
• Respiratory Conditions
  • CAP
  • VAP
  • Asthma
  • COPD
  • Bronchiectasis
  • Pleural effusion
  • PD
  • Pneumothorax and airway leak
  • ILD
  • TB
• Cardiac/ Cardiothoracic
  • Cardiac physiology/ cardiac cycle
  • Heart failure
  • Cardiogenic shock
  • Cardiac output monitoring
  • Mechanical circulatory support
  • Pacing
  • Right heart failure
  • Pulmonary hypertension
  • ACS
  • Arrhythmias
  • Cardiomyopathies
  • Valvular heart diseases
  • OOHCA
  • Temperature control
  • Aortic dissection (thoracic)
  • Cardiac tamponade
  • Hypertension
  • Infective endocarditis
  • CALS protocol
• Neurosciences/ Neurology
  • Hypoxic brain injury
  • SAH
  • TBI
  • ICH
  • Ischemic stroke
  • CVST
  • Spinal cord injuries
  • Neuroprognostication
  • PDOC
  • Status epilepticus
  • CNS infections
  • Tetanus
  • Guillain-Barré syndrome
  • Myasthenia gravis
  • Cerebral monitoring
  • Effects of hypothermia and hyperthermia
  • Eye care
  • Sedation
  • Delirium
  • Sleep physiology
  • Rehabilitation
  • Post Intensive Care Syndrome (PICS)
• Trauma
  • Major trauma
  • Massive haemorrhage
  • Transfusion reactions
  • Drowning
  • Burns
  • Gas embolism
  • Fat embolism
• Haematology/Oncology
  • Clotting disorders
  • VHA analysis (ROTEM/ TEG)
  • HIT
  • TTP
  • HUS
  • Haematological malignancies
  • Haemoglobinopathy
  • HLH
• Renal
  • Acid-base balance (anion gap, SID, Atot, PCO2, albumin effect)
  • RRT
  • Plasmapheresis
  • AKI
  • CKD
  • Sodium homeostasis
  • Severe electrolyte imbalances (phosphate, magnesium, calcium)
• Surgery
  • Laparotomy
  • Pancreatitis
  • Necrotising fasciitis
  • Bowel obstruction
  • Short bowel syndrome
  • AAA
  • Abdominal compartment syndrome
  • Oesophageal rupture
  • Post-flap surgeries
  • Post-transplant surgeries
• Infection and Microbiology
  • Overview of common bacterial organisms classification
  • Antibiotic classifications
  • Antiviral classifications
  • Antifungal classifications
  • Antibiotic stewardship
  • Sepsis, septic shock, and the glycocalyx
  • Nosocomial infections
  • CRABSI/CLABSI
  • HIV
  • Malaria
• Organ Donation
  • Death
  • Pathophysiology of brain coning
  • Brain stem death testing
  • Donation after brain death (DBD)
  • Donation after circulatory death (DCD)
  • Common organ retrieval techniques
• Pharmacology and Toxicology
  • Enzyme inducers and inhibitors
  • Stages of metabolism
  • Common drugs in ICU metabolism
  • Toxidrome (cholinergic, anticholinergic, sedatives, stimulants)
  • Alcohol effects on the body
  • Toxic alcohol
  • TCA overdose
  • Lithium overdose
  • Local anaesthetic toxicity
  • Beta blocker overdose
  • Calcium channel blocker overdose
  • Serotonin syndrome & Neuroleptic Malignant Syndrome
  • Malignant Hyperthermia
  • Propofol Infusion Syndrome
  • Environmental poisoning
  • MCA Act
  • Mental Health Act
  • Capacity assessment
  • Midnight Laws
• Gastroenterology
  • Acute Liver Failure (ALF)
  • Acute-on-Chronic Liver Failure (ACLF) / Chronic Liver Disease (CLD)
  • Ascites
  • GI Bleeding
  • Diarrhoea
  • Constipation
  • IBD flare
  • Stress ulcers
  • Nutrition
  • Refeeding syndrome
  • Fluids in ICU
• Endocrinology
  • Diabetes emergencies
  • Thyroid emergencies
  • Adrenal insufficiency
  • Phaeochromocytoma
• Skin Failure Disorders
  • DRESS Syndrome
  • Stevens-Johnson Syndrome (SJS)
  • Toxic Epidermal Necrolysis (TEN)
• Rheumatology
• Maternal Critical Care
  • Physiology during pregnancy
  • Hypertensive disorders
  • Postpartum haemorrhage
  • Maternal sepsis
  • Cardiac Arrest in Pregnancy
• Paediatric Critical Care
  • Differences in airway anatomy between children and adults
  • Bronchiectasis
  • Neonatal collapse
  • Diabetic Ketoacidosis (DKA)
  • Sepsis
  • Paediatric cardiac arrest algorithm
• Equipment
  • Tracheostomy types
  • Rapid transfusion equipment (Belmont and Level 1)
  • Arterial line
  • Central Venous Catheter (CVC)
  • Renal Replacement Therapy (RRT) circuit
  • ECMO circuit
  • Intercostal chest drains
  • Cardiac output monitors
  • Intra-Aortic Balloon Pump (IABP)
  • Oxygen cylinders
  • EVD setup
  • ICP monitor waveforms
  • Bowel management system
  • Gastric Balloon Tamponade (SBT/Minnesota)
• Anaesthesia
  • Pharmacology of common drugs in anaesthesia
  • Rapid Sequence Induction (RSI)
  • Quick reference guide for anaesthetic emergencies
  • DAS guidelines
• Non-Clinical topics
  • Major incidents
  • Transfers
  • Critical Care Outreach
  • Fire evacuation
  • Critical incidents
  • Scoring systems
  • FICM Midnight Laws
  • GPICS guidance
• Radiology
• ECG
• ABG interpretations
• Common communication scenarios - FICM Midnight Laws

“Practice makes perfect” may sound clichéd, but it’s true - the more question styles you try, the easier it becomes to structure your answers on exam day.

Surprise! You don’t need to know everything to score marks. As long as you say something sensible and relevant, you can still earn marks. Practicing different types of questions you learn useful phrases and approaches that examiners are looking for.  Let’s look at an example to show you how this works: 

Exam Approach Practice

• Pause briefly before answering - take 5 seconds to organise your thoughts. This helps you stay calm and focused.
• Opening statement - Begin with a clear and simple definition of the topic. This makes a strong first impression. Follow this with a broad classification of the topic in question.
• Group Classifications – Use different ways to organise your answer:
  • By system (CVS, Resp, CNS, Gastro, Renal, etc.)
  • By ABCDE
  • By patient factors/disease factors/system factors
  • By disease-specific or treatment-related complications (e.g., how disease X presents in the ICU).
  • By local and systemic complications (e.g., pancreatitis)
  • By immediate, short-term, and long-term complications (general complications)
• Templates – Prepare simple templates for common question types. These help you answer quickly and clearly:
• How to approach disease ‘X’?
  • Take history
  • Do examination
  • Request focused investigations
• Investigations: Divide into general and specific (directly related to the question).
• Management Approach
  • Emergency presentation (e.g., ACS causing cardiogenic shock):
    • Use MDT approach
    • Transfer to specialist unit
    • Check ABCDE for life-threatening emergencies and address them as you go
    • Treat the underlying problem
    • Manage complications arising from the primary presentation
    • Provide supportive care (VTE, Gut prophylaxis, VAP, pressure sores, bowel and bladder, rehab)
    • Extreme: refer to ECMO, Transplant, Palliative Care
  • Chronic health problem (e.g., ILD exacerbation):
    • MDT approach
    • Pharmacological management
    • Non-pharmacological management
    • Focus on quality of life
  • How does condition (x) present in ICU?
    • Disease complications
    • Treatment of disease complications
    • Post-operative issues
    • Unrelated problems
  • How to handle a ‘Critical Incident’?
    • Declare emergency
    • Assign roles
    • Document the event
    • Follow Duty of Candour
• Differential Diagnosis of ‘X’: Use the surgical sieve mnemonic, which is a method to help you think of all possible causes of a condition. It helps you stay organised and avoid missing important possibilities:
  • Vascular
  • Infection/Inflammatory
  • Traumatic
  • Autoimmune
  • Metabolic
  • Latrogenic
  • Neoplasm
  • Congenital
  • Endocrine/Environmental
  • Functional
  • Drugs
• Communication Scenario 1: An error occurred in ICU; what is your approach?
  • Introduce yourself and your role
  • Be open and honest (Duty of Candour).
  • Clearly explain what happened to the patient or their representative. Explain the error clearly and without medical jargon.
  • Offer a sincere apology
  • Describe the steps being taken to address the issue:
    • Reporting the incident - completing an incident form
    • Involving the risk management/governance teams
    • Reflecting and learning to prevent recurrence
  • Offer a meeting with the ICU consultant
  • Provide additional support e.g. refer to PALS and offer a follow-up conversation
• Communication Scenario 2: Angry patient or relative in ICU
  • Introduce yourself and your role
  • Invite them to share their concerns by asking open-ended questions - listen actively
  • Acknowledge their feelings and show empathy & understanding +++
  • Explore what can be done to support them
  • Offer alternative options, even if they seem unrealistic in the exam context
  • Offer a second opinion
  • Suggest a case review
  • Provide written information about the new option if helpful
  • Offer a follow-up meeting to continue the conversation
• Communication Scenario 3: Patient is dying while on full support - how to tell the family
  • Introduce yourself and your role
  • Ask what the family understands about the patient’s condition
  • Explain that the patient is deteriorating despite full support, and that all appropriate treatments have been given
  • Use clear language without medical jargon
  • Pause to allow space for emotions
  • Gently explain that continuing intensive care may prolong suffering, that there is no realistic chance of recovery
  • Discuss the clinical decision to withdraw life-sustaining treatment (WLST), in line with best practice and the patient’s best interests
  • Reassure the family that the patient’s comfort and dignity will be prioritised throughout
  • Explain what to expect during the process, including what they may see
  • Ask if the patient had any known wishes or preferences
  • Pause again to give time for reflection
  • If appropriate sensitively raise the topic of organ donation, especially if the patient is registered, this may help fulfil their wishes
  • Offer support and follow-up conversations

Tip: You don’t need to list every category in every answer. Use the ones that fit the question best. This tool is just to help you think broadly and logically.

Tip: Practice these templates with a colleague. Use simple language and short sentences. This helps you stay confident and clear during the exam.

Buzzwords

There are key buzzwords that examiners expect to hear in response to each question. These are specific terms or phrases that signal your understanding of the topic and help you score marks.

When revising, try to identify the essential buzzwords for each area. Even if your full answer isn’t perfect, using the right terminology shows the examiner that you understand the core concepts. This skill improves with practice.

What to do when you don’t know the answer?

• No one knows everything, the exam is designed to test your safety and judgement - not perfection. However, you need to have a strategy to tackle any curveballs.
• Stay calm and choose a structured approach (see templates above). Even if the question is highly specialised, you can often score marks by covering the basics clearly.
• It’s ok to say, “I don’t know” or “I’m not sure” - just not too often! This shows that you recognise your limitations and know when to escalate, ask for help, or refer to a specialist.

Past Papers

• Review the FFICM chair examiner reports on the FICM website. They highlight questions that haven't been answered well and provide examiner observations. Questions are often repeated every few years.

Non-verbal Composure

• Stay calm and maintain your composure. Some questions are designed to test how you behave under pressure. Take a deep breath before answering and remind yourself that staying calm helps you think clearly.
• Maintain eye contact with the examiner. This shows confidence and helps build a connection. If you feel nervous, look at the examiner’s forehead or nose - it still appears like eye contact.
• Allow the examiner to interrupt you. They may want to guide you to the part of the question where the marks are awarded. Don’t worry - this is normal and not a sign that you are doing badly.
• Wear comfortable clothing. Choose something professional but simple. Feeling physically comfortable helps you stay relaxed during the exam.
• Speak clearly and at a steady pace. You don’t need to rush. Use short sentences and pause between ideas. This makes it easier for the examiner to follow your answer.
• Don’t worry about your accent. Examiners are used to hearing different accents. Focus on being clear and confident. Your knowledge is what matters most.

Tip: Practice speaking aloud during your revision. Record yourself and listen back to improve clarity and pacing. This builds confidence and helps you sound more natural in the exam.

The Night Before the Exam

• Arrive in London early. This gives you time to settle in and avoid last-minute stress.
• If possible, book accommodation where you will actually get some sleep, ideally within an easy reach of the exam venue to avoid travel delays.
• Have a nutritious early dinner. Avoid heavy or rich meals that might disturb your sleep.
• Prepare your clothes for the next day.
• Avoid caffeine after 3:00 PM. It can affect your sleep, even if you don’t feel it immediately.
• Steer clear of cramming and late-night studying. Trust your preparation. Use the evening to relax and recharge.
• Set multiple alarms and check your route to the exam venue in advance. This helps reduces anxiety and ensures you arrive on time.

Resources

I found the following resources helpful during my preparation, including:

• The final FFICM Structured Oral Examination Study Guide by Eryl Davies. This book gives a clear idea of the exam format and how to answer questions effectively.
• Any OSCE book of your preference. Useful for practising clinical scenarios and communication skills.
• Equipment in Anaesthesia and Critical Care by Daniel Aston. Covers essential ICU equipment with concise explanations and diagrams.
• FFICM Examiner Reports these highlight commonly misunderstood questions and examiner expectations. Many questions are repeated every few years, so reviewing these reports is very useful.
• FRCA Reveal App (especially useful for those without an anaesthetic background). Helps build understanding of key anaesthetic concepts that may appear in the exam.
• In-person FFICM Preparation Courses. Available in most regions. Attending one can help you practise exam scenarios and receive feedback from experienced trainers. Practising under exam conditions builds confidence and helps you prepare effectively. See the FICM website for a list of available courses (note: this may not be exhaustive), under the section titled ‘External Revision Courses’.
• FICM Midnight Laws - Cover legal and ethical principles relevant to critical care practice.
• FICM's Case of the Month – Real-life cases that help develop clinical reasoning and structured thinking.
• FFICM Exam Glossary – This glossary explains common phrases and terms that could be used during the exam. It helps you understand what examiners mean and improves your ability to respond clearly.

Tip: Try to use a mix of written, visual, and interactive resources to suit your learning style. Discussing cases with colleagues or mentors can also reinforce your understanding.

Join IMG support groups or forums. Talking to others who have taken the exam can give you useful tips and emotional support.

Remember: passing this exam is not just about knowledge - it’s also about communication, structure, and staying calm. Believe in your preparation and your experience.